Stanley Feld M.D.,FACP,MACE

In my first letter I said repairing the healthcare system was simple. I pointed out the problems in our industrialized food system and its impact on the environment, our energy dependence and our healthcare systems’ costs. The industrial food industry contributes at least 300 billion dollars in increased cost to the healthcare system.

A healthcare cost saving of at least $150 billion dollars could occur if the complications of chronic disease could be decreased by 50%. The practices of chronic disease management using prevention of disease and evidence based medicine makes this promise possible.

The problems in the healthcare system are great. The initial question is who is at fault. All the stakeholders are at fault. The stakeholders are the healthcare insurance industry, the government, the hospital systems, the physicians and most importantly, the patients.

The primary stakeholders are patients with physicians a close second. Without patients or physicians we would not have a healthcare system. Healthcare insurance companies, the government, and hospitals are secondary stakeholders.

The healthcare insurance industry has turned out to be the biggest villain. It has taken advantage of the dysfunction of the government and weakness of patients and physicians as lobbying groups. The control of power in healthcare is in the hands of the healthcare insurance industry. The rules and regulations must be changed so that patients gain control of the healthcare system.

The healthcare insurance industry has abused this power. It has manipulated congress and the administration to serve its own vested interest.

The result is grotesque salaries for executives and excess administrative fees. Our healthcare system is supposed to be for the benefit of the consumers (patients), not for the benefit of the healthcare insurance industry.

The healthcare industry has restricted access to care and has made interpretation of payment for care impossible. It has decreased physicians’ reimbursement and withheld payments for services rendered without explanation or justification.

The government outsources the administration of Medicare and Medicaid to the healthcare insurance industry. The government calls them vendors. There are many examples of healthcare insurance industry abuse of the healthcare system. Medicare Part D fees for 2009 have just been published with the consent of the government. These new fees are abusive to seniors. It is difficult to understand the government regulators reasoning.

Seniors on fixed incomes need a reliable drug coverage plan. The healthcare insurance industry worked for four years to figure out a system that would be to its advantage and not the seniors’ advantage.

The government subsidizes Medicare Part D. Yet the government does not have the right to negotiate drug prices. I have exposed the abuses of Medicare Part D in detail. The abuses stem from the high deductibles and a doughnut hole that does not cover drug costs after a certain amount is spent by seniors for drugs.

Humana and United Healthcare rushed to insure for Part D because they visualized the money making opportunity quicker than most. Both companies also realized that as healthcare insurance premiums increased in the private sector there would be more uninsured consumers. The less lives covered the lower its profit. Therefore a drug plan leveraged in their favor sponsored by the government would cover the decrease in profit in the private sector.

United Healthcare paid AARP over 4 billion dollars to be their exclusive carrier for AARP senior members. There is no shortage of complaining from AARP’s seniors. The payment for sponsorship has not been fully disclosed nor it’s ethics been investigated.

UnitedHealthcare made a profit of $4.7 billion dollars last year from Medicare Part D at patients’ and the government expense. Despite this profit the monthly fee has increased over the last three years from $15 to $27 and in 2009 to $38 a month with the government’s permission.

UnitedHealthcare convinced government regulators they needed a premium increase in order to cover a shortfall. UnitedHealthcare compromised by changing the drug benefit before hitting the doughnut from $2300 to $2700 and lowering the amount you have to spend getting out of the doughnut from $5200 to $4700.

A careful analysis of the math is in favor of the healthcare insurance companies. Seniors have flocked to Wal-Mart and others to buy $4.00 per month generics paying cash and not using Medicare Part D “insurance”. They are paying cash for rather than putting their prescriptions on their Medicare Part D plan. If they put the prescription on Medicare Part D their co-pay would be $6.00 for a month’s supply of medication rather than $4.00 to Wal-Mart. The prescription could be charged between $20 and $50 toward the doughnut even though the healthcare insurance company probably only paid Wal-Mart $4.00. None of these prices are transparent.

President-elect Obama, the problems with Medicare Part D would be a good place to start to understand the abuse of this non transparent system. Similar abuses occur with government outsourcing Medicare Part A and B and probably government employee benefit Part C.

This is a tremendous waste of government and consumer resources for the benefit of the healthcare insurance industry. Real price transparency is essential if you are going to make any progress in reducing the cost of the healthcare system.

Real price transparency in this case means: What is the cost of the drug to the pharmacy? What is the cost of the drug to the healthcare insurance company? How is the price of the drug calculated toward the doughnut? How does the government subsidize the healthcare insurance companies for administration of the program? What would be a reasonable profit for the healthcare insurance industry?

I suggest before your administration gets busy penalizing patients with decreased access to care and physicians with decreased reimbursement, your healthcare advisors should dig deeply into the abuses of the real villain in the healthcare system, the healthcare insurance industry.

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

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 2^1/2 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.