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It Is Time To Reboot

Stanley Feld M.D. ,FACP, MACE

President Obama is trying to make changes in many areas. He is making changes in the healthcare system, the financial system, the system producing energy, the system we use to protect the environment.

During his Presidential campaign he promised us change. He never told us the details of this change. Many people voted for him because they felt we needed change. They were right, America needed to repair its many defective systems.

Sixty years of revising government regulations and government growth plus the cold war and four other wars have created dysfunctional systems in many areas.

Many have complained that the growth of government and its bureaucracy has resulted in so much complexity and expense that government doesn’t work. Some have written books suggesting how to fix government so it works

In formulating a solution to the problems one needs to outline three approaches;

1. A concept of the goal

2. A philosophy to apply to the concept.

3. A mechanism to reach the goal.

I believe President Obama and his administration have the three approaches in mind. Some would disagree with one of the elements of President Obama’s three approaches. Some would not agree with any of the elements.

The scope of my blog is deal with how President Obama is dealing with the Repair of the Healthcare system.

Conceptually, President Obama has the right idea. He wants to provide universal coverage at an affordable cost and increase the quality of care. I do not believe anyone would disagree with the concept.

The disagreement comes with the philosophy and mechanics.

President Obama’s philosophy is mixture of economics and modern socialism. In their pure form both are intellectually compelling. In practice history has proven that neither work as they are theoretically supposed to work. President Obama’s stimulus package has proven it.


Keynesian economics advocates a mixed economy—predominantly private sector, but with a large role of government and public sector—and served as the economic model during the latter part of the Great Depression, World War II, and the post-war economic expansion (1945–1973), though it lost some influence following the stagflation of the 1970s. The advent of the global financial crisis in 2007 has caused a resurgence in Keynesian thought. Barack Obama and other world leaders have used Keynesian economics to justify government stimulus programs for their economies.[2]

When combined with modern socialism it distorts Keynesian success even further

Socialism is an economic and political theory based on public ownership or common ownership and cooperative management of the means of production and allocation of resources.

In a socialist economic system, production is carried out by a public association of producers to directly produce use-values (instead of exchange-values), through coordinated planning of investment decisions, distribution of surplus, and the use of the means of production

Contemporary social democrats propose selective nationalization of key national industries in mixed economies, while maintaining private ownership of capital and private business enterprise. They also promote tax-funded welfare programs.

President Obama is in the process of taking over several industries in order to save our economy. Those industries are not stimulating the economy because they are trying to repay the government and take their industries back. This creates more unemployment and worsens the recession. The creation of larger entitlement programs will result in increased taxes further decreasing consumer spending and deepening the unemployment.

The government with large deficits at the beginning of President Obama’s term of office has doubled it in the last year and a half.


Friedrich Hayek is a Vienna-born, Nobel Prize-winning economist largely forgotten by mainstream economists. Friedrich Hayek championed four important ideas in the 1930’s and 1940’s. His philosophy was a foil to John Maynard Keynes’ philosophy.

When Federal Reserve Chairman Ben Bernanke zealously expanded the Fed’s balance sheet, he was surely remembering Milton Friedman’s indictment of the Fed’s inaction in the 1930s. On the fiscal side, Keynes was also suddenly in vogue again. The stimulus package was passed with much talk of Keynesian multipliers and boosting aggregate demand.”


Hayek ideas in his book "The Road to Serfdom" are being highlighted now that President Obama’s stimulus package has barely dented the unemployment rate and government spending and deficits are soaring.


Budget office director Doug Elmendorf warned;

Under all but the rosiest economic scenarios, significant changes in tax or spending policy, or both may be needed to control the long-term debt and avert a crisis.”

“The federal debt will reach 62 percent of the nation’s economic output this year – the highest level since shortly after World War II


  1. Hayek believed that the economy was simply too complex for the government to attempt to manage its ups and downs. He argued that economist John Maynard Keynes’s recommendation that government spend money to allay an economic downturn could actually make the downturn worse, as well as lead to an inflation problem later.
  2. Hayek highlighted the government and the Federal Reserve’s role in the business cycle. It should not artificially lower rates that could result in inflating a bubble such as the housing bubble distorting other investment decisions. “Current monetary policy postpones the adjustments needed to heal the housing market.”
  3. Hayek contends, “Political freedom and economic freedom are inextricably intertwined. In a centrally planned economy, the state inevitably infringes on what we do, what we enjoy, and where we live. When the state has the final say on the economy, the political opposition needs the permission of the state to act, speak and write. Economic control becomes political control.”
  4. Even when the state tries to steer only part of the economy in the name of the "public good," the power of the state corrupts those who wield that power.

“Hayek pointed out that powerful bureaucracies don’t attract angels—they attract people who enjoy running the lives of others. They tend to take care of their friends before taking care of others. And they find increasing that power attractive. Crony capitalism shouldn’t be confused with the real thing.”

  1. The fourth timely idea of Hayek’s: “By increasing the size of government, government leaves fewer resources for the rest of us to direct through our own decisions.

President Obama has expanded federal control of health care. He is on his way to making physicians indentured servants.

He would like to do the same with the energy market. The government owns Fannie and Freddie and controls the mortgage market.

The government is in control of GM, Chrysler and many banks. America is headed straight for the fiscal wall. President Obama better make a right turn before it is too late.


The mechanism used to pass the healthcare reform bill is deplorable. President Obama used back room deals in his proclaimed transparent administration. He dropped the public option only to have it slip in by default.

President Obama is not doing anything to repair the healthcare system. He is adding layer upon layer of bureaucracy to the disadvantage of patients and physicians who are the primary stakeholders.

The CBO reevaluated the cost of defensive medicine at $50 billion dollars a year. It is still a long way from the real cost of about $750 billion dollars. President Obama believes the cost is insignificant.

None of President Obama’s healthcare reforms get at the major problems in the healthcare system. America will not be able to afford another entitlement program.

President Obama will not accomplish his goals of universal coverage at an affordable price with increased quality.

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

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I Love My Pogoplug!!

Stanley Feld M.D.,FACP,MACE

In January 2009 I met Brad at the Consumer Electronics Show in Las Vegas. It is always fun to hang out with my son for a weekend. This weekend was special because Daniel and my brother Charlie and his wife Cindy were at the show also.

One morning Brad asked me to walk around the show with him. As soon as we arrived at the startup area of the show entrepreneurs gathered around Brad to ask questions. I felt like an extra wheel.

While he was busy I visited a few exhibits. I love to ask a lot of questions about the products for two reasons; first, I want to see how the entrepreneur expresses himself and second, to see if the product interests me.

I stopped at the Pogoplug exhibit Daniel and Jed Putterman. It was a small exhibit with two tables and two guys. It turned out they were brothers. They did not have fancy banners or giveaways. They simply had a dynamite product.

Two brothers, Jed and Daniel Putterman, were starting the company. They described the product with great passion. I was enchanted. It was a small square box. You plug it into the electrical outlet and into your router. Then you plug a USB port into an external hard drive.

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The two brothers got me excited about their Pogoplug. I carry my hard drive back and forth to the ranch weekly. With a Pogoplug I would not have to carry the portable hard drive back and forth. I have been and still am goosey about putting my data in the cloud. With the Pogoplug I could enjoy the advantages of the cloud but avoid losing control of my data.

I asked how much the Pogoplug cost? Jed told me the price was $99.50 per unit. I said, “sold”. They said they had a special at the show. The Pogoplug would not be ready for shipment until March. The show special was $79.50. The delay did not bother me. I felt like buying two of them.

I did not know at the time I was their first sale. I also didn’t know that Brad and the Foundry Group was looking to invest in the Pogoplug.

Eventually Brad finished answering questions and found me near the Pogoplug exhibit. I told him I bought a Pogoplug. Brad said, “no kidding”. He immediately went over to the brothers and told them that if they could sell a Pogoplug to my father, a 71 year old retired clinical endocrinologist, he would invest in the company. I received my Pogoplug as promised in March. It worked perfectly. Jed and Daniel did a magnificent job with this little box. It was clean, uncomplicated and extremely user friendly.

The second generation Pogoplug is sexier and has added functionality.



I love my Pogoplug.

I think all physicians should have a Pogoplug attached to their file sever in their office. They would have a personal CLOUD for all the data in their electronic medical record. Patient records  can be accessed from anywhere on their smart phone. Prescriptions can be written off campus after review of patients’ records and emailed to the pharmacy. The Prescriptions can then be downloaded or emailed to the chart.

The beauty of the Pogoplug is that the physicians would retain physical ownership of his medical data on their own server.

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At my 50th Columbia College reunion the chairman of Columbia University Information Technology Department delivered an Information Technology Lecture to our class. He went through the history of computing since IBM’s first massive computer and ended with a demonstration of the wonders of the Pogoplug.


Wow. I raised my hand and told my classmates the story of my Pogoplug. If anyone does not have one and needs to be plugged into their files in the office or at home get one and plug it into your hard drive.

Get one. You will love the Pogoplug!

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

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President Obama And The Sustainable Growth (SGR) Formula For Medicare Reimbursement

Stanley Feld M.D.,FACP,MACE

President Obama promised the AMA he would fix the defective Medicare Sustainable Growth Rate formula for calculating Medicare reimbursement to physicians. As a result of that promise the AMA supported President Obama’s healthcare reform bill.

The AMA made a big mistake supporting President Obama’s healthcare reform bill. It was as if the AMA did not evaluate the bill’s obvious unintended consequences for both patients and physicians.

The AMA lost support from not only 85% of physicians that are not members of the AMA but also from the 15% of physicians that are members.

The SGR formula makes no sense. Medicare has reduced physician reimbursement to physicians as physicians’ expenses have increased. A 21.2% decrease in reimbursement will result in physicians losing money seeing Medicare patients.


It is stupid to lose money seeing patients. President Obama’s unintended consequence will be physicians will stop seeing Medicare patients. Physicians cannot make up the loss by increasing the volume of patients seen.

Most physicians are decreasing expenses by installing electronic medical records. The available EMRs are not fully functional. The capital expenditure is too high for most physicians. They cannot afford an electronic medical record even with President Obama’s subsidy.

A New York Times article explains the conventional wisdoms. However, there is little proof that the conventional wisdom is correct.


There will likely be no real solution until the American health care system moves away from unfettered fee-for-service payments that encourage doctors to perform unnecessary and costly tests and procedures and pays them instead for better management of a patient’s care over time.”

My interpretation is physicians should get paid a salary by the government as the single party payer.

The media ignores the fact that most physicians do not get paid for the unnecessary and costly procedures.

Hospital systems and national laboratories do the tests and receive the reimbursement. The majority of physicians are single practitioners. Family Physicians and Internists cannot afford the equipment necessary to do testing in office. It is against the law for physicians to bill for testing done outside their office.

Physicians might order multiple tests that could be considered unnecessary by some. They order these tests as part of the defense against malpractice suits. Malpractice reform has been totally ignored by President Obama’s healthcare reform bill.

Until there is significant malpractice reform defensive medicine and the resulting “unnecessary testing” will not disappear. The use of appropriate data can alert the government and the healthcare insurance industry when a physician abuses the system.

The excuse of over testing does not warrant a reduction in reimbursement to Family Physicians and Internists. Doctors cannot afford to see Medicare and Medicaid patients at a loss.

It is obvious that there will be a physician shortage, long waiting periods to see a physician and rationing of care. I will discuss the complexity of the issue in detail shortly.

Family physicians and internists only have time and intellectual property to sell. The Medicare fee schedule recognizes prevention. However, Medicare does not reimburse for prevention, telephone calls or emails. President Obama talks a good game but has done nothing to correct SGR.

The “sustainable growth rate” (SGR) formula was enacted in 1997. Policy wonks concluded it was a way to restrain Medicare spending. I do not think the Policy wonks intended the consequences. The SGR set annual limits for the total amount of money to be paid in the traditional Medicare program. It also included allowances for inflation in the cost of operating a medical practice, for growth in the elderly population, and even a little extra money to pay for increases in the volume and complexity of services performed. It sounded reasonable.

The blue represents physicians’ increased in billings. The red represent application of the SGR formula. In 2007- 2009 Congress waived application of the SGR.


The fatal flaw in the formula was that it had no way to limit the array of services doctors provided or distinguish between valuable and needless treatments.”

“If doctors in the aggregate billings drove Medicare expenditures above the limit set by SGR, the SGR formula called for fees in the following year to be reduced.”

That aggregate punishment was not enough to persuade individual doctors to change behavior.”

Off course it would not change behavior. The threat of a malpractice trumps a punitive monetary penalty. It is not wise to create a punitive environment for any workers. It encourages bad behavior. Why can’t the government find the specific individuals it claims abuse the system and deal with them? The SGR is defective and needs changing. It needs to be changed along with the rules in the malpractice system.

Congress has waived the SGR formula since 2007 after physicians screamed for help. Congress did not suspend the proposed cuts. The accumulation of the yearly suspended cuts resulted in the 21.2% reduction in reimbursement this year.

I said physicians would stop seeing Medicare patients at a loss. This would hurt seniors’ access to medical care.

President Obama ignored the call for help until June 12th. He has had one and one half years to proclaim his support for eliminating the faulty SGR formula. He used the 21.2% reduction to calculate the deficit reduction effect of his healthcare reform bill.

Republicans are screaming that President Obama is spending money like a drunken sailor. Republicans decided to put their foot down. SGR was the wrong issue to put their foot down on. President Obama placed the blame on the Republicans in his weekly radio address.



This year, a majority of Congress is willing to prevent a pay cut of 21% — a pay cut that would undoubtedly force some doctors to stop seeing Medicare patients altogether. But this time, some Senate Republicans may even block a vote on this issue. After years of voting to defer these cuts, the other party is now willing to walk away from the needs of our doctors and our seniors.”

President Obama knew Democrats did not have the votes to eliminate the SGR formula when President Obama made his grandstanding radio announcement. The suspension of SGR failed to pass. Physicians are now going to see a 21.2% reduction in Medicare
reimbursement. The AMA’s deal with President Obama did not work. It was never going to work.

The American public should be getting tired of President Obama’s games. Barney Frank and John Kerry summed up the strategy that had been developed by the Democrats long ago. No one listened. Listen again.

Now President Obama doesn’t need congressional approval to get a single party payer system. He will do it by administrative regulation.

I do not think President Obama has thought out the unintended consequences. The burden to the American public will be huge .

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

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“If You Like Your Insurance You Can Keep It. Period!” President Barack Obama

Stanley Feld M.D.,FACP,MACE

Here we go again. On Friday June 11, 2010 at 4.30 pm internal administration documents were leaked. The documents reveal that up to 51% of employers may have to relinquish their current health care coverage because of ObamaCare. President Obama promised us that if we like our insurance we can keep. (See 3.46 minutes of the following You Tube.}

This is getting to be a habit with this administration.

Late in the afternoon on Fridays is a convenient time to leak information. No one will notice the information. The leaks’ impact will be old news by Monday morning.

The administration claims it did not know how it leaked. It is only a draft of the regulations created by Kathleen Sebalius Secretary of HHS. President Obama’s healthcare bill gives her the authority to write the regulations.

“The "midrange estimate is that 66% of small employer plans and 45% of large employer plans will relinquish their grandfathered status by the end of 2013," according to the document.

In the worst-case scenario, 69% of employers — 80% of smaller firms — would lose that status, exposing them to far more provisions under the new health law.”

The report was part of a joint project of the Departments of Health and Human Services, Labor and the IRS. The final report will be 118 pages. The report examined the effects ObamaCare’s regulations will have on existing, or "grandfathered," employer-based health care plans.

President Obama pledged it would have no effect on the healthcare insurance you have now. He did not say anything about modifications to present plans.


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This is another trick play by President Obama. The Republicans have been caught flatfooted once again. The healthcare reform bill allows President Obama and the Secretary of Health and Human Services to interpret broad provisions in the bill any way they want.

The President has said that a single party payer system works in other countries. It can work in America. His goal is to work his way toward a single party payer.

People have accused President Obama of wanting to eliminate private insurance. He said “we can keep our insurance if we like our present insurance.”

It turns out with these new regulations that we cannot keep our healthcare insurance plan if our employers modify the provisions in our plan. Americans will be forced to buy healthcare insurance from President Obama’s health insurance exchanges.

The health insurance exchange is supposed to provide affordable healthcare insurance. The healthcare insurance will be purchased with after-tax dollars.

The problem is cost controls will be regulated by the government. The program will fail to control costs just it has failed to control cost and improve service in Massachusetts.

President Obama has also said if something does not work we will adjust the system. Here comes the Public Option. However, the government and the states cannot afford to pay for healthcare insurance.

What are the conditions that eliminate your retaining your present healthcare insurance?

* The plan eliminates benefits related to diagnosis or treatment of a particular condition.

* The plan increases the percentage of a cost-sharing requirement (such as co-insurance) above the level at which it was on March 23, 2010.

* The plan increases the fixed amount of cost sharing such as deductibles or out-of-pocket limits by a total percentage measured from March 23, 2010, that is more than the sum of medical inflation plus 15 percentage points.

* The plan increases co-payments as a total percentage measured from March 23, 2010, that is more than the sum of medical inflation plus 15 percentage points or medical inflation plus $5.

* The employer’s share of the premium decreases more than 5 percentage points below what the share was on March 23, 2010.

The regulations are a done deal. Employers modify healthcare insurance plans every year. It is cheaper to pay a $2,000 per employee penalty than $15,000 a year per employee healthcare insurance premium.

A White House official said, “This is a draft document, and we will be releasing the final regulation when it is complete. The president made a promise to the American people that if they liked their health care plan, they can keep it. The regulation, when finalized, will uphold that promise."

Jonathan Alter in his book “The Promise” which is about President Obama’s first year in office quotes him on healthcare. “President Obama said to a group of Single Party Payer advocates that “they had to deal with the world as it is and not wanted it to be.”

President Obama is dealing with the world as he is working his way toward how he wants it to be. A government controlled world.

The next step is a single party payer.

Consumers will not have freedom of choice or free access to care.

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

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The Private Healthcare Insurance System Is Broken


Stanley Feld M.D.,FACP,MACE

During our father son weekend Brad introduced me to Ian Sigalow. Ian is a 31 year old principle in the venture capital firm Greycroft LLC. He received his BS in Economics from the Massachusetts Institute of Technology and an MBA from Columbia University Graduate School of Business. He is a smart fellow.

Ian felt comfortable with the healthcare insurance policy his firm provided him before he got sick. At the Lindzonpollosa he told me his horrible story. He has permitted me to repeat it. There are several important points to illustrate the dysfunction of the healthcare system.

There is also a lesson here for President Obama. Government is supposed to be by the people for the people. Government should make the rules that are be fair to consumers of healthcare.

Ian published his story in the Huffington Post. I hope I will give his story a little more publicity.

Ian had never been sick until he was diagnosed with Seminoma at age 29. Seminoma is a type of testicular cancer that affects one percent of males. It is the most common type of cancer among men aged 20 to 35. It is often cured by surgery alone, but advanced disease requires the addition of radiation therapy or chemotherapy. His seminoma had spread to his lymph nodes. He needed to have chemotherapy for a cure.

“My insurance provider was Oxford Healthcare, a subsidiary of UnitedHealth, the largest private health insurer in the United States.”

“When it comes to testicular cancer, the Centers of Excellence are Indiana University, which treated Lance Armstrong, and Memorial Sloan Kettering Cancer Center (MSK) in New York.”

Sloan-Kettering was not in his Oxford healthcare insurance plan’s network. He couldn’t switch to an upgraded plan because he works for a small business.

“Oxford’s better plans are reserved for large employers. I was willing to pay any amount to get in-network access but there were no options. However, I learned that Oxford offers an "in-network exception", where in-network privileges are granted to out-of-network hospitals based on doctor referral. I was told that if three Oxford oncologists referred me to Memorial Sloan Kettering, an in-network exception would be granted.”

Oxford supplied him with a list of 300 doctors to call. Many were not in practice anymore and most were not oncologists. This was the situation despite Oxford’s claim to be user friendly.

Ian found ten oncologists in the Oxford network. They all recommended Sloan Kettering based on the advanced stage of his disease. Oxford then reneged on its offer to grant an in-network exception.

“Oxford was going to call another set of doctors to see if they could find someone in-network to treat me. I asked the woman from Oxford why I was told to make the calls if Oxford was planning on doing it themselves. Her response was, "We were hoping you wouldn’t bother."

Oxford called a few days later. It was on a Friday afternoon. The representative told him she found three physicians who were willing to meet with him. He was advised by his oncologist that rapid initiation of treatment was important. He had scheduled himself for treatment the following Monday morning at Sloan Kettering. Oxford’s representative knew all this before she called him.

"We cannot tell you not to go to Memorial Sloan Kettering, and we cannot tell you to delay treatment. However, we found three doctors in New York who agreed to meet with you. It will require a new consultation…" and more delay in treatment.

The first lesson is of private healthcare insurance abuse in order to save money. This happens countless times a day. Unless you are the victim you would not be aware of the restrictions of access to care.

The state and federal government must paying attention to the consumer abuse. Consumer abuse has been ignored for 20 years. A simple regulation fining Oxford or rescinding its license to sell insurance in the state where the abuse took place would be an effective deterrent to the industry’s restricting access to care. In order to get Oxford’s full coverage he would have had to delay his treatment and pay an additional deductible to see three other physicians in consultation to grant permission for an in network exception.

“I made the decision to go out-of-network.”

After being treated at Sloan Kettering Ian called the three additional doctors Oxford had recommended. They all agreed he made the right decision to go to Sloan Kettering. He also found out from a former Oxford executive that patients with out-of-network benefits are almost never granted an in-network exception. All Oxford was doing was stalling and trying to impose its will on him.

Ian tried to quantify, in advance, the costs of out-of-network as opposed to in-network. It was impossible. Hospital systems do not publish their fees no matter how hard a patient tries he cannot get them.

This defect presents another opportunity for President Obama to Repair the Healthcare System. All that would have to be done is to require hospital systems to publish their fees in order to get certified to treat patients. Instead, President Obama is creating bureaucratic agencies to fix prices.

Ian obtained Oxford’s reimbursement rates for procedures and drugs. He figured his out of pocket expenses would be between $5,000 and $7,000. He was prepared to pay that fee based on his in network benefits.

His final out of pocket expenses bill were $35,000. Hospital systems have multiple negotiated prices. The multiple fees are one of the travesties of the healthcare system. If you are out of network you are responsible for the inflated retail price.

If a hospital system will accept five hundred dollars for a service from a healthcare insurance industry an individual patient out of network should not be responsible for a fifteen hundred dollar retail price for the same treatment and services. There is a total lack of transparency of negotiated prices.

All President Obama would have to do would be to require publication of negotiated prices Transparency would immediately empower consumers.

“What surprises many people is that the largest part of the bill was not doctor’s fees — those were only $3,000.”

Physicians do not know what hospital systems charge. Hospital systems have lobbied the government to restrict physicians from delivering the chemotherapy in their clinics because the in hospital profit margin is so large.

Why is the government always using physicians as a scapegoat? Physicians are the scapegoat because they are the weakest stakeholder in America’s political system. We lack effective representation.

Ian used the example of drug costs.

“One example of how this adds up: I was prescribed three shots of Neulasta, which is a white blood cell booster. At, a single shot of Neulasta costs $3,500. At Memorial Sloan Kettering, it was $5,600. Oxford’s usual and customary reimbursement was $2,600. I didn’t have a choice. I was left with $9,000 out of pocket for three shots.”

How was the cost of $3,500 at calculated? How much did it cost to produce the drug? How do you price R&D for the drug? Why should Sloan Kettering charge $5,600 a shot? Why would a hos
pital accept $2,600 from Oxford?

There is nothing in President Obama’s healthcare reform bill that deals with this problem. The solution is easy. Develop rules of transparency to price various services and treatments which include all the negotiated prices.

President Obama has chosen to impose prices through price controls and not rules to negotiate prices.

Price controls never work.

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

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War On Obesity: Part 16

Stanley Feld M.D.,FACP, MACE

The public’s perception is that obesity cannot be cured. In my opinion this is wrong.

I received two comments from readers after publishing War on Obesity: Part 15

The first;

Dr. Feld

Don’t you know that Obesity is a genetic disease? No matter what you do people cannot lose weight. If they lose the weight they will gain it back. A genetic disease cannot be cured.

Type 2 Diabetes Mellitus is also a genetic disease.


All obesity is not genetic. There are many diseases, situations that can lead to overeating. The majority of the obesity is due to environment factors.

Type 2 Diabetes Mellitus is genetic. At least 25% of Hispanic and Black people have a genetic abnormality making them less sensitive to insulin. (Insulin resistance). Insulin resistance increases as weight increases.

As the insulin resistance increases the person cannot metabolize glucose. Insulin is needed at the cellular level to permit the glucose to pass into the cell. The insulin resistance decreases the effect of insulin to permit this passage.

The person’s cells are starved of energy producing glucose. This causes the person to release stored glucose from the liver in order to overcome the insulin resistance. The very high glucose causes increased urination and increased thirst. The lack of glucose metabolism causes weakness.

Type 2 Diabetes Mellitus, the result of obesity causing increasing insulin resistance, can be asymptomatic for an average of 8 years.

The resulting high circulating blood sugar denatures proteins in the body. It causes blood vessels to decrease in diameter. Many people present with Type 2 Diabetes Mellitus at the time of a heart attack. Over the eight years of asymptomatic Diabetes Mellitus the blood vessels have been slowly constricting. This can result is a heart attack or stroke.

The hemoglobin molecule is a protein within red blood cells (RBC). RBC’s carries oxygen to the tissues. Hemoglobin molecule with the RBC also gets deformed. It is converted to HbA1c. The measurement of the percentage of HbA1c in the circulation is an estimate of the average blood sugar over a three month period of time.

Each red blood cell lives for 3 months. New RBC’s are born every second. If they are born and live in a high blood sugar they become deformed. The higher the blood sugar the higher the percentage of HbA1c.

Normal Hba1c is up to 6%. The lower the level the less the chance there is for blood vessel narrowing and the lower the risk of complications such as heart attacks and strokes.

The cost of Diabetes Mellitus to the healthcare system is $217 billion dollars a year. The challenge is to decrease the incidence of Obesity. Decreasing obesity will decrease the incidence of insulin resistance. In turn the incidence of Type 2 Diabetes Mellitus and its complications will decrease.

The only way to decrease obesity is through public education program and advertisement, changes in the fast food industry’s economic incentives, and providing economic incentives to consumers to lose weight.

Consumers must be made to be responsible for themselves.

Decreasing obesity will decrease healthcare costs dramatically.

President Obama should be spending taxpayers’ dollars on this goal and not on pilot studies and bureaucracies destined to fail.

The second comment received illustrates that weight loss can be accomplished. A long time reader responded with the following note to my last blog.

I previously sensed he doubted consumers’ ability to control their own health and healthcare dollars.

Dear Dr. Feld

There is hope.  Yesterday I was at a client’s office when I met an old friend who serves as a security officer for the company.

I said, “John you look great” and he told me he had lost 85 lbs.  I said “wow that’s awesome”.  When we were away from other folks there I quietly asked him if something had precipitated the change and he said “yes, I was diagnosed as a type II diabetic and when I was diagnosed I had an A1c of 11.0%”. 

He said “the Dr. wanted to start me on Meds immediately but I said no meds, I want to try diet and exercise first”.  The Dr. was skeptical but let him have 3 months to try diet and exercise.  In the 3 months, John lost 70 lbs and his A1c was 5.5% when he next saw the Dr.  He has since lost 15 more lbs and he is now accountable for his health.

With no accountability, people will not modify their behavior.  Death is inevitable, the questions that we must answer are:

1. How much money am I willing to spend on delaying the inevitable?

2. Whose money is it going to be, mine or someone else’s?

3. Depending on the answer to question number 2, what’s the effect on the answer to question number 1?


It can be done with proper motivation. It is difficult to lose weight. Obesity does not cause symptoms. Type 2 Diabetes Mellitus can be asymptomatic for a long time. This patient did lose weight for his own health. Many people can be helped to lose weight.

As Ross Carlson said it is a matter of eating less and doing more.

Consumers are bombarded with the stress of daily life. Americans are constantly exposed to anxiety by the popular media. Local murders, national oil spills, two wars, auto accidents, other disasters, the threat of unemployment and increased taxes all heighten our anxiety.

Salty and fatty foods taste good and are cheap. These fast foods help relieve stress. Fast food temporarily ameliorates the epinephrine surge caused by stress.

If President Obama wanted to solve the rising cost of healthcare he should concentrate on changing the culture of food production and attitudes about eating and exercise.

He is giving this essential initiative lip service and little expenditure of money.

He should empower consumers to reverse this impending disaster.

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


War on Obesity: Part 15

Stanley Feld M.D.,FACP,MACE

Cecelia and I went to flea market in North Central Texas on Memorial Day. There was a large crowd. I would estimate that more than 60% of the people were grossly obese and 30% were moderately obese.

There was a long line at the fast food restaurant.

Companies providing life and health insurance own nearly $2 billion worth of stock in the fast-food industry. The investments are in Jack in the Box, McDonald’s, Burger King, Wendy’s/Arby’s, and Yum! Brands, which includes KFC, Taco Bell, and Pizza Hut.

The life and healthcare insurance industries are not exhibiting the social responsibility they claim. They are in business to make a profit. The fast food industry is a profitable business. Why not invest in it?

President Obama ought to be investing taxpayers’ dollars for healthcare reform in convincing the public to not support the fast food industry.

The appeal of fast food is it is cheaper and more filing than fresh food such as fruits vegetables and chicken and requires no food preparation. The food also contains lots of salt and sugar which appeals to the tastes buds. Excess salt is a contributor to the onset of hypertension and sugar is empty calories.


Nearly half of all adults in the US have Type 2 diabetes, hypertension or hypercholesterolemia associated with an increased risk of cardiovascular disease, according to data from the National Health and Nutrition Examination Survey (NHANES).

Obesity is the underlying disorder precipitating these chronic diseases. If the U.S controls obesity it will decrease the incidence of these diseases and its complications. The cost of these diseases to the healthcare system is enormous.

Obesity and diet-related diseases are in fact far costlier than smoking, and they are just as preventable.

According to the latest statistics from the CDC, smokers incur health care costs of $96 billion a year in direct medical expenses.

Meanwhile, the annual health care cost of obesity in the US has reached $147 billion, and the medical bills for diabetes are at an estimated $217.5 billion a year!

Truly, the health care cost of smoking is dwarfed by the medical expenses caused by unhealthy food.

If you are obese, you will spend an average of 42 percent more on health care than someone of normal weight. This is just one of the reasons why I keep reiterating that someone needs to spend some time in the kitchen to prepare meals.

In response to my last post on consumer driven healthcare a fellow physician wrote;

Hi Stan,
You are assuming that patients, especially, will be willing to admit they might get sick and take steps to prevent it. I can’t even get overweight male diabetics to lose weight. All cigarette smokers know that smoking is bad for them.

I replied by asking “how much he was paying his overweight male diabetic patient to lose weight.”

When will President Obama listen? If he is listening he is not hearing. He is spending tons of money on bureaucratic infra structure that will not solve our healthcare problems or the costs incurred by those problems

The problem of obesity can be solved. It will take a societal change of cultural and attitude toward food and exercise. It will take innovative incentives. The ideal medical saving accounts provides that incentive.

The government has to develop incentives, and not penalties for the farm and food industry to reverse the production of obesity producing foodstuffs.

To some of us the incentive to stay healthy is enough. However, it is very difficult to eat healthy with all the advertising and food stimuli coming at us all the time.

My son Brad’s Foundry Group’s chief of technology officer, Ross Carlson, had an epiphany.

I saw Ross Carlson before he started his fitness program (see photo). He told me about his fitness program.

“ I’ve been hesitant to write this post for quite a while as it feels rather self-serving.  But as I’m ending phase two of my training program and now entering what I’m calling phase three I figured it was time for a little reflection.

Phase 1
If you’ve known me for more than 3 years you know I used to be fat.  Hey, let’s not dance around it, I was fat.

Fortunately for me I’d finally had enough and decided to finally get healthy.  This is what I call phase one of my fitness program or really fitness progression.

  I tend to be fairly obsessive with things I care about and fitness has been no difference.  My first goal was to lose weight – and a lot of weight.

I did two very simple things to accomplish this: I ate significantly less and exercised significantly more (that is to say I finally started exercising regularly).  I cut my daily caloric intake to around 1000 calories and added in cardio work, mostly cycling.  I continued on this program for roughly 10 months to reach my first goal. 

I guess it’s time for some numbers huh?  Wow, these are pretty scary: (I’m 5’11” by the way…)

Beginning: 235lbs | 40” Waist | 32% body fat | 32.8 BMI
Ending: 145lbs | 30” Waist | 8% body fat | 20.2 BMI

So in those first 10 months I lost roughly 90lbs total, 10” off my waist, 65lbs of fat (and 22lbs of muscle).  It was that last stat that made me begin phase 2 about 3 months ago.

Phase 2 and 3 are combinations of dynamic fitness training to increase muscle mass and cardiovascular fitness.

The key to exercise is to make fitness a way of life.

The key to decreasing caloric intake is to make eating less a way of life.

The key to weight loss is to exercise and burn more calories than you eat.

Nothing is new in the laws of thermodynamics. The patient must be responsible to and for themselves.

Final Thoughts
I plan on blogging more regularly about this subject now that I’ve finally published this post.  I hope to write about thoughts on eating, exercising, and my journey through all this.  If you’ve got questions or comments please let me know, they can be very motivating.  And if you’re considering doing something similar to this START NOW.  There is no better day than today to be healthy.

Oh, and now to leave you with a picture that I’m still scared by.  Left is old,
Fat Ross.  Middle is thin Ross from about 3 years ago.  Finally on the right is me a few days ago.  Just wait until you see me in 90 more days.


Hooray for Ross. Nice job. I am very proud of you.

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

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Healthcare Reform Should Be About Motivating Self-Responsibility Not Dependence

Stanley Feld M.D,FACP,MACE

Last week I heard a lecture about Accountable Care Organizations by a physician leader working for one of the major hospital systems.

His discussion made me realize that large physician organizations and hospitals are spending lots of time solving problems of quality medical care. In my opinion quality medical care has not been adequately defined.

A working definition right now is to decrease hospital stays, efficient medical care for a disease at lower cost, avoidance of medical errors in the hospital, and avoidance of hospital acquired infections.

These are important goals. They must be attached to monetary incentives. Many of these problems can be solved now. The solution demands the development of processes of care. An important question is how much money will process improvement save? I estimate that this process improvement could save an estimated 7 to 10% of the healthcare dollar.

The real question should be focused on how to repair the healthcare system by decreasing costs while improving the health of Americans.

This problem is not only about hospitals and medical practices reimbursement. It is about problems created by all the stakeholders. It is about aligning all the stakeholders’ incentives. The solutions to the healthcare system’s dysfunction must be initiated at the same time. You cannot try to fix one problem because it will result in a problem getting worse in another area.

The key to the solutions is to incentivize consumers of healthcare to control their health and be in charge of their healthcare dollars. Consumers can force secondary stakeholders to adjust swiftly to their demands and make them compete for consumers’ healthcare dollars.

Consumers must have incentive. They should be able to keep anything they do not spend of the first $7500 dollars of healthcare coverage. In our present healthcare system consumers do not control their healthcare dollars. They get first dollar coverage with variable deductible expenses. If the deductible is too high they will avoid necessary care and medications.

Society should not want that to happen because patients will get sicker and cost more to treat. Third party payers control the healthcare dollar. This control has contributed to increase the cost of healthcare. .

Some claim the only incentive consumers (patients) should need is to maintain their health. This claim has turned out not to be true.

Where do all the healthcare dollars go?

1. 65% of each healthcare dollar goes to the healthcare insurance industry for overhead for administrative services and insurance reserves whether it is private or government insurance.


2. Only 35% of the healthcare dollar is actually spent on medical care.

3. 80% of the healthcare dollars spent for medical care is spent by 20% of the people.

4. Most of those 20% have chronic diseases.

5. 80% of those dollars are spent on the complications of their chronic diseases.

6. Some claim there is 40% waste in the healthcare system due to uncoordinated care and duplication of care.

7. Much of the excess testing is due to the fear of malpractice claims and the practice of defensive medicine.

Let us follow the healthcare dollars with consumers being in control of their healthcare dollar.

If a moderate size company of 67 employees were willing to pay $15,000 dollars per employee for healthcare insurance it would cost $1,000,000 dollars. If the employer did not provide healthcare insurance the government penalty ($2,000 per employee) would be $134,000 dollars. This would represent a savings to this moderate sized company of $866,000 dollars per year. It would be the logical path to take. The formula I propose will work for the individual buying insurance.

Assume employers were willing to buy healthcare insurance for their employees. They would put $7,500 per year in a trust for each employee. The employee would be responsible for his healthcare dollars. The fees would be pre-negotiated fees by the government as the healthcare insurance industry does presently with physicians and hospitals. Hospitals and physicians might even want to compete among each other for the consumers’ dollars.

If the employee did not spend all the healthcare dollars in a year the remaining dollars would go into his retirement fund. It would not be used for future medical care.

A new equation for driving healthcare costs would be born.

There would not be a 65% overhead for administrative services for the first $7500 dollars because the healthcare insurance industry would not be administering the first $7500 dollars. The savings would be $4875 dollars.

Patients and physicians would have an additional $4875 dollars working toward direct medical care. The 65% overhead for administrative services for the remaining $7,500 of high deductible coverage could remain the same. The high deductible insurance would provide first dollar coverage after $7,500. The risk to the healthcare insurance industry would be less and so its insurance reserves could be less.

The government pays the same amount for administrative services to the healthcare insurance industry. The government could use the same formula for Medicare and Medicaid.

Consumers would have a monetary incentive to decrease their risk of getting sick (preventing obesity and increasing exercise). If consumers drove the healthcare system the consumption of snack foods and fast foods would decrease with proper education. Those fast food companies would be forced to sell healthy food to stay in business. Consumer would be driven by monetary incentives to stay healthy.

The onset of chronic disease would decrease. The complications of chronic disease would also decrease.

If a patient had a chronic disease at the onset of this new system and controlled their disease well in order to avoid acute and chronic complications of the chronic disease the healthcare system could reward them with a bonus at the end of the year. They would avoid costly hospitalizations.

Consumers would demand and pay to be properly educated to avoid complications of their chronic disease

An added benefit is that there would be less doctor visits and hospitalizations. This would increase healthcare capacity. It would enable the country to provide care for the entire population rather that force the healthcare system to abs
orb additional patients and create shortages resulting in rationing and decreasing access to care.

When people are motive by monetary incentives they are innovative. Innovation stimulates efficiency and decreases costs. It is important to have consumers be responsible for themselves and not dependent on the government.

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

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Small Business Associations And Individuals Joins State Lawsuit Against President Obama’s Healthcare Reform Bill

Stanley Feld M.D.,FACP,MACE


President Obama has tried to marginalize the law suits filed by 20 states concerning the constitutionality of his healthcare reform bill. President Obama has the power of the pulpit. He also has the traditional media helping him.

There are two main issues with these legal challenges:

  1. Is the mandate to force citizens to buy healthcare insurance constitutional?
  2. Is the nationalization of healthcare a constitutional infringement on States rights?

The lawsuits against the Obama administration have come from 20 State Attorney Generals, plus physicians’ groups and constitutional legal centers. An attempt has been made by the administration marginalize each lawsuit without much explanation.

It is difficult for the average citizens to understand the merits of the challenge. President Obama and his staff keep telling us the bill will reduce the cost of healthcare. It will be good for everyone. President Obama says he has been assured by legal counsel that the bill is constitutional.

Two weeks ago the National Federation of Independent Businesses filed an amended complaint to the lawsuit originally filed by 13 states.

In addition two individuals also joined the litigation. One is the uninsured owner of an automobile repair shop in Panama City, Fla. The other is a man from Washington State who prefers to pay his medical bills out of pocket rather than being compelled to obtain insurance, as will be the case starting in 2014.”

President Obama’s administration claims the lawsuits are a political ploy by Republicans. The administration has stated it will challenge the law suits on their legal standings and authority.

Dan Danner, president and CEO of the National Federation of Independent Business (NFIB), a nonprofit, nonpartisan organization that works to promote and protect the rights of small businesses to own, operate and grow their businesses wrote;

We also believe the health-care law is unconstitutional.

The centerpiece of this law is an individual mandate requiring virtually all Americans to purchase health insurance or pay a fine.

We strongly believe that the Commerce Clause of the Constitution does not give Congress the power to force individuals to purchase a private product or face a fine.

Requiring individuals to purchase something simply because they are alive is unprecedented.”

President Obama’s lawyers’ response to the constitutional challenge is it is a political ploy to tarnish the healthcare reform bill.

In court filings the administration has claimed that an individual decision to not purchase insurance is, in effect, a decision about how to pay for future medical care. Taken in the aggregate, those decisions substantially affect interstate commerce by shifting the cost of covering the uninsured to policy-holders, health care providers and taxpayers.

This is a lame argument.

Individual businesses have realized that President Obama’s healthcare bill will dramatically raise health-care costs rather than lower costs. This will increase the overall cost of doing business. There is a built in bias against small businesses.

What’s more, the federal mandate requiring that nearly all U.S. residents carry health insurance by 2014 seriously threatens our basic constitutional rights and individual freedoms.

The government cost estimates are already rising.

According to the Congressional Budget Office (CBO), the overhaul will cost about $115 billion more than first projected, bringing the total to more than $1 trillion.”

One trillion dollars does not even come close to the real and hidden costs of President Obama’s healthcare reform bill. The bill is not a healthcare reform bill. It is a way of centralizing federal power over individual rights.

President Obama has said the law will significantly help small businesses. He continually focuses on the small business tax credit. In reality the tax credit is not real.

The reality is that the tax credit is complex and very limited because firms qualify based on number of employees and average wages.

The credit, which is only available for a maximum of six years, puts small business owners through a series of complicated "tests" to determine if they qualify and how much they will receive.

Fewer than one-third of small businesses even pass the first three (of four) tests to qualify: have 25 employees or less, provide health insurance, and pay 50% of the cost of that insurance.”

“More importantly, the credit is temporary, but health-care cost increases are permanent. When the credit ends, small businesses will be left paying full price. They’ll also be forced to deal with all sorts of new taxes, fees and mandates buried in this 2,000-page law.”

One hidden tax is the healthcare insurance industry fee of $8 billion (that escalates to $14.3 billion by 2018) on insurance companies based on its market share. The fee will be passed on to employers in high premiums.

This tax will be paid almost exclusively by small businesses and individuals. The law specifically excludes self-insured plans. Most large corporations and labor union are self insured and will avoid this tax.

President Obama said his healthcare reform bill is going to “go after” the healthcare insurance industry’s grotesque profits.

The healthcare insurance industry is lining up to help the government write the new rules and regulations.

The rules they are helping write will permit the healthcare insurance industry to load its expenses as it has done previously.

With the business association and individual plaintiffs joining the lawsuit public perception might shift from the lawsuit being primarily a political device as President Obama has tried to emphasize to this lawsuit being a serious constitutional and states’ rights issue.

America wake up!

President Obama’s healthcare reform bill is a very expensive law. It will not decrease the cost of healthcare or increase the quality of healthcare.

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

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