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All items for July, 2014


Physicians’ Barriers To Practice Their Profession

 Stanley Feld M.D.,FACP,MACE

Over the past 30 years practicing physicians have seen their revenue fall. As Medicare deficits have increased the government has lower physicians reimbursement.

Who is responsible for the deficit increase if physician reimbursement has decreased?

Private Insurance premiums have increased because of advances in technology and increases in specialization leading to increases in testing and physician visits.

Private insurance reimbursement to physicians has decreased in an attempt to keep premiums as low as possible for the private employers who need to be able to afford insurance for their workers.

Physicians have tried to compensate for this decreased reimbursement by seeing more patients. Despite seeing more patients physicians’ incomes have fallen.

Physicians’ overhead has increased. The need for more full time employees has increased. As government regulations have increased many practices have had to hire full time employees to do coding for care and paperwork. Physicians have tried to buy fully functional computer systems but they have failed.  Computer systems are expensive and not completely functional.

“Physicians have seen their incomes fall, their clout with insurers shrink, and their practices weighed down by a plethora of new requirements.

What is the value of a physician’s service? What is the value of secondary stakeholders in the healthcare system?

These are hard questions to quantify. The goal of healthcare policy makers is to reduce the national healthcare costs.

The healthcare system is fragmented, complex and unbalanced. Many physicians feel their skills have been devalued by payers, hospital systems, policy makers.  These groups have become more powerful than the representatives of physicians’ organizations.

Healthcare has become a gigantic industry costing our society 2.9 trillion dollars a year.

Healthcare has, unfortunately, become all about money with the third party payers making the rules. Effective medical care has been stifled.

Physicians barriers’ to effective medical care are,

1. Lack Of Malpractice Reform

Government has estimate the value of malpractice reform incorrectly. It thinks malpractice costs the healthcare system 3 billion dollars a year.

Several good studies estimates the lack of malpractice reform costs somewhere between $200 billion to $750 billion dollars a year without including the cost of the wear and tear on physicians and patients.

2. Problems Trying to Increase Reimbursement

3. Lack of Negotiating Clout

4. Being Turned Into Captives of the Insurance Industry and the Government

Physicians do not have the ability to modify charges on the bases of costs. Medicare and Medicaid won't allow physicians to negotiate reimbursement rates. Physicians must take the reimbursement fees or refuse to participate in Medicare or Medicaid. More and more physicians are leaving the Medicare/Medicaid system.

Private insurers have forced physicians to sign contracts limiting charges. Individual physicians and physician groups have little negotiating power or ability to have loss leaders as do hospital systems with multiple hospitals in a regional area.

Physician organizations have not negotiated for physicians. Some organizations have teaching courses that teach physicians to get around the loopholes in the healthcare system.

Physicians have no incentive to add innovative programs. These programs can increase their overhead without being reimbursement.

All of this is to the disadvantage of patients and patient care as insurance premiums rise and access to care falls.

Intuitively physicians know that the medical care contract is between physicians and patients. Third party interference has stood in the way of this interaction. It has disrupted and/or destroyed patient/physician relationships.

More and more physicians are dropping out of Medicare, Medicaid and private insurance because they cannot deal with the third party interference with the practice of medicine financially or emotionally.

Rob Lamberts, MD, an internist in Martinez, Georgia  said "Doctors have been turned into tools of the insurance industry,"  "You always work for whoever pays you. When you work for an insurer, you are constantly under pressure to do a lot of things that don't improve the care of the patient."

Dr. Lamberts became a concierge medicine doctor.

Concierge medical practices need fewer full time equivalents, do less paperwork, deal with less regulations, have more time to practice medicine and more time to spend with their patients.    

5.Being Pressured to Sell Healthcare as a Commodity

6. Being Force Into Abandoning Clinical Judgment

There are many physicians complaining about the commoditization of healthcare.  They are complaining about the constant need for authorization of care demanded by the government and the healthcare insurance industry.

Physicians complain that insurers and other corporate interests have too much control of healthcare. They are dictating what clinical decisions physicians can make. Physicians are becoming accountable not to their patients but to what other interests decide. The system is forcing doctors to give up their medical judgment in favor of clinical practice guidelines.

The clinical guidelines are used to determine prior authorizations. These guidelines are used to determine reimbursement in many pay4performance contracts and shift the risk burden onto physicians.

Several studieshave questioned the validity of guidelines. Close to half the physicians in the 2012 Medscape survey said quality measures and guidelines will have a negative impact on care.

Mark Shelley, MD, a family physician from Port Allegany, Pennsylvania, decried what he calls the "commoditization" of healthcare. "The art of medicine has been turned into the business of medicine". "Rather than trying to make patients functional and happy, the physician gets caught up in financial issues, such as whether Medicare will pay for a wheelchair."

 Dr. Shelley said. "I know doctors who earn a lot of money and are absolutely miserable."

7. Being Captives Under Hospitals' Thumb

8. Being Shunted Aside by Policymakers

9. Being Shunted Aside by Entrepreneurial Management Companies

Many physicians believe that by being employed by hospitals they are at risk of being co-opted by the hospital's vested interests. In many cases this has been proven to be true.

Many employed physicians have passively aggressively undermined the hospital and its vested interests. Rather than making money from physicians intellectual property hospital systems have claimed that they have lost money.

Hospital employment has been attractive to young physicians just completing residency training. They do not have to make an investment in a medical practice and fear the uncertainty of the future of medical practice.

These physicians’ goals are to have regular and predictable office hours in an outpatient practice setting with adequate coffee and lunch breaks. They do not follow their patients in the hospitals.  They have no connection to patients, their anxiety or fears. Patients are interchangeable and seen by the next available physician as in the VA system. A physician patient relationship does not develop.

This is bad for patients.

Another problem is many physicians believe that policy makers have not been listening to the physicians’ perspective about the problems in the healthcare system. Policy makers are trying to solve the problems of our dysfunctional healthcare system from their perspective and not from the physicians or consumers’ perspective.

“Obamacare is often cited as an example of when policymakers turned a deaf ear to physicians' interests. As many physicians see it, the law lacks substantive tort reform, failed to repeal the sustainable growth rate, and doesn't improve healthcare.

Obamacare ignores patients’ responsibility in keeping themselves healthy and staying healthy after being treated. It assumes physicians are responsible for maintaining patients’ health.

Ignoring this point alone will cause Obamacare to fail. There are many other issues involved in Obamacare’s ultimate demise at a great cost to our country and our healthcare system.   

America healthcare system is in trouble. Obamacare is causing more trouble for America’s healthcare system. 

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

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Physicians’ Problems With The Healthcare System

Stanley Feld M.D.,FACP,MACE

I must start this article with a disclaimer. I am a retired Clinical Endocrinologist that practiced Clinical Endocrinology for 30 years. I became involved in medical politics because I wanted to help make Clinical Endocrinology a household word. We succeeded at the American Association of Clinical Endocrinologists to make Endocrinology a household word.

 At that time I saw that the medical profession was slowly being destroyed. I wanted to make whatever contribution I could to save the medical profession in order to preserve the care patients were given and help promote the progress in medical research.

Today I see the delivery of medical care diminishing and the infrastructure of medical care being destroyed by the Obama administration’s ideology coupled by government bureaucrats as well entrepreneurs that see profit in business opportunities that do not add value to medical care.

I do not have a horse in this arena anymore. The only vested interest I have in the healthcare system is that an effective medical care will exist when I need it.

How do we create systems of care that promote high performance? I do not believe it is by a series of top-down highly specific mandates. I believe it is by creating general guidelines for physicians and providing tools to help physicians advance medical therapy using advanced technology.

It boils down to policy makers’ view of physicians.

Are physicians knights to be empowered in their service of patients?

Are physicians knaves not to be trusted?  

Are physicians pawns in a healthcare system to be manipulated by the powers that be?

At present, healthcare policy makers view physicians as knaves and pawns. This view has to change in order to have a functional healthcare system because people behave has you project them to behave.

If the policy makers approached physicians more as knights, physicians would once more behave as knights and not as bitter misanthropes. The result would result in a desire to provide the best possible care for their patients.

The environment is conducive to the destruction of the healthcare system. Barriers that inhibit effective medical care and increase the cost of medical care can easily be overcome if the Obama administration wanted to fix them.

The public and future administrations have to understand the barriers to effective medical care in order for the healthcare system to arrive at a future state that is not on the way to self-destruction.

America’s healthcare system needs a new vision of physicians and patients. The change in vision would result in a new business plan built around a new system of care.

The healthcare systems needs input from physicians and patients. They are the two most important stakeholders in the healthcare system. Without physicians or patients there would not be a need for a healthcare system.

The promotion of a vibrant patient/physician relationship is the keystone to a viable future state of the healthcare system.

I will first list the barriers and then explain them and their solutions in my next blog. Some of the barriers have been covered in previous blogs.  

The barriers to effective and efficient medical care are causing physicians to adjusted in a distorted and destructive way. These barriers are not increasing the quality of medical care they are serving to decrease the quality of medical care.

            Lack Of Malpractice Reform

            Problems Trying to Increase Reimbursement

  • Stripped of Negotiating Clout
  • Turned Into Captives of the Insurance Industry
  • Pressured to Sell Healthcare as a Commodity
  • Pushed to Abandon Clinical Judgment
  • Under Hospitals' Thumb
  • Shunted Aside by Policymakers
  • Shunted Aside by Entrepreneurial Management companies
  • No One Is Advocating for Physicians

The VA Healthcare System is the perfect example of a top down Platonic approach to a healthcare system.  Government bureaucracies have proven over and over again that it does not work.

The American healthcare system needs a bottom up system that is based on empowering physicians to act professionally in the best interest of patients.

The bureaucrats for a top down system should enable a higher level expectation of care from physicians and provide education about the higher level of expectations for patients.

The driver of the healthcare system must be the consumer. The government and physicians must emphasize the consumers’ responsibility in their health, healthcare and medical care.

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

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Creating Confusion And Blame

Stanley Feld M.D.,FACP,MACE

President Obama is in the midst of a leadership crisis on many fronts. A large number of voters have no idea of the details of each crisis or scandal.

They figure they elected a President who will not only take care of a crisis when it develops but he will look after America’s best interests.

There are other voters who have become news junkies. They are interested in each crisis. The source of their information is the traditional media.  The traditional media provides filtered sound bites that lead them to erroneous conclusions.

People are mistrusting the administration and the traditional media because they are realizing that are being fed disinformation. They realize they are being manipulated. It is becoming clear that the administration is not defending the constitution and the people’s freedoms.

The defects in Obamacare are affecting people directly. All of a sudden seniors cannot find a physician who will take Medicare.

If they sign up with a concierge physician they receive no reimbursement from the government for Medicare premiums they have paid.

People with employer sponsored healthcare insurance are having difficulty finding a physician unless they pay a fee to a concierge physician.

Their portion of the healthcare insurance premium has increased with a threat of higher premiums next year. A 15-50% increase is expected. Their copays and deductibles have also increased.

The employer sponsored healthcare insurance plans are going to be available to only full time employees.

Last month there was an increase in employment of 288,000. However there was a decrease in 708,000 fulltime jobs and an increase in 1,115,00 part time jobs because of Obamacare and its mandate to provide healthcare coverage for people who work more than 35 hours a week or face a penalty.

 Writing in the Wall Street Journal, Mortimer Zuckerman — real estate developer and editor in chief of U.S. News & World Report — says yes. Some data seem convincing. In June, part-time jobs (defined as less than 35 hours a week) increased by 1,115,000, reports the Bureau of Labor Statistics (BLS); full-time jobs fell by 708,000.”

Just think of all those Americans working part time, no doubt glad to have the work but also contending with lower pay, diminished benefits and little job security,” wrote Zuckerman.”

The New York Times and Paul Krugman keep telling us Obamacare is a success. They ignore the facts.

 A few weeks ago a study showed that 85% of the people who signed up for Obamacare on the individual market received subsidies from the government.

It turns out many people lied on their enrollment applications and they will not receive the subsidy. The Obama administration took their enrollee's word because it did not have the infrastructure to check the applications. These people cannot afford the premium now much less after the subsidy is removed and back payment to the government is made.

This will reduce the 8 million claimed valid enrollees to below 5 million enrollees.

The execution and implementation of Obamacare is a great setup for fraud and abuse. It is described in the following You Tube.

I do not think President Obama is going to demand back payment. This is not the first time President Obama has changed the law without consulting congress.  

The law states that people can qualify for tax credits. A tax credit is defined as a deduction off the income tax due. People making under $40,000 do not pay income tax. Some receive a check from the government.

How was a tax credit changed to a subsidy?

The law specifically states that the state health exchanges and not the federal health insurance exchanges can provide the tax credits. Thirty-six states have not set up state health exchanges. 

 Those thirty-six states predicted that the exchanges would be a failure and a tax burden to its citizens.

 Many of the remaining states that set up health insurance exchanges are failing.

The federal government set up health insurance exchanges in those thirty-six states instead. The federal health insurance exchanges have not been a  success despite the statements by the New York Times and Paul Krugman to the contrary.   

President Obama’s pledge to bail out the healthcare insurance industry if the industry does not make as much money as they expected to make because of the demographic profile of the people who sign up is another sign of failure. It points out how dependent the Obama administration is on the participation of the healthcare insurance industry.

Where is President Obama going to get the money to pay for all the pledges? The CBO now predicts Obamacare create a 1 trillion dollar deficit rather than an excess over the next decade. This is after collecting increased taxes for 6 years before full implementation of Obamacare.  

There are many other defects in Obamacare. It is a failure.

The Obama administration with the help of the traditional media is trying to distract the public from the facts by withholding facts and feeding the media confusing facts, disinformation and lies about Obamacare’s success.

The administration blames Obamacare’s difficulties on the Republicans using non-facts.

The Obama administration can get away with this for only so long. The middle class is realizing the economic burden Obamacare has created for the middle class and the economy.

The middle class is realizing this because the facts are affecting them directly.

With the atmosphere of mistrust, and distrust created by the economy, the decrease in the value of the dollar, the lies and withholding of information about Bengasi, Fast and Furious, the IRS, the Ukraine, Syria, Iraqi, Afghanistan, Iran debacles, and the VA scandals it is going to take a lot for the people to regain its trust in President Obama.

Alinsky’s methods of lies, obfuscation of the truth and blame are running out of steam.

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

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The Problem With Expert Panels

Stanley Feld M.D.,FACP,MACE

It is obvious to me that Obamacare is going to rely on expert panels of the government’s choosing to determine if there is enough evidence for physicians to perform certain tests, prescribe certain medication or perform certain surgeries.

The panel evaluates the quality of data in published studies. The “medical experts” are not experts in the field of medicine they are evaluating.  

Many of these studies do not take into account the natural history of a disease or the common sense use of clinical judgment.

The panels’ conclusions are used by CMS to determine reimbursements for tests, medications and procedures.

The most recent publicized examples have resulted in controversies between the US Preventative Services Task Force (USPSTF) experts and expert specialists in each medical field. The examples include mammogram testing, PSA testing and bone density testing to name a few.   

 Medical care cannot be commoditized. The evidence of efficacy is always changing. Much of the clinical research is not completely vigorous.  It cannot be put into a nice computer evaluation box.

Published studies are restrictive. It is very difficult to define best practices using evidence based medical care. Many studies are poorly designed. Most clinical studies do not include long term follow up.

Most clinical insights into the natural history of disease are the result observational data. Observational data is not given as much credit as double blind placebo controlled longitudinal studies in evaluating strength of data.

Double blind longitudinal studies are becoming rare because they are too expensive to design and take too long to determine if they alter the course of the disease.

Nevertheless the expert panels to be used in Obamacare are set up to determine payment policy. These payment determinations have many deficiencies.

The error in determining payment policy can lead to restriction of access to care. These errors can also lead to the onset of chronic disease complications.  Chronic disease complications can lead to an increase of medical care costs.

One such abuse is the USPSTF refusing to endorse widespread screening for vitamin D levels in healthy adults, despite research suggesting that a majority of Americans may be deficient or insufficient in vitamin D.

“The United States Preventive Services Task Force decided not to recommend routine testing for vitamin D levels in part because it was not clear whether otherwise healthy adults with low levels would actually benefit from taking supplements of the vitamin.”

The panel members concluded that there was not enough evidence to either endorse or advise against regular vitamin D screening in most adults.

The panel members suggested that testing is something that should be considered case by case.

People produce normal vitamin D levels in their blood when exposed to sun for at least 10 minutes a day. Most Americans avoid sun exposure because of fear of skin cancer and skin aging. Sun block is used to avoid UV light that stimulates the production of normal vitamin D levels.

Is the government going to reimburse physicians for using their judgment in testing for serum vitamin D levels? I doubt it.

The panel hedged. “This is not a recommendation for or against it,” said Dr. Douglas K. Owens, a panel member and director of the Center for Primary Care and Outcomes Research at Stanford medical school. “In our view, when people have concerns or questions about vitamin D, they should discuss them with their clinicians.”

In my view the panel knows very little about vitamin D deficiency. Some studies estimate that more than two-thirds of Americans have deficient or insufficient vitamin D levels.

The first symptom in vitamin D deficiency/insufficiency is weakness in large muscles bundles. An easy clinical test is to see if a patient can rise from a sitting position without leaning on his/her elbow or a support. If a patient needs support it is likely that he has a vitamin D deficiency.

The USPSTF panel issued a draft recommendation based on a review of evidence from more than a dozen studies that evaluated the effects of vitamin D treatment in generally healthy adults.

The studies used vitamin D3 doses ranging from 400 to 4,800 international units (I.U.) daily, and the studies were from two months to seven years duration.

400 I.U. per day is insufficient replacement therapy. 400 I.U. per day would have no impact on inhibiting a disease process or preventing a disease from occurring. It would provide no insight into helping prevent chronic diseases implicated in vitamin D deficiency.

Clinical studies lasting two months would not provide any insight into the efficacy of replacement therapy in chronic diseases such as osteoporosis, hypertension, heart disease, inflammatory bowel syndrome or cancer, to name a few.

Vitamin D deficiency has the greatest direct impact is on the development of osteoporosis. Most of the osteoporosis research has been focused on preventing fractures after a vertebral fracture has occurred.

Most patients with osteoporosis have a component of osteomalacia. Osteomalacia is a thinning of the bone secondary to a vitamin D insufficiency and a decrease in calcium absorption from the gut.

Osteoporosis takes 30 years to result in bone fractures.  Meanwhile patients with osteoporosis also have had a vitamin D deficiency.

 A double blind placebo controlled study for osteoporosis would be impossible to conduct or fund.

In recent years observation data has shown that patients with vitamin D insufficiency or deficiency have an increased incidence of several cancers, hypertension, heart disease (probably as a result of hypertension) and irritable bowel syndrome. This is all observational data that has been discounted by the USPSTF.

The natural history of many cancers is unknown. There are many confounding variables to cancer. However, the observed relationship to vitamin D deficiency or insufficiency is strong and should be heeded by the government.

The design of generating these Task Force Guidelines is defective.

When and if Obamacare takes over the total healthcare system as the single party payer, Americans will experience a restriction to access of care that might result in an increase in the complications of many chronic diseases.

It is too late to test a vitamin D level once the symptoms are presented.

It will have no impact on inhibiting a disease process or preventing a disease from occurring.

This onset of the chronic disease will result in higher costs to the healthcare system.

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

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More Bad News For Obamacare And Taxpayers

Stanley Feld M.D.,FACP,MACE

The Obama administration and the traditional mainstream media are working very hard to keep the bad news about Obamacare away from the general public.

The Colorado exchange (Connect for Health Colorado) expects nearly 24% of the enrollees to drop health exchange coverage in fiscal 2015.

This is a direct contradiction to the Obama administration’s projection of the growth of health insurance exchanges.

“In April 2014 after open enrollement closed, the staff of Connect for Colorado projected 13 percent of people enrolled will drop or not pay for policies in fiscal 2015, but now they are expecting about 24 percent to drop their policies, according to the latest model.”

“And in fiscal 2016, the revised figures show dropped policies going from the 16 percent projected in April to nearly 22 percent.”

The Colorado Health Insurance Exchange’s chief financial officer Cammie Blais said the staff is using the higher drop rate in more recent models because that is how national figures are tracking.

President Obama and the Obama administration are aware of these figures. As usual they are keeping it from the public.

Why is happening nationally? There are multiple reasons.

Eighty five percent of the people who have enrolled have qualified for subsidies on the basis of the information they gave on the enrollment form.

The federal government was not set up to verify the information given on the enrollment form at the time of enrollment.

President Obama told everyone he would take his or her word for the information’s accuracy. This was a tremendous defect in the Obamacare system.

Many enrollees are going to lose part or the total subsidy provided by Obamacare. For some, the original subsidy was not enough to reduce the burden of insurance. In many cases the burden included high deductibles and copays that were unaffordable.

Many of the remaining fifteen percent of the enrollees had preexisting illnesses and could not buy insurance on the open market and/or were making over $50,000 a year.

Their premiums plus deductibles and copays are so high that enrollees making over $50,000 a year realize they cannot afford the insurance and have to drop out of next year’s exchange.

As a result of this adverse selection healthcare insurance industry’s premiums are going to skyrocket in 2015 as they have skyrocketed in 2014.

If the government starts convincing the majority of the public that the free market solution of the health insurance exchanges doesn’t work, the only choice will be a single party payer system for the entire population.

The VA system is an example of a single party payer system run by the government. It is a bureaucratic mess that is inevitable with a government run single party payer system.

A large bureaucratic single party payer systems relying on rules and regulations will end up with as non-transparent bureaucracy built for the benefit of the bureaucrats and not the people.

I think the public understands this. I think the Obama government is out of touch with the people.

President Obama ought to reexamine his premises.

The Obamacare system being built is destined to fail. It is not a consumer driven free market system. It does not follow that a single party payer system will work.

In reality none of the government controlled single party payer systems throughout the world work. They are just free. However, these systems are unsustainable.

The 8 million enrollees that President Obama ran his Obamacare victory lap on continues to dwindle at an accelerated rate.

If the DC appeals court rules against the federal government ability to provide subsidies, the number of enrollees will decrease even further.

The law states that only State health insurance exchanges can provide subsidies.

Obamacare is getting further and further away from being functional.

The Obama administration and the traditional media are working very hard to keep this information from the general public.

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

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Drug Pricing Is Weird

Stanley Feld MD, FACP,MACE

Many of my readers have asked me to explain drug pricing. I have not covered the pharmaceutical industry’s pricing in this blog because I have not been able to figure out drug pricing.

I do know there is a lot profit in both the retail and wholesale drug business. I know government pricing is different that benefit management pricing. I know there has been a growth in drug benefit management companies.

My sense is neither the pricing for Medicare Part D or private insurance drug benefits are for the patients’ advantage.

I recently asked a good friend Dr. Dale Fuller, a retired radiation oncologist, to explain the outrageous cost of oncology drugs (Drugs used to treat patients with cancer).

I wanted to know the reason the government pays almost twice as much to hospitals for the same treatment patients get in the oncologist’s office even though the treatment is given by the same oncologist.

I have added a couple of comments to Dr. Fuller’s note into the body of his reply.


Dr. Fuller writes,


"Is pharmaceutical pricing weird, or what?"

Dale Fuller M.D.

"Lately I have been thinking about pharmaceutical pricing, and as an old pharmacist turned radiation oncologist, it was the pricing of cancer drugs that caught my interest.

Then, my wife showed me some information about a product called “Symbicort” that she uses on a regular basis. 

Introduced into the US in March of 2009, it goes off patent in 2014.  The other day she brought home a 90 day supply for which she had paid $120.00, and Medicare part D allegedly paid $839.89.  At least, the package from Walgreen’s informed her that her “insurance had saved her that $839.89”.

The $839.89 plus the $120 or $959.89 is going to be charged against her Medicare Part D donut.

During the initial coverage phase, you pay a copayment or coinsurance, and your Part D drug plan pays its share for each covered drug until your combined amount (including your deductible) reaches $2840.

Once the patient and the patient's Part D drug plan has spent $2,840 for covered drugs, the patient will be in the donut hole.

Previously, the patient had to pay the full cost of your prescription drugs while in the donut hole.

Starting 2011, the patient gets a 50% discount on covered brand-name prescription medications. The donut hole continues until your total out-of-pocket cost reaches $4,550.

This annual out-of-pocket spending amount includes your yearly deductible, copayment, and coinsurance amounts.

When you spend more than $4,550 out-of-pocket, the coverage gap ends and your drug plan pays most of the costs of your covered drugs for the remainder of the year.

The patient will then be responsible for a small copayment. This is known as catastrophic coverage.

In 2014, Medicare will pay 28% of the price for generic drugs during the coverage gap. You'll pay the remaining 72% of the price.

What you pay for generic drugs during the coverage gap will decrease each year until it reaches 25% in 2020—in 2015, you'll pay 65% of the price for generic drugs during the coverage gap.

Confusing isn’t it.

 That would be a total of $959.89 for her 3 months’ supply of medication, or $319.96 a month, or $2.67 a squirt, of which there are four a day.  Who knows how much Uncle Sam actually paid Walgreen’s for his share of the bill.

 How to save 85% on Symbicort.

However a senior cannot buy this inexpensive brand named Symbicort using his Medicare Part D drug plan because he would be buying it from a Canadian Pharmacy.

So much for competitive innovation in a global economy. Government control trumps innovation.

Similar abstruse drug pricing strategies exist in abundance in the field of medical oncology.

Consider first the situation in the office of the medical oncologist.  The physician purchases pharmaceuticals from a supplier.  He must retain at least a basic inventory of frequently used products, some of which are very expensive.

The “acquisition cost” becomes the basis for the reimbursement the doctor receives from Medicare for the drug.  To the acquisition cost the doctor was allowed to add 6%, which was intended to cover the preparation for administration.

The actual infusion of the medication in the doctor’s infusion room, including the cost of the nurses working there, was reimbursed at a rate of $133 per hour (“chair time”).  Keep that figure in mind.

The US budget debacle in which Uncle Sam cut everything he paid for by 2%, actually amounted to a 33% reduction in the 6% the doctor was allowed,  leaving ~4% to underwite the preparation for administration of the drug required for the care of a Medicare patient.

There are other patients who come to the infusion room, as well.  Some have private insurance, and some have no insurance at all.

The private insurance may carry a different level of reimbursement for pharmaceuticals from that paid by Medicare, or it may not.

Very few uninsured patients have the wherewithal to pay out of pocket for the cost of their care.  The doctor has two choices in handling their situations:  charity or referral to a hospital where the cost of chemotherapy agents and their administration is handled in a different way.

The absence of any significant profitability for many medical oncologists has resulted in the closure of at least 400 practices between 2007 and 2012, and closures continue to this day.  Patients in these situations have been forced to seek outpatient infusion services in local hospitals, where administration reimbursement to the hospital is an average of $299 per hour in comparison to $133 in the doctors’ offices.

It is said that hospital outpatient infusion services use more drugs (see below for how they are acquired), charge higher prices, and require higher co-pays from patients.  Go figure.

And, don’t forget the drugs!  Doctors are now reimbursed by Medicare at acquisition plus 4%, while hospitals, under “340B” programs enjoy a margin of about 30% versus the doctors’ 0-2%.

Remember the Symbicort example I started with?  The 304B acquisition price for  Symbicort  is listed at $88!  Even with a 50% markup for a patient, a month’s supply would come to  $132. Go figure.

 The evolution of this mess has prompted a congressional advisory organization called MedPac to call for changes to equalize payments for oncologists’ care in their offices as compared to payments for services provided in hospital outpatient departments.  And, who can argue against the creation of a level playing field?

Symbicort is now generic. I tried to find the price of the generic drug. I could not without providing a prescription. Go Figure.  Is this transparency?

Patients and physicians are being taken advantage of here. They are the pawns that drive the profits in the healthcare system.

Someone has to stop it for the sake of good medical care delivery.

I wish to thank Dr. Dale Fuller for this submission.

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

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President Obama’s Hatchet Man

Stanley Feld M.D.,FACP, MACE

President Obama’s favorite hatchet man is Paul Krugman. Paul Krugman has reinforced the Obama message in his most recent weekly article in the New York Times using Saul Alinsky’s tactics. He ridicules his opponents and Republicans in an attempt to marginalize their opinions.

Have you been following the news about Obamacare? The Affordable Care Act has receded from the front page, but information about how it’s going keeps coming in — and almost all the news is good.”

“What’s interesting about this success story (Obamacare) is that it has been accompanied at every step by cries of impending disaster.”

"Obamacare’s critics made at least six distinct predictions about how Obamacare would fail — every one of which turned out to be wrong."

The New York Times’ resident Nobel Prize winner has spoken.

Republicans have not figured out how to answer these statements by Paul Krugman for fear of losing votes in the 2014 election.

President Obama keeps telling us all these criticisms and accusations are phony scandals.

He says Republicans are the ones responsible for generating news of these phony scandals.

Once again Paul Krugman’s articles are fact-less.

He declares the enemies of health reform are 0 for 6.

“For reference: I count at least six distinct predictions of Obamacare doom made by the usual suspects (Republicans and conservative pundits), not one of which has come true. Here they are:”

Paul Krugman and President Obama’s enemies are in reality 6 for 6. Paul Krugman and President Obama are winless at 0 for 6.  

Paul Krugman and the President keep churning out fact-less information in order to keep the public misinformed. 

The evidence Paul Krugman uses to make his points about President Obama’s Obamacare follow. His “evidence” is incorrect on all six points.

 1Enrollment will be very low

Paul Krugman gives the critics one zero for being wrong about enrollment because enrollment was 8 million on March 31.

The real truth about enrollment is that of the fourteen million in the individual market seven million people lost their insurance.

The traditional media has portrayed it as showing a generally positive response to the healthcare law. They emphasized that about 6 in 10 of the enrollees were previously uninsured.

HHS Secretary Kathleen Sebelius for the first time on May 1,2014  unveiled demographic details (PDF) about the more than 8 million people who have signed up for health insurance through state and federal exchanges.

The vast majority of those enrolling, 85%, received financial assistance. Those receiving assistance needed to report if they had insurance coverage prior to enrollment.”

5.2 million people applied for financial assistance through the federal exchange. Thirteen percent said they had coverage at the time of application without subsidies. 

Eight million people enrolled through the health insurance exchange and 7 million lost their insurance as a result of Obamacare.

This represents a gain of only 1 million insured.  This is not an impressive gain in insurance coverage.

We do not know how many people will lose their insurance in the group markets as large corporations are only hiring people to work less that 29 hours a week to avoid the corporations’ penalty resulting from the Obamacare mandate.

 President Obama delayed implementation of Obamacare in the group market by granting waivers to the group market for one to two years in order to avoid exposing Obamacare to an increase in the uninsured.

2. Even if people sign up, they won’t pay their premiums.

Reality: Signups exceeded expectations, and the vast majority paid.

The real truth is the closing of the enrollment period was delayed twice. The Obama administration paid millions of dollars in television ads and endorsements by celebrities encourage young people to sign up. Enrollees were not supposed to be counted as enrolled unless they paid the first month’s premium.

Sebelius should read her own agency's report. It states quite clearly that "it is important to note that the Marketplace plan selection data as of the end of the open enrollment period do not represent effectuated enrollment (e.g., those who have paid their premium)." 

Many who paid the first month’s premium have not paid their second month’s premium because they could not afford it. Even some subsidized enrollees cannot afford the premium.

Even worse, the HHS inspector general provided the first independent look at widespread issues the government is having effectively fact-checking the information applicants have put on their applications.

President Obama informed us that applicants lying on the website applications and receiving government subsidies for 2014 will be penalized on their tax return in 2015.

“According to the report, the administration was unable to resolve 2.6 million so-called "inconsistencies" out of a total of 2.9 million such problems from October through December 2013. 

“The government needs to determine applicants' eligibility in order to verify they can enroll and, in some cases, get government subsidies.”

Eighty-five percent of enrollees are receiving government subsidies. The report only covers people enrolled as of December 2013 when the total nuber of enrollees was only 3.5 million. 

“ Without that step (government verification), coverage could be jeopardized. Critics fear these issues also could cause chaos during the 2015 tax-filing season, as many would have to pay back subsidy money they were not entitled to.” 

According to the report, those running the federal marketplace are having trouble resolving problems of eligibility for subsidies. 

"The federal marketplace was generally incapable of resolving most inconsistencies," the report said, claiming the government could not resolve 89 percent of the problems

 So far Paul Krugman is zero for two.

 The American people will never know the truth because of the lack of transparency.

The truth does not matter to Paul Krugman or President Obama.

The media is the message. The American public is getting an untruthful message from the Obama administration through a non-critical traditional media. Wait until the taxpayers realize what the bill will be.

3. “More people will lose coverage cancelled by Obamacare than gain it.

Reality: Sharp drop in the number of uninsured.”

The real truth is there is something wrong with the Gallup survey of 3400 people. There are more people who lost insurance that had insurance previously when one compiles insurance policies lost as in section 1.

4. “Rate shock.

Reality: Like it says, affordable care.”

Paul Krugman should look at the Kaiser Foundation survey for the real truth.

Insurance premiums have only decreased for people making less than $50,000 because they receive government subsidies. The government pays the difference for those receiving subsidies.  

“Among plan switchers, 39% have higher premiums. In order to get the 46% number of switchers who had lower premiums, government subsidies had to be taken into account.”

According to the Kaiser report four in ten people in ACA-Compliant Plans say it is difficult to pay monthly premiums.

The majority of the Non-Group Enrollees (independent market) are confident about being able to pay for routine care with the high deductibles from the exchanges. They are less confident they will be able to pay the deductibles for a major illness.

 Obamacare is not affordable according to the Kaiser family foundation survey.

The Obama administration is heavily subsidizing people who are making less that $50,000 a year. The taxpayer is paying for the subsidy. It will be even worse for taxpayers when the healthcare insurance companies make less that their stated goal.

President Obama has by executive order put machinery in place to bail out the insurance industry to deliver the insurance industry’s expected profit at the taxpayers’ expense.

5.” Young people not signing up, and death spiral.

Reality: Pretty good demographics.”

These two references have nothing to do with the facts or the point Paul Krugman wants to make. He is pretty confident no one would read them the references.

“It’s still the case that just 28 percent of those sign-ups were between the ages of 18 and 34, far short of the administration’s target of 39 percent.”

The real truth is that the President needed 39% enrollment by young persons in order to make Obamacare financially viable in the individual healthcare insurance marketplace. President Obama ended up with only a 28% enrollment of young people.

Kathleen Sibelius announced that 28% was good enough.

6.” Soaring health costs.

Reality: Health costs are below anyone’s expectations.”

Does anyone believe the Obama administration when they tell us there is no inflation?  If you leave food and fuel out of the index there is no inflation. Food and fuel is what everyone buys and inflation is skyrocketing.

Health insurance premiums are also skyrocketing. Deductibles and co-pays are becoming unmanageable. The profits of the healthcare insurance industry unconscionable.

“Insurance firms participating in New York’s ObamaCare health exchange are seeking double-digit hikes for patient medical premiums in 2014.’

“Leading the charge is Excellus Health Plan, which is seeking to sock more than 24,000 customers with a 19.7 percent hike.”

“Health Republic Insurance of New York — the largest on the exchange with more than 68,000 members — requested a 15.2 percent increase for individual plans.”

Paul Krugman seems to have no interest in the facts.

Paul Krugman says, “It’s about politics and ideology, not analysis. But while this observation isn’t particularly startling, it’s worth pointing out just how completely ideology has trumped evidence in the health policy debate.”

Paul Krugman’s ideology trumps evidence. He is not even close to the truth. It is pure disinformation.

He is the one that is zero for six not his critics.

President Obama and Paul Krugman are concealing the truth about Obamacare’s failures.

What is worse is the traditional media and in particular the New York Times is letting them get away with it. 

What the public needs to do is obvious.

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

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