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War On Obesity: Part 12


Stanley Feld M.D.,FACP,MACE

During World Diabetes Day in Dallas Dr. Ken Cooper delivered a terrific keynote address concerning observational studies he has performed. He related fitness to obesity, the early onset of childhood type 2 diabetes mellitus, academic achievement and behavior.

Dr. Cooper is passionate about eliminating obesity in children. He presented us with astonishing statistics.

“Estimated obesity rates for children 6 to 11 years old have increased from 15.1% in 1999 to 18.8% in 2004. The Department of Health and Human Services estimates that 20% of children and youth in the United States will be obese by 2010.

Washington D.C. was first in the nation with 22.6% of children age 10-17 being obese. Texas was sixth with 19.1% of children aged 10-17. Forty two percent (42%) of fourth graders and thirty nine percent (39%) of 8th graders were obese in 2004. Seventy percent (70%) of these children will become obese adults and one in three will develop diabetes.

Type 2 Diabetes Mellitus is common in obese adults over the age of 40. A syndrome consisting of obesity, diabetes mellitus, high lipid levels and hypertension has been described and named “Metabolic Syndrome”. The incidence of coronary artery disease, strokes, end stage kidney disease and the complications of diabetes mellitus is high in patients with Metabolic Syndrome.

These illnesses are costly to the healthcare system. They are secondary to insulin resistance which is secondary to obesity. In order to save the healthcare system from bankruptcy we must have a national War on Obesity.

The obesity epidemic has spread to our children. It has led to an increasing incidence of type 2 diabetes mellitus in our children and earlier in life complications.

“It is estimated that 33% of children born after the year 2000 will develop diabetes with the incidence being higher in Hispanic and African-American children” “ It has been estimated Children developing Type 2 Diabetes before the age of 14 will have their lifespan shortened by 17 to 27 years. “

Dr. Cooper developed a Fitnessgram in 1982. It is composed a series of tests to measure fitness. He demonstrated, in 13,600 men followed for 8.6 years, that the less fit they are the higher the mortality rate. (JAMA, 1998).

He tested the fitness of over one million children. In California he tested fitness against reading and math skills in approximately 1.3 million children in grades 5,7,and 9.

He found; “only 25% of the students could pass all 6 of the Fitness tests. 43% could not walk or run 1 mile in the allotted time. “

As interesting and perhaps more important finding is that the higher the childrens’ fitness scores the higher the children’s test scores in reading and math using California’s standard test.

Children in the national school lunch program did worse in reading and math testing than children not on the free lunch program regardless the number of fitness standards achieved. The free food lunch program was not a healthy diet. The program has encouraged the obesity epidemic. I had not previously known of the school food programs relationship to scholastic achievement.

Public schools in Texas are obsessed with high achievement on the Texas Assessment of Knowledge and Skills test (TAKS). The obsession is related to school district funding, the no child left behind program and federal funding.

Dr. Cooper looked at the Math and Reading scores of 8189 5th and 7th graders and related it to the number of fitness standards achieved. Again the higher the fitness scores achieved the higher the math and reading scores on the TAKS test.

Miller in the Journal of Pediatric in 2006 looked at early onset of obesity and its effect on IQ and found;

A link between marked obesity in toddlers and lower IQ scores, cognitive delay and brain lesions similar to those seen in Alzheimer’s disease was observed.” 


Dr. Cooper’s take home point is obesity is the villain and fitness is the cure. Texas schools eliminated Physical Education in order to have more resources to teach children to pass the achievement tests (TAKS). This seemed backwards to Dr. Cooper. He thought it might be better to promote fitness and decrease obesity. This would lead to an increase in test scores and a decrease in childhood type 2 diabetes mellitus.

Dr. Cooper then petitioned the Governor of Texas a Senator and State Representative to introduce a bill to reinstitute Physical Education in the Texas school systems on the basis of this information. The bill passed but was not funded.

Dr. Cooper raised 3 million dollars in private contributions for his Texas Youth Evaluation Project. He has to date tested over 1 million children. Fitness scores varied from 32 to 8/100 for girls depending on age and 27 to 8.5/100 for boys. The older the children the less fit they were.

His plan is to relate an increase in fitness to a decrease in obesity, and childhood type 2 diabetes mellitus. He is also going to study fitness and its relationship to attendance rates, free lunch programs, TAKS scores, substance abuse, violence and truancy.

My guess is that fitness will have the expected effect on all these parameters. The Youth Evaluation Program is now being spread to many school districts throughout the nation. The federal and state government must support programs to fight obesity. The obesity epidemic is devastating to individual citizens and our society.



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

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War On Obesity : Part 11


Stanley Feld M.D.,FACP,MACE


Chronic Renal Disease (CKD) is another example of a disease that is asymptomatic until it reaches end stage renal disease. CKD is increasing with the rising incidence of obesity. Obesity causes patient to have a resistance to their own insulin. Insulin resistance is the hallmark of the Metabolic Syndrome and causes the onset of hypertension, hyperlipidemia (high cholesterol) and type 2 diabetes mellitus.

All of these chronic diseases along with aging are causing chronic kidney disease (CKD). At one time Dr. Norman Kaplan named this complex of diseases (obesity,hypertension,hyperlipidemia,and type 2 diabetes mellitus) the deadly quartet.

If obesity could be avoided or cured the cascade of these chronic diseases and their complications could be avoided. Since the treatment of the complications of chronic diseases result is 80% of the healthcare dollars spent, the total cost of healthcare would be drastically reduced.  

Many Americans are unaware that they are suffering from chronic kidney disease (CKD) because is often asymptomatic until its late stage. Inadequately treated hypertension can result in CKD. Many patients can not afford routine medical evaluations and do not discover hypertension until it is too late. Many patients can not afford medications prescribed so their adherence/ compliance with their physicians recommendations are less than 50%.

“An analysis of federal health data published last November in The Journal of the American Medical Association found that 13 percent of American adults — about 26 million people — have chronic kidney disease, up from 10 percent, or about 20 million people, a decade earlier”. “The burden on the health care system is enormous, and it’s going to get worse”.

“We won’t have enough units to dialyze these patients.”

It would be better to prevent CKD than to pay the cost for chronic dialysis or kidney transplantation. It can be done by preventing obesity along with early diagnosis and effective treatment of hypertension, hyperlipidemia and diabetes?

“Concerned about the emerging picture, federal health officials have started pilot programs to bolster public awareness, increase epidemiologic surveillance and expand efforts to screen those most at risk — people with high blood pressure, diabetes or a family history of kidney disease.”

Pilot programs take too long to complete. They are usually poorly designed to test the effectiveness of the program in the real world. If the concept is sound with minimum risk of failure it should be rolled out widely.

“Patients don’t understand that CKD encompasses a spectrum, and that the majority of patients are unaware they have the condition.” The path to kidney failure can take years.

“Only a tiny percentage of patients with kidney disease need dialysis,” Patients get dialysis or a kidney transplant only when they are in the final stage of the disease, also known as kidney failure or end-stage renal disease.

CKD progresses over the course of years, with its phases determined according to two criteria: the presence of protein in the urine, known as proteinuria, and how effectively the kidneys are processing waste products.

“ CKD itself can damage the cardiovascular system and lead to other serious medical conditions, like anemia, vitamin D deficiencies and bone disorders. Patients are far more likely to die from heart disease than to suffer kidney failure.”

The cost of dialysis should be zero in an ideal world with effective preventative medical care.

“In 2005, more than 485,000 people were living on dialysis or with a transplant, at a total cost of $32 billion. Medicare pays for much of that, because it provides coverage for patients needing dialysis or transplant even if they are not yet 65. In fact, kidney disease and kidney failure account for more than a quarter of Medicare’s annual expenditures.”

If obesity could be controlled and hypertension and diabetes secondary to obesity were eliminated at least another 24 billion dollars annually could be saved by our healthcare system.

The War on Obesity is vital to the survival of our healthcare system. CKD is just one more disease that is secondary to obesity. Our government must take the necessary role in influencing public opinion to reform our lifestyle to prevent the onset of obesity. Consumers must demand reform of the food industry and restaurant industry. The goal must be to a promote healthy lifestyle and discourage obesity.

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

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Lame Duck President Continues To Destroy The Healthcare System

Stanley Feld M.D.,FACP,MACE


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Many Doctors Plan To Quit Or Cut Back: Survey

  Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

· 20% said they will cut back on patients seen

· 10% said they will work part-time

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


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

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


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

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

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

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


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

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


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

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

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

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

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

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

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

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

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Dear President-elect Obama : Part 3


Stanley Feld M.D.,FACP,MACE

A huge problem in the healthcare system is mistrust between all the stakeholders. Medicare Part D is one example of abuse to consumers by the healthcare insurance industry and the government.

Physicians mistrust the government and healthcare insurance industry because of delayed Medicare reimbursements. The government outsources administrative services for Medicare claims to the healthcare insurance industry. The government pays these companies for claims processing.

The government states that Medicare overhead is only 2%. The healthcare insurance industry has published an overhead of 15%. Does this mean the healthcare insurance industry overhead without a surcharge is passed on to Medicare? In that case Medicare’s total overhead would be 17%. My guess is Medicare’s total overhead is closer to 20% including an added surcharge.

The vendor for Medicare (the healthcare insurance industry)  in California, Nevada and Hawaii is holding back physician reimbursement. In the late 1980 physicians were promised they would be reimbursed within 10 days by Medicare if they electronically billed. The billing software was provided free of charge and installed by the vendor. Now in California, Nevada and Hawaii there is an unpaid claims backlog of up to nine months.

Doctors across California and in two other Western states are owed millions of dollars in backlogged Medicare reimbursements, leading some physicians to turn away elderly patients and pushing others to the brink of bankruptcy.”

How did this happen? The problem has resulted in a California Medical Association law suit. Law suits only add to the cost of medical care as well as an increase in mistrust.

California is not the only state in which this has happened. It has happened to many physicians in Texas also. I suspect the delay in reimbursement is happening in many other states as the administrative service providers (vendors) try to hold on to the float of the cash as long as possible.

“In the most extreme cases, doctors have not been paid since February. Others are owed hundreds of thousands of dollars. Doctors who serve high numbers of Medicare patients say they are defaulting on rent, laying off staff and begging drug suppliers not to stop shipments. One cardiologist said she’s even resorted to doing the office laundry to cut costs.

“Economic stress leads to mistrust.” This should not be happening as everyone should be working together to repair the healthcare system

“Medicare owes Dr. Tim Ganey and his Bay Area practice of oncologists $750,000 in outstanding claims. He sought grace periods from vendors for his drug payments, but now he’s running out of time. He won’t be able to order more chemotherapy treatments unless he pays his bill.
“The things that we’re dealing with, they’re not elective things,” Ganey said. “They’re pertinent to people either fighting their cancer or being cured of their cancer.”

Physicians are always given excuses when Medicare or Private insurance misdeeds are highlighted. There are two excuses published in this case of delayed reimbursement.

“The holdup is twofold. By May, doctors were supposed to be using a new universal identification number assigned by the Centers for Medicare and Medicaid Services. Without the new number, which is like a Social Security number, doctors can’t get reimbursed. Scores of doctors still waited for those numbers.”

Most physicians are using the new physician identifier (NPI). There was a long delay by the government in setting a deadline for its use because of delays in physicians applying for it . Now most states will not renew physicians’ medical licenses without an NPI. A NPI can be obtained instantly on a government web site. I suspect this point is an excuse.

The second excused presented;

“In September the federal agency switched to a new claim processor for its 90,000 California providers. The move to Palmetto GBA in South Carolina, part of a national effort to reform Medicare contractors, compounded the billing issues and left even doctors who had their universal identification numbers waiting months for reimbursement.”

This does not make sense. If the government was moving to a better administrative service organization (healthcare insurance company DBA ASO) why is this ASO worse than the old one?

“This is just a complete disaster,” said Dr. Dev Gnanadev, medical director and chairman of the Department of Surgery at Arrowhead Regional Medical Center in Colton and president of the California Medical Assn.”

“Rep. Henry Waxman (D-Beverly Hills), whose office was contacted by at least two dozen doctors, called the transition to the new contractor “marred by missteps.””

Nevada has the fastest-growing Medicare population in the nation and physicians there are having the same problem with Palmetto.

“If we’re still dealing with this in January or February, Medicare patients are going to have serious access problems,” said Larry Mathies, executive director of the Nevada State Medical Assn.”

I am sorry. Excuses do not work any more. If the previous vendor was insufficient, why hire a vendor that almost paralyzes the medical profession’s ability to deliver care.

President elect Obama, beware of what your goal is with your national insurance exchange and your plan to expand Medicare Part C in its present form. The healthcare insurance industry is going to be your administrative service provider and the costs of healthcare will continue to escalate. They will control consumers healthcare dollars that the government will be providing and abuse your physician workforce.

It is much wiser to let consumers administer the first $6,000 of the healthcare dollar needed for a family of four and provide real healthcare insurance with the second $6,000 while creating incentives and education in order for consumers to be wise and fugal consumers. Any government subsidies for healthcare system with this design will be money well spent and reduce the cost of healthcare.

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Dear President –Elect Obama : Part 2


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.

  • Alan Shimel

    You are right on here Stan. Government approved hikes in premiums should be pegged to the profit these insurance companies are making. Crying with two loafs of bread under each arm is just not right!!

  • Darrell Pruitt

    Dr. Feld, it is refreshing to hear your voice. Very few have the courage to speak up about ambitious stakeholders in healthcare – stakeholders who would have consumers believe that bureaucrats, healthcare IT executives and insurance MBAs are as critical to healthcare delivery as doctors and patients.
    With all due respect, Dr. Feld, I see that someone has successfully taught you to thoughtlessly accept the label “stakeholder” for yourself and your patients. The label you were pushed into buying brings doctors and patients down to the vendor’s level of importance. It is an old stakeholder trick based on semantics. It has to do with spin and other stakeholder PR talents. These guys are slick. And they are empowered.
    On December 21, 2007, the National Committee for Vital and Health Statistics (NCVHS) – an assortment of stakeholders who tell HHS what HHS likes to hear – submitted a letter recommending actions for “Enhanced Protections for Uses of Health Data” to Secretary Michael Leavitt encouraging the elimination of the term “secondary uses” for patient health records.
    “NCVHS observes that ‘secondary use’ of health data is an ill-defined term and urges abandoning it in favor of precise description for each use of health data.”
    The subtle underlying rationalization is that all stakeholders, including doctors and patients, are equally important in a democracy. Since doctors and patients are intentionally poorly represented in stakeholder committees that report happy things to the HHS, such as the NCVHS, CCHIT and the future AHIC Successor Inc., stakeholders unanimously win their power in fair democratic fashion, again and again. And that is why one can expect things to fall short of swell for doctors and patients.
    We are not stakeholders. As doctors and patients, we are principles and we must aggressively fight for the welfare of patients, just like you are doing. Otherwise patients have no representation at all.
    We must be transparent and doctors must be paid fairly. This is too harsh for some to imagine, much less to say out loud, but consumers should be aware that ethics is not free, and you get what you pay for. There are no bargains in spite of what glossy managed care folders advertise.
    Patients and their doctors are principles, not stakeholders. Healthcare is not a natural, renewable resource and mandates are not windfall profits. Patients always suffer the final bill.
    Keep up the good work, Dr. Feld. We’ll overcome stakeholders. We must. Darrell K. Pruitt DDS

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To My Readers: A Call To Action!


Stanley Feld M.D.,FACP,MACE

I believe President-elect Obama is a smart fellow and wants to do the right thing for all healthcare consumers regardless of class. His decisions will only be as good as the information he receives. Some of his published policies are correct and some are wrong.

His advisors are focused on manipulating the payment systems as they attempt to provide universal healthcare. They are not focused on the abuse by all the stakeholders in the system including patients. Their focus has to be redirected to the abuses in the healthcare system and the repair of those abuses.

I believe in a free enterprise system with appropriate rules and regulations and not in socialized medicine. The rules and regulations have to be in favor of the consumer and not the healthcare insurance industry, the drug companies, the hospital systems or the government. Consumer’s in a price transparent environment with appropriate incentives will make sure they are treated fairly by their physicians.

Patients should control their healthcare dollar and be responsible for their health and healthcare needs in a totally transparent environment. Price transparency and not price controls must be negotiated for the consumer by the government and the healthcare insurance industry.

If patients were motivated by incentives such as retaining healthcare dollars not spent we could eliminate the complications of chronic diseases as well as the obscene administrative costs and excess profits of the healthcare insurance industry.

As readers of my blog you are well aware of my positions as well as the logic of these positions.

President-elect Obama has asked us, ordinary citizens, for input. I am asking for your help in getting these positions before President-elect Obama, his healthcare advisors and your congresspersons before they make a mistake. Below are links to President-elect Obama and your congresspersons.

Thank you,

Stanley Feld M.D.,FACP,MACE

  • kayla

    I am very interested in the how care system our son was born with esophageal atresia and down syndrome and other complications. S o strive to stay up on all of this.

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Dear President-elect Obama


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.

  • Jackson-food

    America has also a problem of food allergy. An allergy to food is when you have an adverse physical reaction to a food item after eating it. Health care department has to take care of quality and healthy food. Thank you!!

  • Coal Processing

    Hi this is the use of coal and lignite to produce liquid transport fuels has been given new importance with the looming “peak oil” crisis.

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Aetna CEO Urges Mandatory Health Care Coverage


Stanley Feld M.D.,FACP,MACE

He says
it would lower costs

Of course the CEO of Aetna would want mandatory healthcare coverage with the
government providing a subsidy to consumers to buy healthcare insurance. The
more lives insured the more profit his healthcare insurance company would

“Americans should be required to buy health
, bringing healthier people into plans that will help
bring down costs, the chairman of one of the nation's largest private insurance
companies told a Detroit audience Tuesday.”

This is obviously self serving. Massachusetts
bought into this concept only to see the premiums and state subsidies go up
As long as the healthcare insurance industry’s administrative costs are opaque
and not transparent the healthcare premium costs will not go down.

A mandatory system misses the point of the dysfunction in the healthcare
system. The healthcare insurance industry would become more powerful. The
healthcare insurance industry’s increased control over the healthcare system
would add to the dysfunction.

incentives of all stakeholders must be aligned and consumers must be in control
of their healthcare dollar and not the healthcare insurance industry
. The
insurance company should be in control of the dollars spent after $6000

“A mandatory system would help bring down costs and end a problem known
in the industry as cherry-picking — enrolling healthy applicants and rejecting
those with prior medical problems — because costs and risks would be spread
over a larger group of people, Williams said.”

cherry pickers are the healthcare industry.
The healthcare industry is
required to insure people in an employer group. However, if sick people are in
the group the group premium is increased. Cherry picking occurs when an
individual tries to buy insurance. If the consumer is 55 years old and recently
unemployed he is unable to get insurance if he has hypertension and diabetes. If
he could get insurance the premium would be high and he would be paying with
after tax dollars. The healthcare insurance industry would love every healthy 20
year old to be insured.

Mr. Williams has produced a smoke screen to give states the idea that they
should make health insurance mandatory. He has no interest in repairing the
system because that would decrease Aetna’s profit.

Williams is also in favor of:

“• Selling health insurance across state lines, a proposal favored by
Republican presidential candidate John McCain.”

The healthcare insurance industry has lobbied John McCain to take this
position. This form of deregulation would have adverse effects on the healthcare
system. State
Boards of Insurance can eliminate insurance abuse by refusing to grant a health
insurance carrier a permit to sell insurance in its state because of abuse
So far state boards of insurance have not imposed this penalty. Healthcare
insurance company abuse has only been punished by weak and insignificant
monetary fines. John McCain would eliminate this potential protection for

“• Expanding access of those now eligible for Medicare and Medicaid

John McCain would also like to eliminate the Medicare entitlement.
He would like to move all Medicare patients to private sector run Medicare
Advantage program. The Bush Administration has increased the subsidy to the
healthcare industry for Medicare Advantage $3,600 per patients. The
healthcare insurance industry has increased profit last year by over 5 billion
dollars from the Medicare Advantage program with only 20% of the potential
patients being enrolled. .

"No candidate has the right answer," Williams said.

Neither candidate's program suits Mr. Williams’ goal of increasing his
massive profits.

McCain essentially has no program.
Mr. Williams and Aetna would have to
continue to build up it power slowly.

President-elect Barack
Obama has a program that will fail
because it is outsourced to the
healthcare industry. In my next post I will explain how he can convert his
healthcare plan to a healthcare plan that will succeed. 

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

  • Glenn

    Stanley, you are absolutely right. Aetna is in no way interested in healthcare reform as their own web site makes clear when you cannot select an NP as a primary care provider, even when the only healthcare provider in 50 miles is an NP. Aetna is interested in government subsedies and that is all. Actual healthcare is irrelevant. Sad that so many people seem to think that insurance coverage and healthcare are the same thing.

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