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Nothing New: Same Old Story Spun Slightly Differently: Part 1

September 12, 2009
inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

President Obama’s speech on healthcare reform to a joint session of congress added nothing new to the healthcare reform debate.. It was just spun differently.

He did give a tepid nod to tort reform. Defensive medicine results from a defective tort system. The defective tort system generates between $300 and $700 billion dollars a year in excessive diagnostic testing. Lawyers and insurance companies make large sums of money from the malpractice system. The tort system adds little value to the health of citizens.

President Obama said he will set up a few demonstration projects. Government demonstration projects have not worked in the past. His tort reform projects are too few and will have little effect. Everyone knows the problem as well as the solution. Our healthcare system needs significant tort reform immediately. The President is protecting the plaintiff attorneys because he doesn’t want to take them on. They have been large contributors to Democratic Party member election campaigns.

President Obama said the “Public Option” is the best way to control costs. However, he will not have a Public Option if he gets a bill passed. He is going to try to sneak a single party payer system through the back door as Barney Frank has stated.

The President said no one will have to spend more than $5,000.00 a year in out of pocket expenses.

Who is going to pick up the costs after consumers spend $5,000.00? I assume the government will. Consumers have to buy government mandated and approved healthcare plans.

Consumers will have to pay for policies that have a 40% deductible with after tax dollars as opposed to the 20% deductible with pre-tax dollars. The Obama administration has been convinced by the healthcare insurance industry that it needs the increase in deductible percentage in order to produce a lower “affordable” premium.

Consumers, by paying with after tax dollars, will be paying 35% more for their healthcare policies and 20% more in deductibles expenses. If the tax rate goes up to 40% they will pay 40% more for both. This is a hidden increase in consumers’ taxes and a government increase in revenue.

The big winner is the healthcare insurance industry, not consumers. The healthcare insurance industry will have a greater number of people insured on its roles because of a presidential mandate that he had promised to avoid.

President Obama said he will subsidize businesses and individuals who cannot afford healthcare insurance.

Who is going to make that judgment? The government will make that judgment. He asks us to stop being skeptical and trust his administration. He will take care of consumers in the spirit that made our country great.

President Obama, how can we trust your administration with our healthcare needs when we have had experience with so much false hope from your administration in the last 8 months?

He is leaving the control of the healthcare dollars in the healthcare insurance industry’s hands. The healthcare insurance industry provides administrative services. Can we trust the healthcare insurance industry to be fair and look out for the well being of consumers? No!!

President Obama said there are almost 400 insurance companies in the nation. He claims his plan will force them to be competitive. There are only five major healthcare insurance companies (Unitedhealthcare, Aetna Blue Cross/Blue Shield, Cigna, and Humana). Most of the other healthcare insurance companies are subsidiaries of those five major companies.

There will be no competition. The administration says a “Public Option” is the only effective way to lower the costs of healthcare. It will make healthcare insurance companies compete. However the insurance industry will define the costs and the price of the government’s public option. It has done so for Medicare Part D at the expense of taxpayers and it will do it again.

Medicare Part D is another failed government entitlement whose monthly premium has gone from $14 to $37 in three years. The patient deductibles have increase and the onerous donut still exists.

In addition to increasing the premium price the government subsidizes Medicare Part D with of billions of dollars a year. I predict the premiums for the “Public Option” will slowly escalate at tax payers’ expense.

The only creative way to break this healthcare insurance industry stranglehold is to institute a system with Medical Savings Accounts. The government or employers, as providers, should give consumers first $6,000 for their healthcare needs and teach them how to spend it wisely. What consumers do not spend they keep. The second $6,000 would be used to buy high deductible first dollar healthcare coverage.

This is the only way to reduce the healthcare insurance industry’s influence and grasp on healthcare spending. Medical Savings Accounts will provide consumers with incentives to use their healthcare dollar wisely. It will also provide incentives for patients to comply with medication and treatment prescribed. America might even make serious progress combating our obesity epidemic.

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Public Option vs. Ideal Medical Savings Account: Part 1

August 18, 2009
inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

In response to my last post I received this note.

“Stan

This is interesting.  You may like this but it is very obvious that it is just another stall tactic.  If the current bill, with reconciliation, passes, we still have to address these points.  So where are this fellow’s solutions?”

I watched President Obama’s town hall meeting in Grand Junction on Saturday evening. He is a compelling and seductive speaker. If I thought his plan would work and at the same time be budget neutral I might be seduced.

It will not work for the consumer and it will not be budget neutral. He needs a better plan.

What is missing?

President Obama’s generalities are correct. The country needs a system that provides universal care at an affordable cost and an increase in quality. I believe his strategy is wrong. His strategy is reflected in his healthcare reform bill.

He is correct in pointing out that the healthcare insurance industry controls the healthcare dollar. His prescription to destroy the healthcare insurance industry is wrong because it will penalize patients. President Obama’s healthcare reform bill is not doing anything to limit the healthcare insurance industry 20% gross administrative fee whether we have a single party payer or a private insurance system.

He promises to get rid of the waste in the system. He claims eliminating the waste will pay for two thirds of the 1.1 trillion dollars his healthcare billion will cost in the next ten years. The remainder will be paid for by taxing people making over $250,000 a year. He needs to redo the math.

President Obama’s system sounds pretty simple. However, it seems the government hardly ever does anything efficiently. The costs are always underestimated. There are always uncontrolled abuses or unintended consequences.

President Obama is ready to create a massive new bureaucracy and employ approximately 110,000 new employees. Bureaucracy is always a prescription for inefficiency.

President Obama is ignoring the waste created by defensive medicine. The total cost of unnecessary testing is about $750 billion dollars a year. Nonetheless, tort reform is off the table. Defensive medicine is blamed on physicians wanting to generate more money for themselves. I think defensive medicine came first, and then physicians figured out how to generate more income in response to decreasing reimbursements for their services and an increase in malpractice lawsuits. Placing a cap on malpractice awards destroyed the malpractice business in Texas and California.

Where is the role of patients’ responsibility for their own health and healthcare. Patients with adequate healthcare insurance are satisfied. The healthcare inflation problem is the result of medical care costing little for the patient with insurance except for the deductibles.

Our healthcare system is a fix the sick system. The healthcare system is not geared to prevent an illness. The administration’s healthcare reform plan speaks of prevention but does not provide incentives to patients or physicians to prevent illness or even deal with the obesity epidemic..

“Consumers are receiving quality medical care at little direct cost to themselves. This creates runaway costs that have to be addressed. But ill-advised reforms can make things much worse.”

The public has no great love for the healthcare insurance industry. Their protests about the healthcare reform bill are not to protect the healthcare insurance industry. It is to protect their freedom of choice. The public does not trust the government to make choices for them.

Both political parties have extremely low approval ratings. President Obama’s approval rating is sinking because of the perception of his half truths and a mounting distrust by independent voters.

“An effective cure begins with an accurate diagnosis, which is sorely lacking in most policy circles. The proposals currently on offer fail to address the fundamental driver of health-care costs.”

President Obama’s public option and increase in bureaucratic decision making is not going to solve our healthcare systems problems. He is not focusing on repairing the perverse incentives that are presently in the dysfunctional healthcare system.

Consumers must solve the healthcare system problems just like they solved the auto industries problems. Government role should be to provide the appropriate regulations to level the playing field.

“The health-care wedge is an economic term that reflects the difference between what health-care costs the specific provider and what the patient actually pays. When health care is subsidized, no one should be surprised that people demand more of it and that the costs to produce it increase.”

The solution is not a public option or a single party payer system. Consumer driven healthcare is the solution through the use of the ideal medical savings account.

“To pay for the subsidy that the administration and Congress propose, revenues have to come from somewhere. The Obama team has come to the conclusion that we should tax small businesses, large employers and the rich.”

President Obama’s plan will not work because the health-care recipients will lose their jobs as businesses can no longer afford their employees. The economy will get worse and the wealthy will flee to tax havens.

General anxiety will increase, patients will get sicker and the healthcare system will be overused creating more debt and more taxes.

A few economic self evident truths are:

  1. A free marketplace with appropriate rules encourages innovation and productivity.
  2. In the United States profitability is a strong market driver. If inappropriate rules are set up entities will try to figure out how to benefit from the rules to the disadvantage of others.
  3. The higher the taxes the lower the productivity. The lower the taxes the higher the productivity.
  4. The greater the bureaucracy the lower the added value productivity.
  5. Consumers will try to maximize their purchasing power.

“According to research I performed for the Texas Public Policy Foundation, a $1 trillion increase in federal government health subsidies will accelerate health-care inflation, lead to continued growth in health-care expenditures, and diminish our economic growth even further. Despite these costs, some 30 million people will remain uninsured.”

Rather than expanding the role of government in the health-care market, Congress should implement a consumer driven approach to health-care reform. A consumer driven approach focuses on the consumers being the policemen for their own healthcare dollar. If would focus on the doctor relationship and empower the patients and their physicians to make effective and economical choices.

The patients would be proactive rather
than passive. The result will be an increase in efficiency in the healthcare system rather than a further decrease.

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

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President Obama Says “Healthcare Will Not Be Rationed”

August 4, 2009
inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

 

Rationing of healthcare services is not new. Medicare presently rations healthcare services. Private healthcare insurance also rations healthcare services. Physicians and patients need medical preapproval for tests, surgery and specialty consultations. If a physician wants a patient to have a simple CBC (complete blood count) and the reason for the test is not documented by an appropriate code the government and the healthcare insurance industry does not allow the charge.

Physicians’ offices spend hours trying to get preapprovals for their patients from people who are trained to look up indications for procedures on a computer.

This week President Obama has denied that his healthcare reform bill will ration healthcare services. The facts of HR 3200 and his own speeches contradict his statement. In his speech to the American Medical Association, President Obama said

“The only way to control health care costs is to get doctors to provide less care — fewer tests, fewer procedures, fewer everything. Of course, the Administration wants to eliminate only that care that is "unnecessary."

Who will determine what is unnecessary? The government will with President Obama’s healthcare reform bills!!

Ezekiel Emanuel M.D. .a medical ethicist, (Rahm Emanuel’s brother and President Obama’s medical advisor) has defined unnecessary in his book and papers. President Obama’s Office of Management and Budget Director Peter Orszag has agreed.

Peter Singer, a medical ethicist, had a long article in the New York Times magazine section defending the fact that healthcare must be rationed.

The Administration has determined that neither you nor your physician should be the judge of the treatment you need. The government will tell physicians how it wants them to practice medicine.

The government, in an attempt to avoid blame for healthcare rationing, plans to set up an independent group of “experts” to set reimbursement fees or not allow payment for services it deems unnecessary. If a physician disagrees with the “experts” because the “experts” might not have all the facts the physician can appeal.

The process will be inefficient. It will generate waste and is doubtful it will improve care.

“ The Administration is asking for independent authority to set reimbursement fees for all providers under Medicare. To assist in this effort, the Administration is proposing a new federal health board to decide whether health care services are "effective" or "appropriate."

The Obama administration has concluded that the best way to discourage "unnecessary care" is not to pay for it. Who is liable for not delivering “unnecessary “ care that might be necessary and life saving? The government is not liable according to HR3200. Malpractice reform for physicians and patients is not to be found in President Obama’s healthcare reform bill. Yet $750 billion dollars are wasted on defensive medicine.

The administration’s new proposal represents an increase in regulations and in turn an increase in healthcare services rationing.

If healthcare is to be rationed how should it be rationed?

The administration’s answer is defined by Dr. Emanuel’s philosophy.

He advocates a system he calls a complete lives system. The complete lives system discriminates against the elderly.

“Emanuel advocated allocating health resources in order to maximize collective life years. He justifies denying care to elderly patients in the following way. Suppose a 25-year-old and a 65-year-old have a life threatening disease. Since the 25-year-old has many more potential years of life ahead of him, he should receive preferential treatment, says Emanuel.”

Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Dr. Emanuel has said health services should not be guaranteed to "individuals who are irreversibly prevented from being or becoming participating citizens."

Think about Ted Kennedy. Think about the treatment he is receiving to save his life. Who is paying for it? Is the government paying for his treatment with Medicare Part C? Should he be denied treatment by a panel of “experts” when his prognosis is so terrible and he has already lived a full and productive life? If Ted Kennedy believes in his own bill shouldn’t he stop treatment that might to save his life? Should he have freedom to choose to live or die? Will Ted Kennedy be a productive citizen in the future?

My view is the individual should decide on his treatment along with his trusted physician. The government position should be to provide patients with appropriate education so they can choose the best treatment options. The government should provide funds for physician education to teach the best treatment options. The government should not decide for us.

Peter Clinch of Silver Springs, MD says it all in the comment section of Peter Singer’s article

“Health care, like all finite resources in the universe, is rationed today and will be rationed in the future. The question is who should be doing the rationing. In a society that respects life and values freedom, that task is best left to a marketplace of individuals making decisions for themselves, which is why health care reform should focus on decentralizing health insurance, not socializing it. Americans should be able to make decisions for themselves as to how much of their resources today they want to set aside for insurance that they may need in the future. To surrender our freedom and dignity to power-hungry central planners in exchange for lofty Utopian promises is an act that will mark us for generations to come as well-meaning but misguided fools”

 

President Obama, why don’t you attack the healthcare system’s real problems?

You should be concentrating on real malpractice reform and eliminate the need for defensive medicine, administrative waste, the large administrative service fees paid by outsourcing healthcare administration to the healthcare insurance industry, real price transparency, effective electronic medical records and e-prescriptions legislation, real chronic disease management, and public service advocacy to reduce obesity.

This is where government intervention can be effective in reducing costs to the healthcare system. Don’t continue to impinge on Americans’ freedoms. Americans will not tolerate it and you will have lost your opportunity to Repair the Healthcare System.

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

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Another Complicated Mistake By A Different Administration

February 18, 2009
inChronic Disese Management, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

Medicare and Medicaid (run by the states) are both on the brink of bankrupting the country. The present path is unsustainable.

It would be prudent to repair both programs by innovations that would render these societal entitlements sustainable. In order to fix the system the government should focus on solving the causes of the largest costs to the healthcare system (go where the money is).

The money is in preventing the onset of chronic diseases and its complications. Eighty percent of the healthcare dollars are spent on treating the complications of chronic diseases.

The complexity of President Obama’s “economic stimulus bill” for healthcare is going to lead to increased government spending and increased control over physicians’ medical judgment. It will be a deterrent to innovative research and thinking.

“Congress will provide 1.1 billion dollars for clinical research to the federal government to compare the effectiveness of different treatments (drugs, medical devices, surgery and other ways of treating specific conditions) for the same illness.”

A new government body will supervise head to head clinical studies. The clinical studies will test the difference between medication, procedures and other treatments for specific diseases. The government will then decide on the best treatment for each disease.

The stimulus package creates another bureaucracy that could add a level of inflexibility to the delivery of effective medical care. The government’s goal is noble. It wants to increase uniformity of care at the lowest cost of care. This could lead to rationing of healthcare and elimination of patient choice.

“The bill creates a council of up to 15 federal employees to coordinate the research and to advise President Obama and Congress on how to spend the money.”

It is obvious to me that it will not stimulate new innovative medical science. It could also drive physicians away from treating patients in government programs.

President Obama should be investing in research that promotes the development of more effective medical and surgical treatments for various diseases. They should not be comparing old treatments to decide on which are better. Physicians should be allowed to exercise medical judgment. Physicians should be given incentives to choose the most cost efficient therapy and not restrict their intellectual property. Presently incentives promote the least cost efficient therapy.

Government regulated and supported research has already judged the therapeutic safety of medication and procedures in a limited and artificial way. President Obama’s healthcare team should learn from the experience in other countries before wasting this money.

“Britain, France and other countries have bodies that assess health technologies and compare the effectiveness, and sometimes the cost, of different treatments.”

“Comparative effectiveness is a useful tool in the tool kit, but it’s not the answer to anything,” Andrew Witty, the CEO of GlaxoSmithKline said in an interview. “Other countries have fallen in love with the concept, then spent years figuring out how on earth to make it work to save money.”

Mr. Witty is the CEO of a stakeholder company that is threatened by President Obama’s initiative. His comments can easily be dismissed by clinical researchers because the comment threatens their vested interest. However it is a common sense comment.

Federal government officials can see this as a way to control costs. However not one has looked at its practical effect in countries that have used this approach. It certainly would restrict access to care.

For many years, the government has regulated drugs and devices and supported biomedical research, but the goal was usually to establish if a particular treatment was safe and effective, not if it was better than the alternatives.

The money for healthcare research should focus on medical and financial outcomes in real time in the real world. Most clinical research studies are short term (1 year to 3 years) with limited follow-up evaluations and no long term financial outcome comparisons. Some clinical research studies are poorly designed and the conclusions can be detrimental to good medical care.

A non surgical approach can be as effective as a surgical approach short term. Long term the patient might need a surgical approach. This is what a physician’s clinical judgment is about. The data that will be captured by this new agency using comparison clinical research protocols is limited and can yield poor conclusions.

An example of a disastrous clinical trial is the Women’s Health Initiative. Both the protocol and the statistical analysis were defective. I believe that the defects in the study will lead to more female morbidity and great healthcare cost in the future.

I believe the “clinical research” is going to result in confusion, senseless debates and inaccurate conclusions.

The government will find the incidence of chronic disease has because obesity and environmental pollution has increased.

Obesity is directly linked to diabetes mellitus, hypertension and hyperlipidemia and back problems. Environmental pollution is directly linked to chronic obstructive lung disease and asthma.

The complications of chronic disease absorb 80% of the healthcare dollars. These are the areas government ought to be spending money to inspire innovative thinking.

The $1.1 billion dollars can go a long way toward controlling chronic disease.

The cost of head to head comparisons makes this endeavor a meaningless waste of money. I was hoping the new administration would have the curiosity and common sense to repair the healthcare system correctly.

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

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Health Insurers Will Accept Universal Coverage! On Condition!

December 14, 2008
inHealthcare Insurance Industry, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System
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Stanley Feld M.D.,FACP,MACE

A few weeks ago in a speech in Detroit the CEO
of Aetna Healthcare Urged Mandatory Health Care Coverage.

He
said it would lower costs healthcare insurance
costs.

Of course the CEO of Aetna would want mandatory healthcare coverage with the
government providing a subsidy to consumers who could not afford to buy
healthcare insurance. The
more lives insured the more profit his healthcare insurance company would
make. Aetna CEO’s statement is clearly self serving.

The cost of healthcare insurance could decrease or stay the same.

If the government subsidizes the premiums of all Americans the price of the
premium might also go up. The
Massachusetts mandate has experienced cost overruns for a very simple reason
Premiums have gone up in Massachusetts and the government has paid the
difference. Premiums are put out for bids and the healthcare industry is in
control of determining the bid.

"The
health insurance industry said Wednesday that it would support a health care
overhaul requiring insurers to accept all customers, regardless of illness or
disability. But in return, the industry said, Congress should require all
Americans to have coverage.”

Consumers should have freedom of choice of physicians. If they want
healthcare insurance they should be able to buy it. If they qualify for
government assistance they should be able to buy it under the same conditions a
consumer not qualifying for government assistance buys insurance. The government
should not mandate consumers to buy healthcare insurance.

The healthcare insurance industry claims “In the absence of such a
mandate, insurers said, many people will wait until they become sick before they
buy insurance.”

If the consumer got sick and did not have healthcare insurance the financial
penalty for buying insurance after they got sick would be higher than before
they got sick. This would be a deterrent to consumers’ gaming the system and not
becoming covered by insurance. Healthcare insurance at an affordable price
should be available to all.

“The proposals, put forward by the insurers’ two main trade associations,
have the potential to reshape and advance the debate over universal health
insurance just as President-elect Barack
Obama prepares to take office.

The problem is there is no transparency in the pricing of healthcare
insurance nor is there an effective system of competitive pricing. There is also
no deterrent to overuse of the healthcare system by consumers. Consumers have no
incentive to keep the price down for their care. There is no price transparency
or pricing competition among hospital systems. Hospital systems have inflated
fees. Their actual costs of services are not transparent to the government or
the healthcare insurance industry.

Physicians can be patient advocates. The public must be empowered to make
physicians competitive.

Finally, pharmaceutical prices are random and in most causes not justified.
There are at least five different prices for pharmaceuticals. The prices vary
from a retail price, an average wholesale price and a wholesale price.

The temptation by healthcare policy wonks is to regulate the pharmaceutical
industry by imposing price controls. Price controls never work. They only make
things worse. Real price transparency and competitive pricing of drugs is
essential. It is also essential to make physicians aware of the prices of drugs
they prescribe. If the brand name drug is ten times the price of a generic drug
both the patients and physicians should know it and be aware of the difference.
If physicians feel the drug effect of the brand does not justify the price
difference. Physicians will order the generic drugs.

“Research suggests that some insurers turn down 10 percent or more of
applicants for individual coverage because of their pre-existing medical
conditions.

A
55-65 year old male with mild obesity (BMI=28), mild hypertension and an LDL of
105 (normal is less than 100) would be rejected by a healthcare insurance
company. If he was in a group insurance plan he would be accepted. Unknown
to his employer the premium the employer pays for all his employees would be
increased. Medicare will automatically accept this person at age 65.

“Mr. Obama said he wanted to be certain that insurance was affordable and
available to all before considering such a broad requirement”

This is very wise on Mr. Obama’s part because the insurance industry is going
to control the premium. He needs to guarantee affordability.

“In the individual market, people can choose whether or not to apply for
coverage,” Mr. Hamm said in an interview. “If they know they can obtain coverage
at any time, many will wait until they get sick to apply for it. That increases
the price for everyone.”

The insurance industry wants to be assured that the market is expanded. They
are killing the goose that laid their golden egg because they can be cut out of
the picture entirely.

“The new policy statements are silent on two important issues: how to enforce
an individual mandate and how to regulate insurance prices, or premiums. While
insurers would be required to sell insurance to any applicant, nothing would
guarantee that consumers could afford it. Rate regulation promises to be a
highly contentious issue, since it pits the financial interests of insurers
against those of consumers.”

Medicare has guaranteed rates and insurability regardless of the severity of
the illness. The government subsides the shortfall. The insurance industry’s
only interest is net profit without price transparency.

Alissa Fox, a vice president of the Blue Cross and Blue Shield Association,
said the individual mandate was an indispensable corollary of any approach
forbidding insurers to reject applicants because of health status.

If the healthcare insurance industry continues to make demands that guarantee
excess profits the government will impose universal coverage with a single party
payer (socialized medicine) and all
the problems that will bring.

 

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

 

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Dear President-elect Obama

November 9, 2008
inSummary Blogs
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Stanley Feld M.D.,FACP,MACE

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.

Unfortunately, stakeholders will not voluntarily be socially responsible and the consumer will assume responsibility only with significant education and incentives. The goal of remaining healthy is subverted advertising of the food industry. The food industry’s advertising has to be redirected to consumer education and not consumer self destruction.

Over the past 21/2 years I have analyzed the problems in the healthcare system and presented the solutions to the problems in my blog “Repairing the Healthcare System”. I will review highlights of the problems and the solutions. I have provided links for you to study.

You have promised you will govern for the benefit of people with input from the people and not special interests. I hope this is true.

You will not be able to make the appropriate decisions without appropriate input. I hope my review will come before you. I am asking my readers to help get it before you.

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

The problems with the healthcare system are broader than economics. The problems are problems that results from the interrelationship of other societal problems.

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.

You are correct when you say you want to prevent chronic diseases. This is harder than it sounds because chronic disease management is not done as an extension of a physician’s care.

Several chronic diseases such as diabetes mellitus and heart disease are mostly a direct result of obesity. The obesity epidemic is interconnected with our energy policy and energy subsidies, farm policies and subsidies, environmental policy and conditioned attitudes toward fast food.

Obesity leads to 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 that incidence of diabetes mellitus by at least 50%. Cheap manufactured food subsided by the government consumes 19% of the fossil fuel we use and results in more that 75% of the obesity in this country.

Michael Pollan points out the problem with or 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 your presidency has inherited are tightly connected. The repair of each problem has to must be done in a creative way that aligns all the stakeholders incentive with consumers and their health and wellness being the major stakeholder.

Pollen goes on to say “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 disease. This results in a 1.6 trillion dollar cost to the healthcare system. It is also major reason for our energy dependence and climate change. All America needs is the will to change. The science is available.

It is going to require a lot of public and congressional education. Congress will be harder to educate than the public because congress is driven by vested interest lobbying. You 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. “

Michael Pollan's is a brilliant interpreter of farm policy. He should have significant input in your administration. He should perhaps be nominated for Secretary of Agriculture.

Thomas Friedman should be read carefully. He could provide input into determining the resources need to create the paradigm shift necessary to cure the underlying problems of our environment.

America’s coal resource is abundant and cheap. America’s energy companies would love to expand coal burning plants. Beware of the promise of clean coal burning plants. Dirty coal burning plants result in environmental pollution with soot, sulfur dioxide, mercury and nitrous oxides. The carbon dioxide footprint is currently not required to be measured. The Environmental Protection Agency does not have a CO2 emission restriction policy in place. Without counting the harmful long term effects of CO2 emissions on climate change, coal burning plants presently result in the chronic disease complications of asthma and chronic obstructive lung disease. These diseases result in a one hundred billion dollar a year cost to the healthcare system. These diseases and their complications can be reduced by at least 50% with an effective clean air policy.

My review letter to you is longer than I anticipated. You have very hard decisions to make but if your intent is to be transformational these decisions will be necessary.

The reformatting of the payment system for physicians is not going to accomplish anything but dispirit the medical profession and diminish the effectiveness of a necessary workforce. Physicians are not the villain. I will review who the real villain/villains are.

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

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Governor Jindal: Health care should be left to patients, doctors

October 29, 2008
inUncategorized
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Stanley Feld M.D.,FACP,MACE

 

Governor Bobby Jindal of Louisiana is about to unveil an overhauled Medicaid program for his state. It remains to be seen whether he is going to do it correctly and whether the federal government will support him.

He has hinted that he understands the healthcare system’s problems. Governor Jindal is a Republican governor. The Republican Party’s mandate is to transfer all entitlement programs to the private sector. The result will not be favorable to patients or physicians. Total control of Medicaid by the healthcare insurance industry would mean less access to care and greater profits for the healthcare insurance industry.

“Louisiana’s efforts to improve health-care outcomes must put more power in the hands of doctors and patients and should also include broad public health measures, such as improving nutrition and boosting physical education requirements in schools, Gov. Bobby Jindal said Wednesday.”

The social contract of medical care should be between the doctor and the patient. It should not be between a third party such as the government or the healthcare insurance industry and the physicians or patients.

The government should be responsible for broad public health measures such developing a culture of good nutrition and physical activity in the schools and public service campaigns to combat obesity and promote healthy living.

“It really is looking at health, not just health care,” Jindal said, citing Louisiana’s higher rates of diabetes, obesity and asthma as chronic conditions that can be improved through a sharper focus on public health.”

“Without providing specifics, Jindal said he would favor legislation to encourage more physical education in schools and improve nutrition in school vending machines and lunches.”

Governor Jindal’s plan to revise Medicaid is called Louisiana Health First. Early indications are that it will be a sweeping overhaul of the ineffective Medicaid system. Early indications are that it will not support the concept of a social contract between patients and physicians.

“The plan, dubbed Louisiana Health First, would turn over large chunks of the program to privately run managed-care organizations, which would oversee the health care of as many as 380,000 residents, mainly children.”

We have seen that managed care does not work. It is really managed costs. Managed care usually restricts access to care in order to manage costs.

Governor Jindal is right in the public health area but dead wrong with his managed care organization proposal. He will just be providing a money making vehicle for managed care organizations (healthcare insurance industry) while not improving the health of the people of Louisiana.

“Jindal said he hopes to get the changes approved before the Bush administration leaves office Jan. 20, as the change to a new president could delay the state’s plans. “We simply don’t want to start over from scratch,” Jindal said”.

He wants the change before January 20th 2008. He would love to sneak in a plan that would outsource state and federally subsidize Medicaid to managed care organizations. The Republican Party’s goal is to abandon entitlement programs and hand them over to the private sector (healthcare insurance industry).

President Bush tried to privatize social security. If he was successful it would have been a disaster given the present financial crisis. The President is in the process of privatizing Medicare with the Medicare Advantage program. The administration is paying a premium to the healthcare insurance industry to accomplish the transfer at the expense of taxpayers and seniors. Massachusetts is privatizing universal care and experiencing large cost overruns.They will all fail.

Who do you think will lose? Patients and physician will lose. The only reform program that will work will be to provide incentives for consumers to be in control of their healthcare dollar along with a reward system for consumers if they responsibly maintain their health.

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Is Medical Care a Right or a Responsibility?

October 12, 2008
inPoliticians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust, Universal Healthcare
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Stanley Feld M.D., FACP, MACE

During the debate on October 7 the presidential candidates were asked if healthcare was a right or a responsibility. In my view neither candidate answered correctly. It demonstrated each candidate’s lack of understanding of the issue.

McCain said:

“I think it’s a responsibility, in this respect, in that we should have available and affordable health care to every American citizen, to every family member. … But government mandates I — I’m always a little nervous about. But it is certainly my responsibility.”

John McCain’s answer is  incomprehensible. He is desperately trying to stay on message. He wants to transfer all entitlements including Medicare, and Social Security to the private sector. One has the think of the disaster the privatization of Social Society would have been during this economic meltdown. I think John McCain understands the weakness of his position on entitlements. He weakened himself even further with unconnected gibberish.

Obama said:

“I think it should be a right for every American. … for my mother to die of cancer at the age of 53 and have to spend the last months of her life in the hospital room arguing with insurance companies because they’re saying that this may be a pre-existing condition and they don’t have to pay her treatment, there’s something fundamentally wrong about that”

Barack Obama’s answer does not prove it should be a right. It shows the power and callousness of the healthcare insurance industry. I have said over and over again that the healthcare insurance industry is not the solution, it is the problem

Both candidates’ get a poor grade for their answer. Their answers indicate neither one has an understanding of the healthcare problem. If you do not understand a problem you can not develop a viable solution to fix the problem. The solution has to be fair to all stakeholders.

The correct answer is the individual’s healthcare should be both a right and a responsibility. Healthcare coverage should be the right of every citizen regardless of age, preexisting illness or income. If citizens choose not to be responsible for their health they should suffer a penalty. If a person is ill he should be responsible for adhering to the medical treatment and follow up or suffer a penalty.

If a citizen suffers a random non-curable illness it is an actuarial hazard that insurance should protect against. If a citizen takes care of his chronic disease to avoid complications he should receive a reward. The process will stimulate responsible behavior for the person’s well being.

Obesity should be discouraged. It is a self inflicted major risk for chronic disease. Nothing is being done to reduce its’ incidence.

Affordable availability of healthcare should be a right of every citizen. At the far end we have  viable safety net hospitals. It seem the present administration is doing everything in it power to eliminate these facilities. John McCain’s thinking implies he will do the same.

Citizens should own their healthcare dollar as outlined in my ideal medical savings account. Employer based healthcare insurance has been the foundation of our healthcare system. In recent years employers have been ripped off by the healthcare industry. If the first $6000 of healthcare coverage was the responsibility of the employee and the employee could keep any money not spent for retirement, the employee would have the incentive to shop for the best medical care at the best price. A communications system could be set up to direct patients to this best care model. This system would provide incentives for caregivers to provide better care.

If a person was self employed or unemployed, means testing would determine the subsidy or payment on a fair basis.

Educational programs for avoiding chronic diseases must be set up or supported through grants by the government to encourage citizens to be responsible for their right.

The government must be responsible for passing legislation to promote environment reforms. Dirty coal plans should be banned. We could prevent at least 21,850 hospital admissions per year nationally. There were 26,000 Emergency room visits for asthma alone last year. Asthma is the No. 1 cause of kids ending up in the Emergency Room. Dirty coal burning power plants cause 554,000 asthmatic attacks, 16,200 attacks of chronic bronchitis, 38,200 heart attacks and 23,600 deaths per year.

I have emphasized that preventing chronic disease and its complications is the key to reducing our healthcare costs. Eighty percent of our healthcare dollar is spent on the complications of chronic disease. Ninety percent of the Medicare dollars are spent on the complication of chronic disease.

 

The narcotics industry is another big problem ”The cost to society of illicit drug abuse alone is $181 billion annually.”

Societal costs combined with alcohol and tobacco costs, exceed $500 billion including healthcare, criminal justice, and lost productivity.

The cost of drug addiction is a tremendous burden to the healthcare system. Yet we are supporting a government in Afghanistan where both the enemy and the government profit from narcotics without the United States doing anything about it. There is no sign that the next administration will do differently.

Americans must wake up. The Presidential candidates must wake up. We need universal healthcare. It is a right and responsibility of every citizen. It is the responsibility of the government to promote a healthy environment so we can exercise our responsibility to remain healthy.

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

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Is Barack Obama Any Different Than Other Politicians? Part 6

August 26, 2008
inMedicine: Healthcare System, Patients Problems, Politicians,Healthcare and Vested Interests
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Stanley Feld M.D.,FACP, MACE

 

Some of the ideas in Barack Obama’s healthcare plan are good. However, some of the ideas have defects. The defects will render execution of his healthcare plan impossible. The complexity of his bureaucratic machinery will make his plan inefficient and costly.

Quality and efficiency are important bullet points in Barack Obama’s healthcare plan

· Quality and Efficiency.

“ Participating insurance companies in the new public program will be required to report data to ensure that standards for quality, health information technology and administration are being met.”

I have stated that measuring quality medical care has not been accurately defined. Quality medical care should be measured by positive medical outcomes at the least cost. Successful medical outcomes have to be linked to successful financial outcomes.

Inaccurate quality measurements are presently being used to judge physician performance. The system is called Pay for Performance (P4P).

Hemoglobin A1c testing is an example of a presently used quality measure. Does the physician do four hemoglobin A1c’s per year in treating his diabetics? HbA1c is a measurement of glucose control over a 3 month period of time. The result is a valid measurement of glucose control.

The four measurements of HbA1c are in itself meaningless. The importance of the measurement is to track patients’ HbA1c improvement over the year? How much of the improvement was due to the physician’s treatment? How much of it was due to the patient’s effort to improve his HbA1c? Did the improvement in HbA1c prevent the patient from developing a complication of Diabetes Mellitus?

 

Did the improvement keep the patient out of the hospital? The results and cost savings from these results are the parameters that should be measured to make the judgment of the quality of care and not the measurement of HbA1c itself. The dual fulfillment of the responsibility of the physician and patient should be measured. None of these goals are included in the definition of quality measurements at this time. Until they are we do not have an accurate measurement of quality medical care.

Before the government can demand that participating insurance companies in the new public program can ensure that standards of quality are met quality has to be defined. If the healthcare insurance companies are determining quality the government is essentially putting the fox in the hen house to have a feast.

Lowering costs by modernizing the healthcare system is an essential idea. The responsibility for the cost of care should not be a burden of the government. It should not be a burden on the employer who is providing the benefit. It should be a burden of the consumer (patient). It should be the consumer’s responsibility to take care of him. The employer and government should aid the consumer in his ability to fulfill his responsibility for his wellness and effective and efficient care if he is sick.
Lower Costs by Modernizing The U.S. Health Care System
  • Reducing Costs of Catastrophic Illnesses for Employers and Their Employees:

Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. The Obama plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers’ premiums.

Many of the chronic diseases are the result of our social behavior and environment. Obesity, pollution, drug addiction, smoking, and public hygiene generate many chronic diseases. Who should be responsible for our social behavior and environment? Should it be the government, our employer, the state, or our neighbors?

I believe the government should be responsible for developing programs to eliminate pollution as it did in the past with smoking. Our government has dropped the ball with its public service campaign against smoking. It can be done if Congress and the President had the courage to do it.

The government could also do much to reduce obesity and drug addiction. However, it must be up to the consumer to be responsible for himself. Obesity and drug addiction are tinder box problems for our healthcare system. Coal burning electricity plants are another problem. It increases our carbon footprint but this impact is not even a required measurement for license. The indiscriminate use of antibiotics in cattle feed lots is another tinder box problem. The problem could be a mutation of an antibiotic resistant infectious disease epidemic. Barack Obama should be talking about solving these problems and not providing a rebate for employers who have employees with catastrophic illness.

  • Helping Patients:
    1. Support disease management programs. Seventy five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease and high blood pressure. Obama will require that providers that participate in the new public plan, Medicare or the Federal Employee Health Benefits Program (FEHBP) utilize proven disease management programs. This will improve quality of care, give doctors better information and lower costs.

This is a great idea. Presently these programs are not supported by the government or healthcare insurance companies.

Traditionally the government sets up pilot programs to test every concept. However, when the pilot study for the effect of managing chronic disease failed, it failed not because the concept of chronic disease management was wrong but because the design of the pilot was defective.

 

· Coordinate and Integrate care.

Over 133 million Americans have at least one chronic disease and these chronic conditions cost a staggering $1.7 trillion yearly. Obama will support implementation of programs and encourage team care that will improve coordination and integration of care of those with chronic conditions.

This is another great idea. The emphasis for reimbursement has to shift from procedural medicine to cognitive medicine. Since cognitive medicine has not been well supported with reimbursement, physician care has migrated to procedural medicine. Diabetes education is an essential element in teaching the patient how to become a “professor of their disease”. It is essential that patients know how to self manage their diabetes. Diabetes education program must be supported so that physicians can afford to develop diabetes education centers in their office. The diabetes education must be an extension of the physicians care. It does not work in a free standing clinic that is uncoordinated with the physician. It has to be a team management effort with the patient in the center of the team and the physician the captain of the team. It must be a team effort so the patient feels connected and cared for.

None of the infrastructure for chronic disease management is in place presently. I am happy that in Barack Obam
a’s healthcare plan there is awareness of this essential element to repair the healthcare system. However legislative regulation must occur for this to become a reality.

· Require full transparency about quality and costs.

“Obama will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care. Health plans will also be required to disclose the percentage of premiums that go to patient care as opposed to administrative costs.”

Real price transparency is another big idea.

It must occur if there is going to be any improvement in the costs of the healthcare system. However, if all we have is a single party payer (the government) with the administrative services outsourced to the healthcare insurance industry price transparency will not occur. There will be no competition for healthcare insurance coverage. The lack of competition means the lack of innovation.

Barack Obama has some good ideas.The ideas will fail because big government is king. It is big government’s role to control the lives of the people rather than creating programs which promote people to control their own lives? Most people can be trusted. If they can not control their own lives  under proper incentives and supervision they should be penalized. The government should not try to control the lives of the people.

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