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All items for December, 2008


The Therapeutic Magic Of The Physician Patient Relationship: Part 2


Stanley Feld M.D.,FACP,MACE

The role of patients with chronic diseases and their physicians must be clear to both patients and physicians. Physicians are coaches. Patients are players. They live with their disease 24 hours a day. Day to day fluctuations occur in the management of chronic disease. An excellent example is patients with hypertension. Blood pressure fluctuates all day long. A single blood pressure measurement during a visit to a physician once every six month is meaningless. Patients must continually monitor their blood pressure to evaluate the effect of their medication. Physicians have to help patients evaluate these data points to make logical medication adjustments.

Patients must to be inspired to manage their chronic disease. This requires patients having confidence in their coaches. It is hard work for patients to monitor their blood pressure daily and learn the meaning of the fluctuations in their blood pressure.

Only day to day blood pressure control is going to prevent the complications of a stroke or a heart attack. Physicians along with the patients’ input must make the necessary adjustments. An effective physician and patient team can make appropriate day to day adjustments.

This idea of mutual trust and confidence between coach and player is illustrated by something that happened between a teacher and me in high school. It illustrates the essence of an effective physician-patient relationship.

It was a rainy day in the spring of 1953 during my junior year in high school. I was on the high school baseball team. The team could not practice that afternoon because of the weather. The team was sent to the Study Hall for the 8th period.

Ms. W. was one of the 8th period Study Hall teachers. She was my geometry I and II teacher. I thought she was the greatest. I never missed a question in class or on a test. She came over to me that rainy spring day to say hello. She asked how I was doing in trigonometry.

I told her I was doing terrible. I could not learn a thing from Mr. B. Mr. B. was the chairman of the math department. He taught trig very descriptively. It had no meaning to me. He did not teach us to understand the logic of trigonometry and its uses. No matter how much I tried to derive meaning from the text book by myself the material covered did not stick. I felt Mr. B. suppressed my ability to learn and problem solve. His goal was to have us memorize the material.

Mrs. W. asked me which period I had trigonometry and lunch. I told her trig 5th period and lunch 6th period. She said great she taught trig 6th period and could get me transferred to her class. I could have lunch 5th period.

I was thrilled beyond belief. She also said she hoped I was aware there was a departmental quiz being given the next day. I would be required to take it. She said the chances are I would do poorly on the test but she encouraged me to study when I got home.

The most amazing thing happened that night when I started studying for the quiz. All of a sudden I grasped concepts I could not grasp previously. Now that I was in Mrs. W. class I solved problems I could not solve previously. A difficult textbook seemed easy.

The next day I went into her trigonometry class, took the test, and got 100%. I know this has happened to all of us at some time in our life. I know it was the result of my knowing that someone had trust and confidence in me and the conviction that I could do the job.

The magical therapeutic power of the patient physician relationship.

If a relationship is positive with mutual respect and commitment by physicians and patients, patients can learn about the pathophysiology of their chronic disease. In turn they can learn to manage their disease properly.

In practicing endocrinology I developed a patient physician contract to define this patient physician relationship. My son, Daniel, alluded to this contract in his letter to me.

Physicians must be dedicated to teaching patients to be the professor of their disease. Physicians must enable patients to want to be the professor of their chronic disease to avoid the complications of the disease. Eighty percent of the healthcare dollar is spent on the complications of chronic disease.

The lesson of Mrs. W. is a powerful lesson. Mrs. W. did enable me to be comfortable and confident in my learning situation because of her trust. She empowered me to learn by myself with her confidence in me.

Many times patients with a chronic disease are frightened by their disease. This fright makes it difficult to learn how to control their disease to avoid its complications. Physicians must deal with this through a positive physician patient relationship. A positive patient physician relationship can make it easier for patients to learn to control their disease.

Converting healthcare into a commodity is discouraging physician-patient relationships. The healthcare system cannot be repaired without effective chronic disease management. Chronic disease management will not be effective without effective patient-physicians relationships.



AACE Diabetes Guidelines, Endocr Pract. 2002;8(Suppl 1)
a. Sample Patient-Physician Contract
I understand that if I agree to participate in the System of Intensive Diabetes Self-Management, I will be expected to do
the following:
1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the
diabetes self-management team
2. Regularly visit the clinic for a physical examination, laboratory tests, and nutrition counseling; follow-up visits will
be scheduled every 3 months or more frequently if deemed necessary by my physician or other members of my
health-care team
3. Bring a detailed 1-day food record to each follow-up visit, provide necessary nutrition information for me and my
dietitian, and adjust my eating habits to meet the nutrition goals established by my dietitian
4. Use medications as prescribed by my health-care team
5. Monitor my blood glucose levels at home as instructed and bring the results to each follow-up visit
6. Follow my prescribed exercise plan
7. Obtain identification as a patient with diabetes, for prompt assistance in case of an emergency
8. Ask my physician and other members of my health-care team to explain any aspect of my care that I do not entirely
I understand that if I do not monitor myself carefully, there is a risk of hypoglycemia.
I also understand that if I do not strive to normalize my blood glucose, I am at increased risk of developing the
complications of diabetes mellitus.
My signature indicates that I have read and understand the above agreement.
I agree to provide the leadership for the diabetes self-management team. Team members will be available to answer
your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible
control of your diabetes.

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My Sons Are Great!!

Stanley Feld M.D.,FACP,MACE

I have previously introduced you to my sons Brad and Daniel. Many of you know Brad and some of you know Daniel. Yesterday Brad wrote a great piece about me in Feld Thoughts. At the same time, I received the following email from Daniel. I have a lot to be thankful for.


Great blog post Dad. I knew some of this story, but not all of it. I like learning new things about you!

I can see this is going to be a multi-part series of posts. Good. You should definitely write about how you extended this practice to your own private practice. I tell people all the time about your patient-physician contract that you use to have patients sign taking responsibility for their health and healing. I’ve adopted this myself in my own health and healing and believe it’s critical since we know ourselves better than anyone else, I’m surprised by how few practitioners engage the patient in their own recovery. It’s easier to just write a prescription. It’s also surprising how few are effective listeners (they ask what’s wrong, but don’t get much beyond the “it hurts here” stage).

I also loved that you use to pull out the squeeze doll with popping eyes I bought for you when people were being bozos. Or at least that’s how I remember it from childhood. We should send Obama a squeeze doll since he may need it a few times in the coming term…


 untitled ).

Keep on writing and reminiscing. It’s great to read these.

I love you!

Your (Proud) Son,


Could a father ask for anything more?

My mother always said praising my brother Charlie and me that her “cup runneth over”. We thought it was pretty corny but it expressed her true joy.

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The Therapeutic Magic Of The Physician Patient Relationship: Part 1


Stanley Feld M.D.,FACP,MACE

A positive physician patient relationship has magical therapeutic powers.

I believe I can best describe it with two very difference personal experiences.

Both are reminiscences of events that occurred long before I was a physician. Both gave me incite into the power of a physician patient relationship and stimulated my desire to be a doctor. One experience was doctor related, the other was teacher related.

During 30 years in private practice as a clinical endocrinologist I always tried to treat my patients remembering the therapeutic effect of those experiences. Those experiences had magnificent healing powers for me.

The first episode occurred when I was a first grader in the Bronx. The year was 1946. In those days being left handed was thought to be a curse. My first grade teacher forced me to write with my right hand to avoid the destiny of the curse. I remember the difficulty I had writing with my right hand. I was forced to persist. I made many mistakes and had great difficulty learning to do anything academically.

I had difficulty learning anything new, especially reading and arithmetic. I thought I was a pretty smart kid. My impression was confirmed by my father when he continually told me I was a smart kid. I was told not to listen to my teacher’s impression of me.

I was never a difficult child at home but something agitated me in school. I remember being a difficult first grader. My teacher considered me a trouble maker. She did not understand why I did certain things.

Finally, my teacher called my mother in for a conference. I was forced to listen to the conference. The teacher told my mother she was positive I was a disturbed child and needed psychiatric attention. I was behind in reading, writing and arithmetic and was not adjusting socially. She told my mother she should act immediately before I was permanently damaged. She said if this continued I could be expelled from school.

My mother was beside herself. She did not know what to do. I felt her anxiety but did not know what to say. I did not know what a psychiatrist was. I was told we could not afford a psychiatrist. I thought the solution to my problem was to be allowed to write with my left hand. No one would listen to me. Everyone, including my parents believed that left handed people were cursed.

My father’s boss suggested we go to Dr. Schultz, a family practice doctor, in the West Bronx. I remember the look of Dr. Schultz’s street. It was tree lined with two rows of attached single family houses with and concrete steps. We lived in a 4 room apartment in a walkup apartment building on Bristol Street across the street from the Boston Post Road movie theater.

The first room we entered was a living room with couches used as a reception area. At six years old I was impressed and terrified. My mother was just terrified.

Dr. Shultz’s office had a desk, a few chairs and a mirror behind the desk. He asked my mother what was wrong. She repeated the teacher’s report almost verbatim. He asked some detailed medical history and took notes. When he finished he turned to me and asked me what I thought was wrong.

This is the first time anyone had asked me to express my opinion. He saw I was nervous and frightened. He calmed me down and told me usually the patient can tell him what is wrong if the patient is given a chance to express himself.

I told him that the teacher made me write with my right hand because left handed people were cursed. He said he heard that was a common superstition but there was no proof it was true. He then asked me to write my name and my brother’s name on a piece of paper with both my right and left hand. I did and he said “son, there is nothing wrong with you.”

My mother looked in disbelief. He then picked up the paper and showed it to my mother. She still did not understand. He then put the piece of paper in front of the mirror. My right handed entry was legible now and the left handed writing which was legible at first was now backward. I was mirror writing.

He told my mother that that problem was the result of the strain put on me being forced to write right handed. After I was permitted to write left handed for a while my ability to write, read and do arithmetic would straighten out. My behavior problems would also vanish. He suggested that my mother listen to my complaints in the future. He wrote a note to the teacher ordering her to let me write with my left hand.

Then he got up from his chair, came over to me and gave me a big hug. He also told me to show everyone they were wrong about me. I felt like a million bucks. All the tension left my body. I felt I could achieve anything.

There is no question in my mind that this approach to medical care and the therapeutic effect of the positive physician patient relationship saved my academic life.

The pressures on physicians today to see more patients, to test for everything so you do not miss a diagnosis, the lack of reimbursement for cognitive therapy, the constant threat of financial penalties and continuous assault on physicians’ judgment has served to decrease the ability of physicians to relate in a human way.

“There is considerable healing power in the physician-patient alliance. A patient who entrusts himself to a physician’s care creates ethical obligations that are definite and weighty. Working together, the potential exists to pursue interventions that can significantly improve the patient’s quality of life and health status. “

The simple way to put it is medical care has and is being commoditized and dehumanized. These attributes are the common denominator to patients’ complaints about the medical care system in 2008. I cannot justify or condone physicians’ behavior.

Our healthcare system has to change. It must support the humanizing elements or the patient physician relationship. It has to nurture mutual trust rather than distrust between patients and physicians. A healthcare system that supports distrust, physician and patient penalties and adversarial interrelationships does not permit this princely profession to offer the kind of care physicians are capable of.

President-elect Obama and Tom Daschle imposing more bureaucratic controls on the healthcare system is not the answer. It is clear to me that the consumers and their needs must drive us back to a more humanized system.

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Dear President-elect Obama: Part 6 Why Don’t You Listen To Practicing Physicians?


Stanley Feld M.D.,FACP,MACE

I am asking your administration to use common sense to repair the healthcare system. So far I have only seen political strategy. A strategy that I predict will fail as I predicted the Republican Governor Romney’s universal healthcare strategy would fail in Massachusetts.

No one in your administration is asking for advice from the physicians in the trenches. The practicing physicians are your workforce. The administrators and consultants at large hospital systems and mega clinics are not your prototypical workforce. Practicing physicians are experiencing the bad effects of the faulty healthcare policy of the past. Those healthcare policies have commoditized medical care and destroyed the patient physician relationship. I will explain the patient-physician relationship in the next blog. I am afraid you are about to compound past errors with Tom Daschle’s proposals at a very high cost to taxpayers.

Our present problems are not the result of bad intentions on the part of the federal government. They are the result faulty regulations piled upon faulty regulations to correct the previous faulty regulations. Stakeholders have been driven to adjust in order to benefit from these complex regulation to protect their vested interests.

Willie Sutton said we should go where the money is. In healthcare the biggest waste of money is in:

  1. Administrative waste; $ 200 billion dollars per year
  1. Ineffective chronic disease management: 80% of the healthcare dollars spent or $1.6 trillion dollars per year
  1. Lack of a universal electronic medical record: $75 billion dollars per year wasted in production time, duplication of testing, and illness from medication errors and communication errors.
  1. Defensive medicine: $160 billion a year.

Tom Daschle should be going where the money is and solving these problems. He should not instituting a bureaucracy that will not improve care or save money.

Two hundred billion dollars is wasted on administrative costs. These costs are passed on to consumers. All the stakeholders inject wasteful administrative costs into the system.

The largest administrative cost is generated by the healthcare insurance industry. It has grotesque executive salaries and excessive service fees. Since the healthcare insurance industry administers Medicare and Medicaid services for the federal government, the federal government is paying those costs plus a commission. Mr. Daschle should be focused on discovering the actual cost of healthcare insurance.

The second large waste of funds results from the complications of chronic disease. The estimate is the complications of all chronic diseases cost the healthcare system 80% of the healthcare dollars. If the healthcare system cost our nation two (2) trillion dollars last year the complications of chronic disease cost the healthcare system $1.6 trillion dollars. Diabetes mellitus cost the healthcare system $200 billion dollars last year. One hundred and sixty billion dollars ($160) was spent on the complications of diabetes mellitus. CMS estimated that the cost is even higher at 90% of the healthcare dollar spent for chronic disease complications.

There is little support for physicians to develop chronic disease management in their offices. Therefore physicians have little incentive to invest resources for chronic disease management. The government has supported pilot studies that have shown chronic disease management is ineffective. Chronic disease management is not ineffective. The way the pilot programs delivered the management was ineffective. Patients must be taught how to manage their chronic disease to avoid the complications of their chronic disease. If they effectively managed their chronic diseases patients could reduce the complication rate of their disease by at least 50%. Fifty percent of $160 billion dollars would result in an $80 billion dollars savings to the healthcare system. Effective chronic disease management is not supported by the government or the private healthcare insurance industry. Systems of care could easily be set up with rewards for physicians and patients who execute chronic disease management effectively.

A universal electronic medical record could be distributed by the government. Physicians would be charged by the click for it use. There would be no up front cost per physician ($60,000) for the EMR software or or maintenance service fees. All updates would be free and downloadable. Adoption of the EMR would be rewarded and the physician would pay a small fee by the click deducted from the service provided.

Defensive medicine costs could be eliminated with common sense malpractice reform. Texas malpractice legislation could be a model. It has decreased malpractice claims by over 60%. The plaintiff attorneys have taken an income hit and are trying for rescind Texas medical malpractice reform.

Your administration should be going to where the money is rather than developing a more complex bureaucracy with the potential for abuse. Repair of the healthcare system should be consumer directed with the help of the government and not government directed.

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

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Consensus: A Clever Way To Build One, Whether It Is Right Or Not

Stanley Feld M.D.,FACP,MACE


Barack Obama is inviting Americans to spend part of the holiday season talking
about health care — and report back to him.
He is encouraging average
Americans to host informal gatherings to brainstorm about how to improve the
U.S. system. Thomas
A. Daschle
will attend at least one and prepare a detailed report, complete
with video, to present to the next president.

These sessions, are to be held Dec. 15 to Dec. 31. One might be invited if
one made a contribution to President-elect Obama’s presidential campaign.

"In order for us to reform our health care system, we must first begin
reforming how government communicates with the American people," Obama said in a
statement yesterday. "These Health Care Community Discussions are a great way
for the American people to have a direct say in our health reform efforts."

President-elect Obama’s statement is absolutely compelling. I believe his
heart is in the right place. However, he is ignoring the other half of the
primary stakeholder equation, the practicing physicians.

By applying the high-tech tools and grass-roots activism that helped him
win the White
, Obama hopes to circumvent many of the traditionally powerful special
interests that have quashed previous health-care reform efforts.

I believe Tom
Daschle has decided on his legislative initiative already
. Max
Baucus (D) Montana has introduced an identical plan to congress

Senator Kennedy is next. This call for pseudo public involvement by Barack
Obama is a clever mechanism for claiming a CONSENSUS.

we want to do now is to move to a discussion across the country," Daschle said
in a speech yesterday in Denver
. "We want your exact ideas." By seeking
broad public input early in the process, the incoming administration hopes to
avoid some of the mistakes of President
's failed initiative 15 years ago, said Daschle, who is also Obama's
choice for secretary of health and human services.

"Once we get started, we have to stay focused. Let's finish it, let's not
put it down."

President-elect Obama’s healthcare plan is similar to President Clinton’s
failed plan. Tom Daschle spearheaded the Clinton plan in 1993. The Obama/Daschle
plan is a plan for socializing medicine as the solution to our dysfunctional
healthcare system. It is absolutely the wrong strategy and will make things

The strategy to get the Obama/Daschle healthcare plan past is clear. I
believe their consensus strategy will be so effective with the American people
it will overwhelm common sense. Even Harry and Louise can not

John Goodman of the
National Center for Policy Analysis
had a brilliant blog concerning
consensus building as it relates to medicine. This blog entry is a worthwhile

He begins by saying lots of Democrats have a health plan (Daschle, Baucus and
Kennedy). And the chattering class is exuberant over the idea that a
consensus is emerging on health reform. With respect to the twin problems of
cost and quality, just about everyone seems to hold these positions:”

Consensus Point No. 1:


Consensus Point No. 2:

Somebody else is at fault; and, not to put too hard an edge on it
and you may have to read between the lines to see this, but a reasonable
inference is that DOCTORS ARE AT FAULT.

Consensus Point No. 3:

Again, not to put too hard an edge on it and you may have to read
between the lines even more diligently, but once you do you will surely conclude

I am afraid Americans are being set up. The “consensus” is going to sweep a
defective healthcare policy through the door. The result will be a very
ineffective form of socialized medicine. The plan will not cure obesity, the
complications of chronic disease, or the abuses to the healthcare system by all
the stakeholders.

When the Obama/Daschle plan is passed we will really have problems. Patients
will not have freedom to choose. Access to medical care will be limited.
Physicians will have further restrictions on their ability to deliver medical
care they think necessary. The government will experience unbelievable cost

Tom Daschle’s plan does nothing to repair the dysfunction in the healthcare
system. Doing the right thing seems so easy to me. I can not understand why
politicians who do not understand medicine and the importance of physician
patient relationship do not want to listen to practicing physicians. Politicians
must use common sense. I hope President-elect Obama grasps the concept before it is to
late for the healthcare system.

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

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Health Insurers Will Accept Universal Coverage! On Condition!

Stanley Feld M.D.,FACP,MACE

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

said it would lower costs
healthcare insurance

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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


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Dear President- elect Barack Obama: Part 5


Stanley Feld M.D.,FACP,MACE


Obama Asks Nation for Input On Reforming Health System

‘We Want Your Exact Ideas,’ Daschle Says

I believe Tom Daschle and your healthcare team have preformed ideas on how to repair the healthcare system. Some are good ideas but most are poor ideas. The bad ideas will not work and only make things worse. Their business plan is rooted in an old paradigm. Your administration should change the business plan so that it enables patients to be responsible for their own health and their healthcare dollars.

Here are my exact ideas:

Let’s use common sense to create an innovative system to repair the healthcare system.

In my last letter to you I promised to describe the basic problems causing the dysfunction of the healthcare system. I have previously stated that all the stakeholders are at fault in causing the dysfunction. The biggest villain is the healthcare insurance industry. Government healthcare programs are dependent on the healthcare insurance industry to be the administrative service provider. The healthcare insurance industry’s lack of real financial transparency is the cause of major increases in healthcare costs.

The social contract in the healthcare system is between patients and physicians. If we did not have patients and physicians we would not need a healthcare system. Patients should drive and control the healthcare system. They should not be the victim of a dysfunctional system.

Patients should be responsible for their well being (health) and medical care. Presently, patients’ do not have incentives to be responsible for their health. This attitude can be changed by providing financial rewards for health maintenance. If patients owned their healthcare dollars and had the ability to keep the unspent money in a tax free retirement trust account patients would become skilled purchasers of healthcare. If patients had a pre existing illness and spent the required amount of money to avoid complications of their chronic disease they should receive a reward of additional money. There will be consumers who abuse the system but these outliers should be easy to spot.

Tom Daschle’s plan should be focused on letting patients own and control their healthcare dollars. If he could shift his focus to this concept your administration would be on the way to a solution to fix the system rather than extension of policies that are destined to fail. Massachusetts’ universal care system is a perfect example of healthcare policy that is destined to fail.

How do you get consumers have incentive to be cautious about their health and their healthcare dollar? If s were responsible for the first $6000 of their healthcare insurance dollar you would see a marked reduction in the costs to the healthcare system.

Your administrations should teach consumers how to spend their healthcare dollar wisely. You should also be concentrating on decreasing society’s hazards to our health in a serious way. This approach would be much better than creating a Federal Health Board that dictates access to care.

Repair of the healthcare system could be achieved by instituting my ideal medical saving account. The federal government would end up spending less money and improving care. Patients will be motivated to take better care of themselves. They would be motivated to shop for the best care rather than having care dictated by a panel of experts.

Your administration must create a system where patients are the deterrent to abuse in the healthcare system and not the government. Patients can do it more efficiently. Your administration can set the appropriate rules and regulations.

A recent article in the Journal of Clinical Endocrinology and Metabolism showed that 20% of hospital admissions have undiagnosed diabetes mellitus. These complications could have been prevented if the patients knew they had diabetes and knew how to control their blood sugars before the complications. This awareness could be achieved with the government promoting public service announcement and developing a system of cultural change. I referred to Mayor Blumberg’s subway campaign in my War on Obesity.

Physicians need to be put in a position where they compete for patients. This would result in better service and better care. Punitive damages imposed by your healthcare team will not encourage physicians to excel. It generates more anger and mistrust among your workforce (physicians).

How about some malpractice relief to decrease the national burden of defensive medicine?

How about some recognition for pursuit of excellence by ordinary practicing physicians? The practicing physician is your major workforce and not you academic experts who will be the judges in your Federal Health Board. Recognition is a non punitive way that will encourage physicians to excel.

How about medical informatics crafted as an extension of the physician’s care? Many physicians are opposed to internet information because there is so much junk on the internet. If the information came from the physician’s personal site it would be easier for physicians to put the patient’s disease into clinical perspective.

How about the government providing a universal Electronic Medical Record? The administrator can charge physicians by the click rather than physicians making a capital expenditure they cannot afford. E-prescribing capability should be provided in the same way. The federal government provided us with Electronic billing in the 1980’s and its implementation has worked well.

Money will be saved by creating a better system and not creating a more bureaucratic system.

I hope you will seriously consider implementing some of my suggestions and decrease the fixation on building a consensus without the practicing physicians’ input using the wrong ideas to create healthcare policy. These policies are destined to fail.

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Dear President-Elect Obama: Part 4


Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Where are you now Bobby D?


Stanley Feld M.D.,FACP,MACE

As a Columbia College student in the late 1950’s I worked in a Catskill Mountain hotel resort as a waiter during the summers to earn money for college tuition and expenses.

I had a great job in a wonderful adult only hideaway hotel at the end of a winding road. The tips were great. I was able to earn enough to pay for college tuition and some expenses each year.

The job also brought with it many interesting experiences. One that sticks in my mind is my experience with Bobby D. Bobby was at least ten year older than me. He was a local fellow who worked for the phone company during the week and moonlighted at the hotel on weekends.

Most hotels had waiters and busboys to serve the guests. This hotel had waiters only. The waiters served two tables of eight people each during the week. On the weekends the hotel had an inflow of guests so it hired part time waiters. Bobby was one of the part time waiters. Bobby and I were partners. Bobby had two tables and we shared a third table.

On weekends the lines in the kitchen for the various food courses were unbearably long and could result in disastrously slow meal service. If timing was just right you could get to the next course line first and have a smooth service meal. If you were close to last you were guaranteed to provide poor service. Poor service resulted in poor tips.

Bobby was a genius. He had the solution for getting to the line for the next course first at every meal. The funniest incident occurred during a busy Sunday breakfast meal.

Saturday night was usually a late night for most guests. They had difficulty getting up on Sunday mornings. However, the dinning room usually filled up all at once. It was important to have the right timing.

Breakfast is a difficult meal because all the various egg dishes were individually prepared with custom ingredients. Bobby’s trick was the more times you could get two or three dishes cooked at the same time the faster your service would be. It required teamwork. Sometimes I would stand on line and get three dishes for both of us and sometimes he would stand on the line. He was the quarterback and gave the orders to our two man team. .

One Sunday morning our guests started coming in late and the pace of our breakfast looked like it was going to be grim. He ordered me to get 25 orange juices, 10 tomato juices and 5 grapefruit juices. This was called speculating and it was a potential mistake. We were encouraged not to speculate by the maitre de. Bobby assured me none of the stewards in the kitchen would be watching the juice line. It would not be a problem. I asked where we would put all those juices so the maitre de would not see them. He said don’t worry he would take care of it. It would be his problem. He assured me it would save us extra trips to the kitchen and give us an advantage at the short order cooks’ line for egg orders. I obeyed. He was right.

However, we hit the wall when we ran out of tomato juice at a critical time in the meal. Bobby should have figured that a lot of people would have a hangover from Saturday night and want tomato juice. The popular folklore at the time was tomato juice with Worcestershire sauce would straighten out your hangover.

A young single woman came in an asked for tomato juice with Worcestershire sauces. I asked Bobby what to do? He said give her orange juice and tell her to make believe it was tomato juice.

I looked at him like he was crazy. He said just do it! He was right. It worked. The woman was at the table we shared. It was his turn to get the egg orders. I believe she understood our situation and was o.k. with it because she wanted to get her eggs as quickly as possible.

The next person in was a guy about 6’5” and 250 lbs. He had not been pleasant the entire weekend. He was definitely hung over. He requested tomato juice. It was my turn to get the eggs and Bobby brought over orange juice and told him to make believe it was tomato juice.

Well, you can guess what happened. I hear the yelling and cursing while I was in the kitchen. This guy was not taking his tomato juice substitute in the right spirit. I could hear Bobby trying to console him. Bobby’s strategy was the best defense was a strong offense. Bobby got angry. He suggested the guy choose another table if he couldn’t play ball in the spirit it was intended. I thought the guy was going to tear Bobby apart. The maitre de calmed the guy down and got him his tomato juice. We did not get a tip from this guy for the weekend.

Needles to say we never speculated on juice again. The life’s lesson is to be careful what you speculate on whether it is orange juice, oil prices, real estate or stocks and bonds. You never know what the price will be.

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

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