Stanley Feld M.D., FACP, MACE Menu

All items for August, 2014


The Charade Of Price Transparency

Stanley Feld M.D., FACP, MACE

The government and the healthcare insurance industry have been collecting cost data for years. The data is not reimbursement data.

The government has released a hard to understand database on what they pay per procedure and treatment.

However, the database is very hard to get to and very difficult to understand.

Theoretically one can discover what clinics charge for an MRI and what hospitals bill for childbirth. It is another thing to find out how much they get reimbursed.

New Choice Health’s web site provides hospital charges for some procedures and treatments but it is difficult to navigate. You have to give the site a lot of personal information before you can see anything.

New Choice Health published the following range of prices charged in the Dallas area.

The title of the chart is the Dallas costs for top procedures. The title is totally misleading to the public. The prices charged have nothing to do with the prices negotiated between healthcare insurance companies or the government as the third party payers with the payee being the hospitals, physicians or others  providers.

The chart is meaningless. It is a bogus attempt at transparency. It gives the impression that people are overcharged by physicians and hospitals.

It has nothing to do with what reimbursement is by the third party payer.

 At times it seems to me as if the deeply discounted reimbursement to physicians and hospitals are too much for the service rendered.

Surgeons do better than Primary Care Physicians. Hospitals do much better because of inflated revenue codes.

The easiest example of inflated hospital revenue codes to remember is the price paid by third party payers for chemotherapy in a hospital outpatient setting compared to a private practice setting.

  Difference in prices for 8 27
The charade of this kind of price transparency does not relate to patients’ problems with the healthcare system.

A patient calling the hospital for prices for a certain surgery with a certain insurance company is still going to be in the dark. Patients have to make many calls and go through many bureaucratic barriers to understand their liability.

These continued barriers and pretense of transparency lead to the erosion of confidence in our entire healthcare system., the Texas Hospital Association’s pricing site, is a very useful comparison tool.”

This is what is published in the traditional mass media. It is not.

Consumers cannot get the information they need for their individual case.

With Texas Price Point you can receive the average retail price for specific hospital procedures, total patient mix for inpatient care between Medicare 46.4%, Medicaid 7.6%, and other insurance 46%.

Medicare pays 28% of the average retail fee, Medicaid pays 27% and the private insurers pay 41% of one specific procedure.

The bad debt for that procedure is 2.36% of the total bill and charity is 3.446% of total charges.

These numbers are to the benefit of hospitals and the third party payers. They do not help the patients determine their liability for a bill with insurance payment and their deductible..

It took me about twenty minutes to glean this information from the web site for only one disease entity.

The Internet has provided some transparency and choice in drug pricing. However, it has a long way to go.

The Texas Price Point web site does not do an individual patient any good.

It tells the hospital that private insurance pays more than Medicare or Medicaid. If the hospital was smart it would increase the number of private insurance patients over Medicare and Medicaid patients to make more profit.

I think the hospital knows that without the Big Data on the web site.

The healthcare system has a long way to go to have pricing be transparent to individual consumers.

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

Please have a friend subscribe








  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Anyone Can Get An Exemption From The Obamacare Mandate

Stanley Feld M.D.,FACP,MACE

The third big deal that occurred in Obamacare in the last few months was the elimination of the mandate to buy healthcare insurance in the individual market.

The waiver qualifications have become broader as they have been clandestinely declared by President Obama’s executive orders.

It took the mainstream media four months to discover the new executive order waivers for the mandate.

The Supreme Court didn’t repeal the mandate to buy insurance. The Supreme Court called the mandate a tax.

President Obama insisted the mandate was not a tax. His campaign promise was any family making less than $250,000 a year would not experience a penny of increases in new taxes.


This campaign has clearly been a lie. President Obama felt victorious about the Supreme Court decision. The traditional media gave President Obama a pass on its social, political and economic implications.

In fours years of delays in implementing Obamacare’s deadlines imposes by the law have been changed by executive orders and collecting the laws new supportive taxes on time, no one has questioned what Americans have gotten for these new taxes.

President Obama has changed many aspects of the law without the consent of congress. 

No one in congress has challenged him.

The new mandate waivers were predicted to be the death knell for Obamacare's most controversial component. We had been told that the individual mandate was crucial to the survival of Obamacare.

Very few know about the new waivers. The new waivers allow anyone to skirt the mandate in the individual market. Almost no one has to buy insurance or pay a penalty. The waivers made through executive order, essentially exempts everyone from the mandate to buy insurance or pay a penalty.

 “There already had been 13 distinct exemptions, but this document added one more — apparently it was added in late December. 

 The problem is no one was made aware of the waivers by either the government or the traditional media.

“The most recent exemption was included in an ObamaCare application document. The document said that individuals can now qualify for a "hardship exemption" — meaning they would not have to pay a penalty for not buying insurance — if they "experienced another hardship in obtaining health insurance." 

The document does not define what "another hardship" means, and suggests the administration might not be a stickler when it comes to proof either. It says anyone seeking this exemption should "submit documentation if possible." 

New waiver, number 14, was quietly extended through 2016 on March 14th 2014. The mandate is to go into affect 2017. 

The first 13 exemptions were created for people who are homeless, who filed for bankruptcy, who experienced a fire and who dealt with other financial emergencies. These exemptions covered millions of people.

Waiver 14 reads as follows:

An individual has been notified that his or her plan will not be renewed and

believes that the available plan options are more expensive than the plan that was not renewed."

Patients only have to claim they believe that the available plans are too expensive for them to buy.

The wavier is not well known. It is advertised on purpose by the Obama administration. It has not been picked up by the traditional mainstream media.

The then Health and Human Services Secretary Kathleen Sebelius defended the "hardship exemptions" and blamed them on Republican governors who did not expand Medicaid.

This attack is the typical progressive attack against the enemy and is meant to act as a diversion.

"It's been really aimed at people who could not afford coverage one way or the other," she said. She noted that the list includes people who live in states that did not expand eligibility for Medicaid.” 

Kathleen Sibelius statement is meaningless. The list of states include those states that expanded Medicaid.

To date the federal government has not processed 3 million applications. Republicans have not called out the Obama administration on the unprocessed applications.

Holtz-Eakin, former director of the Congressional Budget Office under the George W. Bush administration, said,

That for someone to qualify for waiver 14, they could simply say they couldn't get through on or plans were too expensive or a special condition they have didn't appear to be covered.” 

Adverse selection of patients is certain to be the result in the independent insurance market. Only people with preexisting illnesses or people making less than $50,000 a year have bought the health insurance exchange insurance. The later group receives a large subsidies.

The problem will be compounded whenever small business waivers expire.

In any event all American will experience double-digit increases in healthcare insurance premiums as a result of Obamacare and its unlawful waivers.

All Americans are paying higher taxes for Obamacare since 2010. Taxes to fund Obamacare have been increasing yearly for the last 4 years.

Obamacare was supposed to be fully implement in 2014. It has been minimally implemented so far.

Obamacare taxes have been implemented. Therefore, increased taxes should produce a decrease in the budget deficit.

Nevertheless the budget deficit has continued to increase yearly by over $1 trillion dollars a year.

There is something wrong with the math unless Obamacare is generating bureaucratic waste.

A reader wrote

"Good judgment comes from experience and a lot of that comes from bad judgment"

 Will Rogers



A reader sent me this list of increased taxes starting January 1,2014

In case you didn't notice

> Here is what happened on
> January 1, 2014:

> Top Medicare tax went
> from 1.45% to 2.35%

> Top Income tax bracket
> went from 35% to 39.6%

> Top Income payroll tax
> went from 37.4% to 52.2%

> Capital Gains tax went
> from 15% to 28%

> Dividends tax went from
> 15% to 39.6%

> Estate tax went from 0%
> to 55%

> Remember this fact:
> These taxes were all passed only with democrat votes,
> no republicans voted for these taxes.

> These taxes were all
> passed under the Affordable Care Act, aka Obamacare.

Is Obamacare worth the increase in taxes?

What are we getting for the increase in taxes?

What it is doing to the economy?

Why are Republicans afraid to say anything? Who should say something?

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

Please have a friend subscribe





  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Obamacare Application Data Is Wrong For 2 Million Applicants Receiving Subsidies

Stanley Feld M.D.,FACP,MACE

The second really big deal is the fact that over two million people lied on their application for Obamacare through the federal health insurance web site

We do not know how many of the 1.2 million who received insurance through state exchanges lied. 

Unfortunately, the Obama administration throws so many numbers out of context at the American public that it is impossible to follow the true facts and subsequent disastrous consequences.

Let us look at the numbers slowly. President Obama was claimed that 8 million people signed up for Obamacare by March 31,2014.

President Obama and the healthcare insurance industry were terrified about adverse selection by the people signing up. Both worked hard to get young people with no preexisting illnesses to sign up so the insurance premiums would not increase next year.

Basketball, baseball and football stars were recruited to advertise Obamacare’s benefits on TV and encourage enrollment.

The population, in the uninsured individual insurance market, was only 14 million out of a population of 350 million people. Three hundred and thirty six million received waivers from Obamacare for one reason or another.

What will happen when 336 million must participate in Obamacare? The percentage of participants in the population will be tiny if the individual market is a guide.

Seven million of the fourteen million lost their healthcare insurance because of Obamacare’s requirements. Eight million signed up for healthcare insurance under Obamacare. This represents an increase of only one million and not and increase of eight million.

Of the 8 million, 85% or 6.8 million people applied and received government subsides. These subsidies were supposed to be tax credits.

The did not have a functional back end to the website to check if these people were lying about their income, job status, and even citizenship.

 If people intentionally misstated information, they were warned they could be charged with perjury. I assume President Obama will waive that charge.

Only citizens and legal immigrants are eligible under the law for subsidized coverage.

 The government signed up about 5.4 million people, while state-run websites signed up another 2.6 million.

Only 1.2 million of those were not eligible for subsidies.

Are these 1.2 million the part of the 7 million who lost their insurance because of Obamacare? Are the 8 million the people who did not have insurance before Obamacare?

Both are important questions that we have not gotten answers to.

My guess is the people who signed up were people who could not get insurance because of preexisting conditions or people who could not afford insurance in the individual market.

In either case the will be adverse selection and increased healthcare utilization. Insurance premiums will increase for everyone in the health insurance exchanges. 

 Some 80% of all those who have enrolled in plans nationwide, according to federal statistics released today, have chosen a silver plan, meaning deductibles of $2,000 for singles and $4,000 for families, or gold or platinum plans, which have no deductibles. “

“Only 18% have opted for bronze plans, which offer lower premiums, balanced by deductibles of $4,500 for singles/$9,000 for families.”

Many consumers can hardly afford the bronze plans with subsidies much less the high deductibles. Those consumers will be forced drop out of Obamacare.

“The Associated Press reports that of the 5.4 million people who signed up for health insurance through the federal marketplace 2 million submitted information that does not match up with federal data.”

The discrepancies could affect their subsidy adversely. Applications were accepted on boy scouts’ honor. The subsidies were determined on the basis of the information on the application. These people will owe the government the difference plus a penalty. They are also liable for perjury.

The back end of is still incomplete.

“Serco, a foreign contractor already under investigation, was awarded a $1.2 billion contract to process Obamacare’s paper applications, and the AP reports they will be tasked with resolving these application issues. “

Despite having had three years and more than $600 million to work with the federal governmentand its chosen contractor could not build a functional website. It cost an additional $200 million dollars and four months to get the front end to work.

The $600 million to build was more than it cost Apple to develop the iPhone. Apple is an American company with American jobs. 

It should be recalled that another foreign contractor (CGI of Canada) got the first contract. Michelle Obama’s Princeton classmate happened to be an executive,


Serco is a foreign company riddled with a history of transgressions. The most recent transgression was that Obamacare contractors were literally being paid to do nothing.”

The White House has attempted to dispel concern about the website being dysfunctional.

However, the report of over 2 million falsified applications has reignited the questions of government incompetence and misleading information about the dysfunctional website as the enrollment period approached.

As Americans for Prosperity reported in the Washington Times early last month, “the website was originally intended to function automatically, calculating premium subsidies, making government payments, and tracking enrollment information that would affect future costs.”

“ But the interim system currently in place (that resulted in the newly revealed data discrepancies) is “pretty much a spreadsheet and some informed estimates,” according to Politico.

Compounding  problems are a Roll Call report that almost 3 million Medicaid enrollees have not yet had their applications processed.

These issues are all separate issues from Obamacare’s cancelled healthcare plans, physicians opting out or retiring, and the scandal with the Veterans’ Affairs health care system.

In reality all the issues are one with the Obama administration making it clear that a government run bureaucratic healthcare system is a nightmare that will destroy the healthcare system in America.

8 20 2014 Obamacare-Delays

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

Please have a friend subscribe



  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Three Very Big Deals

Stanley Feld M.D.,FACP,MACE

Three very big deals occurred with to Obamacare the last few months that have received very little traditional media coverage. There has been sparse traditional media coverage of the significance of these three issues to the future of Obamacare.

It looks like the Obama administration is losing its ability to freeze, marginalize  and scandalize its opposition to gain public approval of President Obama’s agenda.

Obamacare and all of its lawless modifications are negatively affecting all the stakeholders who thought they would be better off with Obamacare.

This includes the indigent, middle class workers, the upper class and all the businesses involved in healthcare.

The three issues are: 

1. The D.C. appeals court overturns subsidies given by federal health insurance exchanges.

2. Obamacare application data is wrong for 2 million applicants receiving subsidies.

3. The Obama Administration adds major exemptions to the Obamacare individual mandate.

I will cover each issue in separate blogs. What is common to the three issues is that the Obama administration changes the law passed by congress at its whim  without the consent of congress.

The D.C. Appeals Court Overturns Subsidies From Federal Health Insurance Exchange.

A three judge panel of the powerful U.S. Court of Appeals in Washington D.C. ruled that subsidies may not be offered in the federal health insurance exchanges. The Department of Justice immediately announced it will challenge an appeals court ruling that strikes Obamacare subsidies for millions of americans using, the federal health insurance exchange.

The subsidies are critical to the success of Obamacare. Otherwise, Obamacare premiums are unaffordable to people making less than $50,000 per year. There is some debate as to whether the premiums are affordable to people making more than $50,000 per year. 

Obamacare was written to encourage states to set up health insurance exchanges. Many states refused to set up health insurance exchanges. The state governors and congress realized the economic and bureaucratic burden was going to be overwhelming even if the government covers 90% of the costs.

Additionally, states that opted out fear the federal government would have too much control over the states’ rights.

As soon as the Obama administration saw this coming in 2010 after the law was passed, it had the IRS issue a ruling that contradicted the law’s intent.

The IRS rule allows the federal health insurance exchanges to provide subsidies to people buying insurance through the federal health insurance exchanges.

The intent of the law passed bywas that only states could provide tax credits. I have not yet been able to figure out how tax credits can mean tax subsidies.

“ ACA Section 1401 provides that eligible taxpayers may receive income tax credits for the purchase of insurance “through an Exchange established by the State under Section 1311.”

"Section 1311 calls upon states to establish health insurance exchanges. It does not provide for the federal government to create health care exchanges."

"Rather, a separate provision of the act, Section 1321, provides that if a state does not “elect” to create an exchange that meets federal requirements, the federal government shall then “establish and operate” an exchange."

"Thus, under a plain reading of the text, the ACA only provides for tax credits for state-run exchanges, and if states fail to create exchanges, there are no tax credits for insurance bought on a federally run exchange.”

The IRS’s ruling provides that eligible taxpayers may receive tax credits for the purchase of qualifying health insurance plans established by states under Section 1311 or by the federal government under Section 1321. The only problem is that this is not consistent with the actual text of the statute passed by congress or the intent of the law.

"Section 1311 expressly requires that an authorized Exchange must be “established by a State.” Section 1304(d) also expressly defines “state” as “each of the 50 States and the District of Columbia.” Later amendments to the PPACA also provide that Exchanges created by territories are to be treated as the equivalent of state-run Exchanges, but there is no such language concerning federally run health insurance exchanges.

There are all sorts of legal arguments on both sides of the issue. It will be up to the Supreme Court to decide.

However, Jonathan Gruber, MIT economist and Obamacare architect has repeat over and over again that“states that set up their own health care exchanges would make their residents eligible for subsidies.’” 

Jon Gruber spent a couple of years barnstorming the country warning states that they had to set up their own exchanges, and that failure to do so would cut their residents out of the subsidy pool. This was the intent of Obamacare as stated by the architect of the law.

In a speech Jon Gruber gave in 2012, he delivered both a promise and a threat

"In the law, it says if the states don't provide them, the federal backstop will. The federal government has been sort of slow in putting out its backstop, I think partly because they want to sort of squeeze the states to do it.”

“ I think what's important to remember politically about this, is if you're a state and you don't set up an exchange, that means your citizens don't get their tax credits.”

“But your citizens still pay the taxes that support this bill. So you're essentially saying to your citizens, you're going to pay all the taxes to help all the other states in the country.”

“ I hope that's a blatant enough political reality that states will get their act together and realize there are billions of dollars at stake here in setting up these Exchanges, and that they'll do it.”

Government supplied subsidies are vital to the survival of Obamacare and its accompanying bureaucratic waste.

It should be pretty clear what the intent of the law is. President Obama has been  brazen in changing and enforcing laws to fit his agenda.

It is obvious he is trying to do the same in this case with the IRS ruling that many believe is illegally modifying the intention of the law without the consent of congress.

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

Please have a friend subscribe





  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


A CMS Mistake!!

Stanley Feld M.D.,FACP,MACE

For years practicing physicians knew that hospital outpatient clinics charges were 30-60 percent higher that physicians’ free standing clinics.

CMS didn’t know it or didn’t want to know it.

CMS administers Medicare and Medicaid. CMS was restricting payment for outpatient procedures and tests done in freestanding practicing physicians’ offices while paying higher fees for the exact same outpatient hospital procedures and tests.

As rules and regulations and the complexity of the business of practicing medicine in private freestanding outpatient clinics increased physicians sold their practices to hospital systems.

The government and the healthcare industry encouraged these sales by increasing the complexity of running a private practice.

The probable logic was they would only have to deal with one entity (the Hospital System) rather than 600 individual doctors or clinics using that hospital system.

The government’s excuse for cutting out freestanding individual practices and clinics was efficiency and patient safety.

The hospitals were overjoyed to be able to buy physician practices.

“As the Affordable Care Act attempts to steer people away from pricey hospital inpatient admissions, hospitals have begun buying up doctors’ offices in hopes of increasing their revenue and market share.”

The hospital systems’ then discovered they were losing money by buying physicians’ free standing practices.

 In essence they were trying to buy physicians’ intellectual property and surgical skills because the traditional brick and mortar hospital building was becoming less profitable. Many surgical procedures were being done as outpatient procedures.

Physicians were less productive as hospital employees than they were when they owned their own practices. They were guarantied a salary.

Hospitals did not bother to calculate the money they made from doing the entire outpatient testing and procedures when presenting the loss to the government.

Hospital systems have been selective, first buying Primary Care Physicians’ freestanding office practices. Next they started trying to buy oncology practices.

The number of oncology practices owned by hospitals increased by 24 percent from 2011 to 2012. By turning what used to be independent medical offices into so-called hospital outpatient centers, hospitals are creating networks that, critics say, give them the power to set prices and ultimately raise costs for private insurers and government programs such as Medicare.”

To further encourage physician owned clinics to migrate to hospital system owned practices the government and the healthcare insurance industry provided separate revenue codes to allow hospital systems to collect more for the same tests and procedures done in physicians’ free standing offices.


“The Medicare Payment Advisory Commission, which advises Congress, are sounding the alarm. In May, MedPAC Executive Director Mark Miller testified before a House panel that these price differences “need immediate attention.”

 Medicare should align rates “to limit the incentive to shift cases to higher cost settings,”

The hospital systems’ excuse for the higher charges is it has higher operating costs than freestanding clinics such as running an emergency room.

Hospital systems receive higher reimbursement than private freestanding clinics doing the same procedure or delivering the same treatment.

The hospital system’s retail price is much higher than what it receives from CMS and the healthcare insurance industry. The discount price is somewhere around 50%

Even with the discount the hospital systems’ prices are 30-50% higher than the freestanding clinics’ prices.

The glossary of charges and discounts should be available to all consumers of healthcare. None of the prices are transparent. Patients’ have to fight hard to get the prices.

The focus or reports of prices has been on the outrageous prices for cancer drugs.

“A treatment of Herceptin, a breast cancer drug from Genentech, cost private insurers $2,740 when used in an independent clinic and $5,350 in a hospital outpatient setting, according to an analysis of 2012 claims by PricewaterhouseCoopers’ Health Research Institute.”

“The price of Avastin, another Genentech cancer drug, increased from $6,620 to $14,100, the Health Research Institute says.”

Echocardiograms in a hospital facility are reimbursed at twice the price as the reimbursement in a private physician owned facility. 

Dr. Keith Smith with the Oklahoma Surgical Center charges less than some patients’ deductible for some surgical procedures without accepting Medicare or private insurance.

If Medicare paid the lower office rate for 66 outpatient services even when they’re performed in hospital-owned facilities, the government would save $1 billion a year and lower Medicare patients’ bills by $200 million, MedPAC Executive Director Mark Miller said before the House panel. Medicare insured 49 million Americans at a cost of $573 billion in 2012.

This is an analysis of only 66 outpatient procedures. There are hundreds of outpatient procedures. Imagine the savings if all the procedures were captured.

Hospital outpatient visits for echocardiograms jumped 33 percent from 2010 to 2012, MedPAC found, while visits to independent offices declined. Echocardiograms cost more than double in hospital-owned locations.”

As hospital system merge the price will go up even further. The hospital systems are now negotiating from a position of strength. Hospital systems are making the money as private physicians’ reimbursement shrinks.

The government and the healthcare insurance industry are finding their scheme to destroy private practice was a big mistake.

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

Please have a friend subscribe





  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Physicians Are Getting Ready To Fight Back



Stanley Feld M.D.,FACP, MACE

Practicing physicians’ frustrations with the healthcare systems are mounting. It is clear that patients are not first. The secondary stakeholders such as the healthcare insurance industry, pharmaceutical companies, hospital systems and the government come before patients in the healthcare system. Money is first for these stakeholders.

The government tries to control its cost as it outsources most of its administrative services to the healthcare insurance industry.

The healthcare insurance industry, pharmaceutical companies and hospital systems try to maximize their profits by trying to get around many of the government’s complex regulations.

The result of maximizing profit is abusing patients’ ability to get medical care and physicians’ attempts to deliver medical care.

Traditional healthcare insurance is not the only way of paying for patient care. It is the most expensive way. Traditional healthcare insurance is most prone to political and moral corruption.

Moral and political corruption leads to increased insurance processing costs which lead to higher premiums and higher deductibles. This leads to less health insurance coverage.

Recently, I wrote about physicians being pawns in the healthcare system. They are the easiest to attack because they are the least organized.

Physicians are the easiest to abuse by the secondary stakeholders because they believe patients come first. Physicians are too busy taking care of their patients to figure out how to respond.

A reader sent me an article that appeared in the Dallas Morning News illustrating a tiny fraction of the abuse physicians take and the lack of respect they encounter when their orders interfere with the healthcare industry’s profit.

The article is about the need for prior authorization to reduce drug costs in an insured patient. As you read this, think of the increase in the insurance company’s administrative waste, and the disrespect for the physician’s time and judgment.

Millions of prior authorization letters are sent every day for drugs, hospitalizations, and treatment plans. They are the result of actions that do not fit into a healthcare insurance company’s computer algorithm.

Insurance company workers know little about medical care these prior authorizations are challenging. These workers know little about medical judgment or medical care.

The healthcare insurance industry believes it is an effective way to prod physicians away from more expensive treatments and toward less expensive alternatives.

It makes it harder to prescribe costlier medications. In reality, it is a wasteful administrative nightmare.

The letter in my hand concerned one of my patients, Mr. V., who suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.

But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.

Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer care representative.

Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.

Three more phone trees and three more customer care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.

At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”

She paused, then asked her next question with the encouraging uplift of suggestion. “Has Mr. V. ever tried 45 pills per month instead of 90 pills?”

Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”

“A simple yes or no will suffice, doctor.”

This interaction demonstrates a lack of respect for the physician and his judgment, and a lack of understanding of the patient’s illness. I have said over and over again that you cannot commoditize patients’ illnesses or physicians’ skills.

If the insurance company’s computer system has a beef with physicians’ judgment it should get a second opinion by a neutral expert physician in the field of hypertension to review the chart and the patient’s illness. 

The writer says,

 I bit my tongue for the remainder of my conversation with the insurance company, holding back long enough to obtain the prior authorization that would allow Mr. V. the 90 pills he needed each month. I tried not to break the phone when I finally slammed down the receiver.”

These interactions are not good for physicians’ health or morale.

They increase physicians’ cynicism.

 “I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.

In the end, we were able to keep Mr. V.’s blood pressure under control. My blood pressure, however, was a different story.”

These interactions go on daily and waste physicians’ time and energy. Physicians have no ability or representatives to fight back. However, they are ready to fight back. All they need is someone to come up with a plan.

A good start is changing the paradigm of healthcare insurance so that it is a consumer driven healthcare system with consumers being in charge of their healthcare dollars and their health. 

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

Please have a friend subscribe




  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


It is About Time For Some Common Sense

Stanley Feld M.D.,FACP,MACE

Last week I received an email from Paul Teirsten M.D., Chief of Cardiology Scripps Clinic through the American Association of Physicians and Surgeons (AAPS).

“APS News (American Physicians and Surgeons News) From: "Teirstein, Paul S. MD" “<>
Date: July 25, 2014 at 1:58:07 PM CDT
To: Undisclosed recipients:;
Subject: MOC Boycott. Send a message to ABIM

Dear Colleague,

Thank you for signing our anti-MOC (maintenance of certification) petition earlier this year. As you know, the American Board of Internal Medicine (ABIM) has recently added significant time and expense to board certification.

We now have over 17,000 signatures and many compelling comments on the petition.

We are making progress.

ABIM is now under fire with many physician organizations (i.e. ACC, ACP, AACE, AAPS) calling for MOC change.

BUT, since there has still been no meaningful change, many physicians are now boycotting the MOC program. Even if you previously enrolled in MOC, you can pledge to boycott future enrollment.


 To more easily spread the word, we created:

 To consider signing the petition and pledge, go to:


If you support this cause, please send it to your colleagues and medical staff offices for wider distribution

Physicians for Certification Change (PCC) Paul Teirstein, M.D Chief of Cardiology Scripps Clinic

858 554 9905

  Can MOC be Stopped? Yes It Can!”

 Bravo!! To The American Association of Physicians and Surgeons (AAPS) under the leadership of Jane Orient M.D.

It is about time some medical organizations are fighting back for their practicing physicians and those physicians’ patients from the abuse of the ABIM.

What are the main issues? There are two.

  1. Control Physicians by recertifying physicians in order to maintain quality of care through formal testing every two years.
  2. It is all about economics. It is all about The American Board of Internal Medicine, the American Board of Pediatrics and all the other certifying boards increasing revenue from the fees to be recertified every two years.

The entire medical profession is for improving the quality of care. A problem is the definition of quality care is artificial and poor defined. Most medical care cannot be commoditized. There is no data that proves that recertification improves quality of care.

The present maintenance of certification tests use “memory-based curriculum,” where doctors need to recall endless amount of facts on board exams. This out of date testing method does not test quality of care delivered or physician judgment.

If there is a recertification test it should be open book.

 “With the advent of mobile apps, UptoDate and IBM’s Watson, more medical information than ever is available on demand. Relying on memory, as board exams do, reinforces an antiquated model of care.”

It seems to me the AIBM’s only reason to increase this burden on physicians at this time is to increase its revenue and control physicians’ freedoms.  In studying of IRS form 990 as of 2009 for 24 specialty board examine organizations it is revealed that all the testing board have total assets of $465 million and annual gross receipts total more than $350 million (

The ABIM collected $42.3 million dollars in 2009. It had expenses of $22.8 million dollars in salaries and expenses and another $24 million dollars in other expenses.

The ABIM reported a loss of $4.5 million dollars in 2009.

 The ABIM claims to pay nothing to the physicians who write the test questions.

I think the ABIM needs to be recertified.

The recertification controversy has been going on since 2010. The American Medical Association has gotten an ear full of dissent from its members according to the AMA News. The AMA’s politically correct solution is to study the problem over the last four years.

Nationwide, physicians from a variety of specialties organizations have voiced their views on the pitfalls and merits of Board Recertification and Maintenance of Certification (MOC).  In a recent New England Journal of Medicine physicians had a very negative response to the MOC changes.

Change Boards Recertification survey included all physicians even those physicians who are grandfathered.

As you can see, our polling results are even more telling than those obtained by the New England Journal of Medicine. As our polling includes MOC for all physicians – not only those who are grandfathered – it further supports the need for change.”

“After one year of voting, it's very clear that the vast majority of practicing physicians oppose the current MOC process.

 After thousands of votes, only 1.6% wish to maintain the current system, while 4.7% supported reform and 93.7% voted to abolish the requirements altogether.

 Had this been a political poll, it would be a landslide victory against the current MOC process.

Yet Board leadership continues to ignore the collective voice of the nation's practicing physician.”

How do we fix this problem?

Recertification exams need to be changed to fit current practice paradigms. They must not be punitive. They must be fashioned to encourage continuing medical education and the joy of learning.

The present MOC is punitive. The boards think they are doing a good thing. They are next planning to use recertification for maintenance of licensure therefore making recertification a mandate.

This action in turn will connect to physician reimbursement by Medicare and the Healthcare Insurance Industry. It will also become a requirement for hospital privileges.

There have been special exemptions given to large clinics to let their physicians avoid MOC. Mayo clinic’s physicians and other large clinic are receiving waivers from maintenance of certification. 

This is wrong.

The AIBM and other boards need to recognize the continuing stratification of internal medicine practices.

Hospitalist and ICU specialists are now taking care of hospitalized patients. It cannot be expected that internists in outpatient practices should be facile in the care of an ICU patient.

The increasing bureaucratic demands on internists are increasing with pre-authorizations for drugs, testing and treatments.

They are also faced with buying electronic medical records that have not increased practice efficiency  or met data collection requirements for pay for performance reimbursement.

These mandates consume lots of time. They cost lots of money in an environment in which reimbursement is decreasing. 

Adding preparation time in studying to take a Maintenance of Certification (MOC) examination is a burden an additional overhead to physician in private practice.

It is no wonder physicians object to MOC even though that are dedicated to life long learning. 

The American Association of Physicians and Surgeons (AAPS) did two things. It sued the American Board of Medical specialties (ABMS) in April 2013.

The Association of American Physicians & Surgeons (AAPS) has filed suit April 23, 2013 in federal court against the American Board of Medical Specialties (ABMS) for restraining trade and causing a reduction in access by patients to their physicians. The ABMS has entered into agreements with 24 other corporations to impose enormous “recertification” burdens on physicians, which are not justified by any significant improvements in patient care.”

The ABMS has been wiggling around technicalities in the lawsuit for over a year as it continues to pursue limiting physicians’ freedoms for ABMS’s own profit.

This is crazy to me as the country is experiencing a physician shortage and many physicians have quit practice because of these burdens.

The Boards are ignoring its constituents’ needs and wishes.

The second thing AAPS is doing is heightening awareness of the tremendous impractical burden the medical specialty boards are imposing on the medical profession.  

The AAPS is asking physicians to sign  “A PLEDGE OF NON-COMPLIANCE WITH ABIM’S MAINTENANCE OF CERTIFICATION (MOC)” in the hope of precipitating sensible and common sense change in the MOC.

1. The American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program is onerous and provides little value.

2. There is no data that MOC improves patient outcomes.

3. The MOC modules are irrelevant busywork that reduce physician time for patient care.

4.  MOC is costly for physicians and has become a money-making enterprise for ABIM

5. There is no public demand for MOC.

6. The existing Continuing Medical Education requirements are a preferred approach to life-long learning.

7. To date, despite numerous calls for change, ABIM has not made meaningful changes to the MOC program

Therefore, I pledge not to participate in MOC unless significant changes are made to the program. If I have previously enrolled in MOC, I will boycott future participation unless significant changes are made to the program.

 If you support this pledge, please send it to your colleagues and your hospital medical staff office for distribution.

 Note: We are aware that many who want to sign this pledge are unable because contracts with their hospitals, third party payers etc require MOC. 

 Supported by Physicians for Certification Change 

 To the physicians reading this blog even if you want to support this pledge but are not able to please make your colleagues who can sign the pledge to aware of it and give them the opportunity to support it. 

 Contact: Physicians for Certification Change (PCC) Paul Teirstein, M.D Chief of Cardiology Scripps Clinic

858 554 9905

  Can MOC be Stopped? Yes!

Or sign petition:

 “The way to win a war is not to show up." “Art of War”

All that is needed is a little common sense to Repair the Healthcare System.

Where did common sense go?

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

Please have a friend subscribe

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Holy Cow!

Stanley Feld M.D., FACP,MACE

 I cannot believe it.

President Obama continues to deceive the America public about his "Accountable Care Act" (ACA or Obamacare). Our elected officials continue to do nothing to stop him. Unelected administrative officials are making spending decisions that neither congress nor the public is aware of until after the fact. A case in point is

William T. Woods, a senior official at the Government Accountability Office in testimony prepared for a House hearing on Thursday, warned of “significant risks in the next open enrollment period, which begins Nov. 15.”

He said, “the marketplace and its website,, were over budget and behind schedule because of “new and changing requirements” imposed by administration officials.”

This is in direct contrast to what Sylvia Mathews Burwell, the secretary of Health and Human Services told the congress and the American people a few weeks ago. She said the problems were mostly solved.

The American people have still not gotten an accurate accounting of how many people have signed up legally through the health exchanges. My best estimate it is less than 3 million and not 8 million.

About 80% are getting subsidies by signing up on the federal government health insurance exchanges. It is also against the law according to the definition for subsidy eligibility as written the law. President Obama said the administration did did not mean what the law says.

Let us concentrate on the costs of the website until this point. Initially it was supposed to cost $56 million dollars.

The cost rose from $56 million dollars to $209 million dollars from September 2011 to February 2014. The Obama administration launched the disastrous web site in October 2013 without having a quality assurance surveillance plan to monitor the work of the main contractor CGI. A principle in CGI was a college buddy of Michelle Obama. A linkage of their friendship and the contract with CGI has never been proven.

On October 1, 2013 the disaster of the web site became apparent. There was confusion within the Obama administration about who had the authority to approve contractor request to expend funds for additional work.

Mr. Woods said,“In 40 instances, the staff members of the federal exchange inappropriately authorized contractors to expend funds, totaling over $30 million.”

Mr. Wood also said, “As the Oct. 1 deadline approached, federal officials identified significant performance problems in computer systems developed by CGI Federal, but “took only limited steps to hold the contractor accountable.”

The administration withheld only $267,000, or 2 percent of CGI’s $12.5 million fee. There is no indication of the profit CGI made on the work done that cost the government $209 million dollars.

It gets more complicated and bizarre.

In January 2014 the Center for Medicare and Medicaid Services (CMS) awarded a contract valued at $91 million to Accenture Federal Services to continue work on the project.

“Accenture Federal Services costs have ballooned to more than $175 million and the marketplace is still unable to perform essential computer functions needed to pay insurers and update information on consumers.”

The question that must be asked is what in the world is going on?

James E. McAvoy, a spokesman for Accenture said that another “task order” had increased the total to $190 million.

Accenture said, “It is helping the government develop an insurance exchange for small businesses, is expanding the federal exchange to serve additional states and is adding new features to verify the income of people seeking federal subsidies.”

The Government Accountability Office, an investigative arm of Congress, said that through March of this year the administration had made formal commitments to spend $840 million on the federal health insurance exchange and marketplace.

The $840 million dollars is a long way from the original $56 million dollar in the original Obamacare budget.

 The plot thickens.

Andrew M. Slavitt the No. 2 official at the Centers for Medicare and Medicaid Services told Congress that the agency was changing requirements for its contracts to expand the scope of work that must be done.

Mr. Slavitt said that the administration was making improvements in the federal health insurance exchange’s software , but that the second round of open enrollment, starting in November 2014, would not be perfect. “There will certainly be bumps,” he testified at a House hearing.

Mr. Slavitt avoided answering how much the website should cost. 

 Mr. Slavitt said, “That’s a really good question.” He did not specify the proper cost, but he said the nation was getting invaluable results, including new insurance coverage for millions of people.

Mr. Slavitt, who joined the government three weeks ago. A congressional panel has questioned his credibility.

Mr. Andrew Slavitt, a former executive at Optum, the technology company tasked with “saving”,ran into sharp questions from a House panel about a potential conflict of interest in his new role.

Rep. Morgan Griffith, R-Va., pressed Mr. Slavitt on his previous job at OptumInsight/QSSI.  Optum, and its parent company, UnitedHealth Group. UnitedHealth Group, one of the nation’s largest insurers, offers health plans on the federal health insurance exchanges. Optum had a large role in the creation of and built the data hub, The data hub is still not working properly.

The Obama administration granted an ethics waiver to Mr. Slavitt so that he could participate in decisions affecting his former employer, Optum, and its parent company, the UnitedHealth Group.  

Optum is the tech firm the Department of Health and Human Services picked in October 2013 to straighten out It was awarded an $84.5 million contract with HHS’s Centers for Medicare and Medicaid Services in January 2012 to build the part of known as the federal data hub.

The purpose of the data hub is to connect multiple government agencies to streamline verification of crucial consumer information—including Social Security number and immigration status when Americans log into the federal and state exchanges and apply for Obamacare subsidies.

Doesn’t this sound fishy? Can we trust the Obama administration to decide what treatment American should get and what treatment Americans cannot get access to?

It looks like the VA all over again?

Let the buyers beware!

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

Please have a friend subscribe







  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.