Results found: 95

Permalink:

Pay For Performance (P4P) Pilot Project Fails

April 11, 2012

inDisinformation and the healthcare system, Medicine: Healthcare System, Pay for Performance (P4P), Politicians,Healthcare and Vested Interests, Stakeholder Mistrust

• Leave a comment

Stanley Feld M.D.,FACP,MACE

The CBO announced that the P4P pilot project did not reduce the cost of providing healthcare nor yielded long-term gains in mortality.

"Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care.1-4

The Centers for Medicare and Medicaid Services (CMS) recently completed a 6-year demonstration of pay for performance for hospitals through the Premier Hospital Quality Incentive Demonstration (HQID), and the Affordable Care Act calls for CMS to expand this program to nearly all U.S. hospitals in 2012.

P4P sounds good theoretically. The government paying more money for better outcomes sounds logical from the payer’s point of view. It is not logical from the payees’ (physicians’) point of view.

The emphasis of P4P is on physicians and hospitals practice process to improve quality through the use of evidence based medicine.

The evidence based medicine guidelines are determined by the Independent Physician Advisory Board (IPAB). The evidence based medicine should improve quality and lead to better patient outcomes and decrease healthcare costs..

This pilot project showed that P4P does not produce the desired result. The hope was to inspire poor performing centers to improve and good performing centers to perform better in order to receive incentive pay for performance as a bonus.

"In summary, we found little evidence that participation in the Premier HQID program led to lower 30-day mortality rates, suggesting that we still have not identified the right mix of incentives and targets to ensure that pay for performance will drive improvements in patient outcomes.

Even though Congress has required that the CMS adopt pay for performance for hospitals, expectations with regard to programs modeled after Premier HQID should remain modest."

This last sentence is great advice.

Congress and President Obama should reexamine their premise.

Patients’ performance is left out of the P4P program. Patients’ attitude toward their disease, adherence to taking medicine prescribed, compliance with prescribed therapy and patients ability to make rapid therapeutic adjustment of medications depends on patients and not physicians or physicians’ practice process.

There is no question that the process of care is important. There is no question that processes based on evidence must be learned by all physicians. There is also no question that processes based on evidence rapidly change and must be swiftly adjusted.

The most important determinant in patients’ outcome depends on patients. Physicians’ practices should not be judged disregarding patients’ behavior.

It is the physicians’ responsibility to teach patients how to be “Professors Of Their Diseases.”

Just imagine how many re-hospitalizations could be avoided for congestive heart failure if patients were motivated and educated to detect the onset of congestive heart failure and how to increase the dosage of medication to abort the episode.

Think of all the heart disease that could be prevented if obesity was prevented.

Think of all the acute asthma attacks and uncontrolled diabetes whose hospitalizations could be prevented.

Think about all the complications of diseases could be prevented if patients were incentivized to lead a healthy lifestyle.

At present the administration is trying to change incentives. It will not work.

The reason is simple.

I have written several blogs on why P4P will fail.

When will someone listen?

I clearly explained the reasons for predicting P4P’s failure in a blog written in April 2007.

Pay for Performance(P4P): Another Complicated Mistake.

April 15,2007

Stanley Feld M.D.FACP,MACE

The intuitive meaning of Pay for Performance (P4P) is the better you perform the more you get paid. This is true in many industries. The concept is well advertised in the well publicized salaries of professional athletes. Recently we have heard of grotesques salaries of fired CEO that get hundreds of millions of dollars in termination salaries for doing a bad job. They are getting paid well for poor job performance.

The underlying assumption is that with P4P, physicians should be responsible and accountable for medical outcomes. The physicians will be reimbursed for medical outcomes. The reimbursements made to the physicians are under the control of the government or insurance industry. These entities are interpreting the criteria for the quality of medical outcomes.

We have seen what happened to Dr. Petak even though his treatment is correct and saves money for the health care system. Many physicians feel P4P is simply code for reducing physician reimbursement. In an environment of existing mistrust between all the stakeholders, the potential is great for generating more mistrust. The growth of the mistrust will result in more dysfunction in the healthcare system and increased cost.

The definition of quality medical care has not been made clear by the secondary facilitators while proposing the P4P rollout. Organized medicine has not been outraged by the proposal. No one has analyzed it with all the potential for unforeseen consequence. Can P4P prevent the onset of disease or decrease complication rate for chronic disease? Who are the responsible stakeholders for increasing quality? The stakeholders responsible for medical quality care are the physician and the patient. If the patients do not adhere to the medical regime prescribed, the quality of care will not improve. Many studies have shown that compliance rates are as low as 30% for certain treatments. Patients will not have improved medical outcomes if they do not follow a treatment plan. Why should the physician be penalized? Why doesn’t the government and the insurance industry declare that patients are equally responsible for both good and bad medical outcomes? The structures of bureaucratic systems would not permit it because not only would it be judged to be insensitive it would be socially incorrect and result in a public outrage.

Patients have to be educated and become professor of their disease, be responsible for their health behaviors such as filling their prescriptions, exercising , decreasing obesity, not smoking or drinking. All preventive measures must be promoted. Patient need to be responsible their behavior and adherence to therapy. The physicians should not experience all of the brunt of poor outcomes or the credit for good outcomes. The P4P movement is misguided.

They are misguided when they think this is the fix. P4P represents another false hope and complicated mistake that in my opinion will lead to great cost to the healthcare system without improvement in medical outcomes.

I have defined quality medical care in a measurable way. None of these criteria are individual indicators of quality medical care. The system of quality of care should be the quality measure of prevention of medical complications and not the measurement of the parts on the path toward quality medical care. The patients’ activity is at least half of the quality equation to reduce the complications of chronic disease.

However, the secondary stakeholders are making a mistake with P4P. They have developed artificial quality indicators that do not measure quality medical care accurately. They want to force physicians to follow their indicators rather than use their medical skill and medical judgment. The way to improve quality is not to be punitive to the physicians. They are only one half of the quality equation to reduce medical care cost. The way to do it is to set up a competitive environment.

Lasik surgery is a perfect example. It stated with all ophthalmologic doing Lasik for $3000 an eye. Insurance did not pay for Lasik surgery. Some ophthalmologists’ developed focus factories that did just Lasik surgery. They developed economies of scale and expertise that enabled them to reduce the price. Patients chose these focused factories on the bases of price, and outcomes rather than the local opthalmologists. The price in some cities is now $250 an eye. Remember patients are not stupid. However, they are the 50% of the quality care equation. They will spend their money wisely and drive quality, if they own their healthcare dollar. It is our job to teach patients how to make the correct decisions. It is not the insurance industry or the government to restrict access to care and judge what is best. I believe the market place can do it.

In diabetes the healthcare system sends 15% of the healthcare dollar on 5% of the population and rising. Ninety percent of those dollars is spent on the complications of diabetes. If patients with diabetes were given control of their healthcare dollar and were rewarded for avoiding complications of diabetes we would be on our way to a competitive environment for the treatment of diabetes. The patients would search for physicians that had economies of scale and expertise to help them improve their quality of medical care. They would drive the creation of focus factories in diabetes as well as any other chronic disease. The system would then be stimulating competition and improving quality medical care not punishing physicians and patients. A negative and faulty penalty system (P4P) will not solve any of our problems. I predict it will only make it worse for the patient and the physician and more profitable for the insurance industry and hospitals. The physician and patient community ought to be outraged. They are not because we are a sound byte society and do not pay attention to the details of issues.

The P4P fad is simply another reason why patients need to be in control of their healthcare dollar. They should be rewarded if they avoid complications and improve their health. Physicians should compete to develop focus factories in order to generate economies of scale and improved medical outcomes. All of this has to be done in a price transparent environment.

April 15, 2007 in Medicine: Healthcare System | Permalink

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

If you like this blog please send it to a friend

Permalink:

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

Please send the blog to a friend

Permalink:

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

Permalink:

Ideal Medical Savings Accounts For Everyone: Encourage Patient Responsibility!

February 12, 2012

inConsumer Driven Health Care, Information Technology in Healthcare, Medicine: Healthcare System

• Leave a comment

Stanley Feld M.D.,FACP,MACE

The third spoke in the future states wheel is Patient Responsibilty for their health and Healthcare dollars.

The Ideal Medical Saving Account would decrease the cost of the Healthcare System because it would dis-intermediate the Healthcare System’s complex and convoluted business model.

The Ideal Medical Savings Account should be an option for all consumers who have all types of insurance coverage. The Ideal Medical Savings Accounts would create competition for patients among physicians. It would create competition among healthcare insurers.

Medicare, Medicaid, corporate self-insurance plans, association healthcare plans, individual healthcare plans and ordinary healthcare insurance plans provided by employers could all offer the Ideal Medical Savings Account.

If MSAs were structured as my Ideal Medical Savings Account is structured the result would be a decrease in the cost of healthcare, a decrease in premium costs and an increase in healthcare quality.

The Ideal MSA must be paid for by pretax dollars as all other healthcare plans are.

If the government, individual or employer puts the first $6,000 of insurance in individual trusts for the consumer the entire healthcare and medical care supply chain would be disrupted by consumers.

An immediate argument is Medicaid patients are not smart enough to determine their own healthcare needs if they were responsible for the first $6000 of healthcare insurance coverage.

This is rubbish. It is condescending to patients on Medicaid. If the government is so worried they should provide education to help these Medicaid consumers make wise healthcare choices using available social media.

The entire goal of the Ideal Medical Savings Account is to provide incentives for consumers to become responsible for their health and healthcare needs rather than be entitled to medical care.

The mechanism for this reversal from a dysfunctional system’s business model to a functional system’s business model is patients’ owning their healthcare dollars and having financial as well as medical incentive to be responsible for their health, maintaining their health, and choosing the most efficient and effective medical care.

Consumers would become Prosumers (Productive consumers) of health care rather than passive consumers of healthcare.

This mechanism has worked in many industries using the Internet as a facilitator.

The Internet can become an extension of the physicians care.

At present there are many web sites offering advice to patients. The defect is they are not an extension of the physician’s care of the patient.

Physicians would be motivated through competition for the patients’ owned healthcare dollars to choose the sites for his patients that would be an extension of their care.

Physicians associations could create web sites for their members. Social networking between physicians and their patients could direct their patients to that site. This would be the meaning of an extension of the physician’s care.

Patient responsibility is the third spoke in my formulation of the future state business model of a functional healthcare system.

It must be remembered that the present state’s business model is dysfunctional. It must be repaired.

The future state must not be encumbered by any of the baggage of the dysfunctional present state business model.

If the future state model is made clear to patients, potential future patients and recovered patients (consumers) they will demand for this future state model.

Using social media consumers can drive the healthcare system to the future state business model.

It turns out everyone is better off and the system is more efficient and costs less for consumers.

The consumers would own the first $6,000. They would be responsible for the management of there healthcare dollars. They would also be responsible for choosing their physician.

I have found that when physicians and patients sign a patient physician contract the treatment results improve. Both physicians and patients have their responsibilities clearly defined.

The patient physician contract motivates patients to be responsible for their own care. Patients responsible for their care is critical to successful clinical outcomes.

If there were a financial incentive attached to this physician patient contract along with a potential bonus the results would be even better.

This was especially true in the treatment of Diabetes Mellitus.

In treating chronic diseases such as Diabetes, physicians must be the teachers, prescribers and coach. Patients must become the professor of their disease. Patients live and care for their disease 24/7.

Financial incentives would motivate patients to take an active role in their medical care.

Obesity is a major problem in America today. Patients and patient education is the only solution to the “The Obesity Epidemic.”

The only way to decrease obesity is by burning more calories than is eaten. Society must encourage exercise, and reducing intake. It turns out society encourages the opposite.

Mayor Bloomberg is doing the right thing in New York City. He uses simple transit Subway advertisements to increase awareness caloric intake. He has required each restaurant to publish calorie counts.

It is a simple educational message that everyone can understand. It is amazing how intelligent people misjudge their caloric intake.

Constant repetition of calorie counts of various foods along with estimates of calories burned can result is a cultural change for the need to burn more than we eat.

Companies such as FitBit are building simple products to help us achieve this goal.

Obesity contributes to the onset of many chronic diseases. The treatment of the complications of chronic disease result in eighty percent of the healthcare dollars spent for direct patient care.

If a consumer abuses his health and ends up spending the initial $6,000 he has no money left to put into his retirement account.

If a patient has a chronic disease and has excellent control of his disease he can avoid the complications of his disease. If the patients take the appropriate medical care avoids hospitalization and the emergency room for the year, the provider of his Ideal Medical Saving Accounts can afford to give that person a bonus for his retirement account.

This would add an additional financial incentive for consumers.

As a society we are smart enough to solve the problem of a dysfunctional healthcare system. The present course is unsustainable.

The future state’s business model with consumers responsible for their healthcare dollars and the patient physician relationship restored can achieve the goal of a sustainable healthcare system.

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

Please send the blog to a friend

Permalink:

Who Said Consumer Driven Healthcare Cannot Be A Market Force?

January 19, 2012

inConsumer Driven Health Care, Medicine: Healthcare System, Patients Problems

• Leave a comment

Stanley Feld M.D.,FACP,MACE

I love Costco. Its prices are great and its selection is abundant. Last week I was dazzled by the display of megavitamins as soon as I walked into the store.

Americans want to be healthy. Few have a death wish but many (60%) are obese. Megavitamins have been touted as the instant route to healthy living. The megavitamin business has grown into a $30 billion dollar a year business.

Megavitamins have been successfully oversold.

There is no evidence that megavitamins are the route to health and healthy living.

“A national survey by the US Food and Drug Administration found that 73% of US adults were found to use dietary supplements in 2002.”

There is little good evidence to support the widespread use of dietary supplements.

The US Preventative Health Services Task Forces reviewed some of the literature on megavitamins and dietary supplements. The group stated there was insufficient evidence for or against the use of multivitamins with folic acid or antioxidants. It also stated that the use of Vitamin A, C or E did not have sufficient evidence for or against its use.

I think these supplements could be helpful if the requisite dosage was known. There is no evidence that these dietary supplements are helpful at the present dosage. There are no scientific studies about which doses would work. There are only testimonials attesting to usefulness.

”Beware of the man with one case.”

A friend of mine worked for thirty years proving the existence of Vitamin D deficiencies in 50% of the elderly population. It took him half that time to convince the medical population that he proved something.

The dosage necessary ended up being 6 times the dosage in multivitamins. Therefore USPHTF conclusions are correct with the present data. However they might have drawn their conclusions from the wrong data.

This is not an unusual occurrence in clinical medicine as I have pointed out previously.

The American Medical Association hedged its bet by stating,

“It recommends supplements specifically for seniors who have generalized decreased food intake.”

Chances are people who are starving or dying from cancer will have a multivitamin and mineral deficiency.

The American Dietetic Association advises,

“low-dose multivitamin and mineral supplements depending on individualized dietary assessment.”

The ADA’s statement is obviously self-serving.

The American Heart Association made the only logical statement in the whole bunch.

“The AHA emphasized healthy eating patterns rather than supplementation with specific nutrients. “

The recommendations against the routine use of supplements are grounded in fairly good evidence if one believes in a methodology used by the Cochrane intervention review.

A Cochrane intervention review of 77 randomized controlled trials with 232,550 participants found no evidence to recommend antioxidant supplementation for primary or secondary prevention of mortality.^[7]^.

There is shabby evidence that cannot be generalized regarding possible harm related to the use of some supplements.

“For example, the Alpha-Tocopherol Beta-Carotene Cancer Prevention Trial demonstrated that beta-carotene supplements increased the risk for lung cancer among male smokers.^[8]^”

At this point there is no good scientific evidence for the use of megavitamins. “People believe what they want to believe.” The placebo phenomenon is extremely important.

The media is the message. Somehow the power of advertising has convinced the public that it is good to take megavitamins.

Costco is trying to take advantage of the hype. Consumers are driving this healthcare choice. The result is a $30 billion dollar a year business. The money is coming directly out of the consumer’s pocket. It is not included in healthcare costs.

Consumers are trying to be responsible for their health on the basis of hype. It is much easier in the mind of most to stay healthy taking a pill than do the heavy lifting required for healthy living.

Why can’t someone create an anti-obesity hype that works as well as the megavitamin hype?

Increases in obesity lead to increased Type 2 Diabetes, hypertension, hyperlipidemia and the resulting Diabetic complications of stroke, heart attack, blindness, amputations, chronic renal disease and cancer.

Many schemes have been devised to decrease the increasing obesity rate. None have worked except eating less and doing more.

With the increasing obesity in children there is an increased incidence of Type 2 Diabetes in kids, teenagers and young adults.

Gastric bypass has become the rage for these young super obese people. To my dismay more and more insurance plans are paying for gastric bypass procedures. Even Medicaid is paying for the procedures.

Is the world going nuts? I guess Medicaid’s logic is if the people become thinner it will decrease the incidence of Diabetes, decrease the complications of Diabetes and therefore decrease the cost of healthcare for these people.

To me it is like painting over rust. The rust will bleed through and the money for the paint will be spent already.

Americans do not get any help from society norms. We are flooded by manufactured foods with tons of calories and tons of salt. Mayor Bloomberg passed an educational law that fast food stores must publish calorie counts on foods.

This is helpful is the calorie count is accurate and people pay attention.

Home cooking served in small portions is essential. The fat, calories and salt can be controlled. There is no need to have a home cooked meal anymore.

All you have to do is go to Costco or Sam’s and buy any precooked meal you want. Dinner is a 3 to 10 minute microwave pop away. Why would any busy person bother to prepare a home cooked meal? The harmful consequences prepared meals are in the distant future.

If you have dinner at a restaurant an average meal contains more calories than the average person burns in a day. My wife and I have been sharing for years.

Consumers want to be responsible but it is very difficult in the cultural milieu of our society.

Ken Cooper M.D. created an exercise craze in the 1970’s. It has lasted until the present. He did not figure out how to get people to sustain their exercise program. He also did not figure out how to get people to decrease their intake in our sea of manufactured food and pre-cooked food.

The incidence of obesity is growing.

Most consumers are not stupid. They seek to be responsible in the easiest way possible.

Someone will come along and initiate a legitimate health craze.

The Ideal medical savings account (by providing financial incentives along with intense public education through appropriate advertising) can be as successful as the Dietary Supplement industry.

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

Please send the blog to a friend

Permalink:

Healthcare Costs Are All About Chronic Disease Management

July 13, 2011

inChronic Disese Management, Consumer Driven Health Care, Medicine: Healthcare System, Patients Problems

• Leave a comment

Stanley Feld M.D., FACP,MACE

The National Institute for Healthcare Management Foundation is a nonprofit, nonpartisan organization focused on healthcare. The foundation just published an excellent report on the distribution of healthcare costs in the population.

The results indicate that reducing healthcare cost is all about reducing and managing chronic diseases.

U.S. healthcare spending has sharply increased between 2005 and 2009 by 23 percent from $2 trillion to $2.5 trillion per year.

This is a result of a combination of factors. Chief among them is the increasing incidence of obesity.

Who spends the money?

Five percent of the population is responsible for 47% of all health care spending in the United States. Ten percent of the population accounted for 63.3% of the expenditures.

Fifty percent (50% percent) of the population accounted for only 3% of the healthcare expenditures.

The low cost person spent $233 in 2008 for healthcare services. Those in the top half of spending cost insurers, the government, or themselves $7,317 a year. The top 1 percent cost $76,476 per year. These are discounted fees not retail fees.

Healthcare expenditures were concentrated among a small group of high-cost patients. These high cost patients were older patients (over 55 years old) with one or more chronic diseases. If they were young and they had one or more chronic diseases healthcare expenditures increased. The more chronic diseases a patient had, the higher the likelihood the patient would be in the top 5% of healthcare dollar utilizers.

Fifty percent of the top 5 percent of healthcare spenders had high blood pressure, a third had high cholesterol, and a quarter had diabetes. The incidence of hypertension, hypercholesterolemia and adult onset type 2 Diabetes Mellitus is directly proportional to the presence of obesity.

It is logical to conclude that as the incidence of obesity and its severity increases the complications of obesity (hypertension, hypercholesterolemia, and Type 2 Diabetes) will increase.

It follows that healthcare costs will increase as a result of the increasing incidence of obesity. America must control the obesity epidemic.

Little progress is being made to decrease the increasing incidence of obesity or Type 2 Diabetes.

In a perfect world, if obesity could be decreased, the incidence of chronic disease would be decreased.

In a perfect world, if the patients with chronic diseases could be taught to self-manage their disease, healthcare costs would decrease because the incidence of complications of chronic disease would be decreased by at least 50%.

The treatment of the complications of chronic diseases is the most costly healthcare expenditure.

President Obama’s Healthcare Reform Act mentions prevention and chronic disease management. There are no concrete incentives for patients to learn how to manage their chronic diseases. There are no specific financial incentives for physicians to develop facilities to teach patients to mange chronic diseases.

Americans are in for a long and costly dysfunctional healthcare system to the disadvantage of consumers and physicians.

President Obama’s Healthcare Reform Act puts consumers in a passive dependent position. Consumers need to be put in a proactive position to care for and be responsible for their health and healthcare needs.

Physicians have to have incentives to teach consumers to be self-reliant.

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

Permalink:

It Will Not Work!

May 11, 2011

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

“The media is the message.” It does not matter if the policy has failed previously. All that is important is the effectiveness of the policy’s presentation and its ability to manipulate the polls.

The government’s purpose is to work for the people who elected it. It does not seem to be working that way at present. Bureaucrats create rules or regulations as they interpret the laws made by congress and the president. Regulations are controlled by the administration’s ideology. Many times the regulations in one area nullify the intended effect in another area.

Regulations and bureaucracy inhibit the use of common sense in policy making for the benefit of the people.

The people did not have an outlet to express their opinions or frustrations until blogging came into its own seven years ago.

Americans do not like President Obama’s healthcare reform act. They also do not like Dr. Don Berwick’s apparent disrespect for their intelligence and his infatuation with the British healthcare system.

“I am romantic about the NHS (British National Health Service); I love it. All I need to do to rediscover the romance is to look at health care in my own country.”

Dr. Berwick’s comments about redistribution of wealth and taking freedom of choice is scorned by many Americans.

“Dr. Berwick complained the American health system runs in the ‘darkness of private enterprise,’ unlike Britain’s ‘politically accountable system.’ The NHS is ‘universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just’; America’s health system is ‘toxic,’ ‘fragmented,’ because of its dependence on consumer choice. He told his UK audience: ‘I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.’”

The NHS is failing. Prime Minister Cameron has declared he will change the system. The British healthcare system has resulted in long waits for treatment and rationing of treatment. If past experience is any indication, generic drugs and expert commissions have done little to lower healthcare costs.

“As the United States prepares to introduce the massive new health-care program known as Obamacare, Britain’s Conservative Prime Minister David Cameron said on Monday that he plans to significantly reform his country’s state-run health-care system due to the program’s massive cost and lackluster performance”.

Theodore Dalrymple wrote a critique of the British Healthcare system in the Wall Street Journal on April 16, 2011. Theodore Dalrymple is the pen name of Anthony Daniels, an English physician.

He is echoing the sentiments of many practicing physicians in Britain.

Dr. Anthony Daniels’ perception contradicts Dr. Don Berwick’s perception. One of them is wrong. My bet is Dr. Berwick is wrong.

Dr. Daniels’ practical experiences are:

“1. All attempts to reduce bureaucracy increase it, and the same goes for cost. Such, at any rate, has been my experience of the British health care system.”

“2. In Britain we have been prescribing generics for years; I cannot remember a time when I personally did not. Our National Institute for Clinical Excellence (NICE) has done cost-benefit analyses of drugs and procedures, often very sensibly, for years. But despite its best efforts, our system has been highly inventive in finding other ways of wasting immense quantities of public money.”

I suspect this is a result of the administrative costs associated with the increased government bureaucracy and regulations.

“3. Don Berwick wants to move from a fee-for-service system, which gives doctors an incentive to perform expensive and doubtfully effective procedures, to one in which doctors are rewarded for preventing diseases that are so expensive to treat.”

“4. On paper, prevention always seems much cheaper than cure. Health-care economists prove it very elegantly and convincingly over and over again.”

“5. Unfortunately, the world always proves to be more complex and refractory than the theories of even the best economists”.

“6. For a long time, a physician was paid a capitation fee: He received a certain amount per patient per year from the NHS, irrespective of what the doctor did for the patient or how many times a year the patient was seen. The physician could not increase his income except by private practice.”

“7. Needless to say, private practice was most extensive in the better-off areas, so that the system ended up reproducing the very social divisions in health care that it was designed to abolish.”

“8. In the poorer areas, doctors had no incentive—at any rate, no financial incentive—to improve their practice. It was rather the reverse. The worse the facilities they offered, the higher their income.”

“9. In the 1990s, Family doctors began to be paid to undertake preventive measures. The experts hoped that this would save money because the cost of preventing diseases would be more than offset by the savings from not having to treat the diseases that they prevented.”

“The costs of prevention were decidedly real, while the savings were inclined to be imaginary.”

a. “The bureaucratic costs of setting and monitoring health-improvement targets—which were often highly arbitrary—were far greater than anticipated, bureaucracies having an inherent tendency to increase in size and spending power.”

b. “Many doctors started to be paid for procedures that they were already doing for no charge, like taking their patients' blood pressure.”

c. “Screening procedures turned out to be highly equivocal in their efficacy.”

d. “Thus the overall benefit was much less than anticipated.”

e. “Some of the more common ills that had been targeted, such as strokes and heart attacks, were in marked decline anyway because of increase in effective technology.”

f. “Worse, much of the expenditure on the treatment of disease proved intractable.”

g. “Technology inexorably increased costs; and even if the health of the population improved rapidly”

h. “The increased proportion of older people in the population meant that the proportion of people ill with expensive chronic diseases increased.”

i. “Procedures such as hip replacement have gone from being relatively new-fangled and exotic to being routine, precisely at a time when there are more people than ever who can benefit from them.”

j. “ Osteoarthritis is no doubt hastened by obesity, but no medical means has yet been found for the prevention of that particular condition.”

“It is true that in Britain we have had our own peculiar reasons for the spectacular rise in the cost of our health-care system.”

“The British system is now capable of absorbing infinite amounts of money with minimal benefit to the health of the population, though with great benefit to the pocketbooks of those who work in it.”

“It is an occupational hazard for politicians to think that they and their ilk know best.”

“I have seen a hundred schemes of cost reduction.”

“ I have never seen any reduction in costs, or at least any that lasted more than a few months. I can't remember a single health minister who did not promise more efficiency at less cost, or a single one who actually managed to achieve it.”

“The long-term solution, I imagine, is the same for health care as it is for pensions: to pay for it with the income generated by dedicated savings accounts, which can be transferred to the next generation after death.”

President Obama is setting up a healthcare system in America that has been proven not to work in Britain. The healthcare reform act should be reconsidered.

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

Permalink:

A Big Idea For President Obama

April 17, 2011

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

• Leave a comment

Stanley Feld M.D.,FACP,MACE

President Obama has been disingenuous during his entire time in office. He has publicly asked for ideas on Repairing The Healthcare System before and after he took office. I will repeat the advice that he has ignored in the next few blog post.

He has been influenced by the ideas of Tom Daschle and Don Berwick to the exclusions of ideas that might actually be effective. Both men are convinced that the healthcare system would be repaired if there were a complete government take over.

President Obama has been extremely cunning in working his way toward a complete government takeover of medicine. Some of Mr. Daschle and Dr. Berwick’s ideas are good. Most of their ideas will not fix the defects in the healthcare system. There is a total disregard of citizens in their program.

President Obama is expanding the bureaucracy and creating a wasteful morass of new agencies. Those agencies are generating incomprehensible and non-enforceable regulations. The regulations are trying to commoditize medical care in America.

Our healthcare system is a mess. Medicare and social security in its present form will result in a 100 trillion dollar a year deficit in 75 years. The solution to Repairing the Healthcare System is relatively simple. The key to the solution is social responsibility by all stakeholders involved in the healthcare system and individual responsibility by the consumers and potential consumers of healthcare.

Neither political party is getting behind a big idea that’s bold enough to actually solve major problems.

Unfortunately, secondary stakeholders (the healthcare insurance industry, hospital systems and government) have not become socially responsible toward the best interests of consumers. Consumers will assume responsibility with significant incentives and appropriate education.

One big idea is to reform the food industry. The food industry’s products and advertising undermine Americans eating healthy. The food industry’s advertising has to be redirected to consumer education and not consumer self-destruction. President Obama’s approach to healthy eating has been tokenism.

He has ignored appropriate input on how to fix the food industry in an effort to decrease obesity in America.

No one has asked for the opinion of practicing physicians. The focus of all healthcare policy “experts” is economics.

Here is a big idea.

Obesity leads to chronic diseases such as Type 2 Diabetes Mellitus. Walk into any Coronary Care Unit in the nation and 80% of the patients with myocardial infarctions are obese and have Diabetes Mellitus. The complications of Diabetes Mellitus cost the healthcare system $160 billion dollars a year. Eliminating obesity will reduce the incidence of Diabetes Mellitus by at least 50%.

Cheap manufactured food subsided by the government results in 19% of America’s fossil fuel use. It also results in more than 75% of the obesity in this country.

Eighty per cent of the healthcare dollars are spent on the complications of chronic diseases. The eighty percent cost to the healthcare system is one trillion six hundred million dollars a year.

The obesity epidemic is interconnected with our energy policy and energy subsidies, farm policies and subsidies, environmental policy and conditioned attitudes toward fast food.

Michael Pollan points out the problem with our entire food supply system and the impact it has on healthcare, the environment and energy.

“Which brings me to the deeper reason you will need not simply to address food prices but to make the reform of the entire food system one of the highest priorities of your administration: unless you do, you will not be able to make significant progress on the health care crisis, energy independence or climate change

The three problems are tightly connected. The repair of each problem has to must be done in a creative way that aligns all the stakeholders’ incentives with consumers’ health and wellness.

Michael Pollen goes on to tell President Obama “Unlike food, these are issues you did campaign on — but as you try to address them you will quickly discover that the way we currently grow, process and eat food in America goes to the heart of all three problems and will have to change if we hope to solve them.

Mr. Pollan’s point is the way we grow food and manufacture food stuff is a major reason for obesity and pollution leading to the complications of chronic diseases (Type 2 Diabetes Mellitus and chronic lung disease). This results in a 1.6 trillion dollar cost to the healthcare system. All American’s needs is the will to change.

It is going to require a lot of public and congressional education. It will be harder to educate congress than the public. Vested interest lobbying drives Congress. President Obama must help the public create a greater voice than the special interests. The public will then lobby the congress.

Michael Pollan says “the 20th-century industrialization of agriculture has increased the amount of greenhouse gases emitted by the food system by an order of magnitude; chemical fertilizers (made from natural gas), pesticides (made from petroleum), farm machinery, modern food processing and packaging and transportation have together transformed a system that in 1940 produced 2.3 calories of food energy for every calorie of fossil-fuel energy it used into one that now takes 10 calories of fossil-fuel energy to produce a single calorie of modern supermarket food. Put another way, when we eat from the industrial-food system, we are eating oil and spewing greenhouse gases.

The reformatting of the payment system for physicians with the theoretical effectiveness of Accountable Care Organizations (ACO’s) will not work. It will only waste money. It will only dispirit the medical profession and diminish the effectiveness of a necessary workforce. Physicians are not the villains.

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

Permalink:

It Is All About Trust And Respect

January 2, 2011

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

• Leave a comment

Stanley Feld M.D.,FACP,MACE

President Obama removed the provision in his healthcare reform bill last year dealing with reimbursing physicians for end of life counseling. There was great citizen uproar about this provision. It was viewed by many as a first step toward rationing of medical care.

“When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system.”

Sarah Palin call the provision the creation of “death panels.” A government “panel of experts” would decide whether Medicare would pay for treatment of patients deemed hopeless. The panel of experts would decide regardless of the patient’s wishes.

Sarah Palin’s term was criticized as “sensationalistic.” The criticism is correct. However, in a sound bite society you have to use effective sound bites to get attention. The eliminated provision illustrates the truth about a world of finite resources and infinite entitlements.

Entitlements are ever expanding as our population expands. The government cannot afford expanding our entitlement programs. Yet President Obama’s healthcare reform act is going to expand the Medicare and Medicaid entitlements to cover 32 million uninsured.

One way out is to decrease benefits. This is the administration’s plan.

Another way out of the mess is to attack the root of the problems. America could create a consumer driven healthcare model. America could also develop of system of logical tort reform. Government could subsidize those consumers that qualify for subsidies. Consumers should own their healthcare dollars as outlined in the ideal medical savings account.

I have objected to President Obama’s healthcare reform act. It puts all the power of medical decision making in the hands of the executive branch. HMS and CMS create rules and regulations without congressional oversight. The most recent revelation portends provisions to come.

President Obama’s administration has achieved the same end of life goal by regulations produced by Dr. Donald Berwick chief of CMS, starting Jan. 1.

“At a stroke, Medicare chief Donald Berwick has revived the "death panel" debate from two summers ago.”

Medicare will enact the same policy removed from the bill through the power of regulation. Congress has had no input. This is the first step in a never ending series of future steps President Obama will take to control our freedom to make healthcare choices. The regulations seem benign on the surface.

“The office of Oregon Democrat Earl Blumenauer, the author of the original rider who then lobbied Medicare to cover the service, sent an email to supporters cheering this "victory" but asked that they not tell anyone for fear of perpetuating "the ‘death panel’ myth." The email added that "Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch."

President Obama has used a number of trick plays on congress and Americans to further his agenda. One trick President Obama pulled was his appointment of Dr. Berwick during congressional recess without congressional hearing after withholding the request for congressional hearings for 3 months.

Dr. Berwick now slips through a regulation about reimbursement that Congress explicitly rejected. Unfortunately for Dr. Berwick an email was leaked illustrating scheming with his political patrons to duck any public scrutiny.

“Expect many more such nontransparent improvisations under the vast powers ObamaCare handed the executive branch.”

An administrative representative immediately stepped in and declared the rule-making is not coercive. He claimed the rule gives seniors more autonomy, not less.

“The facts are that if the medical experts in Congress haven’t decided that some treatment or service is worthy of the fee schedule, then the program won’t pay for it even if it is in the best interests of patients.”

The two most expensive occurrences are the birth of premature infants and the last 30 days of life. As a society, we will have to learn how to deal with these facts. Society must be innovative in dealing with these tragedies to the satisfaction of all. As a society, we also have to conquer obesity and the onset and management of chronic diseases.

Unfortunately, President Obama’s methodology is wrong. He has demonstrated an arrogance and disrespect for the American people. The American people now understand his methodology. They have experienced his multiple trick plays and have lost trust in him and his administration. There is a perception that he disrespects the will of the people he has been elected to serve. President Obama will not achieve his goals as long as the perception exists.

The Democratic Party has experienced this mistrust during the midterm elections. Nonetheless, President Obama and the Democratic Party continued to show their disrespect for the will of the American people during the lame duck congressional session.

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

4
5
6
7
8
9
10
7/11