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All items for September, 2015


Can Government Run Systems Function Efficiently And Cost Effectively?

Stanley Feld M.D.,FACP,MACE

It has been proven over and over again that government does not run its systems efficiently and cost effectively.

Think of the post office, the railroad, the military services, the EPA and the IRS, to name a few. One could go on and on and come up with the same answer to the question. No.

The same holds true for government’s goal to control the healthcare system. It will not work. It has already proven to not be cost efficient or effective.

The Federal Government’s goal is to take over more and more systems operating in the life of the average American. The excuse is to help all Americans live a better life, to help the poor and under privileged. Instead it has kept the poor dependent on government, poor and under privileged.

“Each according to his abilities and each according to his needs” has not worked wherever it has been tried.

Government’s real goal is to have power over citizens. It is to make citizens dependent on the central government.

It is hard to find an example on the planet where this strategy has worked for the people it claims to help.

The results are also just the opposite of what the U.S. Constitution guarantees.

The evolution of the VA Hospital System is a stunning example of how government controlling a system does not work. No matter how much money the central government throws at the system it does not help. Noble goals always go astray. It is because the structure and the incentives in the system are wrong.

No one seems to focus on the main defects. The most important questions are:

Who is the main customer?

What motivates the main customer?

How do you devise a system that fashions incentives to motivate that customer to help make the system work?

It is not a larger bureaucratic structure with larger budgets. Larger bureaucracies move the system further away from the goals of the main customer.

It is not a series of regulations that impose punitive measures on providers and customers who are in the system.

It is not guarantees of tenure for managers of the system.

It is a guarantee to have managers of the bureaucracy listen and understand lower managers in the system who point out the deficiencies in a system.

The larger the bureaucracy the more difficult it is to personalize the system and have participants in the system help and help make the system work. Bureaucracies isolate themselves from the main customers in a system. It is the reason they do not work.

Large corporations in the private sector fail also. These corporations form large silo like divisions that construct systems that do not relate to the main customers or each other.

Large corporations sometimes understand the dynamic and try to reformat the corporation to service their customers. If they do not, their product fails

The people do not have the power to force the government to service them, the customers. Citizens can vote their representatives out of power. The government tries very hard to keep the main issues that disrupt systems out of public view.

There are many government agencies and systems that are failing. Our representatives never fix the systems. Our representatives do not listen to the people who are involved in the systems or who run the systems.

The VA hospital system has had problems since at least the end of WWII. It came to a head since the war in Iraq and Afghanistan.

Veterans Affairs Secretary Robert McDonald had been a successful CEO in the private sector. He made some significant changes in the operations of the VA at the onset of his tenure.

He also needed a $16 billion dollar infusion through the passage of the Veterans Access, Choice and Accountability Act to keep the VA Hospital System open after the scandals in VA care came to the publics awareness.

As government bureaucracies usually act, congress and the president ordered independent multi-consulting firms to audit the VA and tell government how to fix the VA Healthcare system.

Analysts from Mitre Corp., Rand Corp. and McKinsey & Co conducted more than a dozen assessments. No one has told the public what should to be done and what these assessments cost the taxpayer.

“A sweeping independent review of the Department of Veterans Affairs health-care system made public Friday shows the multibillion-dollar agency has significant flaws, including a bloated bureaucracy, problems with leadership and a potentially unsustainable capital budget.”

All that was needed was a little common sense by an authorized executive to realize what the problems were and fix them. All the defects were reported previously.

The government did not need multiple high priced consultants to tell them their problems.

The Commission on Care was mandated by the Veterans Access, Choice and Accountability Act to create a comprehensive reform plan to congress and the VA in 2016.

How much is this going to cost taxpayers?

How long is it going to take?

“The report bears out collectively what I have seen individually, what I have seen in my role as chairman over the past nine months,” said Sen. Johnny Isakson (R., Ga.), chairman of the Senate Committee on Veterans’ Affairs. “There is a huge focus on some glaring deficiencies that need to be addressed.”

The VA needs a lot of common sense and less bureaucracy, not more bureaucracy.

“Mr. Isakson said the VA suffers especially from a system saddled with a number of different departments that can’t effectively talk with each other, as well as a number of vacancies in leadership positions that need to be filled.”

America never learns. Big government does not work. Americans are starting to believe it.

President Obama and Obamacare are leading us in the same direction. It is the path to failure.

We must wake up now and stop this.

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

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Hospital Readmission Penalties

Stanley Feld M.D.,FACP,MACE

 Obamacare has set up a system whereby if a patient is readmitted to a hospital 30 days after discharge the hospital will not be paid for the readmission and will incur a fine.

Hospitals are paid for admissions by diagnoses. The more diagnoses the more they get paid. The length of stay the government will pay for is also determined by the diagnosis.

The number of games played with the diagnosis of a patient is legendary. Hospitals are in the business of making money. The more money hospitals make the higher the administrator’s salary.

If patients have to be readmitted to the hospital within 30 days the patients are told to get readmitted to a different hospital to avoid government non-payment.

Bureaucrats who know nothing about patient care and the natural history of disease created this dumb readmission criteria.

The bureaucrats’ goal was to provide incentives by the threat of penalty for hospitals to improve quality of patient care.

I told my readers that the incentives were wrong. It would be to the disadvantage of patients. Hospitals would figure out how to get around the penalties.

Medicare does not pay for outpatient (observation) admissions. Hospitals can admit patients on observation (outpatients) for 48 hours.

I explained how hospitals could extend outpatient admissions (observations) 72 hours. Patients are responsible out of pocket for the admission bill.

Many of the readmissions are recurrent congestive heart failure. These patients can be treated and released from the hospital in less than 24 hours and at most 48 hours. Patients with congestive heart failure must become “Professors of the Treatment of Congestive Heart Failure.” Patients must be responsible for their care. They must be provided with financial incentives to become “Professors” of their disease.

Most of the time readmission is not the result of poor quality hospital care. It is the result of patients not understanding the cause of the recurrence of their congestive heart failure.

Most of the time patients do not pay attention to what they are taught to abort an episode of congestive heart failure and subsequent readmission to the hospital.

Most of the time hospital call in help desks does not improve patient compliance with treatment.

Hospital readmissions that Medicare penalizes under the Affordable Care Act are largely driven by patient characteristics such as income and education rather than the quality of care they receive, according to a new study.”

“This finding suggests that Medicare is penalizing hospitals to a large extent based on the patients they serve,” the authors conclude.

Hospitals in poor areas and urban hospitals have been disproportionately penalized under the readmission program.

In fiscal 2016, about 1,600 hospitals will see their base operating DRG payments knocked down as much as 3%.

Medicare payments were decreased 1% in fiscal 2013 for readmission before 30 days. That number increased to 2% in fiscal 2014 and 3% in 2015.

Penalties and fines applied only for heart attack, heart failure or pneumonia until 2015. In 2015 readmission rates for chronic obstructive pulmonary disease and total hip and total knee replacements have been added to the penalty list.

The addition of these diagnoses will result in additional fines to hospitals. Additional penalties will affect hospitals’ bottom line severely and not lead to increased quality care.

Only 769 of more than 3,370 hospitals have avoided fines. Some hospital might have to close because of the penalities.

I have said many times that policy wonks do not know how to measure quality.

Hospitals that are flourishing are paying the CEO and other administrators millions of dollars a year in salaries.

Hospitals avoiding penalties and fines are not necessarily providing better quality care. These hospitals might treat less sick patients or more intelligent patients,

The Obamacare incentives are upside down. Punishment hardly ever works to improve quality healthcare.

Has anyone ever thought about providing incentives to patients to learn how to improve their own compliance to medical care?

In an entitlement society patients are taught to expect (entitled) to be cured without applying much effort on their own.

They are taught to be dependent on physicians and hospitals to cure them of their chronic disease.

Physicians should be the coaches. Patients are the players in the treatment of their diseases.

Obamacare’s readmission policy is all wrong. Its goal is to keep patients in a passive dependent role.

Only when government healthcare policy wonks understand that consumers of healthcare must be provided with incentives to be responsible for their healthcare and medical care decisions will America be on the way to Repairing the Healthcare System.

No one in Washington is thinking this way.

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

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President Obama Keeps Doing It

Stanley Feld M.D., FACP,MACE

President Obama is trying to avoid the press attention about  Obamacare’s continuing mess.

The insurance industry announced that insurance premiums in both the federal and state health insurance exchanges are going up to 50% in 2016. The group private markets will increase by the same percentages.

Insurance rates for 2015 were unaffordable for small businesses, and large corporations.

One church that buys insurance in the private healthcare insurance market had its rates increased 37%.

Instead of dropping insurance for their employees and paying the penalty, the church agreed to the pay the increased premiums. The church compensated for this increase in expenses by increasing church membership dues. Some members had to quit the church.

Eighty-five percent of members in Obamacare are receiving a government subsidy. A high percentage of that 85% are receiving higher subsidies than they are entitled to receive because of government lack of verification.

Eventually, when website connects with the IRS, the government will find out that people received higher subsidies than they are entitled to. The recipients will get a bill they cannot afford.

Obamacare’s reinsurance subsidies for the health insurance industries are expiring in 2016.

The insurance industry is raising insurance premiums to cover the revenue lost by not receiving the Obamacare insurance company subsidies in 2016.

President Obama opened the Obamacare reinsurance program when too few insurance companies signed up to sell insurance through the health insurance exchanges.

The reinsurance program was a subsidy to cover the healthcare insurance industry’s supposed loses.

Obamacare hoped that multiple insurance companies would sign up in order create price competition among the companies and result in lower consumer premiums.

The healthcare insurance industry did not want to sign up. The insurance companies knew there would be adverse selection for insurance consumers.

Sicker people would enroll in the federal or state Health Insurance Exchanges. These sicker people could not afford or were not eligible to buy private healthcare insurance. The participating insurance companies would be at risk to pick up these sicker and more expensive patients.

“After finding that new customers were sicker than expected, some health plans have sought increases of 10 percent to 40 percent or more.”

Obamacare healthcare insurance coverage requirements would also cause them to seek an increase in premiums.

None of these issues appear in news stories that are covering this aspect of the story.

The political spin by the Obama administration is that the Obama administration is trying to persuade states to cut back big rate increases requested by many health insurance companies for 2016.”

I predict if the insurance companies do not get their rate increases they will drop out of the healthcare insurance market.

This is exactly what the Obama administration wants. It is a de-facto victory for a single party payout system and all of its ramifications.

It will not work because the Obama administration still needs the healthcare insurance industry to process and pay the claim. The result will be a higher premium for the consumer and an increased payout to the healthcare insurance industry by the government.

The government will be required to raise taxes or increase the deficit.

Kevin J. Counihan, the chief executive of the federal insurance marketplace is trying to convenience the healthcare insurance industry to reconsider its decision.

The facts spin war is starting. Mr. Counihan said in a letter to state insurance commissioners “Recent claims data show healthier consumers.”

This is apparently not true.

Scott Keefer, a vice president of Blue Cross and Blue Shield of Minnesota, which requested rate increases averaging about 50 percent for 2016, said his company had not seen an improvement in the health status of new customers.

“Our claims experience has not slowed at all,” Mr. Keefer said. “The trend has gotten a little worse than we expected.”

I have recently shown that the Obama administration’s claim that it is bending the cost curve is fiction. The cost to the government and the direct out of pocket cost to the consumers has increased.

The government costs have not risen as quickly as predicted by some but they are rising even more now.

Another weak argument the Obama administration is using is the federal tax penalty is increasing in 2016.

The federal tax penalty for going without insurance will increase in 2016, he said, and this “should motivate a new segment of uninsured who may not have a high need for health care to enroll for coverage.”

Why should these people buy insurance when they cannot afford the premiums or the deductibles?

Two additional weak arguments are being used.

“Federal officials said, much of the pent-up demand for health care has been met because consumers who enrolled last year have received treatments they could not obtain when they were uninsured.”

There has not been a very large increase in those insured by the state and federal exchanges between 2013 and 2014 to eliminate the “pent up” demand.

“Federal officials have also told state regulators that medical inflation will be less than what many insurers assumed in calculating their rates for 2016.”

The Obama administration has told these lies over and over again.

Does the president really believe if you tell a lie over and over again it becomes the truth?

There is a much better way to deliver universal health care and spend less money.

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‘Chutzpah’- America Last Chance

Stanley Feld M.D.,FACP,MACE

Chutzpah’s definition :shameless audacity; impudence.

synonyms: audacity, cheek, guts, nerve,boldness,temerity

President Obama has Chutzpah. Why don’t the American people have CHUTZPAH?

We have many smart people in the United States. Most are busy with their daily life at work and raising a family.

They do not have the time or bandwidth to focus on the problems in our country. People do not have the time to ask the important questions.

Why doesn’t the political establishment on both sides of the aisle represent us properly?

We continue to elect politicians that do not represent the will of the people and their welfare.

Healthcare is a big problem. Its costs are unsustainable. The bureaucratic inefficiencies result in a huge waste of resources.

President Obama is methodically transforming Healthcare by destroying it. He is destroying all the independence and innovation that has been in the hallmark of the healthcare system.

He is forcing it into a government controlled healthcare system. The result will eventually be a commoditized third world healthcare system.

President Obama knows exactly what he is doing. He is doing it well.

However, healthcare is not our country’s only problem.

We can easily open our eyes and scream, “What’s It All About Alfie?”

A reader wrote and said this is our last chance to elect people who represent America’s safety, economic growth, racial harmony and prosperity for all. We must elect people who replace lawlessness with sanity.

If our government officials do not act responsibly, how can we expect our citizens to act responsibly?

A reader sent this note to me. I think it is worth passing on.

The note starts connecting the dots of all the misuse of power.

It puts the past 6 years of President Obama’s administration in perspective.


Someone please tell me, what’s wrong with
all the people that run this country.!!!! 

Both Democrats and Republicans
They Say,”We’re broke”
And can’t help our own
Veterans, Seniors,
Orphans, Etc.,?????

But, over the last several years, THEY
have provided direct cash aid to…..

Hamas – $351 M,
Libya $1.45 Billion ,
Egypt – $397 M,
Mexico – $622 M,
Russia – $380 M,
Haiti – $1.4 Billion,
Jordan – $463 M,
Kenya – $816 M,
Sudan – $870 M,
Nigeria – $456 M,
Uganda – $451 M,
Congo – $359 M,
Ethiopia – $981 M,
Pakistan – $2 Billion ,
South Africa – $566 M,
Senegal – $698 M,
Mozambique – $404 M,
Zambia – $331 M,
Kazakhstan – $304 M,
Iraq – $1.08 Billion ,
Tanzania – $554 M,

A total of $14,933,000,000
that’s 14.933 BILLIONS, of Dollars
& they all still hate us.!!! 


But, on the other hand,


Our retired seniors,
living on ‘fixed incomes’, have their
taxes raised, to send to these countries,
& also, are having medical benefits cut. 

Our own citizens receive NO aid, unless they’re the ones who
refuse to work, & have babies
for welfare payments! 

Nor do the seniors & working public
get any breaks, 

while our government
& religious organizations will pour
Hundreds of Billions Of dollar’s,
& Tons of Food,
to Foreign Countries & the illegals,
& the leeches within our borders!

A country where we have
Our brave warriors, damaged for life,
waiting in year long lines for their due,( VA Hospital System)

the elderly going without needed medication,
& the mentally ill without treatment,
& for all of us, our safety is at risk,

& YET …….
They’ll have a “Benefit Show”
For the people of Haiti, on 12 TV Stations ;
with ships & planes lining up with food,
water, tents, clothes, bedding, doctors
& medical supplies. 

Now Just Imagine, if
Our own * GOVERNMENT * gave ‘US’
the same support they give foreign countries.
Sad, isn’t it? 
Logic is dead.
Excellence is punished.
Mediocrity is rewarded.
And dependency is encouraged. 

99% of people won’t have the
‘chutzpah’ to forward this. 

WELL, I’m one of the 1% who just did .!!”

Americans are beginning to see how ineffective and screwed up our government and its bureaucracies are. We must elect a government that puts America’s priorities first.

A majority of the population is starting to see how wrong President Obama is. He has forced us to accept Obamacare. The majority of Americans neither want nor like Obamacare. The majority of Americans neither want  nor like central government control over healthcare.

President Obama is forcing us to accept a nuclear deal with Iran that is obviously not going to be honored by Iran yet they will receive billions of dollars to further their terrorist activities.

Past behavior is a predictor of future behavior if there are no deterrents

Our representatives in congress are not doing a thing about healthcare or the nuclear deal despite their promises to us at election time.

Iran has essentially told us they will not change. They have continued their military and ICBM buildup as the Obama administration dismantles America’s military.

When are Americans going to become angry enough to kick the bums out of office?

How can we force congress and the administration to express the will of the people?

President Obama knows exactly what he is doing it and how fast it should be done.

President Obama knows how to marginalize his critics with his Saul Alinsky tactics. He always comes out on top in battles that he should lose? He should lose these battles because they do not benefit the American people.

James Greene’s latest Jim’s Daily Rant is partially reproduced below with his permission.

The Rant offers a less vitriolic summary of our politicians’ (specifically President Obama) abuse of the American people and their freedoms.

The article defines TOTALITARIANISM.




Greene starts off with

American critic Irving Howe, in his essay on George Orwell’s 1984, “Orwell’s profoundest insight is that in a totalitarian world man’s life is shorn of dynamic possibilities. 

The end of life is completely predictable in its beginning, the beginning merely a manipulated preparation for the end.”

“Howe points out: “The totalitarian state assumes that—given modern technology, complete political control, the means of terror and rationalized contempt for moral tradition—anything is possible. 

Anything can be done with men, anything with their minds, with history and with words. 

Reality is no longer something to be acknowledged or experienced or even transformed; it is fabricated according to the need and will of the state…”

“Obama’s Insane Worldview”

“This is a perfect example of what Howe characterizes as totalitarianism’s “rationalized contempt for moral tradition.”

“Obama’s Black vs. White Divisiveness”

“When you ask why Obama is lashing out against U.S. police forces, you come up with the same answer as to why Obama is weakening U.S. defenses around the world: That’s his strategy.”

Where is President Obama’s instant outrage against police murders all over the country? He has been silent.  “It is because this does not fit into his strategy.”

“Obama: The Anti-Reagan”

“What President Obama wants is to impose his meaning of reality, which amounts to a reign of terror on America, resulting in worldwide and domestic chaos.”

Domestic and worldwide chaos is occurring. Terrorism is practiced on our street corners without consequences.

Americans are starting to notices despite the lack of this news in the traditional media.

It doesn’t matter whether you are a Republican, Democrat, Independent, conservative or libertarian America is slowly becoming a TOTALITARIAN state with complete central government control.

President Obama promised transformation. He has kept his word. Unfortunately americans did not understand his meaning.

He is transforming America from a constitutional Republic that provides many freedoms. Americans should be independent, responsible and undivided despite, color or creed to a people dependent completely dependent on government.

All people should realize that our government is not working well and our freedoms are disappearing. The people are becoming enslaved by central government control.

“Has the American Voter Surrendered?”

“The Obama long-range strategy is that those that come after him can preside over a docile American population that will be glad to give up its individualism and Constitutional freedoms for obedience to government in exchange for government largesse.”

In short, it’s about power over people–instituting the reign of totalitarianism Orwell and many others predicted as a possibility.”

 “Therefore, the next presidential election will not be a contest between Democrats and Republicans; it will be a contest between increased individual freedom and increased government control.”

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ACOs Are Failing

Stanley Feld M.D.,FACP,MACE

A major component of Obamacare is the development of functioning Accountable Care Organizations (ACOs). The theoretically the ACO concept is good. The practical execution of ACOs is very difficult.

The way the bureaucrats in the government wrote the rules and regulations for executing ACOs make them almost impossible to execute.

The inevitable failure of ACOs was further guaranteed by the complicated reimbursement rules created by Medicare’s bureaucrats.

The goal was to create integrated health care systems that would efficiently deliver quality medical care at a lower cost.

ACOs are one part of this Administration’s vision for improving the coordination and integration of care received by Medicare beneficiaries.

ACOs are groups of doctors, hospitals, and other health care providers that work together to give Medicare beneficiaries in Original Medicare (fee-for-service) high quality, coordinated care.

ACOs can share in any savings they generate for Medicare, if they meet specified quality targets.”

Defining quality care is a problem. Another problem is designing systems to execute quality care. To date no one has defined quality medical care correctly.

I said from the onset of the development of ACO’s that the project would fail. Many experts criticized me. They called me  a dinosaur. They said I did not understand systems of medical care.

These people did not know that I was the guy that wrote the AACE guidelines for A System of Intensive Self-Management of Type 2 Diabetes Mellitus.

The way the Obama administration has designed ACOs, they are in reality HMOs on steroids.

They shift the responsibility of the cost of medical care to physicians and not the government.

In reality the cost of quality medical care should be the patient’s responsibility. Patients should be responsible for their care and their health care dollars.

I cannot understand why physicians do not protest.

I am a big believer in systems thinking. However, it has to be a system that is well thought out and well constructed. ACOs are neither.

It is clear to me that the bureaucrats do not know anything about medical practices or hospital politics.

The Obama administration originally picked 30 healthcare systems to be ACO Pioneers. They were called Pioneer Project Goups. Nineteen of the original Pioneer Groups remain.

The Mayo Clinic and the Cleveland Clinic were included in the original group of healthcare systems. These clinics were considered the most integrated health care clinics in the country.

The Mayo Clinic and the Cleveland Clinic turned down the Obama administration’s offer. They said they were happy with their system of care. The Mayo Clinic said they would not participate because they knew they would lose money participating in the ACO project.

I have written extensively on the reasons the ACOs would fail. I invite you to read or re-read these articles so as not to be puzzled by the upcoming outcomes of failures.

“Three out of four Medicare accountable care organizations did not slow health spending enough to earn bonuses last year.”

 In 2014 there were 353 accountable care organizations approved by Obamacare.  There are potentially 2700 hospital systems eligible to develop ACOs. The 353 accountable care organizations represent only 13% facilities available to participation rate.

The hospital systems not participating either fully understood why they could not form an effective or efficient ACO with the physicians on their staff or they did not have the money to execute the system and make a profit.

President Obama’s administration has bragged that the 353 participants represent a large number. The traditional mainstream media has parroted his assertion.

The mainstream media publishes this deception to the public as if It represents facts.  It is just one more deception by the Obama administration.

Private health insurance companys’ subsidiaries are in the process of setting up ACOs. They are trying to recruit physicians to shift the financial liability to physicians from insurance companies the same way unsuccessful HMO companies tried to shift financial liabilities onto physicians in the late eighties and early nineties.

The 353 participants include hospitals, physicians’ groups and healthcare insurance company ACOS. These groups have agreed to meet Obama administration targets for quality care and decreased costs.
In 2014 only 97 ACOs earned bonuses. The money these 97 ACOs saved was a total of $833 million. The 97 hospitals shared  $422 million dollars of that total.

Let us assume it was equally distributed among the 97 systems. Let us assume each of the 97 hospital systems has 1500 beds or 97 times 1500 for a total of 145,000 beds. Four hundred twenty two million dollars divided by 145,000 beds equals $2,910 dollars a year per bed or $7.91 dollars per bed per day.

A $7.91bonus per bed per day is an awful return on investment for the work and money necessary to develop an ACO.

What is more bizarre is there are only a few quality targets measured. Some of those measurements are not an accurate measurement of quality medical care.

It also means that the remaining 258 ACOs of the 353 ACOs either lost money because they did not reach targets or they came out even.

In 2013 hospital systems that lost money on certain targets had to pay the government back. The rule was dropped by the Obama administration after the bureaucracy figured out that this was not the way to promote the development of additional ACO’s.

I think I did the math correctly.

“Bonuses are awarded under formulas that account for hospital system performance on quality targets after the first year in the program.”

The results suggest that ACOs might not be the answers to bending the cost curve just as fudging the books is not an answer to delivering the quality healthcare improvement the Obama administration is seeking to have us believe.

The delivery of high quality coordinated care is very difficult to achieve in a government-regulated system of ACOs.

I believe the Obama administration’s plan for Obamacare has failed and has been very costly.

The government should develop a consumer driven healthcare system using my Ideal Medical Savings Account.

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

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Consumers must drive the healthcare system. Consumers have to be provided with the financial incentives to drive the system.


If America continues to go in the direction Obamacare is going, the cost will bankrupt the country.

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