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All items for October, 2010


Stop Spitting And Scratching

Stanley Feld M.D.,FACP,MACE

To: Bud Selig

Commissioner of Baseball

Dear Mr. Selig;

World Series is an exciting time. It is important to promote the national pastime. Kids play baseball all over the world.


I have been particularly interested in the post season games this season because my home team, the Texas Rangers is in the World Series. They have been playing magnificent baseball.

I have been both a Yankees and Rangers fan ever since the Rangers came to Texas. In fact, my brother and I went to the first Ranger game in Arlington Stadium.

I have been a student of baseball strategy for many years. Baseball is a fantastic game.

Ron Washington manager of the Texas Rangers has been a master manager on many levels. The Texas Rangers have looked tentative and awful in the first two games.


Baseball players are role models to kids all over the world. A baseball player’s behavior on the playing field should be exemplary.

Baseball players have been poor role models as far as spitting and scratching their crotch. I have never become immune to these tasteless rituals.

Spitting or expectoration is the act of forcibly ejecting saliva or other substances from the mouth. It is currently considered rude and a social taboo in many parts of the world including the West, while in some such as China it is considered more acceptable. It is possible to transmit infectious diseases in this way.

Spitting upon another person, especially onto the face, is a universal sign of anger, hatred, or contempt

Various diseases and infections can be spread by respiratory droplets, including tuberculosis, influenza, and the common cold.

1859 many viewed the spitting on the floor or street as vulgar, especially in mixed company. Spittoons became far less common after the influenza epidemic of 1918.

Scratching the crotch can be prevented by providing the players with comfortable underwear and antiperspirant.

Italy Makes Crotch-Scratching a Crime

Scratching your genitals in public in Italy can land you in trouble if you’re caught. According to a report on the Italian daily Corriere della Sera, Italy’s highest appeals court has defined the ‘act’ as "contrary to public decorum and decency."

As Commissioner of Baseball, you should penalize players for spitting and crotch scratching in order to maintain the decency of the game and to decrease this poor habit that might influence children and adults alike.

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

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Barriers To Accountable Care Organizations (ACOs) Success

Stanley Feld M.D.,FACP,MACE

In response to my last blog about the complexity of Accountable Care Organizations, a reader wrote, “Complexity breeds fraud, waste, abuse and inefficiency.  By nature, huge Government programs are complex and breed all four of the problems mentioned.”

Many of President Obama’s well intended government control programs have experienced terrible outcomes because he followed theories of “experts” instead of using common sense.

President Obama’s theoretical Accountable Care Organizations will be a failure. The pity is ACOs will waste money and destroy medical resources. President Obama’s healthcare reform law is not going to solve the healthcare system’s basic problems.

There are three possible reasons:

1. President Obama does not know what he is doing. He doesn’t understand physicians mentality, the process of medical care or previous physicians’ experiences with government control.

2. President Obama refuses to learn from past history.

Government dictated planning and attempts at execution of social, economic and cultural change usually fails. The government should make the rules to level the playing field for all stakeholders and then get out of the way.

Government planning and controls are expensive to execute for all stakeholders. The planning usually restricts freedom of choice by imposing mandates.

3. President Obama knows exactly what he is doing. He wants the healthcare reform plan to fail.

Failure would lead the way for the government to impose a government controlled single party payer system.

There is no question America needs healthcare reform. Rules to create a more efficient system are essential.

Patients own their disease. They should be put in the power position. Patients should be responsible for their care. The government should set up the rules and protections for patients to be responsible for their care.

The secretary of health and human services is required to establish a program within Medicare in which savings from efficient, high-value care are shared using Accountable Care Organizations (ACOs).

The ACO program of payment is to be launched in January 2012. At this time, only two of the 10 demonstration projects have been partially successful in saving money. The demonstration projects were done in ten clinics that were supposed to theoretically succeed in saving money..

At the moment, there are no real world ACOs exist. The rules and regulations regarding qualification as an ACO have not yet been published. We are approaching 2012.

The barriers for the success of ACOs are overwhelming.

“In principle, ACOs will efficiently deliver the measurably high-quality care offered by integrated health maintenance organizations (HMOs) without the “lock-in” that many Medicare beneficiaries abhor.”

The author assumes that HMOs delivered high-quality medical care. ACOs payment will be the same as HMOs without the lock in patients abhor.

ACOs are really HMOs on steroids. Once patients and physicians understand this they will be hesitant to join.

“ ACOs begin not with insurance but with a collection of providers (physicians and facilities) who come together and accept internal payment arrangements that facilitate the provision of efficient, high-quality care. If the ACO does well, the savings it achieves can be shared among the providers or pumped back into the provision of high-value care.”

ACOs are a fixed payment system. The financial risk is shifted from the government to physicians. Why should physicians pick up the risk for irresponsible patients?

Patients are attributed to the ACO on the basis of their patterns of service use. That is, if a patient typically sees a primary care physician who belongs to an ACO, all of that patient’s care is attributed to that ACO. If the costs incurred by the ACO’s “attributees” are sufficiently below Medicare’s spending projections for that population, the ACO shares in the savings realized by Medicare; if the costs are too high, the ACO loses nothing.

Patients will not have a choice of physicians. The experts predict physicians’ incentives are changed from “over testing” to “under testing” patients. However, physicians will be forced to continue to over test for defensive medicine purposes and the threat of malpractice. I think over testing for defensive medicine will not be solved until effective malpractice reform is passed. President Obama has no interest in malpractice reform.

George Thomas, a New York physician, has posted a blog describing to non-doctors and non-sued doctors what is wrong with the malpractice system and its economic effect on healthcare cost. It is written from the point of view of a physician who has been sued five times and won each suit.

“First, being sued does not make a doctor a better doctor. We improve through experience and studying, and not making the same mistake twice.”

I hope President Obama will read this article. Everyone should read this article. The ACO payment system is destined to fail.

Elliot Fisher M.D. of the Dartmouth group is one of the masterminds of the ACOs.

Dr. Fischer has little real world experience. He has described an attribution rule whereby Medicare beneficiaries are assigned to their primary care provider and then to unique physician–hospital networks. Please note the lack of patient choice.

1.“ ACOs must be able to collect information on the quality of care, create new incentives, and accept and distribute bonus payments. Building these capabilities will entail substantial up-front costs for new legal entities, information systems, and other infrastructure. Large multispecialty groups are well positioned to take on these responsibilities”

Most primary care physicians are not in that position and are unwilling to hand their intellectual property over to a hospital system.

  1. All primary care practitioners will not likely to be invited into or want to participate in an ACO.

The ACO concept will generate severe shortages of primary care physicians. There are important legal antitrust concerns about the corporate ownership of physicians in some areas of the country. The Medical Home concept designed to enable primary care to survive will quicken the specialty’s demise.

3.” The ACO concept calls for each primary care practitioner to be part of only one ACO.”

The practice of medicine will be under the dictates of the federal government.

A excellent panel discussion was presented by the online New England Journal of Medicine. Thomas H. Lee, M.D., Lawrence P. Casalino, M.D., Ph.D., Elliott S. Fisher, M.D., M.P.H., and Gail R. Wilensky, Ph.D. presented the virtues and defects in ACOs. Gail Wilensky and Lawrence Casalino point out the impractical ideals of ACOs.

In spite of this, President Obama has declared the ACO payment system a done deal.

He is misguided.

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

  • Tadalis

    Although ACOs will be responsible for the care of their assigned beneficiaries, Medicare beneficiaries will be able to choose their healthcare providers even if such providers do not participate in the ACO to which the Medicare beneficiaries are assigned.

  • Fras

    Nice post.

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Accountable Care Organizations: Another Complicated Mistake

Stanley Feld M.D.,FACP,MACE

Before I beginning I would like to congratulate the Texas Rangers for the magnificent baseball they played against the New York Yankees bringing the American League pennant to Dallas Texas.


Accountable Care Organizations: Another Complicated Mistake

One the many pilot programs being set up by President Obama’s healthcare reform law is Accountable Care Organizations (ACOs). ACOs have become the latest fad among health policy wonks desperate to control costs and boost quality in healthcare.

“An Accountable Care Organization ( ACO) is a health system model with the ability to provide and manage the continuum of care across different institutional settings. These settings include ambulatory (outpatient),inpatient hospital care and post acute care.”

“ACOs should have the capability of planning budgets and resources and are of sufficient size to support comprehensive, valid, and reliable performance measurement.”

In turn, it has become a source of confusion for hospital administrators. Some administrators are hiring healthcare policy consultants to help them create ACOs.

President Obama’s contends ACOs will raise the quality of care and lower the cost of medical care simultaneously.

This is pie in the sky thinking. All President Obama has to do is look realistically at the success rate for Accountable Care Organizations. He continuously uses the following examples of ACOs success:

“What our system needs are more Kaiser, Geisinger, Mayo and Intermountain health systems. These are the integrated delivery systems that are already delivering higher quality and lower costs.”

My question is where is President Obama’s data? Mayo is in the process of not accepting Medicare. Mayo is losing too much money servicing Medicare and Medicaid patients.

Mayo said last week it will no longer accept Medicare patients at one of its primary care clinics in Arizona. Mayo said the decision is part of a two-year pilot program to determine if it should also drop Medicare patients at other facilities in Arizona, Florida and Minnesota, which serve more than 500,000 seniors.”

Mayo says it lost $840 million last year treating Medicare patients, the result of the program’s low reimbursement rates.

In Arizona Mayo lost $120 million dollars. The losses are usually made up by cost shifting to the private insurers and private patients. These losses are getting harder and harder to make up by cost shifting.

"Mayo Clinic loses a substantial amount of money every year due to the reimbursement schedule under Medicare," the institution said. "Decades of underfunding and paying for volume rather than value in Medicare have led us to this decision."

This is a direct contradiction of President Obama’s contention.

Medicare and Medicaid programs have been no more successful than private insurers in supporting the growth of these organizations. Real health reform will occur when President Obama recognizes patients own their diseases. Patients must have appropriate incentives and be active in their care.

Massachusetts has published data on costs. The cost of care has not been reduced by Partners Healthcare System, an integrated delivery system at Massachusetts General Hospital.

“But there is no sign that Partners has used its size and scale to deliver care at a lower cost. Indeed, there is evidence that it has used its market power to extract higher rates from insurance companies.”

There are no data showing that quality, safety, and efficacy in the delivery of care throughout the Partners system is better than other community hospitals or academic medical centers in the area. .

On January 1,2012, Kathleen Sebelius is supposed to establish a Shared Savings Programs through Accountable Care Organizations in which authorized providers contract with the Secretary of HHS to manage and coordinate care for Medicare beneficiaries.

Acceptable providers include group practices, networks of practices, hospital-physician partnerships and other groups that the Secretary deems appropriate.

Kathleen Sebelius has been empowered by President Obama’s healthcare reform law to use her discretion, without congressional oversight about who will be appropriate providers.

In order to be deemed appropriate ACOs must:

  1. Care for at least 5,000 patients.
  1. Have a sufficient number of primary care professionals.

The number of primary care providers has not been defined by Kathleen Sebelius at this time. The term primary care providers has been used rather than primary care physicians. It is a subtle point overlooked by many. A nurse practitioner or physician assistant is a provider. It is only a matter of time before a shortage of primary care physicians will be replaced by M.D. equivalent providers.

  1. Have defined processes to promote evidence-based medicine.

This is a slippery slope. There is constant change in definitions of the best evidence based medicine. There are also defects in clinical studies.

  1. Coordinate care through telehealth, remote patient monitoring and other enabling technologies.
  1. Meet patient-centered criteria established by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans.

Kathleen Sebelius alone controls the money and makes the determinations for appropriate care. How would you feel if the government selected and bought your car or dress shirts? Big brother is getting bigger and bigger on President Obama’s watch.

Patients own their disease. Neither hospitals or physicians can control complications of chronic disease. They cannot control most readmissions. They should not be liable for those readmissions.

Hospital systems would love to hire physicians and own their intellectual property. They have been unsuccessful in multiple attempts. Previous attempts have cost them dearly.

Hospitals are confused and terrified of the potential financial consequences of ACOs. The rules are vague. Hospital are hesitant to invest to form an ACO.

President Obama wants to control every aspect of clinical medicine.

It is time to face the real issue explicitly. President Obama wants hospital systems to form integrated delivery systems. The ACO concept has not been well thoug
ht out by President Obama. The concept is a non- executable mess. President Obama wants them because he thinks knows best.

He wants to shift the responsibility for costs of insuring patients from the government to hospital systems with hospital systems controlling physicians. He wants the government to pay a fixed low price for medical care. Providers will have fight with each other over distribution of the funds.

Accountable Care Organizations are really HMOs in disguise.

“While we are at it, who is looking at the issue of plan design? If you create ACOs, you probably intend to limit consumer choice of physicians and doctors as part of their insurance plans. Do you mean to put the primary care doctors in the middle of that issue, restoring them to the hated "gatekeeper" role we saw during the era of managed care?

Physicians and hospital systems are starting to figure t out. The best way to fight a war is not to show up. Patients will lose.

Health policy wonks are telling hospitals to form ACOs because they will get privileged funding. Hospital systems are having difficulty understanding the logic.

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

  • Gregg Masters

    Hi Dr Feld:
    Good to see the wisdom of the elders injected into the current conversation of health reform implementation.
    I remember well the days of SHP, and the ‘challenging’ extraction of the ‘H’ from the SHP/Genesis joint venture PHO!
    I’d like to guest post your article on ‘ACO Watch’ (, do I have your permission?
    Clearly, we’re resuming the debate on how to re-engineer our unsustainable sick care system; one key question is will we have learned from the mistakes of the past, or is this ‘deja vu’ all over again?

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A Proud Dad!

Stanley Feld M.D.,FACP,MACE

Brad Feld is, in my opinion, a transformational visionary. Cecelia taught him to read at a very young age. He has the ability to absorb everything he reads.

He has also developed the skill of being intrinsically motivated.

Intrinsic motivation refers to motivation that is driven by an interest or enjoyment in the task itself, and exists within the individual rather than relying on any external pressure.”

Brad illustrated this ability during a recent presentation.

“Tonight, I’ll spend about 90 minutes talking to y’all.  I’m doing it because I enjoy it and I learn from it.  While I hope, it is useful to you, that’s not the reason I’m doing it.  While I hope you have fun, learn something, and enjoy our time together, I won’t feel better or worse if you do.  In fact, since my goal is to learn from everything I do, I’d much rather you give me feedback about things you think could have improved our 90 minutes together.”

This is an excellent explanation of intrinsic motivation. Our culture drives us to seek the approval of others. I believe when a person is centered he does things for his interest which in turn will result in benefiting others.

“I then went on to explain that I’m motivated by learning.  I’ve decided to spend my entire professional life learning about entrepreneurship and have decided that my laboratory is “creating and helping build software and Internet companies.”

“ I derive enormous personal pleasure from the act of working with entrepreneurs, helping create companies, and learning from the successes and failures.”

Brad is very generous with his time and energy. He loves to teach and share his successes and failures with others. I have always felt that teaching enables you to learn and get more than you give.

Brad illustrated this point in a recent blog.

“It’s a good example of giving more than you get and letting the universe do its thing.  Gary DiGrazia, the CEO of Mindjamz, emailed me with some questions about his startup.  I didn’t know Gary but as is my habit I gave him some quick feedback.  We went back and forth a few times and then he told me that he helps produce the KRON 4 Weekend Morning News show and asked if I wanted to do an interview about Do More Faster on it.  Um – duh – yeah!  Two weeks later we tape an interview which just aired.”

About four years ago, David Cohen came to Brad with the idea to teach startup entrepreneurs how to run their companies by developing a mentorship program in Boulder. Boulder entrepreneurs would teach these start-ups how to become successful.

Brad and I were in Las Vegas during one of our father son weekends when he explained the concept to me. I thought it was a brilliant idea. Colleges and universities do not provide this kind of opportunity.

He told me he planned to advertise for applicants on his blog.

He did not know how many applications he would receive or how many companies they would take. Brad and David received over 300 applications. They decided they could handle 10 companies. TechStars would fund these companies in order for them to live in Boulder for 3 months for a small percentage of the business. During those 3 months, TechStars would provide the selected entrepreneurs with intensive mentorship, a startup community and an opportunity to pitch their product to venture capitalists and angel investors.

On a visit to Boulder in June, I went to TechStars and asked each participant to describe the vision of their company to me. Some could and some stumbled.

In August, I revisited each company and stayed for Demonstration Day. It was a day in which each company made a 12 minute presentation about their company to venture capitalists and angel investors in a quest for funding at the next stage of their company’s development. Start-ups are forever seeking funding. Brad invited venture capitalists and angel investors from all over the country to come to Demonstration Day. At least 350 people showed up.

The difference in professionalism during their Demonstration Day presentations was amazing.

I knew Brad had something big going on here. He did not stop there. In time, Brad and David started a TechStars program in Boston, then Seattle and recently announced a New York City site.

David and Brad gained a lot of insight from the experiences of both the start-up companies and mentors. They decided to write a book about their experiences as well those of the start-up companies and mentors.

“Do More Faster” is a must read for start-up entrepreneurs as well as entrepreneurs, angel investors and venture capitalists.


It is also a must read for anyone who wants to be innovative.

It provides a template for the components of innovative thinking. It teaches us how successful mentors and start-up companies learn to problem solve. These lessons are useful for anyone.


“When I reflect on the process of writing this book, I realized that I accomplished several goals at the same time that are all related to my lifetime commitment to continually learn, with a specific focus on entrepreneurship. At the most obvious level, I learned what it took to write a book and become a published author. But the process of writing the book gave me a lot of time to reflect on what it takes to create a new company, the attributes of a successful entrepreneur and how entrepreneurial communities work.

While we originally envisioned that “Do More Faster” would target first-time entrepreneurs, now that it’s finished we are hopeful that it is valuable for any entrepreneur, investor, and early employee of a startup.”

“Do More Faster” will be a best seller. Be sure to read the customer reviews on

  • Anwith1n

    Dr. Feld, thanks for sharing this – I met Brad in Seattle and he /was/ very generous with his time and energy. I’ve seen him give to the Boulder community and I’m glad he came out to Seattle and chose it to be a TechStars community.
    I’m currently reading Do More Faster (Thanks, Brad!) and it’s as marked up as any of my textbooks from college.

  • HopkinsSHERRI

    Various people in all countries get the loan from various creditors, because it’s simple.

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Patients Own Their Disease.

Stanley Feld M.D.,FACP,MACE

It is important to listen to what physicians are saying. An article appeared in SERMO, a physicians’ social network, which expressed a physician’s frustration.

It is appropriate to publish some of that physician’s thoughts.

“I first heard this statement over twenty years ago, when I was an intern in general surgery, struggling to find my professional self.”

“My chief resident said; “The patient owns the disease,” “You’re not trying to make them suffer, you’re trying to help. They’re sick, you’re not.”

“The human body is unpredictable.  Disease complications happen.”

The author thought his chief resident was heartless and callous. In a way, he was but he was getting at the heart of the matter. What is the patient’s responsibility in the evolution of disease?

This physician took everything that happened to his patients personally.

The patient owns his disease. The physician does not own the patient’s disease. Lifestyle plays a large role in the cost of the healthcare system.

President Obama’s healthcare reform law ignores the central role patients play in the therapeutic equation.

Day after day in the Emergency Department, people who take no responsibility for their health confront me.  They smoke, they drink, they do drugs, they don’t take their medicines, they drive impaired and crash, and yet they expect me to make them well.

They visit at their convenience, complain about the wait, want their medicines for free, and then don’t pay their bills.

The concepts of health insurance, family doctors, and preventive care have been completely lost.  Everybody except the patient owns the disease.

There was a time that patients knew they owned their disease. They knew they were partners with physicians in the treatment of their disease. Patients had to do the best they could under their physicians’ guidance.

“Somewhere, somehow, things got turned around.  The patients no longer own their diseases.  They’ve given them to us – physicians and society at large.

We are held responsible for everything that happens to a person, regardless of how they conduct their lives or follow our instructions.

  The weight on our shoulders is crushingly real, and forcing many good physicians to walk away from the thing they love most – taking care of others.”

He goes on to say;

I’m still shocked when a patient says, “You have to ….”  It’s endless – “refill my blood pressure and diabetes medicines, even though I don’t know their names or the dose. Patients demand I order an MRI for their two years of knee pain.”

“Say no, explain why, try to educate, offer alternatives, and the reply is  “If you don’t do it and something bad happens, it’s your fault.”

“You can’t tell someone that his or her symptoms are due to obesity, smoking or drinking – that’s judgmental.”

The author’s examples are endless. One last example sums up the dilemma facing healthcare in America.

“I once believed that every time I gave in to a patient’s pressure for an antibiotic for a viral illness, I was contributing to the emergence of super-resistant organisms.

“I believed that I could control the run-away cost of health care by judiciously ordering advanced studies only when absolutely necessary.  I tried to convince people that they owned the disease, that they had responsibilities to meet, that they couldn’t just demand everything be given to them.  And now I’m labeled a “disruptive physician”, because I generate too many complaints.

The increasing prevalence of obesity is a concrete example of the need for patients accepting responsibility for their disease.

Obesity is the cause of many disease processes. Obesity is not a random occurrence. It is linked to eating more than you burn. Potential patients are responsible for their obesity.

When obesity leads to the onset of Diabetes Mellitus, patients are responsible for controlling their blood sugar so they do not develop the complication of Diabetes Mellitus. The complications are heart attacks, hypertension, strokes, blindness, or kidney failure.

The government must provide and promote public education about obesity. Somehow, the appeal of overeating must be squashed and the virtues of exercise promoted.

Physicians and their healthcare teams are responsible for teaching patients how to control their blood sugar.

Eighty percent of the healthcare costs are the result of the complications of chronic diseases. Physicians must be encouraged, not forced, to set up systems of care to help patients become responsible for their chronic disease.

Where is the motivation for physicians in President Obama’s healthcare reform law? Where is the motivation for patients to become serious about intensively controlling their blood sugars in President Obama’s healthcare reform bill? New agencies are being set up to penalize physicians for not using resources to set up systems of care, resources which are uncompensated.

President Obama’s healthcare reform law does not promote patients taking responsibility for their diseases. The law contains nothing that measures patients’ performance. The law contains a lot of proposals that will falsely measure physicians’ performance

The law uses the term preventive care. It is meaningless without providing details. Prevention is immediately defined as providing vaccinations. Vaccinations do not define preventive chronic disease management.

If we are going to decrease the acute and chronic complications of chronic diseases, patients must comply with their physician’s recommendations.

Systems of care for chronic disease management have to be taught to patients and physicians. Medical schools have taught physicians how to treat diseases after its onset. President Obama should focus on setting up systems of public education before the onset of chronic disease.

President Obama’s healthcare reform act puts the burden of successful outcomes on physicians. Physicians do not own their patients diseases.

He should focusing on where money is wasted not building an infrastructure that will waste more money.

“Somewhere between the past paternalistic model of the physician-patient relationship and today’s give-them-what-they-want system, there has to exist a better paradigm.

As doctors, we need to resist the external pressures to make every one happy.  We must legitimize our expectations and have the backing of hospital administration when appropriate.

We should be empowered to refuse unnecessary, expensive, and often harmful demands. We cannot continue to abdicate the responsibility of our education and profession to political correctness.”

The Sermo physician’s statement demands physician leadership for constructive change. He says just say no.

It is difficult for most physicians to say no when they will be penalized by their hospital administrator or get sued under present malpractice laws.

Patients must own their disease!

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

  • Kamagra Oral Jelly

    Physicians and their healthcare teams are responsible for teaching patients how to control their blood sugar.But still i feel that some were it is patient duty to understand the physicians and co-operate with them

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    Patient understands their own disease and their capacity to work closely with doctors and health care team.

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An Interesting Unintended Consequence. Whom Can You Trust?

Stanley Feld M.D.,FACP,MACE

I predicted that the healthcare insurance industry would increase healthcare insurance premiums because of President Obama’s healthcare reform plan.

I had also predicted that employers would drop healthcare insurance coverage for employees. It is much cheaper to pay President Obama’s penalty than it is to insure workers.

McDonald’s Corp. has warned federal regulators that it could drop its health insurance plan for nearly 30,000 hourly restaurant workers unless regulators waive a new requirement of the U.S. health overhaul.”

This is the first corporation to threaten to drop healthcare insurance for employees. It is also a first step toward the failure of President Obama’s healthcare reform plan as written.

I have speculated that President Obama wants this plan to fail. Then the public option could be accepted. The public option will fail. The next step will be government controlled single party payer healthcare system.

The infrastructure for this progression is being put into place. The regulations are being written. The agencies are being formed.


An entitlement system of universal care with restriction of access to care and rationing of care will be a necessary part of this new entitlement program.

The government cannot afford a new entitlement that permits citizens to have the freedom of choice they have enjoyed for so long.

Between now and then, we will hear a lot of babble from President Obama about how the government is doing everything to help consumers take control of their healthcare.

McDonald’s decision is a result of the new regulations. The regulations make the kind of healthcare insurance it offers unaffordable to McDonald’s. McDonald’s provides “mini-med” healthcare insurance for workers at 10,500 U.S. locations. Presently a single worker can pay $14 a week for a plan that caps annual benefits at $2,000, or about $32 a week to get coverage up to $10,000 a year.

It is a plan that offers an insignificant about of healthcare coverage.

The traditional media has made a big deal out of the McDonald’s story. It is a big deal pre midterm elections for President Obama and Democrats seeking re-election. Potentially 1.4 million people could be added to the count as uninsured.

What is going on?

McDonald’s outsources these “mini-med” benefit plans to healthcare insurance carriers. Carriers are supposed to pay 80% of the premium for healthcare insurance benefits in 2011.The healthcare insurance industry has fought hard to exclude many of its overhead expenses from this calculation.

For example, if McDonald’s pays the carrier $100 for a premium, the amount that goes for insurance overhead is excluded from the medical loss calculation. Let us say fifty cents on the dollar is excluded. Then the healthcare insurance carrier must pay 80% of the remaining fifty cents for benefits. If the insurance carrier does not spend the 80%, McDonald’s should get a rebate on their insurance premium the following year.

President Obama’s healthcare reform law is trying to limit credited expenses claimed by the healthcare insurance industry. President Obama wants to regulate profits by regulation rather than by competition.

The healthcare insurance industry is raising its rates in anticipation of the government’s new regulations. McDonald’s has a high turnover of employees. The carriers claim this high turnover increases its administrative services. Administrative services it will not get credit for as expenses in the new regulations. Therefore, it must increase the premium. McDonalds cannot handle the increase in premium for 30,000 employees

“McDonald’s last week sent a top official at the Department of Health and Human Services a memo saying "it would be economically prohibitive for our carrier to continue offering" its "mini-med" limited benefit plan unless it got an exemption from the requirement.”

Mini-med healthcare insurance plans are becoming a stopgap for employee health care coverage. With more employers than ever cutting back or completely removing health insurance from their fringe benefits, providing this minimal coverage plan is becoming more popular. The employee, not the employer, most often carries the entire premium cost for the plan.

McDonald’s offers its hourly workers two different health care plans, which are known as “mini-med” plans. In one, workers can pay about $730 a year for benefits of up to $2,000. In the other, they can pay about $1,660 a year for benefits of up to $10,000.

The “mini-med” plan is very cost efficient for the employer.

These employees of McDonald’s mini-med plans are in reality uninsured now. However, it makes these McDonald’s look like a good corporate citizen. The healthcare insurance industry makes a lot of money. Employees think they have good healthcare insurance.

Two days later, the Obama administration said its top health official will "exercise her discretion" in enforcing a new health-law requirement.

One commenter said;

RE: "The Obama administration said Thursday that its top health official will "exercise her discretion".
“This is it folks; this is the beginning of the end. We once had a government confined law, now we instead are ruled by "her discretion.””

“We are getting a small taste of the wonderful world of big government bureaucracy and unintended

White House officials said they have sought to ensure that insurance coverage for employees isn’t disrupted as a result of the law.

Aetna Inc., one of the largest sellers of mini-med plans indicated that a potential medical-loss ratio waiver could provide relief to dozens of low-wage employers. Aetna provides min-med plans to Home Depot, CVS, Disney Worldwide Services, Staples Inc., Blockbuster Inc., AmeriCorps teaching-program sponsors, and others.

Kathleen Sibelius issued “her discretion” decision to grant waiver through the HHS bulletin.

“In the case of mini-med plans, the HHS bulletin says plan sponsors can seek a waiver from those limits for 2011 through 2013.”

ver, the government bureaucracy went to work. A plan sponsor must apply for a waiver, must detail terms of the plan, the number of covered individuals and the plan’s annual limits for approval.

Also required is a statement by the plan administrator or CEO of the issuer of the coverage that says the plan existed prior to Sept. 23, 2010, and that meeting the minimum annual limits would result in a significant decrease in access or a significant increase in premiums for the plan.

Another commenter said;

“ Wonderful. This is exactly the problem with huge government intervention in the marketplace. Large businesses with enough clout can get a waiver but small guys get the shaft.”

There are several important issues;

    1. President Obama now has the power to interpret healthcare law at “its discretion.”
    2. Healthcare waiver is being used to political advantage to affect the mid-term elections.
    3. Lobbying and big business clout is influencing President Obama’s administration to interpret the law in its favor.

We are going to see these unintended consequences repeatedly in the coming years.

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

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The Media Is The Message, But What Is The Truth?

Stanley Feld M.D., FACP,MACE

President Obama has manipulated both the traditional media and the new media. He has been a likable fellow. His discusses issues in generalities. The devil is always in the details.

President Obama’s healthcare reform sounds great. He is going to provide affordable care to everyone and an increase in quality. He does not discuss the hidden cost to the government or who is going to pay for it.

It would be fine if the health reform plan would work. It won’t. It will increase government control over individual decision making. I predict healthcare reform will fail under the weight of its own bureaucracy

We have already seen signs of its failure with healthcare insurance premiums rising. The McDonald’s incident showed that the Obama administration is willing to show favoritism.

President Obama just launched a new consumer website . On it he explains how you can take control of your healthcare. He explains how the Affordable Care Act will benefit you, your family or your business. He also explains how to find healthcare insurance coverage.

It is worth looking at. The media is the message but not necessarily the truth.

John R. Graham, Director of Health Care Studies, Pacific Research Institute adds some of the missing facts from President Obama’s statements on

“The mission of the Pacific Research Institute (PRI) is to champion freedom, opportunity, and personal responsibility for all individuals by advancing free-market policy solutions.”

Since its founding in 1979, PRI has remained steadfast to the vision of a free and civil society where individuals can achieve their full potential.
Put simply, public policy is too important to be left just to the experts. Individuals are the real decision makers when it comes to their schools, health care, and environment.”

The contrast between President Obama’s explanation and John Graham’s interpretation is eye opening. It is consistent with Charles Krauthammer’s statement,Don’t listen to what President Obama says, Pay attention to what he does and what he is doing.”

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

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The Defects And Waste In Medicare

Stanley Feld M.D.,FACP,MACE

President Obama should listen to individual physicians and physician groups. They can tell him how to make Medicare more efficient.

President Obama is ignoring the power of innovation in competition. Government control leads to increased inefficiency.

Medicare wastes millions of dollars. The government should be focused on identifying and eliminating this waste.

It should not be concentrating on developing a bureaucratic infrastructure that will increase waste.

Taylorism of the early 20th century must yield to disintermediation of the 21st century.

President Obama is not listening to practicing physicians. Republicans and their leaders should be listening to practicing physicians. Republicans should be developing policies to fix the inefficiencies in the healthcare system right now.

I received this note from a group of physician leaders of large group practices throughout the country expressing some major concerns. These are a consensus of their top five concerns. Most practicing physicians and physician groups would agree. All have been frustrated by these issues.

“Stan, we polled a few of my colleagues about what would be our top issues/concerns as it relates to our current involvement with Medicare and Medicaid (CMS). We have summarized our discussions in a "5 top list".

1. “There is an inconsistency and difficulty in administration of local coverage policies versus national coverage policies and the costs associated with the variances.”

The administrative services for Medicare are outsourced to the healthcare insurance industry. Vendors in each state are autonomous. They have the ability to interpret and institute Medicare policy as they wish.

This inconsistency causes problems in tourist states for physicians and patients. There should be national policies and specific guidelines for policy implementation by carriers.

This simple fix would streamline the payment process for seniors and reduce physicians’ costs associated with claims payments. Complex payment appeals by both physicians and seniors would be reduced. The healthcare insurance industry’s staff costs and physicians’ staff costs for processing, reprocessing and adjudicating claims would be reduced. The wasteful administrative cost passed to Medicare would be saved.

2. “Oversight and management of Medicare Advantage Plans must be improved.”

There is a lack of appropriate oversight of management for the Medicare Advantage program. This defect impacts the cost of senior citizens’ medical care. Medicare Advantage does not implement the ever changing policies rapidly. There is no source for adjudication of complaints. Reimburse is delayed in some cases for a year.

Traditional Medicare carriers have no power to offer help. There needs to be more consistency and transparency on coverage policies for Medicare Advantage plans.

Medicare Advantage was created as a step to relieve the government of responsibility for Medicare. It shifts the entire responsibility from the government to the healthcare insurance industry.

The healthcare insurance industry charges the government a $3,000 premium above the cost of traditional Medicare to assume this responsibility. Seniors pay a lower premium for Medicare Advantage also. The healthcare insurance industry profit on Medicare Advantage is greater than traditional Medicare.

It is much easier for physicians to deal with traditional Medicare carriers than Medicare Advantage carriers. The amount of time spent by both providers and carriers in correcting payment problems would be reduced. This reduction in administrative waste would reduce the cost of medical care quickly.

3. “All stakeholders; physicians, hospital systems, insurance carriers and government should be held accountable for fraud and abuse.”

There is no mechanism to measure fraud and abuse by CMS. Physicians’ challenges to carriers are expensive, time consuming and minimally rewarding.

Reimbursement challenges will only increase when future rationing and control of medical care decisions are made by the new powerful commission boards and advisory panels. There is no government accountability or defense by physicians or patients for these new agencys’ decisions.

The government claims CMS saved $900 million by hiring external contractors to review provider compliance. Is this report published and validated?

Does CMS undergo similar audits of best business practices, administration staffing and other benchmarks to test its bureaucratic efficiency of operations?

4. Operational impact of government policy on physician practices must be considered. “

An example of this comment is e-prescribing. The government should make it as easy as possible for physicians to e-prescribe. Instead, e-prescribing is mandated for 2012. The government is creating punitive rules for physicians not in compliance with this mandate.

The government should understand that mandates do not work. Usually, the cost of enforcing mandates is greater than the cost of not having a mandate .

The government should make it voluntary, easy and profitable comply with a rule that should be part of every practice. E-prescribing will make practice more efficient.

More that 90% of physicians have a smartphone. Many physicians have IPADS. All have computers with internet connectivity.

If the government promoted an application like ScriptPad, the e-prescribing problem would be solved instantly at no cost to the government or the physicians.

Monetary incentives for compliance should be provided to physicians participating. There should be no penalty for non participation.

What does ScriptPad do?

ScriptPad allows physician to write e-prescriptions faster and safer than their current paper process. ScriptPad will eliminates prescription writing mistakes. It sends prescriptions directly to the patient’s pharmacy.

This I minute video demonstrates how it works.

The same can be done in the cloud for a fully functional electronic medical record. Instead the government is setting up a complicated subsidy program that falls short of the cost of an EHR. The government should provide a fully functional web based electronic medical record to physicians.

5. “ Medicare Part B fee schedule administration”

CMS changes Part B fee schedules several times a year. Physicians are not compensated for updating their billing systems. Physicians’ reimbursement is often delayed by the changes. Patients and physicians are irritated by these fee changes. The explanations of benefits are always changing for the same services.

"Has someone at CMS kept tabs on how much it costs CMS and the taxpayers for each fee schedule implementation/delay?"

This group of physician leaders estimated the government would save $108,984,375 million dollars a years if fee schedules were not changed so often. The calculation does not include cost savings for the physicians or any overhead for the healthcare insurance carrier the government has outsourced administrative services to.

Small changes such as those suggested above would save Medicare at least one half a billion dollars a year in waste.

I hope someone is listening.

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

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President Obama Is Trying To Fake Us Out Again!


Stanley Feld M.D.,FACP,MACE

In order to gain support for Democratic candidates during the midterm elections , President Obama is on the campaign trail. During his campaigning he is telling Americans to be patient. His healthcare reform bill is going to be great for seniors and all other citizens.

Democratic candidates running for reelection are avoiding his support. They are not campaigning on the healthcare reform act many were forced to vote for.

Americans are not buying President Obama’s rhetoric.

The healthcare reform law is extremely complicated. Many people do not understand the consequences.

At this time, I feel it is important to repeat what is known about the law. The subtext is the government cannot afford to continue spending at the present level for the Medicare and Medicare entitlements .

None the less President Obama plans to expand the Medicaid entitlement in order to insure the uninsured. The logic to expand the entitlement is irrational within the framework of the present healthcare system. President Obama is attempting to change the framework. Budget deficits will increase, taxes will increase, access to care will decrease and rationing of care will increase.

Americans are not interested In President Obama’s plan to pay for the health care law by cutting Medicare services many seniors depend on. Below are just some of the Medicare cuts outlined in the law. There are many other unfavorable consequences of the law that I have discussed previously.

These cuts have been largely denied by the President on his present campaign trail.

· Medicare will cut reimbursements to inpatient psychiatric hospitals. It is not clear to me what profit margins these psychiatric hospitals enjoy. It would be important to know if these hospitals could remain viable. If the hospitals stop accepting Medicare patients the entire economic burden will be on the seniors.

In 2011: 

  • Wealthier seniors ($85K/$170K) begin paying higher Part D premiums. Presently Medicare Part B is means tested and pay high premiums. Wealthier seniors pay up to $250 per month per person for traditional Medicare coverage. It is anticipated these premiums will increase. the total cost for Medicare coverage can rise for full coverage to over $18,000 in after tax dollars for a husband and wife.
  • There will be Medicare cuts to home healthcare agencies. I always thought the fees paid for home healthcare by Medicare were high. However, if the home healthcare agency refuses to accept Medicare, the burden of payment will be on the patient. Patients might have no choice but to go to the hospital. Hospitalization will increase the cost of care unless Medicare refuses to pay the hospital.
  • Medicare payments for ambulance services will be reduced. I always thought that a $1000 plus fee for ambulance services was high. I could never understand how this fee was negotiated. I believe a study of the actual cost of ambulance services would be important before the fees are cut.
  • Medicare payments to ambulatory surgery centers will be cut. Ambulatory surgery centers cost less than hospital surgery centers. It is not wise economically to drive ambulatory surgical centers out of business.
  • Medicare will cut payments for diagnostic labs and durable medical equipment companies. The government should be stimulating competition and innovation. If should be negotiating prices. It should not be dictating prices.
  • New Medicare will decrease payment to long term care hospitals. Long term care hospitals charge less than acute care hospitals. However, these hospitals are charging excessive fees. The government should be discovering where the inefficiency and overcharging is occurring and negotiate fees to increase competition among long term care hospitals. The government’s action will cut prices. The cost of the price cuts will be shifted to seniors.
  • Medicare Advantage premiums will be increased and benefits will be decreased. There is no mention in the law of controlling the healthcare insurance industry effectively. Massachusetts’ healthcare insurance exchange has not be successful in controlling costs.
  • Seniors will be prohibited from purchasing power wheelchairs. Seniors must first rent wheelchairs for 13 months before Medicare will pay for a wheelchair. I imagine the government figures the senior will die before the 13 months are up.

In 2012:               

  • Medicare reimbursements for dialysis treatments will be drastically reduced. This is a clear indication of rationing of care.
  • Medicare will decrease the fees paid for hospice care. Hospice care is a great service. It keeps dying patients out of the hospital. It supposedly results in a tremendous reduction in the cost paid for a dying patient. In my opinion hospice care is one of the most innovative developments in the last two decades. I do not understand why President Obama wants to destroy one of the most cost effective services of Medicare.
  • Medicare will continue to reduce payment for hospital services and nursing home services. Seniors will bear the direct economic burden of these reductions.

The government is at fault for the rising Medicare costs. Rather than setting up a system of competition and empowering patients to spend their healthcare dollar wisely it has dictated rules and regulations that have served to increase the cost of delivering healthcare. The government regulations have caused an increase in abuse and administrative waste by the healthcare insurance industry.

The only way to repair the healthcare system is to permit consumers to own their healthcare dollars. Only then will consumers be motivated to be responsible for their health.

President Obama’s healthcare reform law is accomplishing the opposite. He is making consumers dependent on the government.

It will not work in America.

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


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