All items for March, 2016

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More ICD-10 Codes

March 26, 2016

inDisinformation and the healthcare system, Medicine: Healthcare System, Physician's Problems, Quality medical care measures, Stakeholder Mistrust

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Stanley Feld M.D., FACP, MACE

Everything the Obama administration’s healthcare administrators do, to increase their control over the healthcare system backfires.

The Obama administration has not admitted that the new coding system (ICD-10) has not worked out as well as it should have.

The fact that CMS has to add 5,500 codes in 2017 suggests that somehow the new system is being gamed.

The increase in codes from16,000 codes (in ICD-9) to 68,000 codes (in ICD-10) is a way to force providers to more fully document their diagnosis and treatment.

It is described as a way to improve patient care. I suspect it will be used as a weapon to decrease reimbursement.

The best way to improve patient care and decrease healthcare cost is to let the patients be responsible for their health and healthcare dollars.

A way needs to be developed to measure medical out as it relates to medical costs. These outcomes must be provided to patients.

The more codes there are the more the coding system can be gamed and abused by hospitals, physicians and other providers.

At this point the government is paying many other providers. These providers can also game the system. The increase in codes can result in a further increase in costs to the healthcare system.

Never the less the Obama administration seems to spin everything that backfires on it into a positive. The people are not accepting the spin anymore.

One example of the spin is the information paper CMS published about ICM-10.

One section is entitled;

How will my practice benefit from ICD-10?

ICD-10 provides an enhanced platform for physician practice. As of October 1, 2015, the ICD-10 coding classification became the new baseline for clinical data, clinical documentation, claims processing, and public health reporting.

The statement means physicians have to provide more documentation in order for the government and the healthcare insurance industry to have more control over physicians’ practices.

From proper observation and documentation to improved clinical documentation, progress notes, operative reports, and histories, the benefits of ICD-10 begin with enhanced clinical documentation enabling physicians to better capture patient visit details and lead to better care coordination and health outcomes.

It does not enable physicians to better capture patient visit details and lead to better care coordination and health outcome.

It enables government and the healthcare insurance industry to capture patient visit details. It does not necessarily lead to better care coordination and health outcomes.

Ultimately, better data paves the way for enhanced quality and greater effectiveness of patient care and safety. The benefits of ICD-10 will impact everything from patient care to each practice’s bottom line.

Better data might not lead to enhanced quality care or lead to better care coordination and health outcome. It can lead to more paperwork and more false data.

It also could conclude that the best physicians are the best documenters. It will not tell us which physicians have the best clinical judgment.

Reasons to prepare for ICD-10 can be broken down into four categories:

Clinical

Informs better clinical decisions as better data is documented, collected, and evaluated
Provides new insights into patients and clinical care due to greater specificity, laterality, and more detailed documentation of patient diseases
Enables patient segmentation to improve care for higher acuity patients
Improves design of protocols and clinical pathways for various health conditions
Improves tracking of illnesses and severity
Improves public health reporting and helps to track and evaluate the risk of adverse public health events
Drives greater opportunity for research, clinical trials, and epidemiological studies.
A lot of this is just word salad.

Operational

Enhances the definition of patient conditions, providing improved matching of professional resources and care teams and increasing communications between providers
Affords more targeted capital investment to meet practice needs through better specificity of patient conditions
Supports practice transition to risk-sharing models with more precise data for patients and populations.

Professional

Provides clear objective data for credentialing and privileges.
Captures more specific and objective data to support professional Maintenance of Certification reporting across specialties.
Improves specificity of measures for quality and efficiency reporting
Aids in the prevention and detection of healthcare fraud and abuse
Provides more specific data to support physician advocacy of health and public health policy

This section clearly defines the intention of the expanded ICD-10. It is an attempt to define physicians’ quality of care by computer and award or penalize physicians based on a potentially faulty definition of quality care. It could lead to quality care being defined by documentation, not by clinical judgment.

Financial

Allows better documentation of patient complexity and level of care, supporting reimbursement for care provided
Provides objective data for peer comparison and utilization benchmarking
May reduce audit risk exposure by encouraging the use of diagnosis codes with a greater degree of specificity as supported by the clinical documentation

Physicians can interpret this category as a threat to their reimbursement and their clinical judgment.

Physicians might conclude that they should do what the government tells them to do or they will lose their livelihood.

The government’s healthcare policy wonks. They are not practicing physicians. They do not understand physicians’ potential reactions. They do not consider the unintended consequences of this policy.

Once physicians understand the goal is let the government control physicians’ medical judgment there is no telling what will happen to the quality of medical care.

Quality medical care is not a science or a social science that can be managed by computer. It is a learned process by physicians integrating scientific knowledge an art of personal relationships.

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

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Obamacare Co-Op Folly

March 21, 2016

inMedicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

I apologize for spending so much time on the failure of the Obamacare Co-Ops. It is worth emphasizing because this is an example the common denominator of the many other Obamacare failures.

A reader asked me to list the 12 states that closed down and declared bankruptcy before 2016 enrollment leaving 700,000 consumers without insurance coverage.

In my last blog on Co-Ops I did not mentioned the name of the 12 states Co-Ops that went bankrupt. These state Co-Ops defaulted on their federal loans. The federal taxpayers loss was $1.2 billion dollars.

I did not list them because I predicted that all 22 state Co-Ops would go bankrupt by the end of 2016. Taxpayer’s will lose at least $2.5 billion dollars in loans for a program destined to fail from the start.

CMS has said it will regain most of the money and but has not explained how it will recover the loan losses. There were multiple reasons for the Co-Op failures.

An important reason is the disastrous business plans. The Obama administration hired Deloitte to evaluate each state’s loan application. Deloitte’s advice concerning the applications deficiencies was ignored by CMS and the HHS.

The point is the Co-Ops are ill conceived, as many of the Obamacare “innovations” are ill conceived. Once the ideology is approved the Obama administration ignores the advice from expensive hired consultants.

Deloitte Consulting evaluated the viability of the state Co-Ops by evaluating their loan applications and business plans. Deloitte expressed concerns about the now defunct 13 Co-Ops. According to the study from Republicans on the Senate Permanent Subcommittee on Investigations, the Department of Health and Human Service and CMS ignored Deloitte’s warnings.

“HHS instructed Deloitte to evaluate the proposed budgets for completeness as well as “reasonableness and cost effectiveness.” The Department told Deloitte to review the pro forma financial statements for completeness, clarity of assumptions, and consistency with each Co-OP’s business plan.

In its review, Deloitte identified numerous problems ranging from comparatively minor issues, such as omitting needed expenses, to more significant concerns, like presenting an unreasonable budget.”

2. In addition to inconsistencies, Deloitte noted that many of the Co-Ops’ budgets appeared to be unreasonable or did not align with the states own financial projections.”

This is typical of many bureaucracies in government agencies.

3. Deloitte also expressed skepticism about the risk-taking and unreasonable assumptions reflected in some of the Co-Ops’ financial projections.

4. “Each CO-OP loan applicant was required to “identify its management team, explain their qualifications and experience, and submit an organizational chart and detailed position descriptions, including the qualifications required for each position.

5.Based on its review of this portion of the CO-OP’s business plans, Deloitte consultants expressed concern over key leadership position gaps or thin industry expertise for all of the 12 failed Co-Ops.”

This observation, by Deloitte alone, should have disqualified the state Co-op from obtaining a federal loan.

The devil is always in the details. The details are so voluminous than few dig in to find the defects. The goal is only to have the paperwork done.

Deloitte had many negative comments. The loans were made despite the negative comments by the Obama administration.

Some state CO-Ops did not even list the senior management team.

6.“These failed co-ops were a costly experiment gone wrong, and real people got hurt, including the more than 700,000 Americans who lost their health plans,” Sen. Rob Portman, chairman of the subcommittee, said today at a hearing on the co-ops.”

How many more Obamacare programs are constructed to fail?

Can taxpayers trust the government to control its medical care with a single party payer system when a single portion of Obamacare is so poorly constructed and consultants ignored?

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

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The Obamacare Spin Goes On

March 14, 2016

inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

The Obama administration continues to spin the virtues of Obamacare even as it is becoming more obvious that it is a failure.

Andy Slavitt, acting head of CMS, in testimony before a congressional committee explained the failure of the Obamacare Co-Ops. In an effort to distract the committee Mr. Slavitt repeated Health Secretary Sylvia Burwell’s comment in February, after enrollment ended, that more than 90% of Americans are insured because of Obamacare. She said this was a record number of people who are insured.

The committee was not impressed. To my disappoint none of the Republican dominated committee members pointed out the insignificance of the enrollment statement.

There are 330 million people in this country. If 10% are uninsured there are still 33 million people who are uninsured.

Prior to Obamacare there was an average of 43 million people uninsured or 13% of the population. In 6 years there has only been a 3% increase in insurance coverage at an estimated cost of almost $1 trillion dollars.

Healthcare.gov insurance is even too expensive for people who have receive federal subsidy. A recent blog post said it all.

“Now I Have Insurance. But I Can’t Use It. What Am I Supposed to Do?”

Obamacare is not the successful project Secretary Burwell and the Acting Head of CMS spun to congress and the American people.

The federal loss of $1.23 billion dollars in loans to state Co-Ops alone because of the failure of 13 of the 23 Non-Profit Co-Ops is a large failure. The federal government will never be paid back for the loans to these failed Co-Ops.

The loans will probably not be charged to Obamacare. At present 2 more have failed and 6 of the remaining nine Co-Ops are under investigation and at the verge of failure.

Co-Ops enrolled 400,000 in 2014 and more than 1 million at the end of 2015 enrollment.

Twenty-two (22) of the twenty-three (23) Co-ops lost money in 2014. Only 9 reached targeted enrollment. The 13 failed Co-Ops served 14 states. They have all closed down.

718,000 enrollees lost coverage through the Co-ops that failed.

If the enrollment for 2016 is truly 1 million people these enrollees will be distributed in the remaining half of the states that lost money in 2014. These Co-ops are bound to failure in 2016 unless the federal government pours money into the remaining Co-ops.

As of March 1, 2016 according to acaSignups.net there were 12,668,585 signups for 2016.

9.6 million signed up through HC.gov. The CBO projected 21 million signup for 2016.

The Min-Med programs approved for McDonald’s and other fast food businesses and exempt form Obamacare are still allowed. These workers are essentially uninsured if they become ill. Yet the government counts these workers as being insured.

President Obama and his administration continue to deceive Congress and the American people about the success of Obamacare.

The Republican dominated congress does not challenge the Obama administration on these deceptions. They are afraid the people will react negatively to the congress.

The people are reacting to President Obama, his administration and the congress. Maybe the people are smarter than all the politicians think they are.

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

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Social Engineering

March 10, 2016

inConsumer Driven Health Care, Medicine: Healthcare System, Physician's Problems, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

Obamacare has been a failed attempt at social engineering.

As I have said previously President Obama and his administration have backed off and are continuing to back off many of the deadlines in the law.

Many of Obamacare’s new ideas are ideological utopia. Theses ideas cannot work in system that is dependent on physician judgment and interpersonal patient/physician relationships.

Social engineering’s goal is to eliminate judgment (craftsmanship) and reduce production of goods and services to a commodity production.

I believe the origin of the dysfunctional healthcare system began with government intervention over the last 60 years.

I want to start with some basic points. The delivery of medical care should be between physicians delivering medical care and surgical care to patients. Without physicians or patients there is no need for a healthcare system.

The two main participants (physicians and patients) have a large responsibility to the healthcare system in order to have good outcomes. The patients’ responsibility in the system has been constantly ignored by healthcare policy wonk.

Patients should exercise, must not become obese, do not do dangerous things that could injure themselves, don’t smoke, diligently take their recommend medicine and follow their physicians orders.

Eighty (80%) of the healthcare dollars are spent on the complications of chronic disease. Much of this expense could be avoid if patients were responsible for the care of their health and avoid the onset of chronic diseases and their complications.

At the beginning of the 20^th century the United States was growing rapidly. It was believed that our institutions could not handle this growth adequately.

Social engineering of our industries, manufacturing and political systems became the fad of the day in the early 20^th century.

What is social engineering?

“Social engineering is a discipline in social science that refers to efforts to influence particular attitudes and social behaviors on a large scale, whether by governments, media or private groups in order to produce desired characteristics in a target population.”

The discipline of social engineering attempts to manipulate a population of people by manipulation of norms and ideas using tools available to institutions whether it is a government, the media or an industry.

The goal was to modernize social systems that where outmoded in the society that existed in the late 19^th and early 20^th century in order “to achieve the intelligent management of Earth’s resources and human capital with the highest levels of freedom, prosperity, and happiness within a population.”

The obvious question is who has the authority to manipulate the behavior of billions of people?

The wrong decision-making can affect the safety and survival of literally billions of people.

In a democracy, in which the government should be by the people and for the people, the government should act as a surrogate for the people and not an authority that rules the people.

When something doesn’t work for the people, the government must change to express the will of the people.

“As a result of abuse by authoritarian regimes and other non-inclusive attempts at social engineering, the term has in cases been imbued with a negative connotation.”

In the last 60 years progressives have been enamored with social engineering. However, most of our government’s attempts at social engineering have been a failure.

Universal Health Care”, “Single Payer”, “National Health Insurance”, “Socialized Medicine” are all terms invented in an attempt to social engineer America’s healthcare system. These terms aim is to social engineer the healthcare system so that physicians’ and their patients’ relinquish their autonomy to government control for the sake of the common good.

The unspoken promise to the people is that the healthcare system will be free to the people.

Progressive’s claim that healthcare is a right! Healthcare is rather an individual’s responsibility!

Nothing is free!

Socialized medicine eliminates the need for an individual to be responsible to maintain health and to comply with treatment. The government will take care of us if we get sick.

The people have soundly rejected socialized medicine’s terms and intentions. The present government is ignoring the will of the people.

The result is a mistrust for our elected officials (establishment) and a chaotic and joke-book of candidates on both the Democratic and Republican side.

Who should determine the common good? Who should determine actual good for consumers? The obvious answer to me is the consumer and not some ideology or its attempt at social engineering.

Max Weber was a Prussian 20^th century political philosopher. He laid the foundation for modern sociology and the need for social engineering.

However Max Weber was one of the first to proclaim,

“Bureaucratic administration means fundamentally the exercise of control of institutions on the basis of knowledge. This is the feature of bureaucracy which makes it sound specifically rational.”

However, Weber also recognized the limitations of bureaucracy. He observed that the goal of a rational bureaucracy was more often elusive than realized, if it is ever realized.

In the early 20^th century Frederick Taylor was the leading proponent of scientific management, also called Taylorism. Scientific management is an extension of social engineering.

Taylorism is a theory of management that analyzes and synthesizes workflows.

Its main objective is improving economic efficiency, especially labor productivity. It was one of the earliest attempts to apply science to the engineering of processes and to management.

Taylorism includes the important parts of today’s industrial engineering and management.

“The elements of industrial engineering include analysis; synthesis; logic; rationality; empiricism; work ethic; efficiency and elimination of waste; standardization of best practices; disdain for tradition preserved merely for its own sake or to protect the social status of particular workers with particular skill sets;

It includes the transformation of craft production into mass production; and knowledge transfer between workers and from workers into tools, processes, and documentation.”

The last sentence is exactly what the Obama administration is trying to do to the healthcare system. It is trying to turn the practice and art of medicine into a commodity control by the government.

The major criticism of Taylorism had been;

“for turning the worker into an “automan” or “machine.” Due to techniques employed with scientific management, employees claim to have become overworked and were hostile to the process.”

Consumers are presently experiencing this same reaction from physicians in their response to Obamacare.

Indeed the healthcare system must become more efficient. It can become more efficient with improvements in some processes.

However, a process that causes consumers to be more responsible for their health and the treatment of their chronic diseases must accompany the improved processes.

The expensive creation of bureaucracy that measures physician behavior in inefficient ways and decides on inadequate payment leads to the hostile reaction to the process and increased inefficiency.

Consumers and not the government should drive the healthcare system.

Ronald Reagan said in a 1964 speech long before he was president, “No government ever voluntarily reduces itself in size. Government programs, once launched, never disappear. Actually, a government bureau is the nearest thing to eternal life we’ll ever see on this earth!”

The bureaucracy by ever expanding has given unelected officials the authority to social engineer the healthcare system. The public’s will is marginalized and the central government increases its control over the public’s healthcare decision making.

Obamacare is not working out very well because it is an enormous task to force physicians and consumers to participate in a program that marginalizes the two most important stakeholders, physicians and consumers.

There is little chance that Obamacare will work as intended. Consumers are not interested in becoming commodities.

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

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Obamacare Is Failing

March 4, 2016

inMedicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

The problems the Obama administration is having with Obamacare have not been in the news lately. They appear in government publications as minor policy changes or in press releases. They also appear in minor trade magazines. Little that is new has appeared in the mainstream media.

Readers of the New York Times are under the impression that Obamacare is working and is successful. The readers’ impression is that President Obama has done a great thing for the nation by getting Obamacare passed into law.

If a lie is told enough times it becomes the truth. The media is the message. All one has to do is lie to the media and the message gets through whether it is true or not.

The public’s perception of reality is not more complicated than the information fed to it whether it is true or false.

A key element in getting the message through is trust. It is my opinion, President Obama and his administration have lied to the public so much that there is a lack of trust in him and his judgment. The Republican and Democratic parties have lied to the public so much that there is a lack of trust in both parties.

It has been shown over and over again that Hillary Clinton as lied to the public. Yet, she is gathering millions of votes in her primary contests while others who have told the same lies have ended up in prison.

Black people are figuring out that the Democratic party has lied to them. The war on poverty started in 1965 and little progress has been made to eradicate poverty since then.

Why is there so much poverty and unemployment in the black community?

Why can’t black kids have a choice of public schools or charter schools in New York City? Why can’t education be a top priority?

As Leonard Cohen says, “the deck is rigged.”

I think the reason Donald Trump is running the table on votes in the Republican primaries is people do not trust politicians.

He promises to unrig the deck and make America great again. The politicians, pundits and traditional media are confused about why the public is listening to him.

The public does not trust or believe them. The public trusts Donald Trump and his promises without having objective reason.

Two significant events have occurred in the Obamacare world in recent weeks which are contributing to Obamacares further failure.

President Obama caving in on the “Cadillac tax”

As part of the budget deal President Obama agreed to sign another delay in the Cadillac tax until 2020.

An Obamacare law provision levies a hefty 40 percent tax on the most expensive employer-provided insurance plans: those costing above $10,200 for individuals and $27,500 for families.

The Obama administration predicts it will generate $87 million per year in new taxes.

“If a plan cost $11,200, it would face a $400 tax — 40 percent of the amount above the threshold.”

The Cadillac insurance premium was a 100% tax-deductible expense to an employer providing a high cost healthcare insurance policy to employees.

High paid executives and some unions or union executives enjoy this high cost insurance. President Obama’s goal has been to provide a disincentive to employers from providing this type insurance.

The Kaiser Family Foundation estimates 26 percent of current plans could get hit with the tax in 2018; Towers Watson pegs it at 42 percent. This is the result of healthcare insurance rate increases.

I think it is a trick by President Obama to discourage corporation from providing healthcare insurance for their employees. The Obama administration would like to force corporate employees to buy healthcare insurance from the federal health exchanges. When the federal health exchanges fail the government could take over everyone’s healthcare insurance and dictate the terms of that insurance.

The “Cadillac tax” was suppose to go into effect in 2017 but has been previously delayed until 2018.

Lawmakers on both sides of the aisle agreed to delay Cadillac tax implementation even longer now until 2020. Some sort of political pressure has forced President Obama to sign the amendment to Obamacare. This new law will decrease the funding for Obamacare.

The traditional media has not emphasized this event leading to Obamacare’s demise.

President Obama backs away from new Obamacare rules for 2017.

The execution of Obamacare by the Obama administration has not stabilized the healthcare insurance industry market as promised. In fact the federal exchange markets have become more chaotic. This is partly because of the inefficient bureaucratic structure and the lack of attraction to non-sick people, who would fund the federal health insurance plans. The healthcare insurance plans dictated by the federal government do not fit the needs of the people who would buy them. Instead, even though the health insurance plans are too expensive they attract people with pre-existing illnesses. These people have no choice.

The Obama administration’s typical response to fix unintended consequences is to create more rules and regulations. The new rules and regulations will lead to more unintended consequences.

The Obama administration just backed off of two big new. The Obama administration proposed tight physician and hospital network adequacy provisions and new standardized health plan options provisions.

The previous Obamacare rules and regulations resulted in the healthcare insurance industry’s adjusting to their loss of income by creating narrower networks of physicians and hospitals. Many of the healthcare exchange plans use HMOs only and narrow networks of hospitals and doctors as a way to keep premiums lower.

The result was a decrease patients’ access to care. CMS basically backed off of the strict network options it wanted to dictate. The Obama administration once again proved that it depends on the healthcare insurance industry to function. The healthcare industry is dictating the rules.

The goal of the Obama administration to standardize options was to make it easier for consumers to compare the various levels of healthcare plans offered in the health exchanges. The Obama administration also felt it was necessary to define the levels of basic benefits to make shopping for the most affordable plan easier.

The winner is the healthcare insurance industry. The loser is the Obama administration. The biggest losers are patients both in Obamacare and those who have private insurance.

As time goes on it is becoming clearer to everyone that Obamacare is not the success that President Obama and Paul Krugman are talking about.

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

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