Results found: 100

Permalink:

Keeps Making The Same Mistakes

April 14, 2016

inMedicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

• Leave a comment

Stanley Feld M.D.,FACP, MACE

The Obama administration keeps making the same mistakes in its attempt to execute effectively.

New programs are being started in order to fix Obamacare’s errors. As each new program interacts with other programs the pathway to success gets more convoluted. As this happens Obamacare’s failure accelerates.

Meanwhile President Obama keeps telling us that Obamacare is very successful. He tells us his legacy healthcare program is here to stay.

The problem is the public is not buying Obamacare’s claimed success anymore .

The public has no idea how much Obamacare has cost so far. Obamacare has not decreased the number of uninsured Americans capable of affording insurance. It has increased the number of people insured with Medicaid. It did it by decreasing the Medicaid eligibility requirements. Those who became eligible for Medicaid cannot find a doctor.

The cost of healthcare insurance has increased more than 20%. The administration promised to decrease family insurance rates by $2500 a year.

Consumers have less access to quality care. In fact, the definition of quality care is inaccurate.

The development of Accountable Care Organizations has not gone well.

Healthcare insurance companies are dropping out of Obamacare because participation in Obamacare’s health insurance exchanges is not financially viabile.

The government has not adhered to its financial commitment to the health insurance industry in order to have them participate in the health insurance exchanges.

President Obama, HHS, and CMS want to introduce a new initiative in order to help make Obamacare viable. The initiative is full of bad ideas. It is destined to fail.

The new initiative will shift the risk from the healthcare insurance industry and government to physicians participating in the initiative.

HMOs tried to do the same thing in the nineteen eighties (1980).

Physicians cannot control patient behavior. Patient behavior and compliance is the responsibility of patients themselves.

The Obama administration is learning that government cannot control or dictate physicians’ behavior in order to control costs.

President Obama’s administration cannot control costs when the carrot is a reimbursement system that looks like it should be profitable. Physicians have no way of measuring if the new reimbursement system will be profitable.

Physicians should not be in the insurance business. It is the healthcare insurance industry that should be in the healthcare insurance business.

The Comprehensive Primary Care Plus initiative has two parts.

Track 1: CMS plans to pay a monthly fee for practices to provide specific services. The fee will be in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for care.

At the moment the Medicare reimbursement schedule for primary care physicians is too low for physicians to make a reasonable living. Physicians’ overhead is increasing.

The goal is to pay large practices a management fee to force their primary care physicians to comply with the rules CMS wants enforced.

CMS will try to shift the managed care burden from itself and the insurance companies to the physician groups.

CMS will try to do this initially with 5,000 primary care groups of physicians containing 20,000 physicians or and average of 4 primary care physicians in each group in 20 different regions of the U.S.

“CMS is trying to transform and improve how primary care is delivered and reimbursed.”

The implication here is that all the Obamacare initiatives to date have failed to improve how primary care is delivered and reimbursed.

Providers currently perform a service and then submit a claim to Medicare for payment.

Track 2: CMS will pay primary care practices a monthly care management fee.

Additionally the practices will receive upfront comprehensive primary care payments and a reduced Medicare fee-for-service payment for evaluation and management services.

CMS said that; “This hybrid payment design will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter.”

The example given by CMS was;” practices might offer telemedicine visits or simply provide longer office visits for patients with complex needs.’

This is a totally meaningless example. It should make the primary care practices chosen suspicious of the government’s intentions immediately.

Practices in both tracks will receive upfront incentive payments that “they (the physicians) might have to repay if they do not perform well on quality and utilization metrics.”

This is the CMS stick will use to get the individual practices to comply with government regulations on measures quality and utilization. Physician might have to repay the government if they do not comply with government regulations.

Many of these measurements are defective.

In CMS’s zeal to computerize quality and utilization it misses the point of how individual patients feel they should be treated.

CMS is also shifting the responsibility for cost outcomes onto physicians in the program. It ignores the fact that patients’ responsibility and compliance with recommended medical care is an important determinant of medical and financial outcomes.

“ The CMS initially will pay primary care practices $15 per beneficiary per month for care management under Track 1 and an average of $28 a month under Track 2 to support enhanced, coordinated services on behalf of Medicare fee-for-service beneficiaries.”

How was this fee per patient payment per month determined?

It seems impossible to judge the cost of a panel of patients. It should not be the physician’s responsibility to determine or accept this value.

Physicians disliked HMOs in the 1980’s because they could not price the patients at risk value. Healthcare insurance companies should be pricing the risk.

We have seen that insurance companies cannot price risk. President Obama set up risk corridor reinsurance programs in Obamacare to cover the risk in order to attract healthcare insurance companies’ participation.

The government then reneged on paying the health insurance company for their risk. The government only paid 12% of its commitment.

Why should physicians be responsible for the risk?

A healthcare system must be setup so that patients are responsible for their own health and healthcare dollars.

Patients’ healthcare risks should not be passed on to physicians.

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

Permalink:

If Something Works, Destroy It!

April 8, 2016

inConsumer Driven Health Care, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

• Leave a comment

Stanley Feld M.D.,FACP,MACE

If a program is working well the Obama administration starts regulating the program out of existence. In a very quiet and deceptive way the Obama administration is destroying Health Savings Accounts.

The fastest growing health insurance plan in the private healthcare market is Health Saving Accounts (HSAs). HSAs are also available in Health Insurance Exchanges.

Consumers love HSA’s because the money not spent for their yearly deductible expenses go into a personal trust fund, which goes to pay future medical expenses. Consumers, employers or government can fund the deductible. Healthcare coverage starts after the deductible is reached. The trust fund can grow tax-free until funds are withdrawn.

HSAs are not ideal but they do act to provide a mild financial incentive to consumers to be responsible for their health and healthcare dollars. Consumers decrease their overuse of the healthcare system.

Health Savings Accounts are not as powerful as my ideal Medical Savings Accounts. Medical Savings Accounts provide greater financial incentive for consumers to be responsible for their healthcare and healthcare dollars.

Consumers seem to lack the desire to prevent obesity, which is responsible for many chronic diseases and their complications. These diseases are responsible for 80% of the healthcare dollars spent.

With my ideal Medical Savings Account consumers or the consumer’s sponsors (government or employers) pay a high deductible. The sponsor then buys first dollar reinsurance for healthcare coverage. The unspent deductible goes into a Medical Saving Account tax-free retirement fund. It does not stay in the healthcare system.

The Medical Saving Account provides greater financial incentive for consumers to become more responsible for their health care and healthcare dollars.

Why and how does Obamacare want to regulate Health Savings Accounts out of existence?

In case you missed it, final regulations published on March 8 will make it impossible to offer HSA-qualified plans in the future.

The health insurance industry has been opposed to HSAs and MSAs because the premiums the healthcare insurance industry receives is lower than regular healthcare insurance premiums.

Once the premiums are put into a trust it does not belong to the healthcare insurance industry to invest.

The healthcare industry has tried to influence HHS to dissuade consumers from buying HSAs through Health Insurance Exchanges since the exchanges began.

However HSS has done nothing “(a) to help consumers identify HSA-qualified plans on the exchanges or (b) provide information to individuals that choose HSA-qualified plans about where to get more information about opening and contributing to an HSA.”

Last year’s proposed standardization of healthcare plan design rule gave no hint that the proposal would eliminate the possibility of HSAs surviving.

This year’s rule change made it clear that this was President Obama’s goal.

1)” Plans must apply specific deductibles and out-of-pocket limits that are outside the requirements for HSA-qualified plans.”

2) “Plans must cover services below the deductible that are not considered “preventive care.”

“ Regarding the deductibles and out-of-pocket limits, no Bronze, Silver, or Gold plans adhering to the standardized benefit designs will likely be HSA-qualified for 2017.”

The first step was for HHS to change the definition of a qualified plan. The next step was to force the plan design to be incompatible with HSAs.

HHS and CMS have given the healthcare insurance industry another gift. Maybe it is a payback for CMS short changing the insurance industry on its reinsurance payback promise.

In any event HSAs look doomed. The Obama administration has succeeded in destroying the development of a viable healthcare system that the free market, not the central government controls.

John Dunn M.D.,J.D. wrote a wonderful summary of Obamacare’s failed attempts to control the healthcare system to his chat group followers.

He has summarized all the policies that have failed in the Obama administration’s goal to destroy the private healthcare market and eliminate the free market system.

“ Subject: HSAs being eliminated?

Yep, Obamacare strikes again to accomplish the real goal, elimination of private capitalist free market healthcare.

Now let’s tally up the failures of Obamacare in its attempt to destroy the healthcare system—

more expensive, less accessible,
restrictions on hospitals and care givers,
promotion of mid level practitioners, extraordinary inefficiencies created by computer mandates,
penalties for hospitals and physicians that are created by apparatchiks,
no decline in the uninsured,
in fact there might be an increase in the uninsured because of the cost of premiums and deductible,
more movement of people to Medicaid where coverage is free,
bankruptcies of COOP insurance programs,
exchanges failing with insurers leaving the market for taking big economic hits from adverse selection,
and most of all—the death spiral of private market insurance—with the goal being to destroy the private market ????
Why of course, Medicaid for all.

The goal of government bureaucrats is control and power, achieved in this case by the growth of single payer government controlled medicine—Medicaid on steroids—

The result will be mediocrity as far as the eye can see, and destruction of innovative and creative health care,

but also the loss of the ethics and patient consideration that comes from physician guided health care,

instead a trade for mandarins with frowns and red pencils,

Checking the data banks that aren’t secure from hacking.

It leaves one almost breathless, but it started a long time ago.

Good intentions and unanticipated results—Bastiat von Mises, Fredrick Hayek warned us about the fatal conceit and the problem of government actions to protect certain interests or promote a cause—ignorant of the realities of markets and the benefits of free markets.

Socialism and statism will produce mediocre, expensive healthcare run by bureaucrats and apparatchiks who aren’t interested in good patient care,

They are only interested in control.

Looks like I am not the only one who has figured it out.

I do not understand why the political establishment cannot understand why Americans are getting ready to cast a protest vote against them.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Permalink:

Biased Newspaper Reporting

April 3, 2016

inDisinformation and the healthcare system

• Leave a comment

Stanley Feld M.D.FACP, MACE

I used to read every word of the New York Times. After all it was “all the news fit to print.”

It took me a long time to figure out it was the same sensational journalism as the New York Daily News and the New York Post. Its sensationalism is subtler.

Both the News and the Post had better Sports sections than the Times. All three newspapers are biased. They all leave out important facts.

The New York Times leaves out important facts and does not connect related facts. The result is intelligent people reading and believing the New York Times can have one world view, while another group of intelligent people reading and connecting the facts can have an opposite world view.

The following headline appeared on the front page of the Sunday Times on Easter Sunday.

On Campaign Trail, Republicans Tone Down Criticism of Obamacare.

On its surface the headline infers that Obamacare is working and citizens like it.

The Times claim is, “Among the most embattled Senate Republican incumbents, the campaign websites of Kelly Ayotte of New Hampshire, Mark Kirk of Illinois and Ron Johnson of Wisconsin barely mention the health care law.

The article goes on to quotes Health and Human Services Secretary Sylvia Mathews Burwell.

“The explanation for (the lack of criticism of Obamacare) may be that for all its controversy and imperfections, the sweeping law has taken hold.”

“This (Obamacare) is in the fabric of the nation,” said Burwell.

“To be sure, the presidential election outcome will be a determinant of whether the health care law is reshaped, bolstered or downsized.”

Is reporting this Obama administration bias? To me it certainly is. This conclusion is total nonsense. It is an attempt by the New York Times to help the Obama administration spin the truth and save President Obama’s legacy

The Times also points out that; “President Obama took part in a celebration in Milwaukee this month after the city was given an award for increasing health insurance enrollment.”

Paul Krugman’s New York Times articles have been telling reders how successful Obamacare has been. The problem with his commentary is it does not fit the facts.

Meanwhile President Obama and the administration have been modifying the law almost monthly without the consent of congress.

It has also been spending money without congressional approval because the law has not worked out well for President Obama and his administration.

Obamacare has been a failure for all the stakeholders. It has had a negative impact on the economy and the delivery of medical care.

It cannot be fixed with a few modifications.

I hope the New York Times is just printing the Obama administration’s press releases. However, the Times editorials reflect the lies.

Anyone running for congress who believes the New York Times propaganda about the success of Obamacare should not be elected.

Many patients credit the President with giving them access to coverage even if they have a pre-existing condition and are not in a group plan. Meanwhile, the cost of the insurance has changed with higher premiums and deductibles, and the cost of coverage is increasing annually for both Obamacare and private insurance.

Remember President Obama’s promise, “If you like your insurance you can keep your insurance

The cost of HealthCare.gov has been a debacle. It had been riddled with scandals, inefficiency, cronyism, and disrespect for consumers’ intelligence. I thought the original $800 million dollar cost estimate was ridiculously high. Its present estimate is $2.1 billion dollars. the web site healthcare.gov is still not right.

How much did CMS really spent on Obamacare? No one really knows. It has not been cheap. Most of the expenditures have not been approved by congress.

For the last three years the Obama administration has lied about the enrollment numbers. At the same time they have bragged about the enrollment success. In 2014 the grand total enrollment in private insurance through the Obamacare exchange was 260,000 while 14 million privately insured lost coverage.

However the total number of consumers enrolled through Medicaid was 8.99 million. This occurred with only 23 states participating in the expansion of Medicaid

The enrollment figures had not improved at the end of 2015 even though the Obama administration extended the enrollment period constantly throughout the year.

“Earlier this month (2016), the Centers for Medicare and Medicaid Services announced that nearly 8.8 million Americans had “effectuated” coverage at the end of 2015, meaning they were paying their health insurance premiums.”

The agency praised this number as a sign of Obamacare’s success in expanding access to coverage.”

This is a perfect example of spinning the news. At the of the 2015 enrollment period before the enrollment extensions 11.69 million members signed up and paid. At the end of 2015 only 8.78 million people continued to pay their premiums.

This represents less than the Obama administration claimed enrollment of 2014.

The New York Times is publishing fiction because of it’s bias toward President Obama and Obamacare. The truth about Obamacare’s lack of success is public record. Unfortunately the New York Times ignores the truth.

Obamacare enrollment decreased even further this year (2016). The insurance premiums and deductibles are too high for people making over 50,000 dollars a year. Only the fully subsidized people can afford to stay in Obamacare.

Obamacare’s State Co-Ops were formed to have states run their own state insurance exchanges. Inefficiencies and faulty business model cause 13 of the 23 to fail so far.

The Obama administration provided 2.5 billion dollars in loans to these State Co-Ops. So far the federal government has lost 1.2 billion dollars of it 2.5 billion loaned to the state Co-Ops.

The Affordable Care Act allowed for the creation of consumer-operated and oriented plans, or co-ops, that were intended to inject competition into areas where consumers had few choices.

At present 8 more Co-Ops are on the verge and will probably close for enrollment for 2017.

The Centers for Medicare and Medicaid Services have little hope or collecting the money lent to the State Co-Ops. Information surrounding the liability of the failed state Co-Ops for the loans has not been transparent.

A total of $2.4 billion in loans was awarded to 23 Co Ops start-up and solvency loans to the 23 co-ops.

Now, 12 of the 23 co-ops that opened their doors in 2013 have closed and have left 900,000 consumers without insurance. No one can tell if these people were assimilated into the federal health exchanges. Republicans in Congress are questioning whether the taxpayers will ever get repaid $1.2 billion loaned to those failed Co-Op insurers.

Obamacare has made insurance available to millions of Americans with pre-existing conditions were denied coverage. This is true. However both the premiums and the $6000 deductibles are unaffordable.

A diabetic wrote to me, “Obamacare is great! Now I can buy insurance. My premium cost $12,000 a year. My deductible is $6,000 for a total of $18,000 a year. My medical bills were $100,000 last year.

I asked what was her HbA1c. She said it was 9.2% (normal 4.5% -5.5%).

The high HbA1c means she is a poorly controlled diabetic.

Shouldn’t this patient be responsible to lower the HA1c to 6% in order to reduce her diabetes complication rate?

Not everyone can afford $18,000 per year. Most of the diabetic patients who cannot afford the high insurance rates in the federal health exchanges have even higher HbA1c levels. They will ultimately cost the payer of last resort, the government, even more after the patient is bankrupt.

A better system needs to be developed to incentivized these people to be responsible for their own diabetes control.

Another feature of Obamacare that is publicized as one of the great successes is that children can stay on their parents’ plans until age 26.

The unintended consequence of this feature has given the healthcare insurance industry and excuse to raise insurance premiums by double digits increase each year.

President Obama has bragged, and the New York Times has applauded him for it, that health care inflation has been lowered since Obamacare was passed into law. He say that Obamacare has bent the healthcare cost curve.

This is false. Obamacare was collecting Obamacare imposed tax increases on every income bracket for three years prior to implementation of the healthcare coverage.

The cost curve was bent because there were no expenditures in the delivery of healthcare. In 2015 the healthcare cost curve is rising.

There are 20 hidden taxes in the law that effect citizens earning less than $250,000 dollars a year. .

These new taxes contradict President Obama’s promise that “anyone making under $250,000 a year will not pay a dime in new taxes.” Many of these taxes on businesses are being passed on to consumers in the form of higher prices.

https://youtu.be/eHlRY3kHhBk

Insurance companies are leaving the federal health exchanges in droves because they are not making as much money as promised by the Obama administration. Obamacare will disappear without insurance company participation.

“When compared to 2015, 22 states and the District of Columbia have fewer insurers offering coverage on the exchanges in 2016.

Just 10 states have more insurers offering coverage on Obamacare’s exchange.
The New York Times presents deceiving information about Obamacare. I cannot understand why readers believe these lies.

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

Permalink:

Stop Confusing Me With Misleading Facts

February 8, 2016

inPoliticians,Healthcare and Vested Interests

• Leave a comment

Stanley Feld M.D. FACP, MACE

The truth is derived from facts. In social sciences such as politics and economics isolated facts can lead to conclusions that are far from the truth. It is also possible to manipulate statistics that lead to false conclusions.

Misleading facts can lead to false conclusions and inaccurate opinions.

The Obama administration has mastered the art of picking isolated facts and manipulating statistics. It has used that skill and the traditional mainstream media to mold public opinion.

Government agencies are supposed to be politically neutral. The Obama administration uses isolated reported facts out of context to mold favorable public opinion using the traditional media.

This methodology has been pervasive in misinforming and transforming America. This phenomenon is especially true as it relates to the healthcare system.

Healthcare.gov’s enrollment supposedly ended for 2016 on January 31, 2016. Enrollment has been abysmal for 2016. It is no higher that the enrollment reported in 2014.

The only real increase has been the increase in Medicaid enrollment.

“As announced yesterday, the official QHP selection number ended up coming in right in the middle of this: 12.7 million nationally (9.6 million via HC.gov).”

Nevertheless, Secretary Burwell announced that enrollment surpassed expectations.

In mid-December President Obama announced as proof of the success of Obamacare;

“Nearly 6 million Americans so far have enrolled in insurance for 2016 through HealthCare.gov, President Obama announced on Friday, touting a big increase over last year that he said shows the Affordable Care Act is succeeding.”

The truth is Obamacare is a failure. State healthcare exchanges are failing. Many states have closed down their state healthcare exchanges. Yet, President Obama’s message is that his signature legislation, the Affordable Care Act, is succeeding.

The administration never addresses the reason Obamacare is failing. However, people who know the facts know it is failing and why it is failing. Obamacare simply does not meet the needs of the middle class consumers.

“It’s time to look at the major reasons for the shortfall.

Some of these are well-documented criticisms: Premiums and/or deductibles are simply too damned high for many policies/regions in general.”

There are many additional reasons for the poor enrollment but that is not the point of this article.

The point of this article is the Obama administration deceiving the public .

There are other areas of consumer (public) deception by the Obama administration.

One outstanding example is the administration’s conclusion that there is no inflation in America, which is hard to believe. Every time we go into a grocery store the price of food seems to increase. Every time we buy clothing, an appliance, a car or a restaurant meal the price seems to increase.

Few people know that food and fuel are not included in the Consumer Price Index (CPI). The CPI is a measure used in determining the inflation rate.

The article that stimulated me to write this blog was last week’s announcement that the unemployment rate has just decreased to below 5%.

President Obama, who expressed frustration that he has not received the credit he feels he deserves for the country’s improving economy, said the jobs numbers were further signs of progress.

“After reaching 10 percent in 2009, the unemployment rate has now fallen to 4.9 percent even as more Americans joined the job market last month,” he told reporters at a White House briefing in Washington. “Americans are working.”

The New York Times reported that the Obama administration has used this figure to brag about how well the economy is doing under his administration.

A non-traditional media publication, PJ media, has reported, in detail, the interpretation of the real numbers using the government’s own statistics. It is worthwhile reading the entire article and forming your own opinion about the unemployment rate.

“Every so often a monthly employment report is full of so many irregularities that it pays to discount the report. This might be one of those times.

We’ve commented several times over the years about the BLS cooking the books on jobs. James Pethokoukis lists some other stats that tell far more of the real story about the employment picture than the bare-bones numbers highlighted by the media:

Not everything was great: job gains far short of 185,000 expectations (though averaging 231,000 the past three months), U-6 unemployment-underemployment rate unchanged at 9.9%, long-term unemployment worsened, labor force participation and employment rate still way below pre-recession levels, wages gains short of what you would expect to see in a full-throttle economy. Particularly vexing for Barclays was job weakness in the service sector.

The unemployment rate figure is a fact used to mold public opinion. The mainstream media is the message. The problem is the Obama administration’s message is an absolute lie.

“In other words, the job situation in America still sucks, and the president is blowing smoke by touting the numbers as good news.”

One commenter wrote, using the government raw data;

“empiresentry 1st Boomer • 15 hours ago

Yeah that 30% was a ‘laugh’ and the Dims fell for it. Cali and some other Dim states mistakenly were unable to submit their numbers (cough cough)
.
For January 2016:
First time INITIAL jobs claims for unemployment insurance
Jan. 9, 2016 284,000
Jan. 16, 2016 294000
Jan. 23, 2016 277000
Jan. 30, 2016 285000
————-
940,000 human being lost their jobs

Jan. 623,000 “stopped looking for work”.
We did not stop looking for work. The government stopped counting us because our unemployment insurance ran out.

151,000 people found new jobs, most were retail and restaurant part time.”

The Obama administration and its agencies have presented distorted facts to us over and over again during the past 7 years. It has distorted the truth and, in turn, public opinion.

If one uses the wrong facts, one will come to the wrong conclusion.

Everyone is entitled to his or her own opinion. They are not entitled to their own facts.

That includes the President of the United States of America and his administration’s agencies.

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

Permalink:

Here It Comes!

February 3, 2016

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

• Leave a comment

Stanley Feld M.D.,FACP, MACE

The mainstream media has been very quiet about Obamacare lately as the defects in its execution keep rolling along.

You may recall President Obama telling Senator John Kerry and Representative Barney Frank not to worry about including a Public Option in the bill. He told them they would not have to include the Public Option in the Affordable Care Act.

Barney Frank said we would never get a single party payer system unless we have a Public Option in the bill.

President Obama was right. He didn’t need a Public Option because the single party payer system was already embedded in the bill without anyone knowing it.

Medi-Cal is California’s name for its Medicaid program. California is one of the states that have expanded the Medicaid program under Obamacare.

Twenty states have not expanded their Medicaid program for fear of the federal government impinging on states rights while sticking their state with the bill.

The states also feared increases in their budget deficit. States are required to balance their budget. The result would be an increase in state taxes.

The increase in state taxes would render the state unattractive to companies and their business. Less company growth would mean an increase in unemployment and a decrease in state tax revenue. A decrease in tax revenue would result in a decrease in state services.

President Obama said, “Don’t worry.” He promised to fund Medicaid expansion fully for the first 3 years. Federal funding would decrease after the first three years to 50%. The funding percent has changed a few times since that promise. One could not know the present decrease unless one read the Federal Register daily.

Expanding Medicaid was a key part of the Affordable Care Act (Obamacare). It was also a hidden trap set by President Obama to slip the healthcare system into a single party payer system by default. That is why President Obama insisted we did not need a Public Option.

Obamacare required nearly all Americans, under penalty of law, to have insurance starting in 2014.

“Though a surprise, the high Medi-Cal enrollment is generally hailed as a success. California’s uninsured population has been cut in half since Obamacare, in large part because so many Californians signed up for Medi-Cal, which is free for beneficiaries.

Medi-Cal was opened to all low-income Californians starting two years ago, with the federal government paying for those new enrollments.”

In 2016 one third (1 in 3) or 12.7 million Californians are covered by Medi-Cal.

The total cost of the Medi-Cal explosion is $91 billion dollars, up from $54 billion dollars in 2012. California is responsible for $12 billion dollars. It will increase California’s budget deficit and may result in another tax increase.

The cost per insured is $7,165.35.

“The Medi-Cal program continues to grow at a very substantial rate, which is great. We are very happy that we’re able to provide healthcare to getting close to 13 million Californians,” said Mari Cantwell, chief deputy director at the state Department of Health Care Services, at a hearing in downtown L.A. this month. But, Cantwell added: “Obviously with that comes cost.”

The Medi-Cal is viewed by many state officials as being underfunded.

Medi-Cal patients are struggling to find doctors.

Many patients are receiving low quality of care by government standards.

A psychiatrist in Los Angeles told me that all the private practice internists in L.A. require an upfront concierge fee of at least $2,000 a year at the beginning of the year to be in their panel. If this is true, Internists in L.A. are insulating themselves against the low reimbursement of Medi-Cal. This concierge fee increases the California physician shortage.

The result has been that groups of activists have filed a federal civil rights complaint alleging that Latinos are being denied access to healthcare because the program does not pay doctors enough.

“The Affordable Care Act allowed states to open up Medicaid to anyone making less than 138% of the federal poverty level.”

Twenty states did not sign up for the expanded Medicaid because of the fear of federal takeover and the further impingement of state rights.

Pre-Obamacare, states were required to pay 43% of Medicaid’s cost and the federal government paid 57% of the costs. States ran the program and determined reimbursement.

As costs increased reimbursement was decreased and physician participation decreased because of the decreased reimbursement.

As a result of the 20 states resisting Medicaid expansion the federal government will pay 100% of the cost of new expansion enrollees and 93 percent off the cost of expanding Medicaid over the next nine (9) years instead of the next two (2) years.

The present rule looks like a great deal for the states. However with the federal government paying most of the Medicaid bill for the next nine (9) years the federal government will want to control Medicare.

Who needs a Public Option to get to a single party payer?

Who is going to stop the federal government from changing the eligibility for Medicaid to 200 or 400% of the poverty level?

Who is going to force doctors to participate in Medicaid if they want to practice medicine with a federal license?

Where is the government going to get the money without having skyrocketing increases in taxes?

Tax laws and lack of pro-growth tax reforms are inhibiting America’s economic growth.

America has been set up to have the future state of healthcare be a single party payer system. President Obama has done it in a clever way. He has had no regard for being fiscally responsible in the face of a 19 trillion dollar, and rising, debt.

Single party payer systems have failed in England and Canada.

Why should America create another failure?

Can Americans have a future state healthcare system that is not destined to fail?

Yes we can!

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

Permalink:

Premises Must Be Re-examined

January 31, 2016

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

A few weeks ago I had a terrific exchange with Steve Brachet M.D. who forwarded my blog to Steve Gregg.

“Stan,

I forwarded your recent blog featuring the five essential steps for HC reform to Stephen Gregg of Portland Oregon.

Steve Gregg is a former senior hospital executive, turned CEO of a managed care plan (successful in WA and OR), developer of alternative healthcare products, developer of patient care informatics, and thought leader in past 10 years on dimensions and confounding variables of health care in all its complexities.

He asked me to send the attached (very brief) piece recently published in the Oregon main media.

I don’t know if he expects a comment or two – but if you care to comment feel free to respond to Steve Gregg directly.

I take it that you are continuing to do your best to ‘right this HC ship’ that seems unlikely to improve on its own – nor with the help of the current Congress.

Steve Barchet M.D.”

I was fascinated with the article Steve Gregg wrote. I agree with many of the points he makes. I am publishing his article with Steve Gregg’s permission. I wrote back and said;

Dear Steve

I welcome your article.

My blog explains the elements needed to Repair the Healthcare System from a physician’s point of view.

As a result of the Internet and improved software, consumers have become king and are driving the consumer consumption market. Amazon and ebay have led the way. Opaque purchasing models have been replaced by price transparent purchasing.

Wal-Mart has been forced to close stores because of online purchasing to remain competitive.

A consumer driven transparent online purchasing model has replaced airline ticket purchasing through travel agencies.

Online banking is transforming banking services. Hardly anyone goes into banks anymore.

There is no reason that shopping for healthcare services cannot transform the healthcare industry with all its opacity.

Consumers must be put in a position to drive the healthcare system and be responsible for their health and healthcare dollars.

Our 2020 business model can transform the dysfunctional healthcare system that can align all the stakeholders’ vested interests by empowering consumers and letting them drive the system.

The result will be a decrease in cost. It will eliminate the entitlement mentality of healthcare consumers and create a competitive mentality for all stakeholders as it has done in the examples above.

All Obamacare is doing is trying to put a patch on a healthcare system whose demise has been accelerated since passage of the Affordable Care Act.

Your articles describe many essential premises that must be reexamined.

However, consumers must be involved and be the responsible party in the healthcare system. They have to be given financial incentive to be involved and responsible.

Thank you for letting me reprint your article.

Health Reform…What Next?

Steve Gregg

With the expensive collapse of Oregon’s Health Exchange, a New Year, and approaching changes at the Federal level, it is time to reconsider the formative assumptions driving health care reform.

Ten Game Changing Assumptions Shaping Health Reform:

The ideologies of the left and right will not sustain a reform solution grounded in compromise and “deal making”. The endless search for consensus confuses the problem, and is a recipe for failure.

The State’s public bureaucracy is too conflicted with its own self interest to impartially govern health reform.

3.The plethora of proposed actions to reduce demand will not reduce costs. “Supply” being a more important driver of costs than ”Demand”.

Sustainable reform cannot tolerate the variation in provider pricing to patients with differing sources of payment. Perhaps less than 15% of the typical hospital’s patients pay what the hospital bills.

It is wrong headed to view reform as a matter of amending the existing system.

Financial goals stabilizing health care costs cannot be achieved without prospectively stated and independently measured metrics.

Equal access is not a realistic expectation. Universal coverage must be.

Genuine Altruism is a deceptive and widely abused value of our non- profit institutions and trade associations.

The United States spends twice as much per capita on health care because our health care workers of all stripes (including insurance companies,hospital sytems, government and pharmaceutical companies) s(take out twice as much from the system.

The health care structures of other countries, while instructive, are not transferrable to the United States.

Bonus:

The Oregon Healthcare Project rationing experiment was a colossal hoax that channeled billions of new dollars to Oregon’s health care interests. Never measured, never critically evaluated. It was a severe case of the “Emperor Wears No Clothes”.

Conclusion: Think in terms of 2-3 alternative systems reflecting differing ideologies: Liberal / Conservative / Libertarian.

What would this suggest for process?

Form 3 small task forces assembled around three ideologies: Liberal, Conservative, and Libertarian to articulate assumptions, problem definition, and a broad solution compatible with each ideology.
At the end of the process examine what consolidation can occur and if not presume the development of 3 systems available to the free will of people to chose.

Liberal: Socially and fiscally liberal

Conservative: Fiscally and socially conservative

Libertarian: Socially liberal / Fiscally conservative

Note: The prospect of 3 systems capturing U.S. Healthcare, sounds daunting but in reality we have more than that now: Employer, Medicare, Medicaid, TriCare, Municipal, Insured, Self funded etc.

Alternative List of Assumptions:

A sustainable health reform strategy cannot be achieved without the foundation of a well-conceived definition of the problem and formative assumptions.

Subsidized or “free” health care is inflationary and will overwhelm administrative protocols for cost reduction.

Genuine Altruism is rare and a widely abused cover for proprietary agendas. Excessive profit is a measure of good management.

The community’s health care pathology is infinite and those making a living and profits from health care will seek to capitalize on that.

Our health care system in the main is a proprietary endeavor with millions of economic interests seeking to protect or increase revenues. Any initiative that threatens that cash flow will be vigorously resisted.

Does the system tilt toward choice and self – determination or equalness, limited choice, and a central authority?

“Nearly half of all care delivered produces no medical benefit” is in obvious conflict with a prevailing view of vast health manpower shortages. Does increasing supply reduce prices and the costs of health care?

If the national will demands universal coverage, the utility of competing traditional insurance companies should be called into question.

The reformed system must promote individuals seeking care from the “best” provider of care as early as possible in the development of any adverse health care condition. Forcing patients into an inferior food chain of care is unethical and probably more costly in the end.

There is something wrong with a requirement to select a health plan, provider network, and insurance in advance of acquiring a dire condition, and then being locked out of access to the “best” provider.

Steve

I do not see consumers playing an active role in your assumptions to Repair the Healthcare System.

Obamacare is wasting money developing an entitlement system that cannot work. The only stakeholder that can develop a healthcare system that can work is a system driven by consumers.

Consumers can force the secondary stakeholders to be competitive and transparent, as they have done in other industries.

It would be cheaper for the government to invest in empowering all consumers using the revolution in information technology and providing financial incentives to all using My Ideal Medical Saving Accounts.

Everyone could be insured as I have described in my article The Ideal Medical Saving Account Is Democratic.

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

Permalink:

Obamacare Is In Big Trouble!

November 18, 2015

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

• Leave a comment

Stanley Feld M.D.,FACP,MACE

There are so many parts of Obamacare that are failing it would be impossible to describe each failure in a single blog..

President Obama and his administration keeps telling the American people that Obamacare is working great. It is here to stay.

I cannot believe Americans believe him. I cannot believe he thinks Obamacare is doing great.

It could be true that everything is going great for him if he wants Obamacare to fail and cause hardship for millions of Americans.

At that point Americans would beg President Obama or another progressive president loke Hillary Clinton to institute a single party payer system.

A single party payer system has been Hillary’s dream since Hillarycare 1993. Now she is saying she wants a private insurance based system. The purpose of this statement is to neutralize (freeze) her free market system critics.

Once more America is being exposed to Hillary Clinton’s use of a typical Saul Alinsky tactic. The tactic in his “Rules for Radicals” is to freeze your opponent by stating his position as yours even if it is a lie.

Hillary wrote her senior Wellesley College thesis on Saul Alinsky and “Rules for Radicals”. She also became a big fan and good friend of his.

Hillary Clinton and President Obama know Obamacare is failing. They are just waiting for the tipping point. The tipping point will be when the American people say please help us and give us a single party payer system.

At that point we will hear the typical gee shucks, I guess we will have to try a single party payer system.

A single party payer system will be a bigger financial and patient care disaster than what we have now.

The data on the first week of applications for Obamacare’s healthcare.gov was announced to the rave reviews by the Obama administration.

Since few pay attention to the actual numbers President Obama can get away with the lie.

The CBO predicts 19 to 21 million will sign up for Obamacare for 2016. The administration estimates they are going to have 9.1 to 11 million enrollees for 2016.

The Obama administrations estimate is 30% lower than the announce 13 million enrollees in 2015. In reality only 9.7 million enrollee paid for healthcare insurance through healthcare.gov 2015. Of those 9 million only 6.5 million kept their insurance premiums current for the entire year.

The www.acasignup.net quoted the Obama administrations claim that 595,590 filled out applications to get price insurance quotes. Only 8% of the reported applicants or 47,243 paid their first month’s premium for 2016.

These numbers are not a cause for celebration unless you want to misinform the public by claiming a successful first week enrollment.

Let’s do the math. The enrollment period for 2016 is from November 1^st until December 31^st 2015 or eight and one have weeks with four major holidays, Veterans Day, Thanksgiving, Christmas and New Years.

Let us the assume all 600,000 that filled out applications will pass the application requirements and pay their assigned premium for each month. Let us also assume the average weekly application rate is 600,000 per week for the 81/2 weeks. The grand total enrollees would be 5.1 million enrollees for 2016. This is 4.5 million less paid enrollees than in 2015.

There was an attrition rate 2% a month in 2015. President Obama extended the enrollment period several times to get more people to sign up.

2015 FULL YEAR ENROLLMENT/ATTRITION RATE TABLE PROJECTION:

2014 FULL YEAR ENROLLMENT/ATTRITION RATE TABLE (FINAL):

It is clear that President Obama’s victory laps celebrating the success of Obamacare is unwarranted.

However the media is the message. He controls and manipulates the media. It would have been much easier to provide Medicaid and CHIP coverage to the poor outright than destroying the healthcare system with changes that are not working.

The final enrollment for 2014 was 6,338,622 not over 13 million. The final enrollment for 2015 was 9,736,350 and not over 13 million. This is a net gain of 3.5 million new paying enrollees in 2015.

This year the Obama administration estimates that 9 million will purchase insurance through the health insurance exchanges. At the present rate only 5.1 million will purchase insurance for 2016 at the end of the enrollment period December 31, 2015.

The CBO’s estimate was 19-21 million paid enrollees.

It does not represent a very successful net gain when the government publishes that there are 34 million uninsured Americans. No one knows if the 90 million unemployed Americans are counted in the number uninsured.

All anyone hears is the Obama administration’s reasons our taxes, and insurance premiums are going up, while our insurance coverage is going down. The Obama administration is blaming the healthcare insurance industry and Republicans.

President Obama has used, with the help of the mainstream media, the Saul Alinsky tactic to freeze opponents by shocking them with unsustainable factoids.

The Avalere Health consultancy’s analysis of 2015 signup data showed surprisingly weak ObamaCare enrollment at modest income levels. At between 150% and 200% of the poverty level, just 41% of those eligible signed up for coverage. The number falls to 30% among those between 200% and 250% of the poverty level.

In 2016 President Obama is going to penalize people that do not have healthcare insurance.

It’s now clear that the actual impact of ObamaCare’s individual mandate tax penalty will be far worse than the benign intent that the Obama administration claimed.

“What we’re talking about is a penalty for the few people who will refuse to buy health insurance — even though they can afford it — and who expect the rest of us to pick up the tab for their care,” a September 2009 White House defense of the individual mandate states.”

Reality should be coming into focus by now for the average American taxpayer and the poor. Obamacare is ripping everyone off.

“The mandate’s primary impact will be to compel low-income households to buy bronze coverage with deductibles of up to $6,850 per adult that are well beyond their capacity to afford. “

Even after these poor people pay the $6,850 deductible they have a 40% deductible on the rest of the billing.

Who said poor people are too stupid to handle their own money and be responsible for their healthcare dollars?

They are smart enough to know the government is ripping them off.

George Shore101 • 3 months ago

“If the Obama administration and Democrats love the poor why did they force the poor to purchase something they can not afford and then penalize them for not being able to afford it?”

It is a horrible thought to think President Obama is working to make the poor poorer and make the healthcare system fail the American people.

It looks like he is. His plan to replace it with a single party payer system will result in a bigger failure.

Why are Republicans just standing around doing nothing? Why don’t they publicize my Ideal Medical Saving Accounts?

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

Permalink:

I Told You What To Do 8 Years Ago

October 28, 2015

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

• Leave a comment

Stanley Feld M.D.,FACP,MACE

I started my blog Repairing The Healthcare System in 2006. I methodically described the defects in the Healthcare System.

I provided healthcare alternatives in policy and regulations to both Democrats and Republicans to Repair the Healthcare System.

No one listened to me.

In 2007 the healthcare system was unaffordable and unmanageable.

Republicans had some weak ideas and no inclusive business model for the future.

The election of President Obama and the partisan passage of Obamacare have accelerated our healthcare system’s demise.

I believe President Obama’s goal is to destroy the healthcare system. He wants it replaced with a single party payer system (2003). Consumers of healthcare know the government cannot manage healthcare.

American cannot sustain Obamacare financially. Consumers cannot be sustained medically with Obamacare or after the collapse of Obamacare with a government run single party payer system.

The obvious proof is the dysfunction and failure of the VA Healthcare System, Medicaid and Medicare.

All these healthcare systems are government run single party payer systems. All are unsustainable.

As I was archiving my blogs I ran across four blogs I wrote in 2007 outlining the problems and what should be done about them.

The government has made none of the repairs I have suggested. Obamacare has made the situation worse. I will present all four parts of “What Have I Said So Far? Spring 2007” consecutively as written.

“What Have I Said So Far? Spring 2007 Part 1

Stanley Feld M.D.,FACP,MACE

April 01, 2007 in Medicine: Healthcare System

In August 2006 I summarized my blog to that point. I outlined some important solutions necessary to Repair the Healthcare System.

Since then I have covered many of the solutions to the key questions I raised. Not one of these questions has been addressed effectively by our leadership or people in control of making policy.

One must ask: Do they really want to solve the problems in healthcare delivery in this country or are they focused on preserving their own vested interest to the exclusion of a breakthrough that might benefit not only their vested interests but the vested interest of all the stakeholders.

The questions were:

How do we reduce the cost of medical care? • How do we provide affordable insurance for the 45 million people uninsured?
• How to we provide affordable medical care coverage so that all the patients can have access to medical care?
• How do we align all stakeholder incentives?
• How do we construct a system so that all the stakeholders make a reasonable return on investment?
• How do we close the holes in the system to eliminate abuse by stakeholders?
• How do we restore trust between stakeholders?
• How do we restore trust between the patient and physician?
• How do we stop secondary facilitator stakeholders from continuously destroying the patient physician relationship?

In reality, developing solutions to these questions are in themselves business opportunities for facilitator stakeholders that can help Repair the Healthcare System.

However, neither the insurance industry, hospital systems, nor the government see the long term advantage and economic opportunity.

In a comment to my blog Shel Isreal said “

98% of the people think it is broken and the other 2% work for the insurance industry.

The insurance industry has the money and the power.”

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2007/01/the_ideal_elect.html.

However, we have demonstrated the abuse and misuse of the power of information technology by the insurance industry. The misuse and abuse has lead to further dysfunction in the healthcare system and mistrust by the hospitals and physicians.

The insurance industry and the government have used information technology to penalize both physicians and patients using the wrong data to draw their conclusions.

Insurance companies do not have the information technology resources to measure the correct parameters to measure quality care.

I do not see an attempt on their part to correct this deficiency. I only see a movement to make the healthcare system worse with a Pay for Performance (P4P) reimbursement system that is not well thought out. .

It is essential that the solutions I have proposed be coordinated and introduced simultaneously as a single plan rather than introducing elements of the solution separately.

Unfortunately, the government with the pressures of its present political vested interest influences finds it difficult to present the components of repair as a single plan.

The solutions will have to be driven by the consumer (the patient) and not the government. The patients have the power to drive the solutions because they are the users of the healthcare system. If they were the purchases of healthcare, some clever entrepreneur could provide the option for a compelling insurance product that could reward the patient for being responsible for their own care and well being.

The insurance produce could be built to fix the healthcare system.

All that is needed is for the government to write sensible regulations, enforce them and get out of the way.”

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

Please have a friend subscribe

Permalink:

Wanting Something To Fail?

October 13, 2015

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

• Leave a comment

Stanley Feld M.D.,FACP,MACE

If someone wants something to fail, make it complicated enough so no one understands what is going on.

I am convinced that President Obama wants Obamacare, Medicaid and Medicare to fail.

President Obama wants a single payer health care system. He said it as far back as 2003. This You Tube was uploaded on Aug 12, 2009.

https://youtu.be/LhEX3rHssJI

President Obama won’t tell the American people the truth about his plans for health care. Watch President Obama declaring his intention in his own words.

The result is everyone will receive the same healthcare under the government direction and control.

The ultimate goal is to make people dependent on the government.

The people will have no power to choose their physician or their treatment. It is true that every country in the western world has this system.

No country has proven that a single party payer system works for countries with the single party payer systems economy or their citizens. Surveys have shown that their citizens are satisfied.

The main reason people like it is because it relieves anxiety of being able to receive medical care even though they have relinquished their freedom to choose their physician or insurance company.

The biggest loss is independence from the government bureaucracy. People will be dependent on the decisions of unelected government bureaucrats.

The big questions that are never answered about medical costs are; who is spending most of the healthcare dollars and what are the healthcare dollars being spent on?

Do you want the government to decide if you are young enough to get an artificial hip or knee when you need it?

Do you want the government to decide about your treatment or do you want your doctor to help you decide on what your best treatment is?

President Obama is changing medical care in a methodical way. He is utilizing executive orders and rules and regulations written by non-elected bureaucrats, who are forced to follow his orders. Our elected officials should be in charge of government spending.

Many in congress know better and would not let President Obama do what he is doing. Most in congress are happy that he has exempted congress from Obamacare.

President Obama and his administration have been trying to do bad things very quietly to avoid political uproar. The mainstream media has been a great Obamacare ally.

The mainstream media has helped Obamacare keep these destructive regulations and their subsequent failures out of public view.

The media has also publicized President Obama’s lies about the success of Obamacare.

President Obama is adept at diverting blame for errors and failures in pursuit of his single party agenda.

At the same time he is trying to take power away from the states he is trying to persuade states to not permit big insurance premium rate increases requested by many health insurance companies for 2016.

President Obama’s Obamacare is the cause of the increases. He is positioned to blame the state regulators for the insurance companies not showing up to sell insurance for 2016.

If the states act to cut back rate increases the insurance companies will not participate in the federal and state exchanges for the 2016 enrollment period. The result will be the erosion of the possibility of competitive pricing.

The Obama spin machine started working at the beginning of the summer to shift the blame and/or force insurance companies out of the market.

Kevin J. Counihan, the chief executive of the federal insurance marketplace said in letter to state insurance commissioners, “Recent claims data show healthier consumers.”

He also said, “The federal tax penalty for going without insurance will increase in 2016, he said, and this “should motivate a new segment of uninsured who may not have a high need for health care to enroll for coverage.”

This claim of costs data by Obamacare does not square with the healthcare insurance companies’ costs data. They are finding that new customers were sicker than expected. The insurance industry is also losing money because the Obama administration has paid them $2.5 billion dollars less than they were promised.

Health insurance plans sold through Obamacare’s Federal and State Health Insurance Exchanges are seeking 10 to 40 percent increases in premiums.

They are also seeking the same increase in the private sector as well as in Medicare and Medicaid.

The Obama administration is making up its own story to force state regulators to not allow the increased premiums.

The Obama agenda is choreographed to prove that insurance choices do not work. He is hoping that the public will conclude the only solution is a single party payer system.

The problem is the government cannot afford a single party payer system and the people will not tolerate it.

What is more bizarre is the Obama administration made loans to help start up state co-ops. These state co-ops were supposed to compete with the big insurance companies. They were supposed to sell insurance on the health insurance exchanges. The Obama administration invested $38 billion in startup costs and solvency loans to these co-ops.

Nevada Health Co-op received $66 million in federal loans. It is closing down on January 1,2016 because it ran out of money.

Louisiana Health Cooperative announced in July that it was voluntarily shutting down operations.

CoOportunity Health, which sold policies in Iowa and Nebraska, was liquidated and forced to close earlier this year.

Many state Co-op’s are on the way to bankruptcy. In Nevada alone one third of the health insurance exchange population will lose insurance coverage.

Nevada Health CO-OP’s departure will leave a big hole in Nevada’s exchange market. Open enrollment begins Nov. 1, and consumers will have to shop for plans with other carriers. The co-op had 21,300 members as of the first quarter this year. Nevada’s exchange population was about 63,000 at that time.

A.M. Best’s report shows a majority of the nation’s 22 co-ops have combined medical and administrative expense ratios above 100%.

All these failures and impending failures mean that either the Obama administration is stupid or things are going precisely as President Obama had planned.

The healthcare system is on its way to destruction. The federal government as the payer of last resort will replace it.

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

Please have a friend subscribe

3
4
5
6
7
8
9
6/12