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All items for April, 2013


Why Does Congress Want to Exempt Itself from Obamacare?

 Stanley Feld

In mid-April
Max Baucus one of the authors of Obamacare and a major proponent of the law
made the following statement to Health and Human Services Secretary Kathleen
Sibelius at a Senate hearing.



Unfortunately only 11,723 people watched this 29 second You Tube.  The traditional media gave his statement
sound bite coverage without explaining the reasons for him saying Obamacare is
going to be a "train wreck."

West Virginia Senator Jay Rockerfeller said Obamacare is beyond


Only 157 people looked at this You Tube whick has been up for 3 weeks.

It would have
been a good idea for congress to have read and understood the bill.

Meanwhile, congressional leaders in both
parties have been engaged for months  now in high-level, secretive confidential
talks about exempting lawmakers and Capitol Hill aides from Obamacare’s  health insurance exchanges that they are
mandated to join as part of President Barack Obama’s health care overhaul,
sources in both parties said.

These talks involve the Obama administration,
Senate Majority Leader Harry Reid (D-Nev.), House Speaker John Boehner
(R-Ohio), along with other top lawmakers.

“These talks are extraordinarily sensitive,
with both sides acutely aware of the potential for political fallout in the
2014 mid term elections from giving carve-outs from the hugely controversial
law to 535 lawmakers and thousands of their aides.

along with other Internet news agencies has been the only news agency to have
in depth coverage of this attempt to exempt congress and its aids from
Obamacare and its health insurance exchanges.

Henry Chao, the Administration’s chief
technical official in charge of  the
implementation of the Obamacare’s health insurance exchanges
, “just hopes that Americans can avoid a “third-world experience.”

Why would both
Democrats in congress want to avoid participating in Obamacare and its health
insurance exchanges?

We need to
be reminded that the Democrats had overwhelming majorities in both houses of
congress at the time of passage of the law in 2009 without a single Republican

I am
reminded of Nancy Pelosi’s argument for Obamacare's passage.

 Now that
congress knows what is in Obamacare they want to be exempt.

Congress is content to let the rest
of us suffer.

What is
congress afraid of?


  1. Higher
    healthcare costs for themselves, their families and their aides.
  2. Being
    mandated into Obamacare’s health insurance exchanges will result in  them not qualifying for government subsidy.
  3. Congresspersons and their aids could
    also lose their employer-based coverage.
  4. This is also true for millions of
    ordinary Americans.
  5. They would also face higher costs of
    insurance through health insurance exchange.
  6. Every policy the healthcare insurance
    industry sells will be taxed. It will result in passing the tax on to the
    policy holders.
  7. Contrary to the President’s promises, independent analysts expect health insurance premiums to
    rise sharply, particularly for younger workers and their families.       

members have other fears if they fail to create an exemption for themselves and
their aides. These fears are:

1. They fear the
impact on Capitol Hill employment.

2. The increase in healthcare insurance
costs “could lead to a ‘brain drain’ on
Capitol Hill, as several sources close to the talks put it.”

3. Ordinary Americans who run businesses
are also faced with the same problem. President Obama and Democratic
congressmen have refused to be responsive to the dilemma faced by ordinary

4. American business owner fear they will not
be able to hire or retain valued employees.

5. These businessmen are presently
reducing full-time workers to part-time employees in order to avoid Obamacare’s
mandatory insurance coverage or penalty.

6. This will have the consequence of
increasing the unemployment rate and decreasing consumer spending.

7. In turn it will create an unending
spiral which will seriously impact economic growth.

8. The question Americans must ask is “what about me.”


The Obama
administration and congress have done similar things before in their effort to
passing Obamacare.

was passed using backroom dealings such as the “Cornhusker Kickback,” the
“Louisiana Purchase,” and the threats to political careers.

This congressional
exemption also brings back memories of (more than
1,200 waivers
) to favored
businesses and unions who received special exemptions from Obamacare’s
insurance rules.

“If Congress quietly wants
to exempt itself from Obamacare, that’s great—so long as it includes the rest
of us in that midnight amendment.”

If you are "mad as hell and do not want to take this anymore" 
sign this petition.




click on this link to sign up and send the link on to your friends.

This is the petition


Senator Harry Reid, Senate Majority Leader 

Rep. Nancy Pelosi, House Minority Leader 

You told me we had to pass
Obamacare to find out what was in it. Now your gold-standard health insurance
is on the chopping block as Obamacare is implemented. 

If the tin-plated plan is good enough for me, my family, and my friends, it is
good enough for you and your staff. 

You passed the law — now live with it like the rest of us. Or overturn the whole
rotten thing!

Stop the effort by liberal Democrats to seek an exemption from Obamacare for
Members of Congress and their staff.


[Your name]

Some of us will remember
Walter Cronkite’s signature was ending
each newscast with the phrase, "And that's the way it is".

 I am adding this “it is now up to you ladies and gentlemen.”


Please sign
the petition. Thank you.


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

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EMRs Real Politics.

Stanley Feld M.D.,FACP,MACE


Dr. Jerome Groopman and Dr.Pamela
Hartzmen uncovered the real politics of EMRs.
 They are both on the staff of Beth
Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical

 Dr. Groopman wrote a best seller “How
Doctors Think.”

In a Wall Street
Journal article they wrote,

 The electronic medical record (EMR) is touted
as the key to containing costs, reducing errors, improving quality, and
simplifying administration: an “elegant exercise in wishful thinking

Dr. Groopman and Pamela Hartzman debunk the 2005 RAND study. The
RAND EMR study of 2005 led to President Obama’s belief that EMRs will save $81
billion dollars a year for the healthcare system.

Groopman and Hartzman show that there is little evidence to
support the president’s belief.

The RAND analysts claim that more than $350
billion would be saved on inpatient care and nearly $150 billion on outpatient
care over a 15-year period of time.

Unfortunately, data from three other studies, a cardiology
group, a Harvard group and Canadian group showed there is no savings difference
between paper records and electronic records.

Dr. Groopman claims the RAND study is self-serving to EMR software
companies that sponsored the study.


Healthcare Solutions
, the Cerner Corporation and Epic Systems of Verona, Wis. are the major EMR software companies.

 In February 2009, after years of behind-the-scenes lobbying by
Allscripts and others, legislation to promote the use of electronic records was
signed into law as part of President Obama’s economic stimulus bill.

“But today, as doctors and hospitals struggle to make new records
systems work, the clear winners are big companies like Allscripts that lobbied
for that legislation and pushed aside smaller competitors.”

At Allscripts Healthcare
solutions, annual sales have more than doubled from $548 million in 2009 to an
estimated $1.44 billion last year.

At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that

“Current and former industry executives say that
big digital records companies like Cerner, Allscripts and Epic Systems of
Verona, Wis., have reaped enormous rewards because of the legislation they
pushed for.”

Unfortunately, many of the
EMR systems bought by large hospital systems and physician practices are not
fully functional. They do not fit the administration’s criteria of meaningful-use
EMRs. These EMRs are requiring additional hospital systems and physicians;
practices outlays of cash to make them fully functional.

City-based Pain Clinic of Northwest FL filed a purported class action lawsuit
on Dec. 20, 2012 against Chicago-based Allscripts (NASDAQ: MDRX).

“The purported class action
lawsuit says that about 5,000 small group physicians were sold an EMR called
MyWay from 2009 until late last year, when the company stopped supporting the

“The company was also hit with
a federal shareholder class action securities fraud lawsuit in the Northern
Illinois District last year over allegations that it misled investors about the
performance of its EHR programs.”

 The MyWay EMR cost about $40,000
per physician. ThePain Clinic of Northwest Florida claims it was misled by
Allscripts Healthcare Solution.  The
Clinic stated that MyWay has “shortcoming
and inherent defects,”  

complaint says Allscripts was unable to obtain “meaningful use” bonus status
for MyWay because of the problems with the program. The lawsuit claims that

 “Allscripts has been unjustly enriched by
retaining the money paid by MyWay purchasers and users without delivering an
EHR software product that performs as it was intended to work,”

 These costs are always
passed on to the consumer
. Drs. Groopman and Hartzman  go on to say,

president and his health-care team have yet to address these difficult and
pressing issues.

 Our culture adores technology, so it is not
surprising that the electronic medical record has been touted as the first
important step in curing the ills of our health-care system.

this notion is an overly simplistic and unsubstantiated part of the solution.

It is important to note Drs. Groopman and Hartzman’s total
and refreshing frankness.

“We both voted
for President Obam
a, in part because of his pragmatic approach to problems,
belief in empirical data, and openness to changing his mind when those data
contradict his initial approach to a problem”.

We need the
president to apply
scientific rigor to fix our
health-care system rather than rely on elegant exercises in wishful thinking.”

Please note that Drs. Groopman and Hartzman said it not

a new study The RAND Corp has backed off on its 2005 study earlier this year
and withdrew its estimate of saving to the healthcare system of $81 billion
dollars annually.

In the
RAND Corp’s view, the disappointing performance of health IT to date can be
largely attributed to several factors:


  1.  “Sluggish
    adoption of health IT systems
  2.   Coupled
    with the choice of systems that are neither interoperable nor easy to use;
  3.   The
    failure of health care providers and institutions to reengineer care processes
    to reap the full benefits of health IT.
  4.  We
    believe that the original promise of health IT can be met if the systems are
    redesigned to address these flaws by creating more-standardized systems that
    are easier to use,
  5.  EMR are
    truly interoperable,
  6.  Afford patients more access to and control
    over their health data.
  7.  Providers must do their part by reengineering
    care processes to take full advantage of efficiencies offered by health IT, in
    the context of redesigned payment models that favor value over volume.”


It should not be a blame game.

General Electric sponsored this new RAND study.  It is important to note that GE is a major
Allscripts competitor.

There is true value in the EMRs to patient care. However the
focus of the marketing and development is on the wrong customer.

The RAND still does not get it. Perhaps
it does not want to get it.

EMRs should be for the benefit of physicians and their
patients. It must be at a price physicians can afford to pay. It should not be
for the benefit of the government, the healthcare insurance industry and
hospital systems.

It should be a tool to
continually educate physicians and patients. It should not be a tool used by
secondary stakeholders to penalize physicians and patients.

Patients and physicians control My Ideal Electronic Medical
Record. It should be seriously considered to achieve the maximum benefit of EMRs’

I believe it would be of value to interested readers to go
to this link.

 Those articles will
not only describe the problems with EMRs, problems which I have predicted and are
now recognized. These articles will also outline real  solutions to having universal adoption of

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

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The False Promise of Electronic Medical Records (EMR)

 Stanley Feld M.D. FACP,MACE

promise of the Electronic Medical Record (EMR) is fading for physicians and
patients. The EMR was supposed to reduce the cost of medical care, improve
quality of care, improve physician communications, reduce duplicate testing and
improve efficiency of care.

believe EMRs can accomplish all of the above goals but not with their present
rollout format.

2009 President Obama declared that EMRs,

save some $80 billion a year, safeguard against medical errors, reduce
malpractice lawsuits, and greatly facilitate both preventive care and ongoing
therapy of the chronically ill.

President Obama's estimate is a little higher than that of the Rand Corp. study on the same issue.

EMR’s have
not accomplished its goals. EMRs have been a money-loser for most physicians.

predicted that fully functioning EMRs were too expensive for most practicing
physicians. In addition to the initial expense there are very high maintenance costs.

bought by physicians and hospital systems in the past are not fully functional.
 Less than 20% of hospital systems and
physicians practices that have fully functional EMRs

and hospital systems that already have EMRs will have to purchase new fully
functional EMRs.

historically know that all data collected, whether accurate or not, has been
used against them in the past.

are hesitant to provide more data at their own expense that compromise the
privacy of their patients and potentially harm their own reputation.

would be happy to participate in EMR implementation if the EMR improved their
ability to serve their patients without a potential penalty.

is clear the government and healthcare insurance industry want to control the
healthcare system. The stakeholder who controls the data controls the
healthcare system.

recent survey from
forty-nine community practices in a large EMR pilot study by the Massachusetts
Collaborative studied the projected five-year financial returns on
investment to physicians’ practices. It was published in Health Affairs.

survey concluded,

"We found that the average
physician would lose $43,743 over five years; just 27 percent of practices
would have achieved a positive return on investment; and only an additional
14 percent of practices would have come out ahead had they received the
$44,000 federal meaningful-use incentive

Only a few practices would
have had EMR’s that qualified for the Obama administrations meaningful –use
The Obama administration’s criteria for meaningful-use are too strict
and complex for EMR software that physicians can afford.

More amazing is that the
only way for a practice to have a positive cash return on investment for their
EMR is to game the healthcare system using their EMR. The resulting cost of
medical care would rise.

largest difference between practices with a positive return on investment and
those with a negative return was the extent to which they used their EHRs to
increase revenue, primarily by seeing more patients per day or by improved
billing that resulted in fewer rejected claims and more accurate coding.”

This does not constitute an improvement in medical care. It also
contradicts the idealistic advantages of the Electronic Medical Record.

The survey concludes that current meaningful-use incentives
alone may not ensure a positive return on investment from EMR adoption.

The survey’s authors suggest,

that provide additional support, such as expanding the regional extension
center program, could help ensure that practices make the changes required to
realize a positive return on investment from EHRs.”

 The government and
healthcare insurance industry’s goal is to reduce physicians’ reimbursement to
those physicians that do not meet Obamacare’s imposed criteria for quality
medical care. The controversial Independent Physician Advisory Board (IPAB)
will set these criteria.

Many physicians in practice object to converting medical care
into a commodity. Medical care is a very personal and complex interaction not
taken into account by the rigid criteria.

I have said previously that about 50% of the therapeutic index
(therapeutic effect) of a physician’s treatment is determined by the patient
physician relationship.

 "We need to move to EHR for a number of
reasons, but if I am a small practice I am going to really think about a few
things," she says. "One is how to decrease the cost of adoption and
the cost of the system itself.

“ To the extent you can reduce the upfront
cost that is going to help bring down the amount you have to figure out how to
make up elsewhere.

Increasingly there are new models taking this
into account for small practices to decrease the big upfront costs

There are two basic issues, the cost of a fully functional EMR and
the real purpose of EMRs. I believe both can be remedied.

The costs of an EMR to a medical practice can be paid for by the
click. The data would be fully secured. The data would be available only to
patients and their physicians.

Physicians would pay for the EMR by the click. The EMRs would be
maintained and updated for free in the cloud.

The EMRs could not be used for penalizing physicians. It would
be used for educating patients and physicians thereby improving the quality of

If there is a bad physician in the community, a way needs to be
found to deal with that physician within his community. All medicine is local.

This is where a consumer driven healthcare system with public
critique of physicians would be an effective deterrent to bad physicians.

The current healthcare system is defective. It has to be
changed. Obamacare is making the business plan worse.

America cannot afford it becoming worse.

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

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Getting Around The Rules: Hospital Readmission Rates


Everybody knows about the
Obama administration’s tricks and cover-ups. Few know what to do about them. Some know what to do. More and more people are seeing right
through the charades. 

In America, unfortunately,
strong vested interest lobbies are effective. I pointed out some of the abuses
of hospital systems lobbies a few weeks ago.

Consumer advocacy
lobbyists do not seem to understand the real issues causing the healthcare
system to be dysfunctional, nor have the money to fight these issues.

Steve Brill’s article in
Time Magazine
published hospital retail prices and not the actual prices the
hospital collects. Retail price get the public’s attention. The real issue is
the wholesale prices the government and the healthcare insurance industry pay.
These allowed wholesale prices are also grotesque.

There is a lot of non-transparent
funny business going on behind closed doors with Medicare. It is going to be
accentuated with Obamacare.

Most of us have heard that
hospitals will be responsible for the costs of patient care if the patient is
readmitted to the hospital within 30 days.

This is a very stupid
rule. Sometimes it is the hospital that should be responsible for readmission
because the care was poor, the patient was not ready to be discharged or the
patient had inadequate education about their disease to avoid hospitalization.

The hospital systems’
pressures are to get patients discharged quickly.

My guess is it is the
patient that is responsible for the readmission most of the time.

Many factors could
contribute to a patient’s readmission. They include

  1. Not
    following the physician’s post discharge orders.
  2. Not
    given appropriate post discharge orders
  3. Not
    being taught to become the professor the their disease.
  4.  Not participating in adequate follow-up care.
    Follow-up care is important but it has become outrageously expensive.
  5. Medicare
    has permitted home healthcare services to charge high prices for simple
    services and procedures that have little impact on patient education and
    avoidance of readmission.
  6. Documentation
    by the home healthcare service drives the expensive reimbursement and not the
    value of the care.

The real question is
should the hospital system be responsible for patient irresponsibility?

The answer is clearly no.
The bureaucracy’s answer to the problem is that one size fits all.

Hospital systems are aware
of this defect. Hospital administrators and their lobbyists are working hard to
get around the rule.

Some have figured it out.
They are keeping the patients in the emergency room and charging ER fees that
they can collect rather that putting patients in the hospital and generating
charges they cannot collect.

Hospital systems can
charge patients increasing fees the longer patients stay in the emergency room.

Medicare does
not count most discharged patients who come to the emergency department (ED)
but are not readmitted, according to a 
study in Annals
of Emergency Medicine.”

The study
looked at nearly 12,000 discharged patients from Boston Medical Center. Twenty
five percent of the patients discharged from the hospital appeared in the
emergency room in less than 30 days and forty percent of those patients were readmitted
to the hospital.

keeping patients in the ER amounted to a great saving and indeed profit for the

rules and regulations lead to many unintended consequences. No one has tried to
motivate patients to be responsible for not being readmitted to the hospital.

readmissions cannot be avoided. Many readmissions can be avoided.

The main
question would be how to motivate all stakeholders to have incentive to avoid
readmission to the hospital.

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

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What Happened to the “Physician/ Patient Relationship?”

Stanley Feld M.D.,FACP,MACE

The only way America’s healthcare system will be repaired is by
revitalizing the Physician/ Patient Relationship.

Veterans complaining about the VA Hospital System in my last
blog brought
on a flurry of negative comments about practicing physicians not
connecting with their  Medicare and
commercial insurance patients in the private sector.

The chief complaint is that physicians are not connecting to
their patients or their patients’ illness. I have heard enough stories to
believe it is true.

A 44-year-old male with
private healthcare insurance sent one such complaint to me.

His acute illnesses history was compatible with acute prostatitis.

He needed a new physician because his previous primary care physician
had taken a sabbatical leave.

He called for help in finding a physician to his friends on
Facebook, Twitter and Link In. The consensus was the physician he describes

The physician did multiple tests, several of which I did not
think were necessary, along with a cursory physical examination. The physician
thought the patient had prostatitis and prescribed Cipro for one month. A
follow-up examination was not scheduled.

The last paragraph in the patient’s note to me was,.

By the way, my doctor's office called to let me know the
lab results are in and they are mailing them to me. The doctor told the front
desk person to send me a letter, which I'll get in a day or two. According to
the front desk person, in the letter he says that my labs look good, and that I
need to work on getting my lipids up. Apparently he included a link to a
website that I can learn more about lipids. Pretty great patient care, eh…

This is horrifying to me. The patient will probably do well.
However there is no contact or concern about the patient’s outcome in this
interaction. There was no physician patient relationship formed for a patient
who is looking for a primary care physician.

I would be very upset if this interaction happened to me.  I would be more upset if I then receive a bill
for $800 for the visit.

This patient does not know what the bill will be because the
office said it will bill his insurance company.

The evidence of the loss of the Patient-Physician Relationship of delivering medical care did not happen overnight.

A reader Dr. Dale Fuller sent me this commentary. He walks us through the
evolution of the destruction of the Doctor- Patient relationship.

Dr. Fuller’s view is similar to the view I have discussed in this
blog on multiple occasions. I believe it is important to publish his thought in
its entirety.


 "Whatever Happened to
the “Doctor- Patient Relationship?”


Dale Fuller M.D.

Lately, I
find myself thinking about this question more and more.  I think the first time I heard the term,
“doctor-patient relationship” was back during Harry Truman’s administration,
when there was an effort led by the Democrats to create a National Health
Insurance Program.

Medicine” the opposition cried, and “The end of the doctor patient
relationship!   I wasn‘t even a student
in college back then, and in the absence of more information, I saw the
doctor-patient relationship in the context of my experience with the doctor who
looked after me on those rare occasions when I needed to see him,

Dr. T.D.
Jones, who was a very kind man.  He was a
small town doctor, and the only doctor in my hometown as well as a good many
other towns around it during World War II.

I kind of
understood the term “socialized medicine” in the context of the then-new
National Health Service being launched in Great Britain. 

Truman and
company lost the battle for NHI back then.

The next big
“Socialized Medicine initiative arrived in 1960 
“Socialized   during the Republican administration of Dwight

Robert Kerr, of Oklahoma and Rep. Wilbur Mills of Arkansas, both Democrats
introduced the Kerr-Mills act, the “Medical Assistance for Aged Act 1960-1965”
(benefiting primarily the elderly on Old Age and Survivors’ Assistance).

was passed in 1960, again over cries that it would destroy the doctor-patient
relationship.  But this time the cries
were neither so loud, nor as successful. 
By this time I am a newly minted MD, and my awareness of the total
meaning of the term is still mostly intuitive.

During the
administration of Lyndon Johnson, came the Social Security Amendments of 1965,
which brought us Medicare and Medicaid. 

When I
entered practice in 1968, Medicare and Medicaid were just getting under way, so
I never experienced what it was like to practice in the absence of the law.

In March of
2010, President Obama signed into law The Patient Protection and Affordable
Care Act, and we are now living through the incremental steps preceding that
law becoming fully in effect in 2014.

The various
legislative initiatives have, to be sure, impacted the doctor-patient
relationship in many ways, as the opponents predicted, but it appears to me
that we have been hearing less and less about that relationship as the years
have passed. 

I think it
might just be that the relationship we are discussing may be threatened by a
number of other forces other than the laws described above, but before I
attempt to list those forces, I want to spend a little time setting the stage
to describe just what the doctor-patient might and might not mean.

Goold and
, in an article published in 1999 (1) called the doctor-patient
relationship “a keystone of care: the medium in which data are gathered,
diagnoses and plans are made compliance is accomplished, and healing, patient
activation, and support are provided.”

They say that
the medical interview is the major medium of health care, and that more than
82% of diagnoses are made by history alone.

The three
functions of a medical interview are the gathering of information (both through
history and physical examination) developing and maintaining a therapeutic
relationship, and communicating information.

In the eyes
of the law, physicians also have a fiduciary responsibility toward their
patients. Physicians are bound to act in their patients’ interests even when
those interests may conflict with their own.

In that
physicians are often directly involved with events and conditions that are
life-altering for their patients and families, at birth, during severe illness,
healing or death, it can also be said that in being a physician, and providing
health care, doctors are engaging in a moral enterprise.

There was a
time when the unwritten social contract laid out above, simply existed as an
understanding between patients and doctors.

In the early
1940’s the arrival on the scene of what became the Blue Cross and Blue Shield
program, initially serving the employees of the Dallas, Texas Independent
School District began to interpose a third party, the insurance company,
working through the employers, in the social contract that was the Doctor-Patient relationship.

that interposition was pretty innocuous, with the insurance plan simply paying
the bills of the doctor as they were presented. The phrase, “usual and
customary” arose to define the fees involved that the insurance company paid.
Unusual fees or fees exceeding customary levels became subject to challenge,
requiring justification if they were to be paid.

Over time, a
database of fees that really were usual and customary began to become a better
and better tool to define where the usual kind of fee stopped and the unusual
kind of fee was recognized.

when it came along, introduced the federal government as a payer, and
relatively soon thereafter, the health care bureaucracy began to grow and
insert itself between doctors and patients to an increasing degree.

Since this
was in the “Pre-Medicare era” the number of patients involved was relatively
small, and so the impact on the doctor patient relationship was still somewhat

The arrival of Medicare and Medicaid served to
illustrate that the old “camel entering the tent” analogy was beginning to come

while the organizations were formed to administer the programs, “usual and
customary” was still the order of the day where payments were concerned, and
the social contract still functioned much as it had always done.

At the
request of the Department of Defense, organized medicine (AMA) created a set of
relative value scales in an attempt to standardize professional fees. The set
of codes was called “Current Procedural Terminology (CPT codes)” (first
introduced in 1966).

The charges
were to be based upon a blend of time required, professional skill involved,
and liability risk.

The compendium
of procedures have grown over the years, the principles remain essentially the

In a fit of
zeal, the Federal Trade Commission inserted itself and accused professional
societies of “price fixing” via the CPT codes.

eventually ensued, and money passed from the societies that were sued to the
FTC, and life, after the “nolo contendere pleas’ went on as usual.

The reason
for this was that the societies were not well enough funded to defend their
position vs. the FTC, even though they might have won their cases.

though, as might be expected, the government began to insert itself more and
more into the transaction between doctors and patients, generally, drawing upon
the reality that it was paying, directly or indirectly, for more than 50% of
the care given in the US.

and rules have proliferated, respecting what can and cannot be done for
patients who are beneficiaries of federal programs. 

Another force
was also becoming more vocal in making statements and policy regarding what
could and could not be done for patients.

This force
began with the passage of the Health Maintenance Act of 1973.  This act enabled a vast acceleration of the
whole concept of managed care. 

Insurance Companies citing the growing demand for, and cost of medical care to
employers, found a ready market among employers for their “products” to serve
as “benefits” for their employees. 

and hospitals, fearing that they might be left out of the managed care programs,
made haste to “join” this program or that program, seeking access to the
populations of patients enrolled in the programs by the insurance companies
selling coverage to employers. 

The fear was
that exclusive arrangement with insurance companies would eliminate whole
populations of patients from providers who had not “signed up”.

This meant
that the traditional bilateral social contract between doctors and patients
essentially had come to an end of sorts.

Patients’ expectations
were that service and behavior of the doctor they were allowed to see remained
pretty much the same except for a small by important fact.

employees covered by managed care were required to see the doctors who
participated in the program, and to use the hospitals the programs had
agreements with.

penalties awaited those patients who sought their care “out of plan”, for
whatever reason. 

Now patients
and doctors both have someone else “calling the tune” when it comes to the
delivery of healthcare.

Each time the
“plan” purchased by the employer changed, for whatever reason, there could be a
change in the physicians and hospitals available to the patient. 

This brings
us to a key element of the doctor-patient relationship. A key element is
continuity of care.

Continuity of
brings with it an opportunity develop relationships in which doctors and
patients really know and trust one another. This relationship allows physicians
to recognize changes in patients and recognize the early onset of disease.

Neither the physicians’ understanding nor the
patients’ trust cannot be rebuilt immediately between two individuals each year
who are basically strangers to one another.

 Doctor of days past, the trusted counselor, often
friend and confidant, is no longer exists. 
Now, patients are simply seeing another person in an office. Both
parties are at sea when it comes to knowing what they need to know about one
another to allow the encounter to produce the necessary result within the time

Time, like
continuity, is also a vanishing element in the doctor-patient
relationship.  Fewer and fewer
practitioners have the time, amidst the pressures of “patient throughput” to
really engage in patients’ needs.

must gather and record data, establish a diagnosis, and create a treatment plan
of quality.

documentation has to be complete in order to get paid by the government or the
healthcare insurance carrier.

Doctors must also
explain his treatment plan in such a way that they are assured of patients’
compliance with the treatment proposed in the time available to doctors.

As a result
of decreasing reimbursement and increasing overhead the time necessary for
patient education is insufficient. Patients do not understand the significance
of the therapy. The result is a lack of compliance.

problem is that the “third party payers” rather than the patients approves of any
tests and procedures that doctors believe are needed to strengthen the

The result is
a further erosion of patients trust in the doctor.

The time for
a consultation is short. Tests and procedures are now increasingly used to
substitute for the gathering of data to make the diagnosis.

Tests and
procedure escalate the costs of medical care.

gathering by history and physical examination is time consuming. If a history
and physical examination is properly done it can yield the diagnosis of patients’
problems about 80% of the time.

doctor-patient relationship is indeed fading into the past. The third party carriers
and the federal government have, in their zeal to contain cost, pretty much
seen to that.

The reality
is that the destruction of the doctor-patient relationship costs more in the
long run.

The federal government, in its enthusiasm to
make a positive impact on the quality of care patients receive, has mandated
the use of electronic medical records.

The EMR in
its own way have also served to diminish the doctor-patient relationship.

In many
doctors’ offices, the focal point in the room is a computer with data entry.
The keyboard and the screen have almost the full attention of the doctor, who,
without looking at the patient, asks the questions and types the responses.

The patient is lucky if the doctor makes eye
contact with him/her for a brief interval a couple of times during the visit,
thus further diminishing the possibility that trust can be built in the

The quality
of the encounter can, in the opinion of various policy makers and consultants,
be measured and changed in the same way that manufacturing processes can be
impacted by applying the principles taught by Deming and others.

Maybe it can,
but it has yet to be demonstrated. 
Processes peripheral to the interaction of patient and doctor, may be
made better, but there is little evidence that the same approach can bring back
anything like the doctor patient relationship we used to know."

The three basic goals of Obamacare are
to create an affordable healthcare system with access to care of high quality.

A complicated and complex
bureaucracy that is over regulation will be very difficult to enforce.

It will penalize physicians’
judgment as it tries to decrease reimbursement. It will restrict patients’
access to medical care. It will reduce freedom choice.

Obamacare will not enhance the
Patient Physician Relationships that are so vital to a successful therapeutic

A healthcare system that places
consumers in control of their healthcare dollars and provides incentives to
consumers to be responsible for their health and healthcare will encourage
physicians to save money and rejuvenate the Physician Patient Relationship for
improved therapeutic outcome at an affordable cost.

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

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Perception Is Reality


I mentioned Joe Klein’s criticism of the VA
healthcare system in my last blog
. I promised to cover some of the problems veterans
are having in the VA healthcare system.

I cannot believe the VA healthcare system is as
bad as illustrated by the following examples.

However, perception is

I believe if the government completely takes
over the healthcare systems and creates a single party payer system, Americans
will have the same perceptions that these veterans have had about the VA
healthcare system.

I have read some of the government’s official reviews
of complaints by veterans. The VA Office of Inspector General Office of
Healthcare Inspections writes the government’s official reviews.

The typical conclusion of the Inspection General
for the VA was that the overwhelming majority of the complaints in various VA
hospitals are unwarranted or insignificant.

“The VA Office of Inspector General Office of
Healthcare Inspections
conducted an inspection in response to allegations of
misdiagnosis and other care issues at the Atlanta VA Medical Center (the
facility) in Atlanta, GA, and two community based outpatient clinics (CBOCs) in
Veterans Integrated Service Network 7.”


"The purpose of this
inspection was to determine the validity of the allegations. We did not
substantiate that a facility emergency department physician misdiagnosed a
stroke as vertigo (a feeling of motion while one is stationary) in September
2010. We determined that the facility emergency department physician’s evaluation
and management of the patient’s complaints and hyperglycemia were appropriate."

"We did not substantiate that the patient received
deficient care o
r that facility and CBOC providers failed to appropriately meet
the patient’s vision, hearing, and stroke rehabilitation needs."

This is the typical
verbage of many reports written
by the VA’s Inspector General. Unfortunately,
these conclusions do not foot with veterans’ complaints.

general characteristics of most of the complaints fall into specific

One universal
characteristic of each complaint is the lack of development of a positive doctor patient relationship

An Army
Major with a combat brain injury felt he had never been treated so poorly in
his life. A VA physician reviewing his condition did not even look at his
record. The physicians showed no compassion when the patient needed compassion the

I have such a low regard for the
VA. I have never been treated in my life as poorly as I had with the VA.”

perception was that “everyone
in the system blames others or passes the buck to someone else.”

physician simply wrote a prescription for some medication.”

The physician
showed no interest in the patient or his disease. He showed no empathy for the

former Marine, Mike Ligurri, who has written the book, 
. He was
diagnosed with Post Traumatic Stress Disorder.

Ligurri also expressed the lack of personal contact with him by the VA physician.
He was given medication to take without explanation of the medication.

 “My attitude was I don’t want to take pills
just because you tell me I will feel better.’  

He felt
the physician he dealt with was cold hearted and not involved.  

There is
no incentive for VA physicians to become involved with patients in the VA
system. The patients are not their patients. At
each clinic patients usually see a different physician.

perception of patients is that the VA physicians and the VA system do not
connect with them.

Patients are treated as commodities.  

I can
relate to that feeling. When I was in training at a charity hospital I was
never able to form a relationship with patients. I did not even see the
patients I admitted to and discharged from the hospital.

There was
little continuation of care or follow-up by me.

When I went
into practice the patient was my patient and I was his doctor. The positive
patient physician relationship made the visit more satisfying to me and more
therapeutic for the patient.

If I
didn’t relate to my patient while in private practice, my patient had the
option of leaving my practice and finding another physician.

I, as
other physicians in private practice, made it my business to relate to my patients.
My incentive was to build my practice and reputation. I was a consultant to
other physicians as a clinical endocrinologist.

In order
words, I had incentive to treat my patients well and my patients and referring
physicians had freedom of choice of any other physician.

experience patients have at the VA is reflected in the following comment,

“They made
me feel like they had no time for me.
All they did was to take notes, never
engaging with me, and after ten minutes decided to write me a pill
prescription. I was never told about alternate forms of therapy.”

want to know about their disease. They want to learn the reasoning for their
treatment. They are not stupid. They want to know what to expect from their
disease and their treatment.

They want
to have a caring and comforting physician because they are frightened about
their disease.

education and a positive patient physician relationship are essential for good
therapeutic outcomes.

A few
weeks ago at medical grand rounds I sat next to a fellow physician and good
friend who was cured of testicular cancer 30 years ago at age 32.

At that
time he was frightened out of his mind because he had no experience with
testicular cancer. He was sent to a radiation oncologist who explained his
disease, his prognosis and what to expect throughout the course of therapy.
This relationship was a total comfort to him.

mentioned this to me during our conversation. He said that he felt very bad
because he had not appropriately thanked the radiation oncologist for the
fantastic physician patient relationship. The relationship permitted him to
tolerate his therapy well. He said he been given hope of surviving and a
positive feeling about his outcome.

I told
this physician I was going to have lunch with that radiation oncologist the next
week. He asked me to be sure to tell the oncologist that he thinks of him all
the time.

He has
been so thankful for his help. He added that post testicular cancer therapy he
enjoyed a fantastic marriage and has been blessed with two wonderful sons.

Now that defines a wonderful physician patient relationship! 

Another complaint of
VA system patients is the long wait time for appointments and the mountain of
paper work that has to be completed in order to make each appointment.

If a patient misses
an appointment because of bad weather or unforeseen circumstances you have to
start the process all over again.

It must be maddening
for VA patients. A Veterans’ study committee has reported an average wait time
has been quoted as 50 day to 273 days.

Recently an older
veteran told me that he had a cataract that was progressing yearly. He was at
the point that he needed cataract surgery to be able to see.

He was told that the
wait and backup was one year.

He made enough of a
stink about the delay in his surgery that the VA healthcare system sent him to
a private practicing ophthalmologist. The private ophthalmologist did the cataract
surgery in one week.

He was thrilled
because he could see clearly again.

I am compelled to
tell some of these stories not to point out the solutions to the problems with
the VA system.

The VA system is run by
long term employees entrenched in their jobs without a threat of either losing
their patients or their jobs.

These employees have
little accountability; they create reports and publish meaningless evaluations.
These reports are of little value in fixing a healthcare system that works
poorly for patients but looks good on paper.

 “Even Jon Stewart is blasting the
handling of Veterans’ benefits, “That is f—- criminal. The VA has a backlog
of 900,000 people. McDonalds handles ten times that many customers in an hour,
and may I remind you they are run by a clown.”

The point is that Obamacare with its ever increasing
bureaucracy, agencies, and regulations is going to lead the entire population
into this trap by decreasing incentives and limiting choice.   

It Is “Coming Our Way with Obamacare.”


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

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The Traditional Mainstream Media Is Waking Up To Obamacare’s Defects

 Stanley Feld M.D.,FACP,MACE


Klein is TIME's political columnist
and author of six books, most recently “Politics
.” His weekly TIME column, "In the Arena," covers national
and international affairs. In 2004 he won the National Headliner Award for best
magazine column.

is a Democrat and a big supporter of President Obama.

Klein is a major liberal leaning reporter within the traditional mainstream media.
His last two articles in TIME magazine are finally starting to show
understanding of the problem with Obamacare. Here are some of these articles
more important statements.

starts one article with,

me try to understand this: the key incentive for small businesses to support
Obamacare was that they would be able to shop for the best deals in health care
superstores — called exchanges.

 "The Administration has had three years to set
up these exchanges. It has 
failed to do so."

 "This is a really bad sign.”

administration continuously claims it is not its fault programs are failing. It
is always the other guy’s fault.

other “guys fault” was the main
strategy of President Obama’s reelection campaign. He needs more time to make
things work.

There will be those who argue that
it’s not the Administration’s fault
. It’s the fault of the 33 states that have
refused to set up their own exchanges. Nonsense. Where was the contingency

Obama administration just announced it couldn’t have the health insurance
exchanges program ready by January 2014.

is refreshing to read a liberal mainstream media writer saying what I have said
all along.

Obama administration’s trick here was to stick the states with the costs of the

states that have thought out the consequences have refused to accept
responsibility for the health insurance exchange.

Obama administration has also demanded that states follow the administration’s
conditions and rules. The states have viewed this as a threat to states rights.

Supreme Court sided with the states’ rights argument.


"The Obama Administration has announced
that it won’t have the exchanges ready in time, that small businesses will be
offered one choice for the
time being — for a year, at least."

A hidden story is the administration does not have the funding
to pay the states for the health insurance exchanges for three years.

This is one of the reasons President Obama is again demanding
the ability to raise taxes in a budget agreement. Republicans are saying he has
received his tax increases January 1, 2013.

“No doubt, small-business owners will be skeptical of the Obama
Administration’s belief in the efficacy of the market system to produce lower
prices through competition. That was supposed to be the point of this plan.”

Joe Klein goes on to say,

“We are now seeing weekly examples of this Administration’s
inability to govern.
Just a few weeks ago, I 
reported on the failure of the Department of Defense and Veterans
Affairs to come up with a unified electronic health care records system.”

We have been told that the VA had an excellent electronic health
record. The VA advertises that every physician can download it and use it free.
I downloaded it.

The VA EHR is very difficult to use.

 Joe Klein had sharp
criticism for the “Head Start Program”,

 "There have been the
oblique and belated efforts to reform Head Start, a $7 billion program that a
study conducted by its own bureaucracy — the Department of Health and Human
Services — has found nearly worthless." 

list of Obama administration failures is indeed endless. It is the work of a
community organizer trying to run a big business.

Obama is not a “how” President.
Oh, he pays lip service to government reform.
His people can tell you the number of unnecessary regulations they’ve

It barely scratches the surface of what needs to be done—there is no creative
destruction in government, regulations pile up on top of each other like silt,
generation after generation.”

next statements confirm Joe Klein’s liberal leanings.

 “One thing is clear:
Obamacare will fail if he doesn’t start paying more attention to the details of

 “But, as a Democrat — as
someone who believes in activist government
— he has a vested interest in
seeing that federal programs actually work efficiently. I don’t see much
evidence that this is anywhere near the top of his priorities.”

 “And, in a larger sense,
the notion of activist government will be in peril — “  

The problem is not, as the Republicans
claim, big government. It’s bad government.”

last the traditional mainstream media is starting to get it. There is starting
to be recognition of the problem with government controlled and operated

have explained many times that the mess in the healthcare system is not a
liberal or conservative problem

is a problem in creating a healthcare system that aligns all the stakeholder
incentives and works for every consumer of healthcare.

consumer driven healthcare system with appropriate tort reform will have to be developed
by the government.

healthcare system must be constructed that allows consumers to own their
healthcare dollars and be responsible for their health and healthcare.

government could provide the subsidy to the needy. The result would be a
healthcare system that would be more efficient and less costly.

responsibility and freedom to choose is essential for a successful healthcare


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

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Reality Vs. Fantasy

Feld M.D., FACP, MACE.

I’m Busted” ,my last blog, generated
several interesting comments.

The comment below was a
standout. It represents a total disregard for historical understanding of what
made the healthcare system totally dysfunctional.

It is obvious from the
comment that this individual has not gone to any of my links in the blog nor
has he been a long time reader. I suggest he read the letters I sent to
President Obama at the time after his first election.

“We’ve been through
this before Dr. Feld.  While your generation was/is in charge of the U.S.
Healthcare System our Quality has Sunk and the Costs have Risen
Dramatically.  ( )” 

Physicians are not in charge of the healthcare
system.The government and the healthcare insurance industry is in charge.

I could not open the link this reader sent. He goes on to say,

 “ Take Some Responsibility for this Healthcare
Mess.  Stop Crying and Placing Blame on those searching for Workable
Options to Fix What You Proudly Created.  Please share this with your
readers.  Stop being so one-sided. 



I have stated innumerable times that all stakeholders including
physicians are responsible for the dysfunction in the healthcare system.

Key to the understanding of the healthcare system's dysfunction
is the need to understand the evolution of the dysfunction
. I cover the history
in my summary blogs. 

The dysfunction in the healthcare system started in 1965 with
the passage of Medicare.

Every subsequent government regulation was followed by a more
expensive reaction to the regulation by the stakeholders.

Life was simple pre
1965. The healthcare social contract was between the patient and the physician.


  •  Personal Care – The Physician Knew Me And
    My Family
  •  The Healthcare System Was Efficient – Consumer
  •   It Was Adequate for 90% of Medical Problems
  •   It Was Democratic
    – Rich & Poor


  •  Lifespan / Expectancy – Short
  • Lived
    Unhealthy Lives
  • Misdiagnosed
    Many Illnesses- Lack of Technology
  • Limited
    Body of Knowledge- Limited Treatments And Drugs


Patients made their own healthcare decisions. Patients and
physicians had positive relationships.

This positive patient/physicians relationship is 50% of the therapeutic

As the medical knowledge base increased more money was pumped
into the healthcare system thanks to Medicare. Secondary stakeholders were
needed to deal with the increase in money and complexity. Soon these secondary
stakeholders began to dominate the healthcare system.

 Secondary stakeholders have disrupted Patient/physician
relationships. These stakeholders have created large barriers between
physicians and patients.



Both patients and physicians have become commodities. In its
present form, the healthcare system, as it has grown in complexity and expense
has precipitously diminished physicians’ control over his medical care and his
ability to apply his medical judgment.

Obamacare is adding more layers of complexity to the healthcare system
to an already dysfunctional healthcare system.

Obamacare will be difficult to execute and impossible to

When the reader says, “Stop Crying and
Placing Blame on those searching for Workable Options to Fix What You Proudly

 I am not crying. I am sad for patients and their
future medical care within the Obamacare healthcare system.

I am trying to get consumers to see the inevitable.

Past evidence has proven that when government
controls and operates any systems the actions proposed are unworkable and unenforceable.
The result is great costs and more inefficiency.

 The healthcare system’s incentives will only be aligned
when the system is consumer driven
. The government must support but not control
the healthcare system.

The government should set the rules to align
incentives and then get out of the way.

I have made a strong case for consumer driven

The healthcare system model the government brags
about is the VA Hospital System model.

Recently the VA has received bad press in the traditional
mainstream media.  VA public relations
department has tried to marginalize the criticism.

It has also tried to compensate for the criticism
by outsourcing medical and surgical care to the private sector with success.

 Elise Cooper’s article in the American Thinker:
VA: a Culture of Disconnect”
says it all. I will add to her title “Coming Our
Way” with Obamacare.


  • "Many veterans feel disconnected with the VA.
    They regard it as a huge bureaucracy that is very impersonal
    and unhelpful. The vets get frustrated because they do not know where to
    turn for help.”

veterans and others involved with the VA to reveal some personal examples and
to see if the complaints are justified

I will discuss in detail these interviews shortly.
I will say the complaints are justified.  

America is running out of time to repeal Obamacare.
Consumers have to wake up now and see what it is doing to their healthcare
system, their taxes and their economy.

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

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I’m Busted

 Stanley Feld M.D., FACP, MACE.





we get closer to 2014 and the scheduled full implementation of Obamacare
conditions in the practice of medicine are getting worse.

have described how most of the major programs initiated by Obamacare,

as the Accountable Care Organizations, the Electronic Health Record
s and the Health Insurance Exchanges development), are failing or off
to a slow start.

 A detailed critique of the Obama
administrations’ Obamacare can be found using the search engine in my blog.

you receive my blog by email (RSS) double click on the blog title or go to the
web site http//

for the topic in the search engine in the top right corner of the blog post.

shortcomings of Obamacare are becoming obvious to many citizens. Most physicians
and hospital systems are finding Obamacare’s new programs difficult to execute.

reader wrote

"Dear Dr. Feld,

Once it becomes so painful for the
average voter, Obama will simply say, “a single payer system is the only way to
fix this insurance company mess.”  He’s doing exactly what he planned to
do, he’s just not telling the truth about it.


is becoming more apparent that President Obama’s goal has been to destroy the public
and private sector healthcare systems. In reality the money in both the public and
private healthcare system has been controlled by the healthcare insurance
industry and not by the government.

Obama administration is building the infrastructure to easily convert the
healthcare system to a single party payer system. The majority of Americans are
opposed to a single party payer system. It eliminates choice.

expense of Obamacare has been and will be enormous to all stakeholders with 300
new agencies and 20,000 new regulations.

new healthcare taxes are scheduled to take effect almost monthly.

present at least 40% of the healthcare system is a single party payer system
when considering the government healthcare plans in place.

Obama administration will have two major problems converting America totally to
a single party payer.

public will be outraged when it becomes aware of that the direct costs to them,
the lack of availability of medical care and restriction to access to care
caused by Obamacare.

are two possible solutions. Either repeal Obamacare and start from square one
or let the government control the entire system.  

government will not be able to afford a single party payer system. It will have
no choice but to increase taxes further to support the healthcare system.

other major problem Obamacare will have with a universal single party payer system is the
healthcare insurance industry will continue to control the money in the system.

government does not have the infrastructure to provide the administrative
services and to adjudication claims. There are many hidden cost in the movement
of money that most are unaware of.


The entire situation reminds
me of Ray Charles’ song “I’m busted.”

In 2008, after President
Obama was elected I wrote him six letters explaining how he could reduce the
costs of medical care in America by introducing cost savings initiatives.

Dear President Obama Part 1

Dear President Obama Part 2

Dear President Obama Part 3

Dear President Obama Part 4

Dear President Obama Part 5–elect-barack-obama-part-5.html

Dear President Obama Part 6

I took a Willie Sutton
approach. “ Go where the money is.” 

If the government provided incentives to decrease
wasteful spending, the healthcare system would self correct without the myriad rules
and regulations    that
will not work and cannot be enforce.

Simple things such as:

  1. Incentivize individual responsibility with Medical
    Savings Accounts,
  2. Encourage the use of a Universal Electron Health
    Record with a fully functional EHR in the cloud. Physicians and hospitals would
    pay for its use inexpensively by the click. It would be sort of like a toll way
    fee without capital expense. The EHR could be upgraded and serviced at no
  3. Create a healthcare system that is consumer driven
    with consumer owning their healthcare dollars and being responsible for their
    healthcare choices.
  4. A Tort Reform System that eliminates the need for
    defensive medicine that over tests patients to avoid law suits.
  5. Chronic Disease Management Systems to teach patients
    to be the professor of their disease in order to avoid costly complications of
    their disease.
  6. Develop patient educational systems available on the
    Internet 24/7 as an extension of their physicians’ care.
  7. Help develop disease specific Social Networks. The development
    of a disease specific community can serve to solve some problems patients have.
  8. Eliminate secondary stakeholder waste, fraud and
  9. Eliminate the purchase of first dollar healthcare coverage
    from the healthcare insurance industry  

I believe if all of the
above was done correctly it would save $750 billion to $1 trillion dollars a
year for the healthcare system.

President Obama has ignored
every point I have tried to make. Obamacare has not included any of the real
cost drivers in a non-punitive way.

He has simply added a huge
bureaucracy with rules and regulations that are expensive, difficult to execute
and more difficult to enforce.

If my recommendations were initiated
and executed properly America would have a sustainable healthcare system.

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

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