Stanley Feld M.D.,FACP,MACE

You made a promise to the American people. You would listen to everyone and choose the best plan. If it did not work you would change the plan. You campaigned on a platform of universal healthcare without mandates. It has recently been reported that a consensus is emerging on universal healthcare.

“The prospect of bold government action appears to be accepted among players across the ideological and political spectrum, including those who opposed the idea in the 1990s”.

I see no evidence that this consensus includes the opinions of practicing physicians. There is some evidence that you have included large well known universities, clinics and hospital systems. However they do not represent the majority of the practicing physicians in the country. The practicing physicians  are your workforce and they are the people whose opinion you should seek.

“The answer says leading groups of businesses, hospitals, doctors, labor unions and insurance companies — as well as senior lawmakers on Capitol Hill and members of the new Obama administration — is unprecedented government intervention to create a system of universal protection.”

This sounds like the typical government way of doing things. The consensus crafts the laws and regulations. When the programs fail the law makers are confused. The programs fail because the laws and regulations do not get to the basic problems. This leads to more regulations leading to more failure.

I am afraid you are going to rely heavily on Tom Daschle. He is a nice man and an effective legislator. He is also a self appointed healthcare expert. I have written an extensive review of Mr. Daschle’s book and plan. His plan is dead wrong. His policies do not solve the basic problems of the healthcare system. 

I beg you. Please do not rely on his plan to solve the healthcare problems. It will only increase the cost, decrease compliance and drive the country into healthcare bankruptcy more quickly.

There are some good ideas in his plan but they are poorly crafted. The recession and rising unemployment will certainly increase the uninsured to well over 250,000. I believe universal healthcare is a concept that has come of age.

“Mr. Daschle wants to open to all Americans the Federal Employee Health Benefits Plan–a menu of private-insurance options now accessible only to government workers.”

He suggests there would also be some form of means-tested premium support (or tax benefits) for Americans who couldn’t afford one of the presently available plans. This could solve the uninsured problem. It would at least put the uninsured premium payment on a pretax dollar schedule and level the playing field. Private health plan contributions made by employers enjoy pre tax status. 

However, by making the Federal Employee Health Benefits Plan available to all citizens you are providing a perfect excuse for employers to drop the health benefit.

Providing a healthcare benefit to employees has become too costly. The Bush administration, by distorting the goals of my ideal Medical Savings Accounts, with Health Savings Accounts tried to provide an excuse for employers to drop the healthcare benefit

Employers have had to decrease healthcare coverage to keep the premium prices within reach. Many citizens are under insured. Employers would rather pay the government and let you be the provider of healthcare insurance for their employees. Universal healthcare with a single party payer then becomes socialized medicine with restriction of freedom of choice by the patients and restrictions on practice of physicians.

Your administration would have to continue to outsource the administrative services to the private healthcare insurance industry. This would thrill the healthcare insurance industry as I have described previously.

Your expanded government program would experience the same financial debacle the state of Massachusetts is experiencing with its universal healthcare plan. In fact the state of Massachusetts has applied for an addition 8 billion dollar bailout after receiving 2 billion dollars from the federal government already.

The Federal Health Board is an example of a bad idea with potential for terrible results. Rather than being a board that creates educational programs for physicians to improve the quality of care (an attribute that has not been clearly defined) it is punitive to physicians and restrictive to patients’ access to care. Remember ,when the CEO of Winn-Dixie was asked what his secret to success was. He said, “Don’t get the A&P mad”.

“The health board would manage the pricing, and use, of tens of thousands of medical products and procedures. How can a single board (instead of, say, the market) make so many decisions, and wisely? Mr. Daschle proposes a dozen or so “experts” who would be “chosen based on their stature, knowledge, and experience, ensuring that the decisions they make have credibility across the health-care spectrum.”

Mr. Daschle admits that the board is loosely based on the National Institute for Clinical Excellence in Britain and the Federal Joint Committee in Germany. Both are charged with managing the public’s access to higher-cost drugs, medical devices and procedures. “But both are growing increasingly unpopular in their home countries–precisely because they’ve become a triumph of cost-containment over patient access and choice.”

“Despite the fresh enthusiasm Mr. Daschle shows for his federal health-board proposal, it’s not exactly a new idea. Mr. Daschle himself proposed it as part of the failed American Health Security Act of 1993.”

This is not the way reform the U.S. healthcare system. The healthcare system needs to be reformed using common sense. I am hoping you will use common sense and get to the core of the healthcare systems problems. I will discuss common sense reforms in my next letter to you.

Stanley Feld M.D.,FACP,MACE

President Bush continues to try to destroy the infrastructure of the healthcare system despite the fact that he is now a lame duck President.

“In the first of an expected avalanche of post-election regulations, the Bush administration on Friday narrowed the scope of services that can be provided to poor people under Medicaid’s outpatient hospital benefit.”

“Public hospitals and state officials immediately protested the action, saying it would reduce Medicaid payments to many hospitals at a time of growing need.”

As the recession deepens, more and more American’s will be uninsured. As more people lose their jobs they will lose their healthcare insurance coverage. America has a defective definition of poverty. Poverty was last defined in 1955. That level is inadequate. A new poverty level must be defined to enable people in need to qualify for Medicaid.

President Bush is trying to eliminate the Medicaid entitlement. However, cities have to attract lower income workers and deal with their healthcare needs. Poverty must be redefined in order to provide Medicaid and keep low income workers in cities and states.

President Bush should realize that no matter what happens to Medicaid the government is going to be the payer of last resort. It would be wise to provide preventive medical care with incentives to the poor to avoid illness before they develop complications of chronic diseases. End-stage kidney disease is on the rise because hypertension and diabetes is not controlled. Dialysis consume 32 billion dollar a year in Medicare and Medicaid funds

“The new rule conflicts with efforts by Congressional leaders and governors to increase federal aid to the states for Medicaid as part of a new economic action plan. “

President-elect Barack Obama has endorsed those efforts to redefine poverty. The Bush administration continues to issue executive orders that will compromise safety net hospitals.

“In a notice published Friday in the Federal Register, the Bush administration said it had to clarify the definition of outpatient hospital services because the current ambiguity had allowed states to claim excessive payments.”

The administration’s excuse is transparent. The fiscal integrity of Medicaid has already been compromised.

“This rule represents a new initiative to preserve the fiscal integrity of the Medicaid program,” the notice said.

After the rule was published a series of protests appeared but has fallen on deaf ears. The administration is willing to bail out the banking system and institutions like AIG as well as the auto industry. Yet it does not permit a vital rung of our healthcare system to survive.

Reform of the Medicaid system is needed. The solution is not slashes in funding at this difficult time. The short and long term effects of destroying Medicaid supported institutions on our economy and health of the underprivileged is great. 

“John W. Bluford III, the president of Truman Medical Centers in Kansas City, Mo., said: “This is a disaster for safety-net institutions like ours.

Alan D. Aviles, the president of the New York City Health and Hospitals Corporation, the largest municipal health care system in the country, said: “The new rule forces us to consider reducing some outpatient services like dental and vision care. State and local government cannot pick up these costs. If anything, we expect to see additional cuts at the state level.”

New York State and California is bankrupt and looking for bail out money.

“Carol H. Steckel, the commissioner of the Alabama Medicaid Agency, said the rule would reduce federal payments for outpatient services at two large children’s hospitals, in Birmingham and Mobile.”

“Richard J. Pollack, the executive vice president of the American Hospital Association, said “The new regulation will jeopardize important community-based services, including screening, diagnostic and dental services for children, as well as lab and ambulance services.”

Whatever the government claims it is not fixing the healthcare system’s problem. It is creating a larger healthcare system problem.

“Matt D. Salo, a health policy specialist at the National Governors Association, said, “The new rule is consistent with the administration’s effort to squeeze, shrink and flatten Medicaid spending.”

Ann Clemency Kohler, the executive director of the National Association of State Medicaid Directors, said: “We have to question why the rule is being issued now, three days after the election, with a new administration coming in.”

Ms. Kohler said the rule would cut “money going to the states, to safety net providers, at a time when states are really being stressed.”

Larry S. Gage, the president of the National Association of Public Hospitals, said, “We will urge Congress to extend the moratorium to this rule, and we will ask the Obama administration to withdraw it.”

These continuing destructive actions by the Bush administration will not enhance the possibility of him having a positive legacy. He is doing more damage to America’s fragile infrastructure.

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

  Stanley Feld M.D.,FACP,MACE

Barack Obama’s goal is to institute a universal healthcare system. I have pointed out that America has a demoralized primary care physician work force. It also has a shortage of primary care physicians. The physician workforce will not be able to care for the influx of patients that will occur in a universal healthcare system. This is especially true as the charity hospitals are on the verge of bankruptcy because of the Medicaid payment system and restrictions on Medicaid eligibility for indigent patients.

The Physicians Foundations completed a survey that asked physicians across the country how they see the medical practice environment? How do they feel about the state of their profession, and that of the industry at large? What plans do they have for the future of their individual practices? Do they believe there are enough of them to handle an influx of more patients?

The Physicians Foundation is an organization with $98 million dollars in available grant money that seeks to advance the work of practicing physicians and to improve the quality of healthcare for all Americans.

“The Physicians Foundation is unique is in its commitment to patient safety, physician education, and quality improvement in physician practice.”

Interestingly the foundation was founded in 2003 as part of a settlement in an anti-racketeering lawsuit among physicians, medical societies, and insurer Aetna, Inc.

The survey was mailed to 270,000 primary care doctors and 50,000 practicing specialists. The survey managers received 11,950 responses. Chad Autry PhD, Professor of Statistics at Texas Christian University said the margin of error for this survey is less than one percent.

The responses to the survey are vital to the future of medical care in America in a universal care setting and the present primary care practice environment.

· An overwhelming majority of physicians – 78% – believe there is a shortage of primary care doctors in the United States today

· 49% of physicians – more than 150,000 doctors nationwide (extrapolation) – said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely. In that same time frame:

· 11%, or more than 35,000 doctors nationwide(extrapolation), said they plan to retire

· 13% said they plan to seek a job in a non-clinical healthcare setting, which would remove them from active patient care

· 20% said they will cut back on patients seen

· 10% said they will work part-time

· 60% of doctors would not recommend medicine as a career to young people

Paperwork

· 63% of doctors said non-clinical paperwork has caused them to spend less time with their patients

· 94% said time they devote to non-clinical paperwork in the last three years has increased

Government

“Declining reimbursement” rated highest on list of issues physicians identify as impediments to the delivery of patient care in their practices, followed by “demands on physician time”

82% said their practices would be “unsustainable” if proposed cuts to Medicare reimbursement were made

65% said Medicaid reimbursement is less than their cost of providing care and 36% said Medicare provides reimbursement that is less than their cost of providing care

Over 33% of physicians have closed their practices to Medicaid patients and 12% have closed their practices to Medicare patients

Finances

· Only 17% of physicians rated the financial position of their practices as “healthy and profitable”

· If they had the financial means, 45% of doctors would retire today

Morale

· “Patient relationships” rated highest on the list of things physicians find satisfying about medicine, while “reimbursement issues” and “managed care issues” rated the highest on the list of issues physicians find unsatisfying about medicine

· Only 6% of physicians described the professional morale of their colleagues as “positive.” 42% of physicians said the professional morale of their colleagues is either “poor” or “very low”

· 78% of physicians said medicine is either “no longer rewarding” or “less rewarding”

· 76% of physicians said they are either at “full capacity” or “overextended and overworked”

The results are clear. America is destined to have a medical care system meltdown unless conditions are changed for primary care physicians. Most physicians trained in America are going into subspecialties. A good start for the Barack Obama’s administration would be to permit states and the federal government to redefine the antiquated definition of poverty, and recognize the value of cognitive services and increase reimbursement to attract more primary care physicians into this specialty.

Primary care physicians should be given incentives (educational support and reimbursement) to treat chronic diseases with systems of care that will prevent the complications of those diseases.

It would be a disaster to use physician substitutes for the treatment of chronic diseases. This approach would not only compromise the potential quality of medical care it would be wasting the valuable resource of physician education that both the physicians and society paid for dearly.

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