Stanley Feld M.D.,FACP,MACE

The Congressional Budget Office report states that President-elect Obama’s healthcare plan would carry a high price tag. The healthcare plan would generate only modest savings.

“Mr. Obama and other Democrats have not been precise about the cost of their proposals, nor have they said in detail how they would pay for them.” Some of the options, including proposals to increase taxes on cigarettes and nondiet soft drinks, are sure to meet stiff political opposition.

President-elect Obama has not been precise about any of his proposals on purpose. Both political parties say they will make a serious effort to overhaul the health care system in 2009. In our current economic crisis it is essential to that. As unemployment rises the uninsured population will rise. The fear in the population will create pressure on congress to pass any bill that promises hope and relief.

However, President-elect Obama’s transition team is going about the overhaul of the healthcare system the wrong way. I am positive they think they are doing it the right way.

“One bright spot in a generally bleak picture was the estimate of potential savings from a requirement for doctors and hospitals to use health information technology (EMR), including electronic medical records, as a condition of participating in Medicare.”

Such a requirement could save the federal government $7 billion in the first five years and a total of $34 billion over 10 years, by reducing medical errors and avoiding unnecessary tests and procedures, the budget office said.

President-elect Obama does not plan to create a universal electronic medical record. Electronic medical records are essential to repair the healthcare system. The administrations healthcare transition team believes it can force physicians to purchase, install and service electronic medical records most physicians cannot afford. The government plans to make EMR a condition to participate in Medicare. Many physicians would not mind being forced out of Medicare.

Most installed EMRs in large hospital systems are not fully functional. Many do not have total functional cross hospital system compatible interfaces that would allow efficient flow of information. Most EMRs do not allow for real price transparency that can stimulate efficient use of healthcare system resources.

If the government requires physicians to buy an EMR by penalizing them, physicians will drop out of the Medicare program. The result will be the creation of a shortage of physicians. The government should make available a fully functional EMR free of charge. It should not require a capital outlay. Physicians would pay by the click monthly.

Without action by Congress, the report said, health costs will continue to soar, the number of people without insurance will rise by nearly one million a year, to a total of 54 million in 2019, and spending on health care will increase to 25 percent of the gross domestic product in 2025, up from 16 percent in 2007.

All agree that something must be done to repair the healthcare system. The Congressional Budget Office (CBO) must work with the data they have even if the data is incomplete. CBO’s estimates are modest. During our present economic recession I think the number of uninsured will rise to 54 million by the end of 2009, not in ten years.

“Lawmakers from both parties said they would pay close attention to the cost of new federal subsidies for health coverage because these subsidies — unlike the one-time bailouts for banks and other financial institutions — would be recurring federal obligations for years to come.”

A large problem is that all the proposals would force a stakeholder to do something. In order to accomplish real change the government needs to provide incentives for stakeholders, not mandates. Historically, mandates never work.

1. Requiring employers to provide health insurance to their employees.

1a. or pay a fee to the federal government would bring in $47 billion of new federal revenue in the next 10 years, the report said.

The savings of 4.7 billion dollars a year is insignificant in a healthcare system that has 150 billion dollars of administrative waste a year. The government should go after the administrative waste.

A proposal to establish a national insurance pool for people who cannot obtain coverage on their own in the individual market would cost $16 billion in the next decade in subsidies.

The real issue is the need to put the individual market on a level playing field with the group market. Secondly, it is essential consumers be in charge of their healthcare dollar. Presently the healthcare dollar is owned by the healthcare insurance industry. Ownership of the healthcare dollar will remain with the healthcare insurance industry in a President-elect Obama’s administration.

Mr. Obama and many other Democrats want the government to negotiate with drug manufacturers to get lower prices for Medicare beneficiaries.

This is an important action. Medicare Part D is a structural disaster. Medicare Part D has to be restructured to be in favor of the consumer, not the healthcare insurance industry. Part D was a good idea turned into an overpriced plan. The plan does not improve patient compliance because patients cannot afford the medication. The result is that it will not decrease the complication rate of chronic disease.

But the budget office said Medicare could save $110 billion in the next 10 years if Congress simply imposed a form of price controls, requiring drug makers to provide the government with a 15 percent rebate, or discount, on brand-name drugs covered by the new Part D of Medicare.

Historically price controls do not work. Incentives and competition work, if Medicare Part D was structured correctly there would be no overcharging for medication.

Under the current proposals the saving would be insignificant compared to the rising cost because President-elect Obama’s team is trying to fix the wrong things.

Doing what they are proposing is going to result in a more expensive healthcare system. The result will be cost overruns and a decrease in access to care and quality of care.

We have all experienced inefficient government rules and regulations. We must brace ourselves for the worse and start understanding the deficiencies now so we can speak out with one voice.

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

Stanley Feld M.D., FACP, MACE

A major defect in our healthcare system is that the healthcare insurance industry controls the entire healthcare dollar. In California, Nevada and Hawaii the healthcare Medicare vendor has held back physician reimbursement and restricted access to care.

Private healthcare insurance companies have done the same.

Government funded healthcare programs such as Medicare and Medicaid outsource their administrative services to the healthcare insurance industry. The federal government provides Medicaid funds to state governments. State governments outsource their administration services to the healthcare insurance industry. The healthcare insurance industry controls these dollars.

A recent headline in the Dallas Morning News read, “Is Texas looking out for you? Health-care Outsourcing is rolling on, but many patients suffer from silent treatment.”

Evercare of Texas, a unit of the giant UnitedHealth Group, is the Medicaid administrative services vendor for more than 80,000 elderly, blind or disabled North Texans.

“We help make it easier to get the care you deserve,” the company promises on its Web site.”

The state has received hundreds of complains about its administrative services vendor. Evercare’s excuse is the same as Palmetto’s excuse in California

“Evercare said it experienced the normal start-up problems associated with a program that serves tens of thousands of people.” “It was a massive undertaking,” said Beth Mandell, regional executive director of Evercare of Texas.

Evercare has been servicing Texas for a while now. It was fined 1 million dollars in 2007 and $400,000 in 2008.

A few horror stories can be expanded to many. The healthcare insurance industry controls the healthcare dollar. They are in the business of making money. It would be much easier and less costly if patients controlled their healthcare dollar.

“Willis Stewart, a 61-year-old carpet layer who had his teeth pulled during treatment for mouth cancer, said he has waited three months for Evercare to approve the dentures that will allow him to eat solid food again.”

“ Steven McGee, a 55-year-old truck driver disabled by multiple sclerosis, said he phoned the company for seven months without reaching a medical coordinator.”

“Mary Hunt, a 72-year-old widow, said she has waited months for dental care. “They ought to call them ‘Nevercare,’ “ said Hunt, among the hundreds of people who have complained about denied or delayed medical care.”

Physicians have experienced the same difficulties with reimbursement that patients have experienced with receiving care.

“North Dallas doctor William Walton says caregivers must be vigilant in working with UnitedHealth, parent company of Evercare of Texas.”They’re dishonest, and they’re sneaky,’ Walton said.”

The state’s recourse is to fine Evercare. However the fines are insignificant compared to the money made by Evercare while exercising this behavior.

“UnitedHealth caught the front end of the Texas outsourcing wave launched by Gov. Bush. Since 2003, the state has paid the company’s Evercare and United Healthcare units more than $1.2 billion to provide managed care to more than 255,000 Texans under four programs.”

Fines are not high enough to be a deterrent to the abuse of patients, physicians and other vendors.

“The state has fined Evercare, more than $1 million in the last year, ordering it to increase staff and fix other problems. The most recent fines, totaling nearly $400,000, were in reaction to the mounting complaints about the North Texas program.”

The healthcare insurance industry does this all over the country. No one seems to connect the dots. The only recourse governments have exercised is to fine these companies. The fine is usually minimal compared to the healthcare insurance company’s financial gain.

President-elect Obama and HHS secretary Tom Daschle plan to provide universal healthcare coverage. Federal universal healthcare coverage in the present healthcare system will result in an expansion of outsourced administrative services. The state of Massachusetts has expanded outsourcing of administrative services. It has experienced massive cost overruns with little evidence of improvement in the delivery of care.

I fear that if and when the present Obama/Daschle plan provides universal healthcare to our entire population, Americans will suffer the same abuse with massive cost overrun and without appropriate recourse.

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

Stanley Feld M.D.,FACP,MACE

Consensus is usually defined as a general agreement by groups of people. Consensus decision-making is the process of developing a consensus. A consensus is theoretically inclusive, participatory, cooperative, and egalitarian. Egalitarian means all stakeholders in a consensus decision making process should be afforded equal input into the process. All stakeholders should have the opportunity to table, amend or block proposals.

The consensus decision making process should be solution oriented. It should strive to be all inclusive, promote compromise and resolve positions of difference.

President-elect Obama issued an important challenge to forming a consensus.

"In order for us to reform our health care system, we must first begin reforming how government communicates with the American people," Obama said in a statement yesterday. "These Health Care Community Discussions are a great way for the American people to have a direct say in our health reform efforts."

The consensus decision making process has been contaminated by President-elect Obama’s healthcare transition team in order to arrive at Tom Daschle’s predetermined solution. The results of the consensus building will be molded to fit the ideas the Secretary designate of HHS has to repair the healthcare system.

Dr. Val Jones had a Healthcare Community Discussion in her home. It seems the healthcare transitions teams goal is accumulate as many horrible healthcare interface stories as they can to use as evidence of the need for the new bureaucracy to be imposed on the healthcare system.

“President-elect Obama and Secretary of HHS designate, Tom Daschle, invited concerned Americans to discuss healthcare reform in community groups across the country. My husband and I hosted one such group at our home in DC yesterday. Although we had been instructed to compile a list of compelling stories about system failures – instead we decided to be rebellious and discuss “what’s right with the healthcare system” and compile a list of best practices to submit to the change.gov website.

Even in Val’s attempt to be rebellious she had only one physician in her group.

“The event was attended by a wide range of healthcare stakeholders, including a government relations expert, FDA manager, US Marine, patient advocate, health IT specialist, transportation lobbyist, real estate lobbyist, health technology innovator, Kaiser-trained family physician, medical blogger, and EMR consultant. Here is what they thought was “right” with the healthcare system:”

The deck is intentionally being stacked against the private practice of medicine. It ignores the fact that eighty percent of the medical workforce is in private practice. Uwe Reinhardt said do not get your workforce mad. I would think private practicing physicians as a stakeholder should have significant input into forming a true consensus.

“President-elect Obama has picked up a hardheaded political strategist in Tom Daschle for his push to overhaul the nation’s healthcare system.”

I believe President –elect Obama has a great chance of overhauling the healthcare system. The problem, in my opinion, is elements of Tom Daschle’s overhaul are wrong. The public opinion manipulation will probably get some legislation passed, but will it be the best?

“ Learning from Clinton’s mistakes, the nominee for Health and Human Services secretary favors going on the political offensive to bring about reform.”

A common denominator in this consensus building is everyone agrees something has to be done to fix the healthcare system. The next administration is close to developing this common denominator. They are not building a consensus on what should be done. This issue has already been decided by Mr. Daschle. It does not matter if what is done is wrong.

“Guided by lessons from President Clinton’s healthcare debacle 15 years ago, Daschle has put a premium on cooperation between the White House, Congress and major healthcare interest groups, many of whom agree that major action on healthcare is vital.”

Bertrand Russell said it perfectly.

“What a man believes upon grossly insufficient evidence is an index into his desires — desires of which he himself is often unconscious. If a man is offered a fact which goes against his instincts, he will scrutinize it closely, and unless the evidence is overwhelming, he will refuse to believe it. If, on the other hand, he is offered something which affords a reason for acting in accordance to his instincts, he will accept it even on the slightest evidence. The origin of myths is explained in this way.”

Naomi Klein in the Shock Doctrine said in times of economic or political upheaval policies are enacted that could never have been passed in ordinary times. We are not living in ordinary times.

“Tom Daschle favors moving decisively to seize political momentum and, if necessary, cut off opposition, something he said Clinton failed to do in 1993.”

"This means going on the offensive," he wrote in "Critical," his recent book about healthcare,”

I do not believe Tom Daschle is going to repair the healthcare system. He does not fully comprehend the problems in the healthcare system. Brute force will not work. Aligning stakeholders’ incentives is the only thing that will work.

Stanley Feld M.D.,FACP,MACE

The role of patients with chronic diseases and their physicians must be clear to both patients and physicians. Physicians are coaches. Patients are players. They live with their disease 24 hours a day. Day to day fluctuations occur in the management of chronic disease. An excellent example is patients with hypertension. Blood pressure fluctuates all day long. A single blood pressure measurement during a visit to a physician once every six month is meaningless. Patients must continually monitor their blood pressure to evaluate the effect of their medication. Physicians have to help patients evaluate these data points to make logical medication adjustments.

Patients must to be inspired to manage their chronic disease. This requires patients having confidence in their coaches. It is hard work for patients to monitor their blood pressure daily and learn the meaning of the fluctuations in their blood pressure.

Only day to day blood pressure control is going to prevent the complications of a stroke or a heart attack. Physicians along with the patients’ input must make the necessary adjustments. An effective physician and patient team can make appropriate day to day adjustments.

This idea of mutual trust and confidence between coach and player is illustrated by something that happened between a teacher and me in high school. It illustrates the essence of an effective physician-patient relationship.

It was a rainy day in the spring of 1953 during my junior year in high school. I was on the high school baseball team. The team could not practice that afternoon because of the weather. The team was sent to the Study Hall for the 8^th period.

Ms. W. was one of the 8^th period Study Hall teachers. She was my geometry I and II teacher. I thought she was the greatest. I never missed a question in class or on a test. She came over to me that rainy spring day to say hello. She asked how I was doing in trigonometry.

I told her I was doing terrible. I could not learn a thing from Mr. B. Mr. B. was the chairman of the math department. He taught trig very descriptively. It had no meaning to me. He did not teach us to understand the logic of trigonometry and its uses. No matter how much I tried to derive meaning from the text book by myself the material covered did not stick. I felt Mr. B. suppressed my ability to learn and problem solve. His goal was to have us memorize the material.

Mrs. W. asked me which period I had trigonometry and lunch. I told her trig 5^th period and lunch 6^th period. She said great she taught trig 6^th period and could get me transferred to her class. I could have lunch 5^th period.

I was thrilled beyond belief. She also said she hoped I was aware there was a departmental quiz being given the next day. I would be required to take it. She said the chances are I would do poorly on the test but she encouraged me to study when I got home.

The most amazing thing happened that night when I started studying for the quiz. All of a sudden I grasped concepts I could not grasp previously. Now that I was in Mrs. W. class I solved problems I could not solve previously. A difficult textbook seemed easy.

The next day I went into her trigonometry class, took the test, and got 100%. I know this has happened to all of us at some time in our life. I know it was the result of my knowing that someone had trust and confidence in me and the conviction that I could do the job.

The magical therapeutic power of the patient physician relationship.

If a relationship is positive with mutual respect and commitment by physicians and patients, patients can learn about the pathophysiology of their chronic disease. In turn they can learn to manage their disease properly.

In practicing endocrinology I developed a patient physician contract to define this patient physician relationship. My son, Daniel, alluded to this contract in his letter to me.

Physicians must be dedicated to teaching patients to be the professor of their disease. Physicians must enable patients to want to be the professor of their chronic disease to avoid the complications of the disease. Eighty percent of the healthcare dollar is spent on the complications of chronic disease.

The lesson of Mrs. W. is a powerful lesson. Mrs. W. did enable me to be comfortable and confident in my learning situation because of her trust. She empowered me to learn by myself with her confidence in me.

Many times patients with a chronic disease are frightened by their disease. This fright makes it difficult to learn how to control their disease to avoid its complications. Physicians must deal with this through a positive physician patient relationship. A positive patient physician relationship can make it easier for patients to learn to control their disease.

Converting healthcare into a commodity is discouraging physician-patient relationships. The healthcare system cannot be repaired without effective chronic disease management. Chronic disease management will not be effective without effective patient-physicians relationships.

AACE Diabetes Guidelines, Endocr Pract. 2002;8(Suppl 1)
a. Sample Patient-Physician Contract
I understand that if I agree to participate in the System of Intensive Diabetes Self-Management, I will be expected to do
the following:
1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the
diabetes self-management team
2. Regularly visit the clinic for a physical examination, laboratory tests, and nutrition counseling; follow-up visits will
be scheduled every 3 months or more frequently if deemed necessary by my physician or other members of my
health-care team
3. Bring a detailed 1-day food record to each follow-up visit, provide necessary nutrition information for me and my
dietitian, and adjust my eating habits to meet the nutrition goals established by my dietitian
4. Use medications as prescribed by my health-care team
5. Monitor my blood glucose levels at home as instructed and bring the results to each follow-up visit
6. Follow my prescribed exercise plan
7. Obtain identification as a patient with diabetes, for prompt assistance in case of an emergency
8. Ask my physician and other members of my health-care team to explain any aspect of my care that I do not entirely
understand
I understand that if I do not monitor myself carefully, there is a risk of hypoglycemia.
I also understand that if I do not strive to normalize my blood glucose, I am at increased risk of developing the
complications of diabetes mellitus.
My signature indicates that I have read and understand the above agreement.
__________________________________________
Patient
________________
Date
I agree to provide the leadership for the diabetes self-management team. Team members will be available to answer
your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible
control of your diabetes.
__________________________________________
Physician
________________
Date