Stanley Feld M.D., FACP, MACE Menu

All items for July, 2007


This Is Not The Way To Repair The Healthcare System. Part 1

Stanley Feld M.D.,FACP,MACE

On July 24, 2007 the Washington Post headlined an article entitled “Doctors Rated but Can’t Get a Second Opinion: Inaccurate Data About Physicians’ Performance Can Harm Reputations.”

In our dysfunctional healthcare system tensions are building to great heights between the insurance industry, patients and physicians. The appearance of this article makes me think that the insurance industry subconsciously has a death wish to completely destroy the Healthcare system. The insurance industry is totally insensitive to patients and physicians. Its only concern is its bottom line and seducing employers to buy its product.

The healthcare insurance industry truly believes it owns the healthcare system and can push anyone around. It can force people to do anything it wants. I do not believe this bullying can last.

“After 26 years of a successful medical practice, Alan Berkenwald took for granted that he had a good reputation. But last month he was told he didn’t measure up — by a new computerized rating system.
A patient said an insurance company had added $10 to the cost of seeing Berkenwald instead of other physicians in his western Massachusetts town because the system had demoted him to its Tier 2 for quality.

“Who did you kill?” the man asked sardonically, Berkenwald recalled.”

No one notified Dr Berkenwald about his demotion to a Tier 2 doctor. You will also note that none of the insurance executives have taken a cut in their salaries. However, they feel compelled to cut costs, to keep the health insurance premiums down.

“In the quest to control spiraling costs, insurance companies and employers are looking more closely than ever at how physicians perform, using computers, mountains of health claims and billing data and sophisticated software. Such data-driven surveillance offers the prospect of using incentives to steer patients to care that is both effective and sensibly priced.”

You might recall the surveillance Blue Cross Blue Shield used on Dr. Petak. They made him a second tier physician because he used a medication that helped patients become pregnant without the use of expensive invitro fertilization. The fact is Dr. Petak saved the insurance company tens of thousands of dollars. So much said for automatic surveillance.

Why can’t the health insurance industry learn to use some common sense? The answer is they do not have to.

“It also raises questions about the line between responsible oversight and outright meddling in the relationship between caregivers and their patients. And it shows how people such as Berkenwald are at risk of losing control of their reputations as corporations and other organizations mine electronic data to draw conclusions about them and post them online.”

This is especially true when the criteria they use to judge performance might be faulty and have nothing to do with that physician’s clinical outcomes. There should be some serious consequences to the healthcare insurance industry. The interesting thing is the power to regulate the healthcare insurance industry belongs to the individual states. The state insurance board gives permits to the healthcare insurance companies to sell insurance in each state. It would be interesting if we had some local leadership exert its authority.

“The trend is in its infancy, but such programs are already in more than 100 insurance industry markets or regions across the country, from entire states such as Massachusetts to metropolitan areas such as Los Angeles.”

If the insurance industry can get away with the insanity, why not? It will increase the healthcare insurance industry’s bottom line. It will also result in a reduced payout in fees to physicians. Worst of all it will result in a decrease in medical care to the patients.

” Supporters say the programs have slowed the rate of growth of insurance premiums by 3 to 6 percent in their first year.”

I would like to see the statistical evidence for this minimal decrease in insurance premium growth. I would like to see the absolute dollars saved. I would like to see the reduction in premium. I would like to see if insurance executives’ salaries have decreased also.

Arnold Milstein, chief physician for Mercer Health and Benefits, a health-care consulting firm based in New York, whose firm is analyzing data for the Massachusetts program that ranks physicians said:

“In every industry, consumers have a thirst for performance information, “People don’t want to go to a movie or buy a book or buy a car or go to a restaurant without some ability to assess value for dollar. What’s taking place here is inevitable.”

Dr. Milstein is gathering data for the insurance industry’s benefit and not for the patients’ benefit. The information gatherers do not even have the meaning of quality medical care defined accurately. These consulting companies also make multiple collection errors because of their lack of understanding of the therapeutic contract (patient-physician relationship) and the analysis of inaccurate information.

“Physicians who have been profiled, including those with top ratings, say that the data often contain errors and that doctors often lack the ability to correct them. The effort is more about cutting costs than raising quality, some say, adding that doctors could begin to “cherry pick” healthier patients whose problems are less costly to treat. Such systems fail to capture the intangibles of quality, such as a doctor who visits a dying patient at home, critics say.”

In my view this is absolutely the wrong way to go about fixing the healthcare system. It is the way to destroy and demoralize the physician work force. It is a way of depleting a talented pool of physicians developed through years training. It is a great way of producing a physician shortage. It is a way for the healthcare insurance industry to make the physician community never trust you and never want to cooperate with you. At this moment in history cooperation is essential.

This is the reason I have been advocating consumer driven healthcare. The healthcare insurance industry has little concern for our well being. Its concern is for its bottom line.

It is especially clear that the healthcare insurance companies do not understand the value of the therapeutic contract (patient-physician relationship). Physicians and physicians’ organizations would like to ignore all this noise. They have better work to do. Their work is taking care of patients who are sick. However, we can not ignore this insanity any longer.

The information about quality has to be collected accurately. If a physician is not practicing quality medicine he should be taught how to improve by his peers and not punished by a third party with an unusual agenda.

As I stated, quality is not defined by how many tests you do but by your clinical outcomes. A recent NEJM article reported the British healthcare system is going broke by rewarding quality improvement measures. Clinical outcomes have not improved significantly.

“Doctors are rated on standards of quality of care and cost efficiency. An internist, for example, gets higher ratings on quality if he puts his heart attack patients on beta blockers, a medicine that reduces the workload on the heart, or if diabetic patients are tested for blood-sugar control.”

Just imagine the worst physician in a community figuring out what tests would give him a high rating and increase his income. He does the required tests routinely whether the patient needs them or not. He misinterprets those tests to the detriment of the patient. Yet he is rated the best doctor in the town. It is like a bizarre Fellini movie

The healthcare insurance industry is doing absolutely the wrong thing to improve the healthcare system. It thinks it owns the healthcare system. Their consultants do not practice medicine. They believe they understand the principles of good medical care. They also believe they can measure quality medical care and penalize physicians who do not adhere to their rules. Unfortunately, they are wrong. Unfortunately, patients will suffer.

The only stakeholder that will fix this system will be patients and not the healthcare care insurers.

  • McCamy Taylor

    This is just a variant on the incentive withholds of the 1990s with a new twist. They discovered that they could not cut physician’s salaries enough to make them practice bad medicine–except for the ones who began to drive away the sick and carve out managed care practices of Healthy Members Only to keep their numbers good—so now they are attacking the more vulnerable pocketbook, that of the patient who has already been driven near bankruptcy by high premiums and deductibles.
    Insurance companies know nothing about medicine, but they know a lot about money.

  • jo

    It is a huge conflict of interest for any “for profit” entity to have shareholders and be traded on the stock market then to decide what is best care to save a life. If you truly want reform all health insurance companies would at the very least non-publically traded companies, or be non-profit and all extra monies going toward lowering premiums and better reimbursement payments to physicians.

  • •••
  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


It Is Time For Questions And Comments

Stanley Feld M.D., FACP,MACE

Question 1 – I, too, don’t like single payer. I don’t like single anything. Monopolies are bad, governmental or otherwise. But I believe we must get to true universal health care. How do we force the payers to do the right thing by the patients and doctors?

You can not force anyone to do anything. The effective method to create change is through motivation. I do not like single party payer either. The healthcare system needs a dose of innovative thinking. The healthcare system is way behind other business sectors in the use of information technology to create innovative and competitive systems of care. The two major stakeholders in the system are the patients and the physicians. All the other stakeholders should be facilitators for the patients’ and physicians’ needs. Presently, the insurance industry dominates the healthcare industry. The government pays for a good deal of our healthcare costs. If the government was wise, it would create an environment whereby consumers could own their healthcare dollar and drive their healthcare costs. Bureaucracies can not be successful. Both the government and the insurance industry have failed to control costs. If fact, due to escalating costs they have driven the consumer to become uninsured. Neither the government nor the insurance industry wants to give up control to the consumer. The excuse is the consumer is not smart enough and needs to be protected.

The insurance industry has also made grotesque profits because it controls the money, as well as access to care. It has taken advantage of the healthcare system at the expense of the patients. The insurance industry’s only interest is to maximize profit. If it was smart it would be trying to educate and motivate the consumer to promote innovation by the physicians. The insurance industry should provide incentive for patients to utilize medical care effectively and efficiently. The simplest way to do it is to let patients own and control their healthcare dollar.

If the government controlled the system with a single party payer we would have other troubles. We would have the usual cumbersome bureaucracy that we have in other areas of government. The cost of medical care is escalating partly because of the burden of bureaucracy and administrative costs. As the government is forced to reduce the increasing cost of care it is going to be forced to decrease access to care. The weakest link in the chain is the physicians. Physicians will continue to be blamed for the increasing costs. They will have reimbursement decreased even further. Patients will continue to have access to care restricted. The government seems unable to control hospital fees.

The solution should be to let patients make the decisions about their care with their own money. This is the beauty of my Ideal Medical Savings Account. Patients own the first $6,000 of the insurance premium. The insurance company can administer that money. It is the patient’s job to spend the money wisely. Consumers spend their salary on food and clothing themselves. Insurance for medical care should function as true insurance.

Wikipedia’s definition of insurance is:

Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of a contingent loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium. Insurer, in economics, is the company that sells the insurance. Insurance rate is a factor used to determine the amount, called the premium, to be charged for a certain amount of insurance coverage. Risk management, the practice of appraising and controlling risk, has evolved as a discrete field of study and practice.

The insurance industry obviously doesn’t want to give up the power over patients and physicians nor the power over excessive money they accumulate from the present forms of insurance. However, they have priced themselves out of business. Excessive premiums to large and small companies have led to the 46 million uninsured consumers. You may recall the salaries and bonuses healthcare insurance executives collect for creating so much profit for their company. They make most of the money restricting access to care, reducing physician and hospital reimbursement, and holding the float. Naturally, the insurance company retains all the excess monies.

An innovative business group with sufficient information technology infrastructure will figure out how to instantly adjudicate claims for the patients and help patients manage their $6000 deductible. If patients want to spend money stupidly they will not have the opportunity to accumulate money in their Medical Saving Account for retirement.

The government should not be thinking of creating another entitlement they can not manage. They should be figuring out how to teach the patients how to take care of their medical care needs and spend their money wisely on medical care. The government should subsidize patients who are retired and have paid into the system already. They should also subsidize patients would can not afford the high deductible insurance. If a patient spends the money wisely and avoids a complication of a chronic disease he should receive a bonus from his employer or the government. The bonus should be deposited into his Medical Savings Account.

Question 2 “It seems like the system we have now is all about saying no. Can we have an affordable system that is about saying yes?”

My answer to the question is yes. You will recall 90% of the money is spent on complications of chronic disease. Decrease the complication by 50% and you can save $900 billion dollar in a 2 trillion dollar system without saying no to anything. The patient has to be the one that makes the decision and not the insurance company. If you empower patients through education to take care of their chronic disease and give them the appropriate financial incentives they will act to spend their money wisely. Any money saved in the healthcare system presently belongs to the insurance company. It is no wonder the insurance industry restricts the access to care. Their reasoning is that if the patient develops the complication of a chronic disease after they are no longer insured by that company, the complication of that disease is the new insurance company’s problem and not theirs. Where is the motivation for the insurance company to spend money now to prevent complications later? The complications will not be their problem today. The patients get stuck with the complications of the chronic disease. The entire healthcare system is stuck with the bill.

Consumers driving the system will force physicians and hospitals to become price efficient in order to compete with other physicians and hospitals. Every other industry is becoming innovative and efficient through the use of information technology. This has occurred because the consumer has driven these industries to compete. If they do not, they will vanish. The Healthcare System can also make the adjustment if the consumer has a chance to drive the system.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Just Do It !

Stanley Feld M.D.,FACP,MACE

The mechanism the facilitator stakeholders use to slow down improvement, in my opinion, in the healthcare system, is to do pilot studies on innovative ideas and improvements using faulty criteria in the context of the present dysfunctional healthcare system. The results are usually contradictory to the expected result, statistically flawed, and confusing. However, pilot studies generate another funding source for academic institutions which perform the studies.

A recent article in the Archives of Internal Medicine stated that the measurement of quality indicators were no better in clinics with Electronic Medical Records than in those clinics without an Electronic Medical Record. The data was collected between 2003 and 2004. I will review the flaw in this data in the future. However, a big flaw in the data is that quality indicators (frequency of specific testing for specific diseases and screening testing) are not a direct measurement of clinical outcomes or the financial costs to achieve the improved clinical outcomes. I covered this topic in detail in my blog on the Ideal Electronic Health Record.

In 2004, the United Kingdom invested $3.2 billion in a new program to reward general practitioners for the delivery of high-quality care defined as adherence to quality indicators. The authors examine longitudinal data on quality and report that the incentive program may have prompted a modest improvement in the quality of care for two of the three chronic conditions they studied.

It has been clear for many years that an improvement in the measurement of quality indicators does not mean an improvement in quality care. Improving the clinical outcomes by acting on the findings of the quality measurement is the meaning of improving quality of medical care. The execution of the findings is dependent on the patient’s adherence to appropriate therapy recommendations. The only way to improve quality and clinical outcomes in my opinion is to create a competitive environment among physicians driven by patients owning and retaining their healthcare dollars. This will lead to transparent pricing and drive innovation and cost efficiency.

Yet, the entire pay for performance movement is based on grading physicians on the basis of their quality indicator measurements. This is the reason I said P4P is another complicated mistake.

I understand the reason policy maker advocate P4P. It is because they believe they can easily quantitate the quality of medical care. They will discover as the British have that they will be spending more money without improving clinical outcomes. It is the patient/physician relationship that must drive quality care and improve clinical outcomes.

These interim pilot studies take years to complete. They do not help move medical care into the digital age. If anything it slows medical care down.

Consumers must demand legislation to level the playing field. They must make it clear that they are the primary stakeholders and should be the drivers of the system. It is vital for us to create a true consumer driven healthcare system with the patient and the physician being responsible for the execution of medical care. Consumer driven healthcare would permit consumers to drive the system. The government and the insurance industry have failed, as Regina Herzlinger has pointed out in Who Killed the Healthcare System.

Pilot studies of innovative ideas in our dysfunctional system cannot predict the outcome of these ideas in a new system. Our government can not continue to protect old systems that do not work. Health insurance should mean what insurance means after a certain point of risk. Insurance is a form of risk management primarily used to hedge against the risk of a contingent loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium. Only then could we see if these innovative ideas would work.

In the last couple of years the President and Medicare have called for change. Their requests have gone nowhere because facilitator stakeholders to not want to change a system that is to their advantage. The system must be changed to the patients’ advantage.
The changes required have to be enacted simultaneously because single point change will permit secondary adjustments by the facilitator stakeholders. These changes include:

• Pre tax insurance guaranteed for all.
• Community based rating for premium pricing with government oversight.
• Total price transparency of the lowest negotiated prices for all based on cost and not fiction. The hospitals, the physicians and the insurance companies must be required to comply. This is critical. It would generate a competitive marketplace and force stakeholder to be innovative and develop more cost efficient systems.
• There should be guaranteed insurance coverage for all (universal coverage) with government subsidies. The subsidies should be full or partial for the people who can not afford insurance. The Massachusetts model is going to fail because it is built in a non consumer driven system to the advantage of the insurance industry.

• There should be the option for the Ideal Medical Saving Account and not the contaminated Health Savings Accounts built in favor of the insurance industry. Patients must have incentive to control their healthcare dollar. They must be allowed to retained the money they do not spend in a trust account for their retirement. If the patient has a chronic illness and he maintains good clinical and financial outcomes he should receive a financial reward.

A single party payer system would impose a new and inefficient bureaucracy that would be devastating to the incentives and innovations necessary to Repair the Healthcare system. Innovations and incentive in a competitive entrepreneurial environment is what America’s greatness is all about.

An affordable Electronic Health Record must be available to all as described in the post the Ideal Electronic Health Record.

All of the above must be implemented at the same time for the new healthcare system to work. It will require strong and bold leadership. This bold leadership will only be precipitated by a very vocal demand by an informed public. In our evolving knowledge based economy this People Powercan be accomplished.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Chronic Disease Management Part 4

Stanley Feld M.D.,FACP,MACE

Now that you understand the Type 2 Diabetes Mellitus disease process and what you have to learn about your imaginary disease, the strategy for treatment should be simple to understand.

The goal is to decrease the increasing resistance to insulin as you age, gain weight, do less exercise or increase your stress. The blood sugar increases cause a further increase in insulin resistance. By decreasing insulin resistance the result is to decrease the burden on the pancreas to produce insulin. We have to eliminate the causes of insulin resistance, namely, weight gain, stress and the increasing blood sugar. Additionally, exercise increases the effective number of insulin receptors and decreases insulin resistance. If this strategy was simple to execute there would be much less need for the powerful medications developed over the last few years to decrease insulin resistance. A survey done by the American Association of Clinical Endocrinologists (AACE) of its members a few years ago showed that most Type 2 Diabetics were on at least 3 oral medications. The average cost per year of each medication is about $1700.00. If the patient was spending his own money and understood that weight loss, decrease in stress and increase in exercise could help restore insulin sensitivity and decrease blood sugars. The result would be that much of the medication costs could be decreased markedly in most patients. Patient motivation with the appropriate coordinated education about Type 2 Diabetes and the appropriate follow-up by the Diabetic Education Team (DET) would be high.

Another critical self management tool is home glucose monitoring. Patients can now monitor the effect exercise, weight loss, and stress reduction has on their blood sugar. They can also monitor the effect of the various medications on their blood sugars at various times of day. If patients understood how the various medications worked and learned how to spot problems they could make adjustment between visit to normalize the blood glucose level after email consultation with the physicians and their diabetes education center. However, this consultation time spent between visits should be compensated in order to motivate the physicians to expend the time and energy to set up and execute such a system. The new system has to be driven by the patient and his control over his healthcare dollar (Consumer Driven Healthcare).

I have outlined a system of care for Type 2 Diabetes Mellitus. I will review the power of chronic disease management in other chronic diseases.

If our society really wants to fix the healthcare system these various systems of care must be developed, promoted, and funded. The government, insurance industry, and health policy makers are starting to develop an interest in doing the right thing. However, this potentially means their losing power over the consumer and his ability to drive the system in a real market healthcare economy.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Chronic Disease Management Part 3

Stanley Feld M.D.,FACP,MACE

This blog is dedicated to Joan Colgin R.N., MSN the best Diabetes educator I have ever met. Joan Colgin R.N. is dedicated to the nursing tradition that the patient is first. She is dedicated to helping the physician help the patient.

You recall I asked you to image you have discovered you have Type 2 diabetes. I have provided you with an understanding of the pathophysiology of Type 2 Diabetes Mellitus. You understand why you have an elevated blood glucose level. I reviewed the devastating effects an elevated blood glucose level can have on your eyes, kidneys, nerves and heart.

Now I need to tell you what must be done to enable you to control your blood glucose level to prevent the chronic complications of Diabetes. I understand some people learn faster than others. Some people have so much fear and anxiety about diabetes that they have a very difficult time understanding what has to be done.

The basic educational process initiated by the physician must be reinforced by the Diabetes Education Team (DET). The DET must be an extension of the physician’s care in order for them and the educational process to be effective. It is very important that there are no contradictions in the educational process.

In 1995 the American Association of Clinical Endocrinologists (AACE) published Diabetes Guidelines: Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of Intensive Diabetes Self-Management.

These guidelines were updated in 2002. This system of care was developed by Endocrine Associates of Dallas P.A. We developed a Diabetes Education Center within the practice. Joan Colgin R.N.,MSN. was the chief nurse educator. The physicians, the nurses and the dieticians worked together as an integrated team. We learned a great deal from patients and from each other. We figured out how to teach patients with various learning skills how to become the professor of their diabetes.

We learned that the patient must make a commitment to become as knowledgeable as possible. The patients had to learn how to self-manage their disease and understand the meaning of the results of home glucose monitoring. You will see in the AACE guidelines a Patient Physician contract. (p78)

Patients have to commit themselves to become the professor of their disease and the physician and his team commit themselves to teach the patients how to control their disease.

The AACE guidelines also contain as series of test questions of the patients’ knowledge. (p71-77). The correct answers are starred. Patients are tested at the onset of the education process and at the end of the course. The recommendation is that the education should be given on an individual basis so teaching can be customized to the patient’s learning skill. The test is repeated at 6 months to determine how much the patient has retained. If there are areas of weakness in understanding they can be addressed.

In the process of follow up with the physician the patients are taught to question their reaction to medication and make suggestions to the physician about changes in therapy.

If the physician discovers areas of patient misunderstanding that will hinder the patient’s self-management, the DET can reinforce the education in that specific area. The goal is to normalize the HbA1c in order to avoid complications of Diabetes Mellitus.

This is a very powerful process of care. The difference between the 2002 AACE Diabetes guidelines and other chronic disease guidelines are they are patient centric. Most guidelines are physician centric. Empowering the patient can improve control of blood glucose levels and thus prevent the complications of diabetes.

It introduces the process of rapid cycle improvement into the care of chronic disease management. The care of the patient is led by the patient’s input and participation in the treatment decision making process. The adjustments to therapy are not led by periodic static testing in the physician’s office. Periodic testing is simply a snapshot of the disease process. It tells us the results of the previous care. It is not proactive and tells us little about the changing disease process.

It has been stated most patients are not smart enough to learn about their disease and participate in the care of their disease. I recently received a comment from Dino Ramzi’s expressing this.

“I also know patients who do not have the intellectual capacity to understand the information they are being presented, despite our use of video, comic books and printed material to explain the principles of self-care. Some are too financially constrained or socially overwhelmed to do the right thing. Sometimes paying the rent and putting some food on the table is more important than exercising or taking your pills. Other patients are too depressed to motivate themselves to proper self-care. Others seem to have had some unpleasant interactions with the healthcare system or perhaps a personality disorder (this is a somewhat charitable way of describing the peculiar dysfunctional manipulations of a sorry minority).

The grand fallacy of relying on personal responsibility is that people have at their disposal all the choices to be made. The worst can’t do better.”

I agree with Dino Ramzi’s comment to some extent. However, many people who fit into his categories have not been given the opportunity or financial incentive to learn about their disease. Some patients cannot be motivated to self manage their disease because of their social circumstance. However, with focused training and financial incentive a great number of these people will respond.

However, these patients represent a very small minority of the patients with Type 2 Diabetes Mellitus. Our present system is not effective in decreasing their complications of diabetes. These patients will have complications in any system.

I am talking about the patients that want to learn and self manage their disease. The goal is to educate and motivate the great majority of people who are capable of learning and taking responsibility for their care.

Michelle Sobel, chief creative officer for Emmi Solutions, Inc, a Chicago-based company that produces interactive patient education videos expressed the concept beautifully, “The engaged patient is more than an informed patient. The engaged patient is activated. She understands information critical to her health, communicates effectively and confidently with her clinical team, complies with instructions related to her treatment, and is positively transformed by her experience with care.”
You will recall the adherence/compliance rate for the treatment of most chronic disease has been studied to be only 40-50%. By engaging patients to be proactive in the care of their disease the adherence/compliance rate increases to up to 90%. Only with the appropriate treatment and the appropriate patient adherence to treatment will we decrease the costly complication rates of chronic diseases.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Jake the Pickle Man

Stanley Feld M.D.,FACP,MACE

My son, Brad, has done it again. He is continuously giving me new ideas.

During our most recent visit to Boulder he said “Dad, your blog is great! You are explaining the problem and expressing ideas that should be adopted by the healthcare system. However, the blog is missing your personality.” I was perplexed. He went on to say that my blog needed to express more of my personality. “You have so many great stories about your past which reflect your personal development. These stories should be shared with your audience because they are funny and educational. These “Feld-isms” have inspired me and others. Your blog will then reflect your personality and have greater impact.”

Brad’s suggestion came on the heels of my meeting an old friend a few days earlier in an Art Gallery in Santa Fe. I had not seen Tom McConnell in years. Tom McConnell M.D. is a pathologist. He told me about his life long fantasy to become a writer. During his childhood his father rejected his fantasy so he became a pathologist. He recently began a web site called “ Notes from a Life”. His stories are a riot. “Paratrooper Circumcision” is the funniest and a worthwhile read. Our conversation lasted almost two hours and we have a luncheon date on August 24.

Since I was talking about Diabetes Mellitus and how a high blood glucose level pickles proteins in the body I felt it appropriate to tell you about Jake the Pickle Man.

So here goes. Every Saturday afternoon during my childhood my parents and my brother and I went to visit my grandfather (Pop) and my grandmother on Charlotte Street in the Bronx. Charlotte Street was a street perpendicular to Jennings Street. Jennings Street was a street of food markets just after WWII. There were two butcher shops, two milk stores (dairies), two bakeries, and two fruit and vegetable stands. There was only one sour pickle stand. Jake’s Pickle Stand.

Jake’s Pickle Stand was located in the alley between two buildings. Pop taught my brother Charlie and me one our first business lessons. Pop told us when you have two stores selling the same thing it is good for the customers. The store owners have to compete and be innovative to attract the customers’ business. I doubt Pop used the words compete and innovate to a four year old and a seven and a half year old. However, we understood his point.

Jake had a monopoly. He was the only Pickle Man for miles. It probably did not matter whether Jake had competition or not. Jake made the best sour pickles and sour tomatoes in the Bronx and probably in the universe.

However, Jake had a funny way of marketing his product. He did not do any marketing. If he did not like you he charged you a lot for a sour pickle. If he really did not like you he would chase you away from his pickle stand.

My grandmother always made a large Saturday evening dinner for the family. Naturally we needed sour pickles for dinner. Jake did not like my grandfather very much. Sometimes he would give him only one pickle for a quarter.

My grandfather was very smart and innovative in his own right. He decided to send Charlie and me down to Jake’s Pickle Stand with two pickle jars. I got the bigger jar because I was the big brother. My brother was too small to carry the large jar. Pop gave me fifteen cents. He gave Charlie ten cents. He told us to go stand in line and buy sour pickles from Jake. You have to understand that Jake’s pickle line was longer and slower than any Starbucks coffee line in the country.

We both waited in line patiently. Mrs. Jake, with her four diamond rings, noticed us and whispered something to Jake. I was in front of my brother. At my turn I asked Jake for fifteen cents worth of pickles.

Jakes counting methodology floored me. The first pickle in the jar cost four cents. After he put the second pickle in the jar I only owed him two cents. With the third sour pickle I owed Jake five cents. After adding seven more pickles to the jar I had spent the fifteen cents. Jake filled the three quarter full pickle jar with delicious pickle juice.

Next, it was Charlie’s turn. He had a smaller jar and only his ten cents. Jake started counting ten cents worth of pickles for my brother’s pickle jar. Jake stuffed 14 pickles into Charlie’s smaller jar. Jake could hardly fit any pickle juice into that jar. Our family had plenty of pickles for Saturday night dinner and for the next week as well.

Charlie and I did this week after week. The people in line in back of us were amazed. A seven and one half year old and a four year old walked away with a greater number of pickles for twenty five cents than the total number of pickles any six in line would receive for a quarter a person.

There are at least three business lessons the healthcare system could learn from Jake the Pickle Man. Pop understood Jake’s psyche. Jake did not have children. We were cute and bold. He liked us. Therefore he gave us plenty of pickles for a low price. He did not know that Pop was our grandfather. If the vendor likes you for some reason, your chance of getting a better price in a non market driven environment is better than the person a vendor does not like. Therefore the most efficient markets are truly competitive markets. They should also be consumer driven. Healthcare is not a competitive marketplace and it is not consumer driven.

Do not make Jake mad at you. The moral is do not make the people in power angry. They can ruin your goals. It is constructive to present people in power with ideas that will help improve their business. In the healthcare system the idea should be to align the facilitator stakeholders’ incentives with the primary stakeholders’ incentive, namely the consumer of healthcare. It is difficult to force people in power to be reasonable and fair. Jake the Pickle man would not budge if he did not like you. In the healthcare system the consumer and the physicians are starting to realize that they really have the power. The facilitator stakeholders in the healthcare system are forcing them to do things they do not want to do. These actions, I fear, will lead to more trouble for the medical care system.

I believe most events in life have multiple meanings. The story of Jake the Pickle man illustrates this belief. The healthcare system should learn something from the story of Jake the Pickle Man.

  • Paul Romano

    I have been fascinated with the story of the Bronx in general, and the Crotona Park East neighborhood in particular, and am AMAZED at how many people remember this Jake the Pickle Man. It seems he was murdered in the early 60s, as the neighborhood went into a death spiral. I’ve read numerous accounts of it, but have never discovered whether or not his murderer was ever apprehended. Does anyone know if they were caught?

  • Howard Kasten

    I,too,remember Jake the pickle man.My mother told me he would be very generous with his pickles to my uncle but not so with her.His name we found out was Jacob Sher(t)zer.He was strangled in the early 60’s with socks stuffed in his mouth.I remember reading about it back then.I remember seeing 4 or 5 great danes being walked near Jake’s once in a while.As kids we were terrified of them.I lived on Hoe Ave between 172nd and 173rd Sts,Moved to Bklyn in 1959.Incidentally,MeTV is showing my all time favorie TV show Car 54 Where are You.I loved hearing familiar Bronx streets being mentioned.

  • •••
  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


What Does Chronic Disease Management Mean? Part 2

Stanley Feld M.D.,FACP,MACE

The responsibility for the control of the onset of the complications of chronic disease is the responsibility of the patient. Patients live with their disease 24 hours a day and need to learn how to manage it.

There are 20 million patients with Type 2 Diabetes Mellitus in America. This number is growing every day because we are experiencing an obesity epidemic. As I have previously discussed, this epidemic is the fault of our cultural conditioning.

The physician’s responsibility is to teach the patient how to manage his chronic disease.

Imagine you were told you have Type 2 Diabetes Mellitus. Think about your potential emotional responses. Think of all the bad things you have heard about diabetes mellitus. Think about the fantasies you would have about your future morbidity and mortality. These fantasies are the result of the media information and free public service campaigns various organizations have to heighten awareness about Diabetes Mellitus.

The complications of Diabetes Mellitus cost the healthcare system at least $150 billion dollars per year. At a July 4th party, I spoke to a diabetic patient who has had diabetes mellitus for thirty years. He became a professor of diabetes mellitus 28 years ago and has had his blood glucose levels under exquisite control. He has not suffered one complication of diabetes mellitus. There are many patients like this patient.

How does one start to teach patients to be the professor of their disease? I believe it is important for readers of this blog to understand what patients need to learn. It is also important for readers to understand how this process of self-management is a continuous learning project for both the patients and the physicians. The patients’ effort and responsibility in controlling this chronic disease is enormous, and can be very difficult.

You have just been told you have Type 2 diabetes mellitus. If I describe what needs to be learned you can start understanding how this empowerment could result in better control of the blood glucose level. You could also understand how the information could extinguish your fantasies and anxieties about diabetes mellitus. The result would be a decrease in the complication rate of Diabetes Mellitus.

The teaching process has to be a coordinated effort between the physician and the Diabetes Care Team, the nurse educator, dietician, and exercise therapist. We start by teaching patients what Type 2 Diabetes Mellitus is,
why they got it, and how they can reverse Type 2 Diabetes or at least control the rising blood sugar. If patients understands the pathophysiology they know the enemy. They are not frightened about the consequences of the disease. Then a plan can be developed for patients to actively self manage their disease.

At least 20% of the population has the genetic tendency to develop Type 2 Diabetes Mellitus. The genetic defect is an underlying resistance to their own insulin. We have insulin receptors on every cell in our body. These receptors attract insulin. The insulin receptor/insulin combination permits our cells to absorb circulating blood glucose. Once in the cells the glucose gets metabolized to carbon dioxide and water. In the process, packets of energy (ATP) are stored in our cells.

Increasing weight, stress, decreasing exercise, and development of infection decrease the insulin receptors affinity to attack circulating insulin. In effect you have an increased resistance to your own insulin. These external factors are additive to the underlying genetic defect. The more weight gained, the less exercise done and the more stress one has the greater the insulin resistance. As the effective insulin receptors decrease (increased insulin resistance) our body produces more insulin to compensate for this increase in insulin resistance. Over time we can not compensate with sufficient output of insulin to overcome the insulin resistance and our blood glucose rises.

Diabetes Mellitus is defined as a fasting blood sugar of greater than 126mg% on two occasions. Patients can have fasting blood glucose of greater than 126 mg% for many years without symptoms. Many people, mostly men, do not have periodic blood glucose measurements.

High blood glucose levels are the cause of the complications of Type 2 Diabetes Mellitus. The complications are eye disease, kidney disease, neurological disease and heart disease. The average time from the onset to the diagnosis of Type 2 Diabetes Mellitus has been calculated as 8 years. The average time of onset of complications of diabetes varies with the height of the elevation in the blood glucose levels. If you do not recognize that your blood glucose is elevated because you are asymptomatic you can not appreciate that you are harming your body. Many patients first discover they have diabetes mellitus when they are in the Cardiac Care Unit after suffering the cardiovascular complication (heart attack) of Type 2 Diabetes Mellitus.

Why does a high blood glucose level cause eye disease, kidney disease, neurological disease and heart disease? I have observed that once people understand the concept they become motivated to control their blood glucose levels.

Understanding causality is simple. A graphic way of understanding the process is to know that sugar helps alter proteins. The process of converting cucumbers to sour pickles comes to mind. You mix water, vinegar, salt, spices and sugar together. Then add cucumbers to the liquid and put the container in the closet for two weeks. The cucumbers have turned to sour pickles because the proteins in the cucumber have been deformed.

One can think of a person with a high blood glucose level deforming all the proteins in their body. They are essentially pickling all the cells and vessels in their body. The blood vessels narrow because the cells lining the blood vessels are deformed. For example, If there is not enough blood supply to the eye, the body tries to compensate by making more vessels. These new blood vessels (neovascularization) float on the surface of the retina and are fragile. If they bleed, patients can become blind. This narrowing applies to the blood vessels around nerves resulting in neuropathy. As blood vessels narrow, nerve endings will fire ineffectively. Many times these nerve ending misfires are painful. Many patients lose feeling in their extremities as a result of misfiring of nerve ending.

The hemoglobin molecule carries oxygen to the cells of the body. Each red blood cell has a 120 day life cycle. If a red blood cell is born in a high glucose environment it gets deformed or pickled and rather than being a simple Hb molecule it is now a HBA1c molecule. The higher your HBA1c level is, the higher your average blood glucose level has been over the three month period of time. A normal HbA1c level is under 6%. The HbA1c is that high in normal people because after a meal a normal blood glucose can go as high as 160mg%. National laboratories have calculated that the average Type 2 diabetic has a HbA1c of 9.2%. This finding means that neither patients nor physicians are doing a very good job in lowering the HbA1c to normal.

The patient I referred to earlier with diabetes for 30 years has a HbA1c level of 5.5%

Next time I will describe how that goal of a normal HbA1c can be achieved by the patients. It is the essence of the principle of chronic disease management. Normalization of the HbA1c levels can reduce the complication rate of Type 2 Diabetes Mellitus by at least 50%. It can theoretically reduce the complication rate of Type 2 Diabetes Mellitus by 100%. Fifty percent of $150 billion dollars is not a shabby dollar amount toward the repair of the healthcare system. However, the necessary education process to empower the patients to control their blood glucose levels and prevent obesity is not supported by society, the insurance industry or the government.

  • Electronic Medical Records

    Gaining favor with employer groups, health-care organizations and health payers, these programs are being increasingly questioned

  • Keranamu Gula

    Interesting and valuable post. I believe those with diabetes will appreciate your post. Thanks.

  • •••
  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


What Does Chronic Disease Management Mean? Part 1

Stanley Feld M.D.,FACP,MACE

Ninety percent (90%) of the Medicare dollar is spent on the complications of chronic diseases according to CMS. Eighty percent (80%) of the healthcare dollars for all age groups is spent on the complications of chronic diseases.

I have stated that our medical care system is great at fixing things that are broken. Our healthcare system has not been good at preventing things from breaking. The medical care system has not been good at preventing the complications of chronic diseases once the patient is afflicted with the disease.

There are two reasons for our inability to prevent things from breaking. One, is that most of the abuse to the human body is a result of the patient’s behavior and lifestyle. An additional factor is the genetic predisposition patients have for a particular chronic disease. Physicians can do little to control genetic predisposition presently. Genomics represents a great hope for preventing the onset of chronic disease in the future. Inhibiting stem cell research seems foolish in the face of its potential benefit. Prohibiting the use of embryonic material that is going to be destroyed anyway to me is illogical. The controversy is a result of the science wars presently going on between theology and science. It is my belief once the public understands the potential of genomics and the illogical nature of the controversy, public opinion with turn on the foolishness of the argument and the controversy will evaporate. This is for the future and the prevention of the onset of chronic disease.

Once the patient has a chronic disease, there is much that can be done for each disease to slow or halt its progression and slow or halt the onset of devastating complications. If we were effective in preventing the complications of chronic disease after its onset, this would result in an improved quality of life for patients and a marked reduction in cost to the healthcare system. The present costs of the healthcare system are leading to an increasing number of uninsured as well as bankrupting the nation.

Presently, most studies demonstrate that, with adequate treatment, we can reduce the complication rate of most chronic diseases by 50%. The reduction to the cost of the healthcare system would be 800 million dollars. Theoretically, with perfect control of the chronic disease and perfect medical therapy we could reduce the complication rate by 100%. The result would be a 100% reduction of the 90% of the money spent by the healthcare system on the complications of the diseases.

Most healthcare economists, “healthcare policy experts” and politicians are starting to understand the math. What I have discovered is that they do not understand the process of chronic disease management and the importance of the patient physician relationship. They do not understand the pathophysiology of the chronic diseases or the origin of the complication of the diseases.

The chronic diseases we are talking about are cardiovascular disease and hypertension, diabetes mellitus, osteoporosis and muscular skeletal disease (arthritis and collagen vascular diseases, lung disease, AIDs, and cancer. We have a $2 trillion dollar annual healthcare system. The total cost of all chronic disease complications to the healthcare system is $1.6 trillion dollars per year.

A lot of brain power is going into trying to do something to reduce the healthcare system costs because we simply can not go on with ever increasing costs and ever increasing opportunities for facilitator stakeholders to increase there profitability while there are ever increasing number of uninsured persons.

We must have a universal healthcare system. However, universal healthcare does not mean a single party payer. I believe a single party payer system will add bureaucracy and impose rules that will stifle and inhibit innovation. The result will be increased inefficiency and increased cost. We all agree that what has made America is innovation by entrepreneurs and not rules by bureaucrats. I know that the physicians are not the problem. They are part of the problem. There is no reason to create a healthcare system that will methodically inhibit physician innovation. Even worse, drive a skilled labor force (physicians) out of business whose education we as a society subsidized.

Who is responsible for the complications of chronic diseases? It is the patient who lives with his disease and lifestyle 24 hours a day. The patient must learn how to control his disease to avoid the complications of the disease. The physicians can only be the coach or manager of the patients and modify their treatment plan through his experience and clinical judgment. Physicians must teach patients how to adjust to changes in the course of their disease. Physicians have to do this with their healthcare team with the patient being the most important person on the team.

Patients must be provided with education, incentive and financial reward for their successful adherence to treatment regimes. The promise of good health does not seem to be enough of a reward. Once patients understand that they are responsible for their self-management and the management of their health care dollar adherence to treatment will improve and outcomes of chronic diseases will improve. Physicians also have to be compensated for their effort. To help make the patients the professors of their disease is a very hard process. It is much easier for a physician to set a broken arm, fix a hernia, or even do bypass heart surgery. Yet the insurance industry does not value or reward this effort.

If patients owned their healthcare dollar and needed to spend their money wisely, they would become intelligent consumers of healthcare. This would force innovation by physicians and hospitals. They would force and increase the quality of chronic disease management at decrease the cost. This would also create a competitive environment for hospitals to control prices. They would produce a market driven economy as occurs in other areas of commerce. Healthcare is a not marketplace presently. Hospital prices presently have nothing to do with hospital costs. This is why we need the ideal medical saving account owned by patients and not the insurance industry. The Ideal Medical Savings Accounts would align all the stakeholders incentives to enable the best product at the best price in a truly consumer driven healthcare system.

In order to understand its complexity I will discuss the disease management concept of several diseases. Obesity is the worse epidemic we are experiencing at the moment. It leads to diabetes, heart disease and hypertension, each of which has devastating and costly complications. In my “War on Obesity” I have discussed some of its problems. I will integrate obesity into the disease management process.

  • Aiams1

    I’m curious as to what type of care and treatment patients with Cronic illness will receive if we have universal healthcare. Not those who can prevent symptoms etc but those who need continual aggressive treatments?

  • 2012 moncler coats

    Don’t know what is wrong what is rite but i know that every one has there own point of view and same goes to this one

  • •••
  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


CORE: An Example of People Power

Stanley Feld M.D.,FACP,MACE

This post is dedicated to Tom Wageman a very smart person with unique leadership abilities.

Last weekend the Citizens Organizing for Resources and Environment (CORE)” met at Twin Oaks Ranch in Fannin County Texas for a thank you party for the three young people who helped lead the group. CORE was formed originally when several people became aware of TXU’s plan to build a “Dirty Coal Burning Plant” in the backyard of the Savoy Texas Independent School System’s school buildings.

Each citizen recruited friends to join the group and learn more about the environmental hazard of burning dirty coal. The group was interested in learning the effect it would have on our children’s health and on the lakes and soil in both Fannin and Grayson County. A Goggle group was set up and they were off to the educational races. The goal was networking the community electronically and providing instant information and education on the issue of the “Dirty Coal Plants” affect on our environment.

Citizens from all over the hillsides of North Central Texas started to participate in the news group. Many added information and insight for the education of all of us. The brain power was additive. Shortly after Dallas Mayor Laura Miller made presentations at the Bells and Savoy town hall meetings, Bells and Savoy joined the Coalitions of Texas Cities. Bells is a city of 1700 people and Savoy less than 800 people. TXU decided to build its coal plant in Savoy expecting little opposition. Bells and Savoy received special standing with the coalition because they were close to ground zero. Our lakes and soil were going to be contaminated with mercury and our air with particulate matter, sulfuric acid and nitric acid.

I was especially interested in the medical aspects of these contaminants. Mercury levels are related to the incidence of autism and attention deficit syndrome. The others are related to asthma and chronic obstructive lung disease. It has been calculated that lung disease from particulate matter, sulfuric and nitric acid represent an expenditure of $34 billion dollars per year to the healthcare system. This does not include the pain and suffering in the affected communities. The toll for autism and attention deficit syndrome to local school systems and families is unable to be estimated. A guess by an autism specialist at University of Texas, Southwestern Medical School was a cost nationally of $100 billion dollar in hard and soft costs.

Our governor, Rick Perry was not interested in listening to anyone, especially a few dozen country folks as he was fast tracking the TXU permits to build the “Dirty Coal Plants”. However, the movement (CORE) with the use of internet communications grew and grew as leadership of the Dallas Business Coalition for a Clean Environment joined in. Many small towns joined and we were finally got the Texas legislature aroused.

We all know the result. KKR bought TXU and promised the citizens of Texas they would not seek to build all the coal plants TXU wanted to build. They also promised to clean up the old “Dirty Coal Burning Plants in Texas. Texas is the most polluted state in the nation. KKR also promised to lower our electric bills by 15%. The question remaining is whether KKR/TXU will stand by their promises.

My main point is small groups of people can grow into large groups of people protecting their property, health, and childrens’ health from the dysfunction of the government and industry. We got the attention of old school institutions and positive change resulted.

While we rejoiced, I told everyone this might be a trick play on KKR/TXU’s part. We were relieved that this idyllic part of Texas would be spared deadly contamination. We were also very proud of the small role we played in making it happen.

Last weekend we had a party at Tom Wagemen’s Ranch to thank the three people who helped lead us in this truly citizen driven movement. It convinced me that people as consumers and as the electorate can have an impact on the system. If we understand the data and facts we have phenomenal power and potential. Most importantly, the exercise created a sense of community and friendships among neighbors that did not exist before the group was formed. One person told me that he knew none of these people before CORE. Everyone should know that medically participation in community activities is good for your health and well being.

In the hyper speed technological society the people can impact societies’ slow paced, malfunctioning, obsolete institutions and overcome the inertia of the institutional structures of the old society.

In the United States our culture smiles at innovators, supports positive change makers, and roots for the underdog. People are all feeling a sense of frustration. They are the underdogs to our bureaucracies, clogged courts, legislative myopia, pathological incrementalism and power of vested interest lobbyists. However, with ‘People Power’ we have the brain power and the purchasing power to change our disadvantaged position. Our small group (CORE) was able to demonstrate “People Power” and ignite the interest and support of others feeling the same frustration.
I applaud the CORE group’s leadership.

I also believe with the appropriate understanding of the data, the information and the knowledge that can be derived about the healthcare system, Americans can create the solutions to the healthcare systems problems. Americans want the enormous benefits of the greatest medical care on the planet. They will root out, replace, or radically restructure the legacy institutions which stand in the way. The knowledge about the healthcare system will be communication by physician blogs on the internet. Some innovator working in a large company will come along, produce a medical insurance program, the ideal Medical Savings Account, and the healthcare system will be restructured overnight. The employees want it. The employer wants it. The government wants its. The physicians want it. We need stronger leadership that want to really understand the problem and not leadership that is seeking the best sound bite to win votes.

One problem is that politicians, policy wonks, and government do not understand the patient-physician relationship and its importance to clinical and financial outcomes. They do not understand the patients’ responsibility for their care nor the physicians’ responsibilities in the medical care system. They focus their efforts on commoditizing healthcare and imposing formulas on the healthcare system for physicians and patients to follow. Eighty percent of the population does not use the medical care system because at any one time only 20% of the people are sick. They have no idea of the need for a positive patient physician relationship as a therapeutic tool.
Shel Israel, coauthor of Naked Conversations wrote to my blog this winter, “repairing the medical system in America is a lofty goal and about 98 percent of the American people see the need. The rest work for insurance companies.”

To me those odds seem pretty good. All we have to do is educate Americans and free them from the political spinning of disinformation. I believe this blog and other blogs written by physicians will help Americans understand what is happening to them and the healthcare system. People power will then force legacy institutions to respond, thereby changing the healthcare system to the advantage of the patient.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.