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Medicare Coding Is Becoming More Complicated Under Obamacare

March 25, 2012
inMedicaid, Medicare, Medicine: Healthcare System, Physician's Problems
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Stanley Feld M.D.,FACP,MACE

Physicians make coding errors. These errors result in decreased reimbursement.   The denied claims might not be noticed for months by the physicians’ office.

In a busy practice the details of all the changes in coding rules are sometimes impossible to understand.

An entire coding industry with coding professionals taking certification examinations has developed with a great increase in the cost to the healthcare system.  

President Obama’s healthcare reform act is trying to institute a completely new electronic claims system. It is called 5010. It will replace claims system 4010.

As far as I can tell the goal is to obtain more data on physicians’ practice patterns. The goal of the new system is to determine the “quality” of physicians care. If the quality is poor, reimbursement will be reduced. Claims will be denied. Its execution looks confusing and expensive.

5010 was suppose to be in place and required for all to use by January 1, 2012. Apparently, it was not fully installed or tested by enough healthcare organizations to be validated. The date of full implementation was moved to March 31, 2012. Last week full implementation was moved to June 30, 2012.

The other complicated “innovation” of Obamacare is ICD 10 coding system.  This new coding system replaces ICD-9. It has increased the number of codes from 18,000 to 68,000 for coding in-patient and out-patient care. Effective implementation of these codes will be very difficult.

The implementation of these two “innovations” will add billions of dollars to the cost of healthcare.

 It will increase physicians’ paperwork. It will result in more mistakes. It is questionable whether the new systems will increase the quality of care.

It is adding more complexity to an already dysfunctional system.

It is impossible for physicians to keep up with all the new regulations the Centers for Medicare and Medicaid Services is about to impose on them.

Most physicians do not have the time to study the new regulations and their implications. They hope their professional organizations will pick up the important ones and point out the problems in plain English.

Many times one regulation contradicts another regulation. The administrative service providers (healthcare insurance industry) for CMS interpret the regulations the way they want. There is often a lack of consistency from state to state.

The Texas Medical Association recently informed us of an error related to submission of measure No.235, Hypertension: Plan of Care for the 2012 Physician Quality Reporting System.

 The Texas Medical Association sent the following message to all Texas physicians. I challenge anyone to understand this message.

The Centers for Medicare & Medicaid Services (CMS) has identified an error related to the submission of measure No. 235, Hypertension: Plan of Care, for the 2012 Physician Quality Reporting System (PQRS). Hypertension: Plan of Care is a claims/registry measure with G-codes that are inactive due to an error. Consequently, Medicare carrier TrailBlazer has rejected or denied claims containing the G-codes associated with the measure.

The following is a note I received from a physician.

“I thought I went to medical school to learn how to take care of sick patients?”

“I did not go to medical school to deal with complicated and impossible rules and regulations daily. These regulations interfere with my ability to help sick patients”

Physicians are faced with these confusing rules daily. I do not believe that these rules promote quality care for patients. These rules serve to irritate physicians. The rule changes result in a non-user friendly Medicare system.  I predict it will ultimately result in non-cooperation by physicians.

The TMA goes on to tell us what CMS is going to do and what we can do to obtain reimbursement for treatment given using CMS’ rules.

 CMS will reactivate the codes G8675, G8676, G8677, G8678, G8679, G8680, and 4050F with its next update of the HCPCS code data in April 2012. For 2012 claims-based reporting, PQRS requires at least three measures be reported at a 50-percent reporting rate.

In the interim, if you had intended to report this measure via claims for the 2012 PQRS, consider doing the following:

  • Report additional measures to substitute for measure No. 235, Hypertension: Plan of Care.
  • Hypertension: Plan of Care is a per-visit measure, which requires reporting for 50 percent of eligible patient visits. Therefore, you could report the measure on more than 50 percent of eligible visits from April through December 2012 to increase the likelihood for successful reporting of the measure.

As an alternative to reporting PQRS quality measures via claims, physicians can report using a qualified registry (PDF). TMA endorses two such vendors. Or, practices can submit measures using a qualified electronic health record (PDF).

Published March 16, 2012

Is it any wonder the Medicare and Medicaid System have tremendous bureaucratic cost overruns?

There has to be a better way?

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

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  • Brandon • August 31, 2012

    Interesting… thank you for the blog. In regards to the medical coding, you said they added some 50,000 new codes. Was the purpose to dilute the system, or to just make sure there is a code for every imaginable situation? Is there like a database or something that you just search keywords and you find the correct code? I have to be honest, I find this fascinating, I had no idea this was how medical billing worked.. or didn’t work I should say.

  • does textyourexback work • October 3, 2013

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The Relationship Between Type 2 Diabetes Mellitus And Statin Therapy

March 21, 2012
inChronic Disese Management, Consumer Driven Health Care, Medicine: Healthcare System
• Leave a comment

Stanley Feld M.D. FACP, MACE

Readers have continuously reminded me that consumers are not smart enough to purchase the right kind of healthcare.

"Hello Dr. Feld,

What is your solution for patients who simply aren’t educated enough to make these decisions on their own? In “Redefining Healthcare” Michael Porter advocates a role for insurers to help in this regard and I’m wondering what your thoughts are given that the fastest growing demographic in America is poor, uneducated, and potentially (as a result) unhealthy folks."

I refuse to believe that consumers are too stupid to be educated if properly motivated.

I welcome insurance companies trying to educate consumers but they are doing it for their benefit and not the patients’ benefit. The education offered is not an extension of the physician’s care and will therefore be ineffective.

I respect the intelligence of all consumers. They will want to become educated consumers as soon as there is a financial benefit.

Any educational system built will have no effect on about 10% of the population. These people will be a burden to society.

The government and the healthcare insurance companies had their day trying to fix the healthcare system.

It is now the consumers’ turn to use their consumer power to fix the healthcare system. Consumers are starting to realize they need to be responsible for their care. They are also realizing they must control their healthcare dollars.

In order to be a wise healthcare consumer, they must understand their chronic disease.

The recent FDA statement about statins causing Type 2 Diabetes has been confusing to patients. Statins can be expensive. Patients will not spend the money for the statin nor adhere to a treatment plan if they think they will be harmed by the medication.

An understanding of the pathophysiology of Type 2 Diabetes and hypercholesterolemia will make it clear that there is no relationship between statin therapy and its causing diabetes.

At least 20% of the population has genetic insulin resistance. There is a slight difference between ethnic groups with the incidence being 30% in Hispanics and Native Americans.

This genetic defect results in a rising insulin level as the patient becomes obese, older and/or stressed.

The increase in childhood obesity in genetic insulin resistance children is causing an increase in childhood Type 2 Diabetes.

The underlying genetic defect can express itself before the blood sugar rises out of the “normal range.”

Insulin Resistance Syndrome has had several names over the past 30 years. One name was the Deadly Quartet. The quartet consists of obesity, hypertension, hypercholesterolemia, and diabetes.

Insulin Resistance Syndrome’s new name is Metabolic Syndrome. Each disease can present independently at different times. Hypertension, hyperlipidemia and diabetes are usually precipitated by obesity, stress or steroid therapy.

If patients understood the pathophysiology of metabolic syndrome they would try hard to lose weight and adhere to medication prescribed.

Patients must be taught to become the professor of their disease.

It is insufficient to say “doc, my cholesterol is high, fix me”. The only people who can “fix” patients with chronic diseases are patients themselves.

What do we know about Type 2 Diabetes Mellitus and insulin resistance?

1. The incidence of Clinical Type 2 Diabetes Mellitus is high in patients who are obese.

2. Clinical Type 2 Diabetes (high blood sugar) can disappear with weight loss and exercise in early onset diabetes. These patients still have insulin resistance but the resistance is decreased and the blood sugars become normal.

3. Obesity must be decreased in order to eliminate overt diabetes. If not, the medical cost of treating diabetes and its complications will continue to rise.

4. High LDL cholesterol is a frequent complication of Type 2 Diabetes.

5. High LDL levels cause coronary artery plaques. The result can be myocardial infarction (heart attack).

6. Diabetes Mellitus is frequently first discovered at the time of a myocardial infarction (heart attack). Mildly elevated blood sugars could remain asymptomatic for an average 8 years and discovered after a complication of diabetes (heart attack) occurs.

7. Treating high LDL cholesterol with statins in Type 2 Diabetics decreases the incidence of myocardial infarction.

8. Statins decrease the production of LDL in the liver by inhibiting an enzyme that produces LDL.

9. High blood sugar and high insulin levels also decrease nitric oxide levels in the lining of blood vessels (endothelium). The result is a narrowing of the coronary arteries.

10. Statins stimulate an increased endothelial nitric oxide production. Statins dilate the coronary arteries.

11. The dilatation of the coronary arteries along with the decrease in LDL production decreases plaque formation and the risk of a myocardial infarction.

12. High insulin levels in early Metabolic Syndrome inhibits LDL receptors ability in the liver to attach to circulating LDL. This inability to attach to the liver cells decreases the liver’s ability to sense there is enough cholesterol in the blood stream. The liver then increases the production of LDL.

13. Statins inhibit the liver from producing more LDL. Lowering the LDL produced decreases LDL in the blood stream.

14. Logically, by lowering LDL cholesterol production with a statin the effect of insulin resistance to increase cholesterol production is neutralized. The use of statins in Insulin Resistance Syndrome does not cause diabetes.

15. Therefore data for the FDA’s black box warning is wrong.

Education is the key to chronic disease management.

Physicians must teach patients in terms they can understand. Education will only be effective if patients are motivated to learn.

Physicians must be motivated by consumers to teach. Consumers controlling their healthcare dollars could motivate physicians to teach them at their level. Physicians could use their own social networks to provide customized instruction.

Obesity is the core-precipitating problem in Metabolic Syndrome. My ideal Medical Saving Account with its financial incentive could help change the obesity problem in America.

The ideal MSA might even compel the experts to not throw misinformation around lightly and frighten the public.

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

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  • Pietr • March 23, 2012

    “Those who restrain desire do so because theirs is weak enough to be restrained.”
    ― William Blake
    >It is insufficient to say “doc, my cholesterol is high, fix me”. The only people who can “fix” patients with chronic diseases are patients themselves.
    Dr. Feld, this statement is a copout. You throw the responsibility back at the patient and your hands in the air. Since you recognize that obesity is an refractory to treatment, it is easier to blame the patient to sloth and gluttony and absolve yourself.
    The treatment of obesity was available 20 years ago with the combined agonists fenfluramine and phentermine. Unfortunately, these drugs were off patent and Dr. Weintraub and his colleagues didn’t see the danger. When the cardiac and pulmonary problems occurred, FEN/PHEN had no advocate and its promise disappeared.
    Treatments for OCD and addiction using dopamine and serotonin agonists/precursor have been described. The current protocol uses the immediate precursors levodopa and serotonin. Another duo taken together increases cerebral acetylcholine and crushes nicotine craving. Lecithin and pantothenate (vit B5) are dirt cheap and have absolutely no risk.
    These simple treatments do not make money for PHARMA, in fact they are a threat to its very existence. PHARMA would be foolish not to fight against their use. In my case, they destroyed my career, reputation and life.
    Tell your alcoholics, cocaine addicts and fatties that the system has failed them rather than blaming them.
    I hope you enjoy the Blake quotation.
    We seem to differ not only on the price of nude tennis balls (Spaldeens) in 1950 but also the solution for medical management. I hope we can converse civilly in the future for I respect the quality of your writing and the degree of intellect and trust in your motivations.
    Pietr Hitzig
    http://sites.google.com/site/pietrhitzig/

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New Statin Therapy Warnings and Its Science

March 18, 2012
inConsumer Driven Health Care, Disinformation and the healthcare system, Information Technology in Healthcare, Medicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

I have said repeatedly that patients have to become the Professors of Their Disease. A reader recently wrote, “ The average consumers are not smart enough to evaluat complicated clinical data.”

My answer is that it is the responsibility for their physicians to teach them how to evaluate the data used to decide on their cause of therapy.

Physicians’ goals are to their treat patients with the best possible evidence based medicine. It is the patient’s responsibility to understand the reasons for the treatment and be responsible for adhering to the treatment.

In my opinion, during the last decade, arriving at the best evidence based medical care has become very difficult. The design of clinical research studies has become sloppy. The statistical results of the studies have frequently been misrepresented. Statistical trends have been interpreted as being statistical truths.

However, once a statistical trend has been reported and accepted as evidence the non- statically significant data have resulted in producing defective healthcare policy and decreasing the quality of medical treatment.

One prime example has been my opinion of the effect of the Women’s Health Initiative on women’s health. Another is the conclusion of the FDA to put a black box treatment warning in the labeling of statins.

The conclusions drawn from the clinical data for the recent black box warning are wrong. The studies are wrong because the clinical studies were designed poorly or the conclusions were not statistically significant.

There are a few simple statistical rules that must be followed for a study to prove that the conclusions are correct and a medication has a certain statistically significant effect.

The p value must be less than .05, the confidence interval must not cross 1 and the hazard ratio must be 2 or greater. It must also be a well designed study to be able to show a valid effect.

  The women’s health initiative was poorly designed. In my opinion the study design alone disqualifies the study results. 

  1.  TNT (Treating to New Targets) trial,[4] 351 of 3798 patients randomized to 80 mg of atorvastatin and 308 of 3797 randomized to 10 mg developed new-onset type 2 diabetes mellitus (T2DM) (9.24% vs 8.11%, adjusted hazard ratio [HR]: 1.10, less than 2, 95% confidence interval [CI]: 0.94-1.29, crosses 1 P = .226). Not significant.
  2.  In the IDEAL (Incremental Decrease in End Points Through Aggressive Lipid Lowering) trial,[5] 239 of 3737 patients randomized to atorvastatin 80 mg/day and 208 of 3724 patients randomized to simvastatin 20 mg/day developed new-onset T2DM (6.40% vs 5.59%, adjusted HR: 1.19, 95% CI: 0.98-1.43, P = .072). Not Significant.
  3. Across the 3 trials, there was no difference in the major cardiovascular events, which were 11.3% in patients with and 10.8% in patients without new-onset T2DM (adjusted HR: 1.02, 95% CI: 0.77-1.35, P = .69) including the SPARCL trial were not significant.  
  4. In a meta-analysis of 13 clinical trials with 91,140 participants showed no significant difference. It is my opinion that meta-analysis is worthless because of variation in each study’s design.  

I understand that the first reaction of a reader would be that it is impossible for the average person to understand the significance of this science.

There is no reason this information could not be explained to people in various formats from very advanced to cartoon simple. The explanations could be available on an Internet social network 24/7 chosen by their physicians.

I believe patients could understand the information once they were motivated to be responsible for their medical care.

I am astonished that “experts” would propagate this disinformation on topics as important as the health and well being of the population.

Hopefully a consumer driven healthcare system would compel everyone to be more careful in examining data from clinical research studies. 

 

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

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  • warhammer tau • March 21, 2012

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Let’s Talk About Statins

March 14, 2012
inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems
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Stanley Feld M.D.,FACP,MACE

The New York Times did it again. Once again we are experiencing media hyperbole. The first sentence tells it all.

We’re overdosing on cholesterol-lowering statins, and the consequence could be a sharp increase in the incidence of Type 2 diabetes.

Bingo.  For years teaching physicians have worked hard trying to convince practicing physicians the virtues of statin therapy to lower the incidence of coronary artery disease by lowering LDL cholesterol (bad cholesterol).

Finally, it took hold. Practicing physicians tried for years to convince their patients to take statins to decrease the risk of heart attacks.

Over the years evidence mounted proving that normal total cholesterol value should be lower than 200 mgs% from a previous normal of 240 mg%.  The normal LDL cholesterol should be lowered to 100 mgs% from 150% mgs%.

This was not a pharmaceutical industry’s conspiracy. It was arrived at with actual statistically significant clinical data.

The New York Times goes on to say;

“This past week, the Food and Drug Administration raised questions about the side effects of these drugs and developed new labels for these medications that will now warn of the risk of diabetes and memory loss. The announcement said the risk was “small” and should not materially affect the use of these medications.”

As soon as the first sentence was read it immediately put the safety of statins in question. There was no discussion of the flawed data used to reach this conclusion.

I predict the warning that resulted from flawed data will result in the unwarranted  decrease in physicians prescribing statins and patients refusing to take statins.

“ The data are somewhat ambiguous for memory loss. But the magnitude of the problem for diabetes becomes much more apparent with careful examination of the data from large clinical trials.”

I believe the data is shabby for both increasing the incidence of diabetes and the decrease in cognitive function.

I also believe the scientists at the FDA also believe the data is shabby.

FDA’s statements include;

"1. However, because statins are so widely used, there is a heightened awareness by the public when we make any safety-related labeling changes to this class of drugs."

"These changes do not in any way alter the risk-benefit calculus for this class of drugs. We continue to believe that the benefits of statins far outweigh their risks, but we do want clinicians and patients to be aware of their side effects so that they can be used in the most safe and effective manner possible."

The media has emphasized the safety label change warning patients of the possibility of getting diabetes as a result of taking statins. The fact is there are so many flaws in the studies sited that initiated the label change that the changes are unwarranted.

The FDA goes on to state,

“ We are not recommending that patients be discontinued from their statin therapy based on a small increase in blood sugar levels.”

“Rather, elevations in blood sugar levels should be treated with dietary and lifestyle management and/or adjustment or initiation of antidiabetic therapies. We do not consider this a reason to not continue or not initiate statins, particularly in the diabetic population where patients are at increased risk for major adverse cardiovascular events and statin therapy has been shown to reduce that risk.”

This disclaimer had not been emphasized in the traditional media. The Women’s Health Initiative (WHI) another flawed study did not have one statistically significant leg to the study. Yet it’s handling in the traditional media changed the course of women’s health forever. Evidence from the WHI was used as study material. The statement below assumes the conclusion of harmful effects of statins is real.

“Despite the higher hazard ratios observed in the WHI study, we do not have strong evidence suggesting that there is a gender effect for the development of this adverse effect.”

The FDA looked at the effect of statins on neurocognitive function.

“We looked at those study results; there was no difference in neurocognitive functioning observed between patients exposed to statin therapy vs those unexposed, including in executive function (attention and speed) and memory, both immediate and delayed.”

There is no evidence here.

"There were trials conducted with statins to see if they could improve cognitive functioning in patients with mild to moderate Alzheimer disease. We reviewed the results of one such study, which showed neither evidence of benefit nor harm in cognitive functioning associated with statin therapy.”

My fear is the misleading warnings being publicized in the press will change the course of therapy for patients at risk for coronary artery disease.

The science used to arrive at these warnings is shabby. It is important to understand the defects in the evidence so that society does not do to statins what it did to hormone replacement therapy for women's health.

 

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

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

March 11, 2012
inChronic Disese Management, Consumer Driven Health Care
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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

 

Slide22

 

 

 

Slide21

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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  • 避孕藥牌子 • October 20, 2013

    Its like you read my mind! You seem to know so much about this, like you wrote the book in it or something. I think that you simply can do with some percent to power the message house a little bit, but other than that, this is great blog. A great read. I’ll certainly be back.

  • arvixe hosting • August 22, 2016

    Very nicely explored the stuffs. chronic disease management is not simple as it looks. thanks for exploring in informative ways.

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It’s Baseball Time

March 6, 2012
inLife's Experiences
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Stanley Feld M.D.,FACP,MACE

Every year my brother (Charlie) and I go to Baseball’s Spring Training Cactus League with our boys.

 

Brad and Daniel are my boys. Jon and Kenny are Charlie’s boys. Their ages are one-year apart. They are each in their 40’s.

We have always enjoyed our time together on long weekends. It is bonding time.

We catch up with our lives, watch baseball games and philosophize.

P1060474

Brad, Charlie, Daniel

I always come away invigorated.

This year Kenny could not come. Last year Jon brought his son Jack. He was 10. We put Jack on our Junior Varsity.  This year we promoted Jack to the varsity. He knows baseball better than all of us.

The first game was the Oakland A’s vs. The Seattle Mariners. It was not a great game. The games never are. The great thing about the games is the smell of the grass, the pop of the mitt, the crack of the bat and being with our boys.

P1060483

Oakland A's Field 

 

Gaylord Perry       Bert Campaneris  Fergie Jenkins

 

Saturday’s game was the Colorado Rockies vs. the Arizona Diamond Backs at the new Salt Lake Fields At Talking Stick.

Salt River Fields at Talking Stick is a stadium complex located in the Salt River Pima-Maricopa Indian Community near Scottsdale, Arizona.

It is the newest Major League Baseball spring training facility. It is the shared home for the Arizona Diamondbacks and the Colorado Rockies.

P1060495

It is a beautiful ball field. The Cactus League is growing each year. Arizona weather is wonderful in March. It is much better than Florida’s March weather. The humidity is high in Florida’s Grapefruit League.

The Cactus League has figured out the right price point for the tickets to the games. Tickets in Florida can be five to ten times higher.

 

P1060500

Daniel and the DiamondBacks

P1060503

Stan and Daniel

Publicity is great and the baseball experience is user friendly.

On Sunday we saw the opening Spring Training game for the Texas Rangers and Kansas City Royals. They share a relative new training facility (10 years old) in Surprise Arizona. Surprise is a new town about 30 miles northwest of Scottsdale.

Every year the roads to Surprise get better and the trip shorter. Surprise is growing by leaps ad bounds. A person would never think America is in a Recession/Depression.

There are more new restaurants and shopping centers popping each year than can be imagined.

P1060511

Josh Hamilton 

We had a treat. Ron Washington kept the first team in the game for five innings. It didn’t matter to any of us that the American League Champs were really lousy on Sunday.

The only thing that matters to the six of us was being together and the smell of ice cold beer, peanuts, popcorn and Cracker Jacks. 

Next weekend my brother and I are going to hit some baseballs.

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

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Healthcare Insurance Industry’s’ New Business Model Is Wrong.

February 29, 2012
inConsumer Driven Health Care, Healthcare Insurance Industry, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D.,FACP,MACE

One percent of the people spend 25% of the healthcare dollars. Twenty percent of the people spend 80% of the healthcare dollars.

It would be important to know why this is true. Then figure out what could be done about it Stakeholders need to agree on a course of action.

It would be a good idea to understand what physicians think should be done. 

“One percent of patients account for more than 25 percent of health care spending among the privately insured, according to a new study. Their medical bills average nearly $100,000 a year for multiple hospital stays, doctors’ visits, trips to emergency rooms and prescription drugs.”

The 1% and the 20% are suffering from complications of a chronic disease.

The incidence of chronic diseases is on the rise in the United States. A major precipitating factor for this is obesity.

The incidence of Type 2 Diabetes Mellitus is increasing in both adults and young children, as the incidence of obesity is increasing.

The incidence of complications of Diabetes Mellitus will increase in the future. The result will be an increase in the cost of medical care.

President Obama’s healthcare reform act will expand healthcare coverage to 32 million uninsured in 2014. Obamacare is forcing the healthcare insurance industry to change its business model in order in order to remain profitable.

Premiums are out of the reach of most businesses and individuals. Premium increases are not an option.

High-risk individuals are denied healthcare insurance coverage. High-risk patients automatically get coverage in corporate healthcare plans. The healthcare insurance industry simply raises premiums on corporate groups in order to maintain its profits.

Something must be done to decrease the increase in chronic disease and its complications. 

The government cannot afford to insure its present patient obligations much less the 32 million uninsured.

“As the new federal health care law aims to expand care and control costs, the people in the medical 1 percent are getting more attention from the nation’s health insurers.”

Twenty percent of the population not 1% should be getting the attention of the healthcare insurance industry.

“Studies have already shown that Medicare spending is concentrated on a small group of individuals who are seriously ill.

An analysis by the IMS Institute for Healthcare Informatics, the research arm of IMS Health, a health information company in Danbury, Conn., provides a rare glimpse into the medical problems of people with private health insurance that are under 65.

About three-quarters of them suffer from at least one chronic condition that could spiral out of control without proper care.”

Most of these people were obese.

The healthcare insurance industry cannot avoid these patients after 2014.

“Insurance companies will be required to enroll millions of new customers without the ability to turn them away or charge them higher premiums if they are sick. They will prosper only if they are able to coordinate care and prevent patients from reaching that top 1 percent.”

The healthcare insurance industry realizes it must fundamentally change its business model.

The healthcare insurance industry has a problem developing a new business model that would work. The industry does not want to lose control over patients, their physicians and the monies paid into the healthcare system.

The healthcare industry does not have a clue about how to actually repair the healthcare system. It is focused on its own bottom line rather than looking at business models that will be beneficial to everyone and align all the stakeholders’ incentives.

The healthcare insurance industry is planning on instituting programs that will tinker with the edges. It will not fix the problems.

The new business models will increase the percentage of money the insurance industry receives for direct patient care maintaining a Medical-Loss ratio of 15%. There is no interest in providing patients with financial incentives and a choice.

The net result will be higher costs and system failure. The weird thing is most of the healthcare insurance industry executives know it.

“The reality is if we don’t figure out how to get to the patients, we’re not going to get where they need to be,” said Dr. Lonny Reisman, the chief medical officer for Aetna.

The reality is that the system must be consumer driven with consumers in charge of their healthcare and their healthcare dollars.

At the moment patients have no incentive to decrease the cost of care. Hundreds of patients have told me that they go to the doctor to fix their illness. Medicare or their insurance pays. The patients have no idea of the costs they incur nor do they care. They have no interest in controlling their disease.

My ideal medical saving accounts would give the patients incentive to learn about their disease. They would be interested in self-managing their disease with the physician and his medical care team being the coach.

“The next challenge, say insurers, is to figure out how best to work with a person’s doctor. Because many of these patients seem to be seeing many doctors and taking many medications, there may be no one who is accountable for the patients’ overall health.” 

Physicians have figured out what services get paid by the healthcare insurance industry. They do not get paid for educating patients about their disease.

The healthcare insurance industry and the government have developed a punitive bureaucracy.   

An attempt is being made to penalize or reward physicians for medical outcomes. Pay for Performance (P4P) is a punitive payment system. It will fail. 

Patients are responsible in large part for the onset of their medical problems and in controlling their medical outcomes. Physicians cannot be responsible for patients’ outcomes. It is the responsibility of the patient.

“Insurers are also still grappling with their understanding of human nature — why some people simply don’t take care of themselves or take their medicine or go to the doctor, even when it is clear that they should.”

Patient outcomes have nothing to do with human nature. It has everything to do with financial incentive and effective education.

Spokes 5 and 6 of my future state business model has everything to do with patients’ responsibility for caring for their disease and the physicians’ responsibility to the patients. It has nothing to do with physicians’ and patients’ responsibility to the healthcare insurance industry or government.

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

Please send the blog to a friend

 

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Spokes 5 and 6- Future State Of Healthcare Business Model

February 26, 2012
inChronic Disese Management, Information Technology in Healthcare, Innovations in Healthcare, Medicine: Healthcare System
• Leave a comment

Stanley Feld M.D.,FACP,MACE

Spokes 5 and 6 of future state business model for the healthcare system’s survival must be understood as one unit.  Chronic Disease Management and Education As An Extension Of The Physicians Care are two simple concepts.

 

Slide22

 

Slide21

 

Patient education is a crucial element in the care of patients whether the disease is acute or chronic. Systems must be set up so that education is an extension of the physician’s care in order to be effective.

Education is less effective if it is not personalized and unrelated to the patient’s physician.

Both concepts have been devalued by President Obama’s healthcare reform plan. The chronic disease management concept has been devalued with the administration’s pilot studies showing that chronic disease management programs do not decrease the quality of care or cost of care.

The pilot studies were conducted by freestanding clinics. The education was not an extension of the patient’s physician care. Medical care is a personalized endeavor that requires a personal relationship between patients and physicians.

At its core the quality of medical care is enhanced by a strong physician patient relationship. This relationship is critical to a successful patient outcome and decreases in the cost of medical care.

An analogous educational event happened to me in my junior year in high school.

I was on the high school baseball team. Baseball practice started in February. It rained and snowed a lot in New York City in February. If it rained we would practice in the gym. We couldn’t have baseball practice outside one day.

On that day the gym was taken. The baseball team was sent to the study hall the last period of the day. My year before geometry teacher was in charge of that particular study hall.

I was an excellent high school student. I never missed a question on a geometry test.

I loved my geometry teacher. It was easy for me to understand everything she taught.  This was an example of a positive teacher student relationship.

I was taking trigonometry that spring term. The chairman of the math department was my teacher.

I had a poor relationship with that teacher. He was not enthusiastic about trigonometry.

He was detached from his students and their needs. He had no interest in relating to us.

I could not understand a thing he taught.  I figured I could tolerate him.  I thought I had to ability to learn the course directly from the textbook.

To my surprise I could not understand any of the concepts in trigonometry when I was studying at home. I was resigned to the fact that I was going to fail trigonometry.

My geometry teacher saw me in the study hall. She came up to me an asked me how I was doing. I told her I was going to fail trigonometry.

I could not stand Dr. B and I could not retain anything he taught. I also found it impossible to teach myself trigonometry from the text.

She asked me what period I had lunch and which period I had trigonometry. I had lunch the 5th period and trig the 6th period.

She said she taught trigonometry the 5th period and she could transfer me into her class and into 6th period lunch. She was also a student advisor.

Her words were as if a weight was lifted from my back. She said there was one problem. The departmental first quarter test in trigonometry was being given tomorrow. If you do not know anything you will fail. I said I understood.

After dinner I went into my room to study for the test. I started on page one of the text. Everything I read stuck. All of a sudden trigonometry was understandable and every trigonometry problem was easy to solve. All my anxiety about trigonometry melted away.

The next day I took the departmental test in my new 5th period trigonometry classroom. I got 100% on the trigonometry test. I received an A+ in trigonometry at the end of the semester and 100% on the New York Regent examination. I did not miss a trigonometry question the whole term.

This lesson stuck with me throughout my medical career. A positive physician patient relationship is just as powerful as the positive teacher student relationship. Both enable patients and students to reach their potential.

Obamacare is interfering and methodically destroying the ability to form a positive patient physician relationship.

The regulations are punitive. Patient care is becoming depersonalized and commoditized.

I predict Obamacare is going to make the medical outcomes worse and the cost of healthcare higher.

After 30 years of practicing Clinical Endocrinology I am convinced that the therapeutic effect of the patient physician relationship is a major factor contributing to the healing process.

Chronic disease management does not work unless the patient physician relationship is intact.

President Obama has proven this with his pilot studies in chronic disease management.

President Obama has not proven that chronic disease management as an extension of physicians care does not work.

Combined with a positive patient-physician relationship, chronic disease management with education as an extension of the physicians care can work.  Patients can be motivated to maintain control of their disease. Patients controlling their disease will decrease the complications, morbidity and mortality of the chronic disease.

The result will be a decrease in the cost of healthcare.

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

Please send the blog to a friend

 

 

 

 

 

 

 

 

 

 

 

 

 

  • Education Management Software • March 5, 2012

    Do yourself a favor and learn them while you’re young. They have a lot of practical applications, including remembering people’s names.

  • Practice Management Software • April 13, 2012

    A lot of what you say is absolutely correct. It’s no use longing for the better “old” days ’cause there was no such thing. It was precisely becuase there was a problem with healthcare, that Obamacare became a reality. Yes, the doctor-patient relationship is sacred, but at whose expense? If the patient has no respect for the associated costs, takes little, if any, responsibility for his/her healthcare, the burden falls elsewhere. Despite our increasing standards of living, healthcare cost increases has seen no abatement. I see Obamacare as an attempt to do something about this. We do not have unlimited resources, even though healthcare is a basic human right.

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How Could A Social Networking Company Make Money In Healthcare?

February 22, 2012
inChronic Disese Management, Consumer Driven Health Care, Medicine: Healthcare System
• Leave a comment

Stanley Feld M.D.,FACP, MACE

My last blog about individual healthcare insurance policies generated a lot of comments from young people starting up a business and individuals operating their own business at home. I also received several from entrepreneurs looking to start a business.

One person wrote,

"Dear Dr. Feld

So we have now learned that high deductible plans are what people should be purchasing. We also learned that they should be self insuring for $10,000 which is the highest deductible insurance at the lowest price.

 Over $10,000 is where are at the greatest financial risk. True insurance should cover our greatest risk.

I would like to know where is the business opportunity is for an Internet company that runs social networks?

 

 

 Sincerely

Z"

I said the world belongs to young people 20-50 years old. They also understand the power and mechanics of social networking.

If there was a social network dedicated to describing the advantages and disadvantages of the healthcare insurance options available to the unemployed, self- employed and under insured there would be many members. If those members had the ability to have input it would grow even larger with appropriate marketing.

I have not figured out how social networking sites make money except through advertising. I imagine many companies would like to get the attention of these consumers who are seeking healthcare insurance advice.

It has been reported that people change their job up to 8 times during their career. More and more people are in start-up businesses and need healthcare insurance for their employees. Many people are becoming consultants and are self-employed. They all need healthcare insurance for their family.

President Obama’s answer to the problem is the government will provide the healthcare insurance for you. Healthcare insurance is a right as an American.

There are several problems with this statement. The government cannot afford to provide adequate healthcare insurance for the entire population.

Britain has proved it. They are reverting back to a pay for service system. The socialist democrats in Europe have proved that. Each country is going bankrupt.

The business opportunity would be to teach the people who are self-insured or uninsured about the rip off of the healthcare insurance industry and to teach them how to save money.

How many start up companies do you guess are uninsured or under insured or not insured for catastrophic illness because they cannot afford the healthcare insurance premiums?

The chances are many start up employees will not get sick. True healthcare insurance should be a hedge against catastrophic illness.

If someone gets sick in a company, the company could pay the employee for the amount he spent before they reached the full deduction.

The high deductible individual policy is not tax deductible. If it were made tax deductible by citizen demand to congress through social networking the voice of the individual could be heard. Congress might be forced to act.

Start up companies and other companies would save money. These companies would be placed on the same playing field as companies who pay for employee insurance with pre tax dollars. The social network could even form an association of self-employed companies and enjoy the tax benefits and purchasing power of large corporations.

This would represent a threat to the healthcare insurance industry. They would do everything to stop. So would the government.

If you do the math for the government, the government would be saving much more money than it would collecting taxes. 

An appropriate social network could stop the healthcare insurance industry's grotesque business model in its tracks.

It could save billions of dollars. It could create incentive for people to take better care of themselves. 

Many large and small companies are self-insured. The law lets these companies deduct their healthcare insurance with pre tax dollars. These companies could offer my ideal medical saving account with a $7,500 trust account. They could then reinsure employees for over $7,500 with a reinsurance company. 

Employees would obtain first dollar coverage after the deductible is reached.

In the worst case the company would save $6,000 per employee. In the best case it would save $13,000 per employee.

http://www.lijit.com/search?uri=http%3A%2F%2Fwww.lijit.com%2Fusers%2Fstanleyfeld&start_time=&p=g&blog_uri=http%3A%2F%2Fstanleyfeldmdmace.typepad.com%2F&blog_platform=&view_id=&link_id=7386&flavor=&q=ideal+medical+savings+accounts&x=0&y=0 

I suspect even the traditional insurance companies would provide the re-insurance.  These healthcare companies have already negotiated fees with physicians, hospitals and drug companies. 

If the healthcare insurance industry did not provide re-insurance its negotiated fees could be obtained easily.

A bank or a mutual fund could adjudicate the claims instantly.

The large corporations, who are self-insured, all have HR officers. The HR officers I have met either do not seem to have the bandwidth to investigate the possibility of the ideal medical saving account structure or they are trapped into outsourcing the details of the corporation’s self-insured healthcare plans to middlemen. I have a feeling the commitments of some with middlemen are long term.  

If all this could happen it would be an important first step in the development of social networking in healthcare and medical care.

Consumers need education for the care of their chronic disease such as diabetes, asthma, chronic lung disease, heart disease and chronic gastrointestinal diseases. Many of these diseases are a result of obesity.

If social networking could discourage the ever-increasing incidence of obesity, society would decrease healthcare costs dramatically. 

If patients learned how to manage their own disease the cost of medical care would decrease precipitously.  

Why?

Because 80% of the healthcare dollars spent on direct patient care are spent on the complications of chronic diseases that are not well managed by patients.

Many drug companies and medical device companies would advertise on these social networking sites.  

Consumers must drive the healthcare system in order for the healthcare system to be repaired. Not government or the healthcare insurance industry.

Consumers feel powerless at present. Empowering consumers through social networking will disrupt the entire healthcare systems supply chain for the better.

Consumers are up against a government that wants to tell them what they have to do. They are up against healthcare insurance companies that charge obscene premiums. They are up against hospitals, physicians and emergency rooms that have exorbitant charges.

Consumers are up against diseases such as obesity which precipitates many chronic diseases.

Consumers are frustrated and need leadership and guidance.

The phenomenal growth in social networking can give consumers the tool they need to control their health and drive the healthcare system.

Social networking is the only way to start a consumer driven healthcare movement. It has to happen before the medical care system is destroyed.

The young people expert (20-50 years old) in social networking have to become engaged. 

Those young people have to understand physician mentality and the importance of the patient physician relationship.

I will be happy to help in any way I can.

 

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

Please send the blog to a friend

 

 

 

 

 

 

 

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