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Why Vermont’s Single Party Payer Healthcare Plan Failed

 Stanley Feld M.D., FACP,MACE

Vermont’s single party payer healthcare plan was doomed to fail from the onset for several reasons.

Healthcare policy consultants do not understand the medical care system. The healthcare policy consultants for the Vermont healthcare system were the same consulting architects President Obama used for Obamacare.

The consultants were Harvard’s William Hsiao and MIT’s Jonathan Gruber.

William Hsiao has spent most of his academic career helping governments install healthcare systems. William Hsiao is the K.T. Li Research Professor of Economics in Department of Health Policy and Management and Department of Global Health and Population, at Harvard T.H. Chan School of Public Health.

Jonathan Gruber is a professor of economics at the Massachusetts Institute of Technology, where he has taught since 1992.[1]

He is also the director of the Health Care Program at the National Bureau of Economic Research, where he is a research associate.

Jonathan Gruber has been heavily involved in crafting public health policy.

He has been described as a key architect[2] of both the 2006 Massachusetts health care reform, sometimes referred to as “Romneycare”, and the 2010 Patient Protection and Affordable Care Act, sometimes referred to as the “ACA” and “Obamacare”.

There is little evidence that the systems he and Dr. Hsaio have built are overwhelming successful, cost effective or preserve consumer freedom of choice.

In fact, a study by NPR and Harvard’s T.Chan School of Public Health concluded that Obamacare is a complete failure.

Dr. Hsaio is on the faculty the Harvard T.Chan School of Public Health.


In a New York Times interview in 2009 Dr. Hsiao discussed the system of healthcare Reform he installed in Taiwan.

The question was:

What’s the most important lesson that Americans can learn from the Taiwanese example?

Dr. Hsiao.

You can have universal coverage and good quality health care while still managing to control costs. But you have to have a single-payer system to do it.

The Taiwan government managed to insure 98 percent of the population with a premium cost of 4.6 percent of wages.


Has your system of healthcare in Tiawan translated into better life expectancy or lower complication rates from major diseases?

Dr. Hsiao.

“There is evidence of positive health results for select diseases, like cardiovascular disease and kidney failure.”

There is no medical or financial data available to prove outcomes have improved.

“Overall, it’s really difficult to say that national health insurance has improved the aggregate health status, because mortality and life expectancy are crude measurements, not precise enough to pick up the impact of more health care.”

“That said, life expectancy is improving, and mortality is dropping. And everyone now has access to good health care”.

This is not good science. It is not even good social science. This is a biased opinion.


What are the system’s weaknesses?

Dr. Hsaio

“In the legislative process, compromises had to be made. First, the president yielded on payment reform, so Taiwan kept its fee-for-service payment system. Unfortunately, that encourages doctors and hospitals to give more treatment in order to boost their income.

“Second, the Taiwanese system doesn’t have a systematic way to monitor and improve quality of care.”

“Third, in the legislative process, they rejected a provision to adjust the premium automatically when the national health system depletes its reserves.”

“In every country, health care costs are increasing faster than wages. When that happens, the premium has to go up. But that provision wasn’t incorporated into the law. As a result, the system is running a deficit.”

“National health insurance tries to cut the fees for hospital and physician services. But eventually these fee reductions will adversely affect the quality of health care.”

President Obama was so anxious to change the healthcare system in the United States to fit his socialist ideology that he picked two professors, Dr. Hsaio of Harvard and Jonathan Gruber of MIT to be the architects of Obamacare.

Jonathan Gruber has been introduced as the ‘architect’ of the Massachusetts law and/or Obamacare”.[52]

Neither professor had scientific evidence that a single party payer system would work efficiently.

Obamacare was not working efficiently yet the progressives in Vermont hired Dr. Hsaio and Dr. Guber to be the architects for Vermont’s single party payer system.

Jonathon Gruber has turned out to be a honest about the Obama administration’s lies.

Many of the videos show him talking about ways in which he felt the ACA was misleadingly crafted or marketed in order to get the bill passed, while in some of the videos he specifically refers to American voters as ill-informed or “stupid”.

In October 2013, Gruber we said: “the bill was deliberately written “in a tortured way” to disguise the fact that it creates a system by which “healthy people pay in and sick people get money”.

Some of Americans are waking up to the fact that they cannot trust President Obama and his administration to be our surrogate. This is true not only in healthcare but in his decision making in every area of the economy and our live.

Gruber said this obfuscation was needed due to “the stupidity of the American voter” in ensuring the bill’s passage. Gruber said the bill’s inherent “lack of transparency is a huge political advantage” in selling it .[31]

 In 2010, Jonathan Gruber expressed doubts that the ACA would significantly reduce health care costs. He thought lowering costs played a major part in the way the bill was promoted by the Obama administration.[36]

President Obama said he never met Jonathan Gruber and did not think he came to the White House. President Obama forgot he hired him and paid him a $400,000 consultation fee.

In 2014, the Obama administration claimed that Gruber did not have a major role in creating the PPACA.[50]

President Obama acted irresponsibly to the public by hiring healthcare policy wonks to change America’s healthcare system without evidence for the success because their thoughts fit his ideology.

I don’t think President Obama understands he has changed the way hospitals and physicians have changed their approach to healthcare and medical care.

In my opinion, healthcare and medical care has changed for the worse.

Rich Lowry said that the videos were emblematic of “the progressive mind, which values complexity over simplicity, favors indirect taxes and impositions on the American public so their costs can be hidden, and has a dim view of the average American”.[41]

The American public eventually figures it out.

Commentator Charles Krauthammer called the first Gruber video “the ultimate vindication of the charge that Obamacare was sold on a pack of lies.”[42]

 The Vermont governor hired Dr. Hsaio and Dr. Gruber to create a single party payer system in Vermont figuring,the system would be easier in one small state than in the nation.

Vermont Governor Peter Shumlin (D.) announced that he was pulling the plug on his four-year quest to impose single-payer, government-run health care on the residents of his state.

“In my judgment,” said Shumlin at a press conference, “the potential economic disruption and risks would be too great to small businesses, working families, and the state’s economy.”

Watch out Colorado!

Why doesn’t a single party payer system work?

All of the healthcare policy wonks, especial Dr. Hsaio and Dr. Gruber, leave out the most important ingredients in a successful healthcare system.

Consumers cannot be treated as a commodity. Consumers cannot be forced to take what is given to them. The healthcare system must have a viable physician patient relationship provision.

The physician patient relationship is a big part of the therapeutic index. If treatment is to be successful patients must participate in their care.

Consumers of the healthcare system must drive the healthcare system. It must not be government or the healthcare insurance industry.

Consumers must be a the center of the healthcare system.

A system needs to be developed that puts patients in charge, not the government. Consumers must be responsible for their healthcare and their healthcare dollars.

This will motivate doctors and hospitals to compete for patients’ business.

My Ideal Medical Savings Account will provide incentives for the consumers to have a consumer driven healthcare system. This system will in turn drive hospital systems and physicians to compete for their care.

The end result will be to decrease the cost of the healthcare system and improve medical care and consumer satisfaction with the healthcare system.


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

 All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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More On Women’s Health, HRT And WHI

Stanley Feld M.D.,FACP,MACE

The Women’s Health Initiative (WHI) was published in 2002. I presented a critique of the study in 2003. I gave a lecture in different parts of the country at that time debunking its statistical significance.

No one paid attention to the statistical results. The media was the message and the message has lasted despite good data refuting the message.

My last blog reviewed the lack of statistical significance of all the conclusions of the WHI study.

I published these thoughts once before in a 2007 blog post. I was stimulated to republish my comments last week because of two excellent lectures I heard at a recent American Association of Clinical Endocrinologists (AACE) meeting reviewing the recent literature as to the value of estrogen replacement therapy in post-menopausal women.

Holly L Thacker M.D. presented “Women Getting Older-and Even Better”.

Dr. Thacker is the Director of the Center for Specialized Women’s Health at Cleveland Clinic.

  1. Mitchell Harman, M.D. presented “Hormonal Treatment of Menopausal Women: What Are The Data Telling Us (and Not Telling Us)?”

Hopefully these two presentations will help us move forward in getting to the truth about hormone replacement therapy in the post menopausal woman.

Neither presentation stated outright that the Women’s Health Initiative conclusions were invalid because of the fact that none of WHI conclusions were statistically significant.

However, several important new points were added to the discussion using the WHI’s own data. I will present the discussion.

First, I want to present an email exchange a reader had with a retired statistician about my last blog.

Mon, Jun 6, 2016,

S wrote:


The blogger writing below is a now retired endocrinologist, academician and oft critic of ObamaCare.

In his post below he takes on many of the reports that were published based upon the WHI and related.

Passing it along to you FYI owing to his assertions as presented below.

 Perhaps instructive after all.

June 6.


I sent your post on the flaws of WHI data and interpretation to a retired statistician for comments.

He applauds your evaluation and comments.  As do I.


From: R
Sent: Monday, June 06, 2016
To: S
Subject: Re: FW: Repairing the Healthcare System

 The points made are good ones.  The major point missed is that the study was done with horse piss estrogen, not human biologically identical estrogen which have been shown to produce none of the negative effects of horse derived estrogen.

None the less, the scientific criticism of the reported study are very accurate and very good.


In 2011 AZ LaCroix using the WHI’s own data analyzed the myocardial event risk. Women talking estrogen between ages 50-59 had less risk of having a myocardial infarction than women starting to take estrogen replacement therapy from age 60-69 and from age 70-79.

The WHI lumped conclusions lumps all three groups together in its analysis.

  Estrogen early Memopause results


It is well known and accepted that the incidence of myocardial disease increases in women as they age and increases in post menopause to the same incidence as males.

Estrogen slide 2

The timing hypothesis for starting estrogen therapy was proposed as a result of this new interpretation of WHI data.

The effects of HRT on CVD are dependent upon time HRT is initiated relative to menopause and/or age (the “timing hypothesis”).


The upper two curves reflect the thickness in the carotid artery tested with ultrasound in women starting to take estradiol ten years after menopause. There is not a significant difference in the increase in intimal thickness between the placebo group and the treatment group (p==.029). Significant p values are 0.05 or less (i.e. 0.001).

Whereas the lower curves where estrogen started in less than 6 years post menopause the placebo thickness increased greater than the estradiol thickness for a very significant p value of 0.007.

This data reflect the influence of estrogen on vessels when taken shortly after the onset of menopause. The result presumes the protective effect of estrogen in post-menopausal women as opposed to the conclusions of the WHI.

I believe that WHI stimulated fright that estrogen causes breast cancer has been exaggerated. Only 4% of the causes of death in women are the result of breast cancer.

It is true the WHI was published in 2002. Prior to 2002 early detection of breast cancer with mammogram and treatment with surgery and chemotherapy was prevalent. It certainly resulted in a decrease in the incidence of death from breast cancer. Today the incidence of death from breast cancer might even be lower.

There is a sense that the breast cancer death rate might be even lower if estrogen is used immediately in postmenopausal women. There has been an 80% decrease in women being treated with hormone replacement immediately post menopause.

The goal should be to lower the death rate from breast cancer to zero.

Causes of death in women

The huge death rate from cardiac disease in women easily surpasses the death rate from breast cancer.

There is evidence that estrogen replacement might serve to lower the 4% death rate from breast cancer if given appropriately as opposed to the message that estrogen raises the breast cancer death rate as the WHI concluded.

Eliminating patients with Breast Cancer genetic makers from receiving estrogen replacement would lower the death rate even further.

Estrogen only cofidcience limits

The subgroups in the WHI Estrogen only arm were analysized in 2004. Please note that all subgroups at all the diseases catagories crossed 1 and is not statistically significant. Only the incidence of stroke in the 60 – 69 group did not cross 1.

Therefore none of the subgroups except the 60-69 stroke subgroup was statistically significant. However that group did not attain a hazards ratio above 2 required for it to be statistically significant.

Importantly, the Breast Cancers subgroups all crossed 1 indicating there was no difference statistically significant between estrogen treated age groups and placebo age groups. It cannot be concluded from the WHI study that estrogen causes breast cancer.

Estrogen adjusted reative risk nurses

Colditz,in the Nurses Health study did not use nominal confidence limits as did the WHI in its conclusions. Colditz considered all of the confounding variables such as age, age of menopause, BMI, hysterectomy or normal onset of menopause, BMI, blood pressure, cholesterol level, smoking, oral contraceptive use, and family history of cardiac disease, or breast cancer.

He used adjusted confidence limits required to be used with confounding variables.

The confidence interval for the occurrence of breast cancer in nurses currently using estrogen was 0.59- 1.00 and using estrogen in the past was 0.63-1.09 both touching or crossing 1. Therefore the results were not statistically significant.

The game changer after all the evidence that the WHI data was misinterpreted was the Danish study DOPS published in the British Medical Journal in 2012.

Game changer

I have presented this data to my readers to ponder after I heard these two excellent reviews at the American Association of Clinical Endocrinologists (AACE) meeting.

I wanted to point out once again that the media is the message. The media without proper peer review of data has changed the way women are treated post-menopausal forever.

Hopefully disseminating this data will help remove some of the emotional stigma that has influence the thinking and use of estrogen replacement therapy since 2002.

It might stimulate the medical profession, the government, the malpractice legal system and women to start re-thinking their recommendations and conclusions.

This is especially true when women are living longer and estrogen therapy can alleviate some of the emotional, and physical effects women suffer in menopause when estrogen is prescribed appropriately.

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

All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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Lies About Government Spending

Stanley Feld M.D.,FACP,MACE

President Obama and the mainstream media have been bragging about how well Obamacare is working. They cite that Obamacare is bringing down government health-spending growth.

However they have not been telling the truth. They have taken numbers out of context and have spun a lie.

The evidence presented by federal actuaries is that health growth has been under 4% in the five years prior to 2014.

The Obama administration has made a big deal out of this finding. President Obama has bragged that he is bending the cost curve with Obamacare.

His statements are deceptive. It means government health spending growth has been just under 4%. It is still increasing by 4% year to year and not the usual 6%-10% increase.  

Obamacare spending for direct medical care did not go into effect until 2014. All that went into effect was increases in taxes from 2010 until 2014 and spending on the growth of the bureaucracy resulting in a 4% growth. The math had nothing to do with increased direct medical care.

According to federal actuaries, spending on all health care grew 5.5% in 2014. Actual enrollment was lower than expected enrollment in 2014.

2014 was the first year of spending on direct medical care. Healthcare spending will continue to increase in 2015 to 5.3%. The reason is spending for Obamacare took affect in 2014 and continued in 2015. The reason for the slight predicted percentage decrease for 2015 is at least two fold. Less people signed up for Obamacare in 2015 than predicted and reimbursement for physicians and hospitals decreased.

Other reasons for a government decrease in spending are consumers are paying a greater share of their medical bills and reining in their use of medical care services.

One in three Americans said they or a family member delayed medical care because of costs in 2014, according to a report late last year by survey company Gallup.”

President Obama and his administration are deceiving the American public about the success of Obamacare.

The cost to taxpayers and people who are insured has actually increased. President Obama continually tells us costs are decreasing.

The mainstream media, especially The New York Times and Paul Krugman, continually repeat the lie. If you repeat a lie enough times people begin to believe it is the truth.

A reader asked me where did the New York Times readers leave their thinking apparatus. Someone else pointed out that the New York Times readership is decreasing because the newspaper has lost its credibility.

The New York Times opinions seem to be presented without supporting evidence.

The truth is premiums are increasing, coverage is decreasing and insurance deductibles are increasing for everyone including the middle class. Access to medical treatment is decreasing. Out of pocket expenses are skyrocketing.

The deception continues unchallenged by Republicans. No one is talking about the fact that the Obama administration is lying about what is happening on the ground.

“According to a report from actuaries at the Centers for Medicare and Medicaid Services published in the journal Health Affairs. In the years through 2024, spending growth is expected to average 5.8%, peaking at 6.3% in 2020.”

The cost of healthcare to the government is going to increase further and faster than predicted by federal actuaries as a result of expanded government insurance coverage under the 2010 health law, and the ever expanding Medicare’s baby-boom beneficiaries entering Medicare age.

As technology increases and as the baby boomers enter Medicare and more expensive life-saving drugs are developed costs to the government are going to increase.

The cost of pharmaceuticals is reported to have increased by 12% last year. The deals the government makes with the pharmaceutical companies are pathetic. The prices continue to mount for the government as consumer out of pocket costs for drugs increase.

By 2024 healthcare costs to the government and consumers are projected to be over 20% of our GDP and rising at the present Obamacare rate.

Americans will be older and sicker.

There is little government focus on helping our population become motivated to become  healthier and more responsible for their health and their own healthcare as they age.

Obamacare is forcing Americans to become more dependent on the government for their healthcare needs.

Hopefully, people are noticing that government does not work and more government will be a disaster to our medical and financial health.

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Meaning and Significance Of Evidence Based Medicine

Stanley Feld M.D.,FACP, MACE

I received the following from a reader after re-publishing Medical Care Must Not Be Converted To A Commodity.

"Hello Dr. Feld,

Can I ask a question regarding voluntary Physician compliance with evidenced based care. Your thoughts 

Who sets the guidelines (and changes them) and how do we get compliance when we know it takes a LONG time for new guidelines to gain adoption?

I believe a carrot and stick approach may be necessary with more carrot and less stick.  Your thoughts?


These are three great questions. They demand an answer.

1. Can I ask a question regarding voluntary Physician compliance with evidenced based care? 

This question is very difficult to answer with our present state of knowledge.

There is no Level 1 evidence based data available to the answer question.

Level 1 is evidenced based data is defined as;

Level I: Evidence obtained from at least one properly designed randomized controlled trial

2. Who sets the guidelines (and changes them) and how do we get compliance when we know it takes a LONG time for new guidelines to gain adoption?

I believe most practicing physicians try to comply with clinical guidelines written by their specialty organization. Most specialty organizations publish guidelines.

The guidelines are taught in courses physicians are required take to obtain Continuing Medical Education (CME) credits required for medical re-licensing. Guidelines by specialty groups differ slightly reflecting each specialty organizations clinical emphasis, clinical experience and clinical judgment in addition to the available evidence based medicine.

It would be nice to be able to determine if each physician in the country was up to date in every single area of medicine and surgery.

I would also be nice to have accurate measurable criteria to judge physicians’ practices.

How do you evaluate physicians’ judgment and clinical experience with a computer program? You can not.

This is the reason physicians object to cookbook medicine and the commodization of medicine and surgery. Physicians have been trained to use clinical judgment. Clinical guidelines and algorithms are a guide to help physicians reach the best conclusion they can reach.

The problem with evidence-based medicine is that does not define quality medical care. It defines the quality of studies that are rigid protocol studies that do not honor clinical observations, experience or  judgment.

I have made this clear with my observations about the deficiencies in the USPSTF’s studies and conclusions about subclinical hypothyroidism, the PSA value or the study of osteoporosis in men over 70 years old and breast cancer screening to mention a few.

In this era of decreased funding money for clinical studies that are random, double blind controlled research studies is rare.

Observational data studies and clinical judgment studies are considered weak and invalid.

Who suffers?

Patients suffer as the government takes over more of the healthcare payment system. Government is making consumers dependent on government’s healthcare decisions.  Government relies on the advice of the USPSTF to determine the value of treatments. Many of the USPSTF conclusions are invalid in my opinion.

Rather than going through the explanation of the shortcomings in Evidence Based Medicine (EBM), on which the conclusions of the USPSTF is based, I quote the literature and will let my readers judge for themselves.  

Evidence-based medicine (EBM) is a form of medicine that aims to optimize decision-making by emphasizing the use of evidence from well designed and conducted research.

Please note that clinical judgment and observational studies are not valued.

a. Although all medicine based on science has some degree of empirical support, EBM goes further, classifying evidence by its epistemologic strength and requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations; weaker types (such as from case-control studies) can yield only weak recommendations.

In my opinion meta-analyses is invalid statistical trick. It combines studies that do not have the same design. Each included study has different numbers of patient and different statistical power along with statistical significance. Combining different study designs does not increase statistical significance overall.

 b. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians.[1]

EBM is one factor in improving medical care treatment. It should not be used exclusively in evaluating quality and paying for medical care.

Consumers of medical care are the ones that can evaluate the many factors that make up quality care. Unfortunately the government has no interest in the consumers of medical care. The focus is on decreasing the cost of care and not on improving the quality of care.

c. Use of the term rapidly expanded to include a previously described approach that emphasized the use of evidence in the design of guidelines and policies that apply to populations ("evidence-based practice policies").[2]

It has subsequently spread to describe an approach to decision-making that is used at virtually every level of health care yielding the broader term evidence-based practice.[3]

What is evidence-based practice?

Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992.

Its basic principles are that 1) all practical decisions should be made based upon research studies

2) That these research studies are to be selected and interpreted according to some specific norms characteristic for EBP.

Typically such norms disregard both theoretical and qualitative studies.

3) EBP considers quantitative studies according to a narrow set of criteria of what counts as evidence. If such a narrow set of methodological criteria are not applied, it is considered better just to speak instead of research-based practice.[1]

Students of EBM, EBP, and EBBP are starting to recognize the limitations of Evidence Based Medicine (EBM).

The methodology used by the Obama administration should be change before both healthcare and medical care are completely destroyed.

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

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When Will We Ever Learn

Stanley Feld M.D.,FACP,MACE

When will President Obama ever learn?

His ideology blinds him to the facts. I vividly remember him telling John Kerry and Barney Frank not to worry about not having a Public Option.

Barney Frank said we need a Public Option for the Affordable Care Act to work. The only way Obamacare could work is by ending up with a single-payer system.



President Obama had a clandestine “Public Option” built into Obamacare.  

Progressives believe deeply in their ideology. They do not consider past history, present reality or facts. 

All progressives have to do is look at what is happening to socialized medicine all over the developed western world.

It is failing even as some people believe it is succeeding.

 The Commonwealth Fund (a private progressive foundation) with a focus on healthcare is certain that a single party payer system is the only viable healthcare system.

The report ranked healthcare systems throughout the developed western world.  In its published ranking the National Health Service of Great Britain was considered the best medical system among the 11 of the world's mostadvanced nations, including Canada, France, Germany, Switzerland and Sweden.

 The United States came in last.

 Few have the time or patience to read the complete report or pick out the defects in the study.

Most people reads the summary. The summary in this study is not close to the evidence presented.


The Commonwealth Fund’s rankings of countries are contradicted by objective data about access and medical-care quality in these countries in peer-reviewed academic journals.

The Commonwealth Fund’s methodology is defective. Its conclusions relied heavily on subjective surveys about "perceptions and experiences of patients and physicians."

Kenneth Thorpe made an important point by examining differences in disease prevalence and treatment rates for ten of the most costly diseases between the United States and the ten European countries with a single payer system.

He used surveys of the non-institutionalized population age fifty and older. Disease prevalence and rates of medication and treatment are much higher in the United States than in these European countries.

Why would that be?

There are many reasons for this finding. The main one is the availability of care in the United States compared to the ten socialized western countries.

Another is lifestyle and incidence of obesity in the United States. Both lead to the onset of chronic disease and increased treatment.

 “Efforts to reduce the U.S. prevalence of chronic illness should remain a key policy goal.”

“Americans are diagnosed with and treated for several chronic illnesses more often than their European counterparts are.”

Americans diagnosed with heart disease receive treatment with medications and procedures more frequently than patients in Western Europe.

In the past local peer review was all that was needed along with confidence in the treating physician’s judgment. This confidence in physicians’ judgment has been destroyed by excessive media sensationalism. The real percentage of abuse is small and easily discoverable by peers and the use of the new social media.

Cancer treatment survival rates in America are far greater than the survival rates in Britain, and countries in western Europe.

The reasons for the higher cure rates are the availability of early detection and treatment.

Cancer treatment costs are high. The government should look into the reasons for this high cost and try to lower the cost.

The Commonwealth Fund’s report does not consider any of these factors.

The NHS has a waiting list of 3.2 million people for admission to the hospital. In London alone over 500,000 patients are on a waiting list for diagnosis and treatment.

A large percentage of patients triaged as urgent after being diagnosed with suspected cancer have a 62-day wait time to receive therapy.

The British Health and Social Care Act 2012 authorized the use of the small private sector of healthcare to help the NHS with its problems.

The share of NHS-funded hip and knee replacementsby private doctors increased to 19% in 2011-12, from a negligible amount in 2003-04. Each year there is an increase in NHS funded care by the private sector.

It sounds like the VA Healthcare System’s solution to its problems.

Englishmen who can afford private care and private healthcare insurance to avoid the NHS are switching to private insurance even though they have to pay $3,500 for each man, woman and child in a family into the NHS.

The single party payer system (NHS) is struggling with unsustainable costs even though we hear from progressives how great socialized medicine is in England.

The key ingredient missing in all these systems is patient responsibility for their health and their healthcare dollars. Both are powerful motivators to healthy living and detecting disease early.

There are big problems in Canada that have been undisclosed in the United States.

There were two articles in American newspapers in 2011 that applaud the Canadian system.

 Article 1. Debunking Canadian health care myths – The Denver Post                                                                                                                         

Article 2. Everything you ever wanted to know about Canadian health care in one post. Washington Post

Both articles are opinion articles and lack concrete evidence. The articles contain both misinformation and disinformation.  

The Fraser Institute is a well-respected Canadian think tank. Its research is considered accurate with a libertarian slant.

Its 2011 report contradicts the statistics in these articles on the Canadian government healthcare costs.

 Article 1. “Ten percent of Canada's GDP is spent on health care for 100 percent of the population. The U.S. spends 17 percent of its GDP but 15 percent of its population has no coverage whatsoever and millions of others have inadequate coverage. In essence, the U.S. system is considerably more expensive than Canada's.”

Article 2.  “In 2009, Canada spent 11.4 percent of its Gross Domestic Product on health care, which puts it on the slightly higher end of OECD countries.”

This is not true according to the Fraser report. Six of ten Canadian provinces are on track to spend half of their revenues on health care, according to the Frazer Institute. To be specific, in 2011, health care spending consumed 50% GDP in Canada’s two largest provinces, Ontario and Quebec.

“Total federal, provincial and territorial government health spending has grown by 8.1 percent annually, while the national GDP in Canada rose by only 6.7 percent during the same period.”

 The provincial governments have raised taxes and rationed care, while increasing patient wait times.  

“Provincial drug plans have also more often refused to pay for most of the drugs that are certified as “safe and effective” by Health Canada.”

“Unsustainable rates of growth in health care spending crowd out the resources available for other purposes including education, public safety, and economic growth-enhancing tax relief,”

One has only to think about the Obama administration’s initial propaganda and the stunning reality we are facing presently.

The VA is now asking for additional funding to clear up the disaster.

The problem is entitlements are too expensive for a government.  Entitlements do not work because governments cannot legislate behavior by directives. Individuals must be responsible for their health and healthcare dollars.

The other problem is government entitlement programs generate a large bureaucracy. The bureaucracy stimulates the development of inefficiencies and corruption. The new bureaucracy practically guarantees failure of the entitlement.

The Government can help people be responsible for their health with incentive programs.

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




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The Problem With Expert Panels

Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The design of generating these Task Force Guidelines is defective.

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

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

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

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

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

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Bureaucratic Barriers To Medical Care

Stanley Feld M.D.,FACP,MACE

The greatness of America lies in the freedoms provided by the constitution and the bill of rights.

These freedoms have stimulated Americans to be innovative, creative and inventive.

The constitution promotes individual freedoms with the federal government being held in check by the states.

Many feel that over the last 50 years as society has become more complex the power of Federal government has increased. The central government has increased its power, limited individual freedoms and increased control over the people.

The usurping of power by the Federal government seems to have accelerated over the last 5 years.  President Obama has even usurped power over the congress and might have intimidated the Supreme Court. He has decreased the effectiveness of the checks and balance system.

It could be argued that congress has given President Obama and his administration the power and control in the checks and balances system that congress is supposed to have.  

Obamacare is the best example of this. When Sarah Palin screamed about the Independent Physician Advisory Board (IPAB) being a “Death Panel” she was ridiculed as being ignorant.   

Sarah Palin’s fear was that government bureaucrats, opposed to individuals making that decision, would usurp the individuals’ right to make their own life-and-death medical decisions.

The argument for the formation of the IPAB is that this board will make rational and cost effective medical treatment decisions that individuals are incapable of making.

The IPAB will take the freedom of treatment choice out of the individual’s hands.

I contend that the ultimate goal of Obamacare is to work toward a single party payer system. The government will be the single party payer.

Since the government is the payer, the government will say it is entitled to make the best and most cost efficient treatment decisions for patients.

I have heard cries from Democrats that this is not President Obama’s intention.

The irony is that it is happening right now. CMS is issuing regulations to restrict care even before the IPAB has been formed.

“The introduction of a powerful and largely unaccountable board into health care merits special scrutiny.”

In the Affordable Care Act unfettered power to make policy decisions has been given to the Secretary of Health and Human Services by a partisan Democratic congressional vote.

Last year (2013) government bureaucrats had already usurped a life-and-death medical decision. Health and Human Services Secretary Kathleen Sebelius refused to waive the bureaucratic rules barring access to the adult lung-transplant list by 10-year old Sarah Murnaghan.

 A judge ultimately intervened and Sarah received a lifesaving transplant June 12,2013. 

There will not be recourse for patients to any IPAB decision once the IPAB is formed. Obamacare also stipulates that there "shall be no administrative or judicial review" of the board's decisions. Its members will be nearly untouchable, too.

 “But the grip of the bureaucracy will clamp much harder once the Independent Payment Advisory Board gets going in the next two years.”

“An Obamacare Board Answerable to No One.”

The IPAB is directed to:

  1. Develop detailed and specific proposals related to the Medicare program.
  2. Include proposals cutting Medicare spending below a statutorily prescribed level.
  3. Encourage to make rules "related to" Medicare.

 The IPAB will control more than a half-trillion dollars of federal spending annually. After the health insurance exchanges failure the IPAB will control the 2.7 trillion dollar healthcare industry.

Once the board acts, its decisions can be overruled only by a three-fifths supermajority in Congress. If the IPAB fails to implement cuts in spending, all of its powers are to be exercised by the HHS Secretary.

None of the Republican congressmen have made a stink about this board since Democrats shot down Sarah Palin for being so ignorant as to call the IPAB “Death Panels.”

The Obama administration is feeling its oats even before the IPAB has been formed.

CMS created its own panel to restrict access to care. The panel is called Medicare Evidence Development and Coverage Advisory Committee.

Medicare panel determined that there is not enough evidence to justify annual CT scans to detect early lung cancer in heavy smokers. The nine-member panel is against Medicare paying for the screening tool.

 A December 2013 recommendation by the U.S. Preventive Services Task Force said current or past heavy smokers ages 55 to 80 should get the scans. The two government agencies have contradicted each other.

I wonder if there was a pulmonologist or lung cancer special on either panel. Is this what we are to look forward to with the IPAB?

Under Obamacare, the U.S. Preventative Services Task Force's recommendation means that private insurers are required to cover the screening with no out-of-pocket obligation for their non-Medicare members.

The reason is Obamacare offers better insurance policies through the health insurance exchanges than insurance coverage pre Obamacare. The increased cost is passed on to the consumer in higher premiums.

This is called redistribution of wealth.

The CAT scan should typically cost $300 to $400. If the patients were responsible for the bill under present law, it might cost $1,000- $2,000 dollars.
The Medicare Evidence Development and Coverage Advisory Committee advises CMS on coverage determinations. The committee gave a lame explanation for the reason to discontinue coverage.

 The committee members said they had little confidence that the benefits of subjecting Medicare beneficiaries to regular scans outweighed the risks of the psychological trauma or unnecessary surgeries that could result from false positives.

The USPSTF made their decision based on the National Lung Screening Trial, which found a 20% reduction in deaths among current and former heavy smokers over age 55 who were screened using CT scans versus those screened using chest X-rays.

Smoking-related lung cancer kills about 130,000 Americans each year.

 The five-year overall survival rate for lung cancer patients in the U.S. is 16.8%. That low rate has been attributed to the late stage of diagnosis for the disease.

The Preventive Services Task Force estimated that as many as 20,000 lives could be saved each year if its recommendation was fully implemented.” 

Which government agency is right?

It is not enough for the Medicare panel to say, “they agreed the study was impressive in its implementation and results, they concluded it was not enough to recommend a new coverage policy to the CMS.”

Is the makeup of the committee qualified to make that judgment that will affect 20,000 patients’ lives?  Unknown.

Please note that patients (consumers) had no input on the decision. We are told that President Obama is an advocate of disease prevention.

This recommendation contradicts President Obama’s pledge to prevent the onset of disease or to catch disease early in order to cure the disease.

 The two agencies even contradict each other. Which one is right? Where is the scientific discussion?

Should Americans give up their freedom of choice to inconsistent government bureaucrats who might not be qualified to make the personal decisions for them?

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

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Facts and Misuse Of Facts


Stanley Feld M.D.,FACP,MACE

All of us try to understand
the facts and make logical decisions by synthesizing the facts.

There is a lot of
misinformation and disinformation being printed. This misinformation and
disinformation leads to the wrong conclusions because the facts are inaccurate.

 A master purveyor of this misinformation and
disinformation is Paul Krugman.

I believe his misuse of
facts is icreasing as he is subconsciously realizing his ideology is incorrect.

Here are a few examples of
disinformation or misinformation in Paul Krugman’s most recent article “Mooching
off of Medicaid”

“For there
is a lot of price-gouging in health care — a fact long known to health care
economists but documented especially graphically in a recent 
in Time magazine
. “

This is true. The margins on hospital systems
retail prices are outrageous. The margins on some discounted hospital system prices
are equally outrageous.

 There is a continuous price war between hospital
systems and payers (government and healthcare insurance companies).

 The uninsured and under insured primary stakeholders
(consumers) are stuck with these outrageous prices.

"As Steven
Brill, the article’s author, points out, individuals seeking health care can
face incredible costs, and even large private insurance companies have limited
ability to control profiteering by providers."

 This statement is not quite true. Most people
have healthcare insurance. The healthcare insurance industry and government
have negotiated discounted prices that are as low as 10% of the retail prices
published in Steven Brill’s article.

In the struggle to retain providers, private
insurance companies offer slightly higher prices than the government.

The healthcare insurance industry knows the
government’s exact reimbursement prices. The private insurance companies
provide the administrative services for the government’s healthcare plans.

Individuals not under the umbrella of these discounted
prices are liable for these high prices. As insurance premiums increase,
employers are reducing insurance coverage for employees.

The deductibles and co-pays are increasing to unaffordable
levels for everyone as an increasing numbers of employees are becoming under insured.

 “For there
is a lot of price-gouging in health care —"

 Price gouging is the result of a lack of
transparency and special deals the government and the healthcare insurance
industry makes with certain hospital systems   

does much better
at preventing price gouging , and although Mr. Brill doesn’t point this out, Medicaid — which has
greater ability to say no — seems to do better still”.

 This is false. There are fewer physicians
seeing Medicaid patients because reimbursement is very low. In fact, in most
cases physician reimbursement is lower than physician overhead. The result is
access to care for a Medicaid patient is restricted. The access to care for
private insured patients is not.

Hospitals receive a bonus for
seeing Medicaid patients. This fact is not transparent and known by few.

despite some feeble claims to the contrary, privatizing Medicaid will end up
requiring more, not less, government spending”,

Paul Krugman makes declarative statements as if
they are unequivocal evidence.

there’s overwhelming evidence that 
Medicaid is much cheaper than private insurance.”

The evidence in Paul Krugman’s quoted study is
not that overwhelming.

I reviewed this 2008 study. The demographic
difference of the Medicaid group compared to the privately insured group is
different. The difference can reveal alternate conclusions.


Jpeg demographics krugman

Note the demographic differences of the Medicaid
vs. Private insurance patients.


Heath status good 
    53.5% vs 41.2%

Mental health             17.4 % vs 

Hispanic                     23.4% vs 16.9%

African American        27.5%
vs 16.4%

White                          49% vs 66%

Employed                   48% vs 74.6%

No hi school degree   36.7% vs 17.2%

Married                        33.6% vs 51.7%

Income less than poverty 62.3% vs 22.2%


An alternate conclusion could be that it is too
difficult for Medicaid patients to find a physician. Medicaid patients are more
poorly educated. The do not seek physicians’ help compared to the privately
insured group. Medicaid patients cannot afford the minimal out of pocket

Jpeg 2 costs


To my amazement the unadjusted annual per person
Medicaid spending was higher in this article for the Medicaid insured group
than the privately insured group by $1000.  

Paul Krugman states Medicare
and Medicaid have lower administrative costs.

this reflects lower administrative costs, because Medicaid neither advertises
nor spends money trying to avoid covering people”.

 He goes on to say.

 “But a lot
of it reflects the government’s bargaining power, its ability to prevent price
gouging by hospitals, drug companies and other parts of the medical-industrial

The government does have
bargaining power. However reimbursement to physicians is so low that it is
difficult for Medicaid patients to find a physician.

This could be a reason
Medicaid costs are lower than privately insured patients with a high school
education and a job.

Acute care hospitals have a
10% Medicaid threshold. They can also be eligible for incentive pay.

 In addition, to be eligible to receive a
Medicaid EHR incentive payment,
acute care hospitals must also meet a 10
percent Medicaid patient volume threshold.”

Krugman and others conclude,

Our nation cannot control runaway medical spending without
fundamentally changing how physicians are paid.”

Physicians receive only 9% of healthcare
dollars spent. The real facts are physicians write orders for the inflated services
of the hospital systems without receiving financial benefit. In fact, the
government restricts physician participation. Physicians’ reimbursement
decreases yearly.

It is very easy to draw the
wrong conclusions when relying on inaccurate facts from so called experts.

The real challenge is to
dig down and get the correct facts.

This is not done because
ideology, non-transparency and bias stand in the way. This contributes to the
healthcare system becoming more dysfunctional and costly each year.

 Healthcare policy errors are made because
policy is made using incorrect facts.

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

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Actions Contradicts Goals


Stanley Feld M.D.,FACP,MACE

promise of Obamacare is to deliver quality medical care at an affordable price.
Prevention has been emphasized. Prevention will avoid costly complications of a

The talk about prevention is excellent. The healthcare
policy action falls short of the promise.

Despite strong efforts by the International Society
for Clinical Densitometry
and other sister societies in the Fracture Prevention
Coalition, a provision to increase Medicare payments for DXA was not included
in the fiscal cliff legislation.

Congress adopted the American Taxpayer Relief
Act of 2012, HR 8, on January 1, 2013. The bill included a number of other
provisions affecting Medicare payments to physicians that have caused disappointment. The
bill did not include the need to incentivize the use of bone density for the
early diagnosis of osteoporosis.

Below is
a summary of how the various Medicare provisions were resolved in the act and
the bottom line for DXA:

1.  The new law blocks the 27% Medicare physician payment cut resulting
from the Sustainable Growth Rate (SGR) formula, freezing
Medicare payments at the 2012 level through calendar year 2013.

2.  The automatic  "sequestration" cuts that would also
have reduced Medicare physician payments by another 2% are postponed
for two months until 3/1/12013.  

3.  The bill authorizes cuts to reimbursement for advanced
imagining services
such as MRI and CT. These cuts do NOT apply
to DXA,
 which is not considered an advanced imaging service.

As a practical matter, the new payment rate for DXA in the office setting
dropped on 1/1/2013 from a national average of $56 to $50. 

I have written about the definition of quality medical care for osteoporosis.

Osteoporosis can be diagnosed early by bone densitometry (DXA). Osteoporosis
is a progressive disease.



Discouraging the use of DXA is not a step in the right direction for preventing
costly complications.

Osteoporosis affects the spine (vertebral column). It is initially manifested
by a decrease in bone density as determined by DXA. As osteoporosis progresses
patients develop compression fractures. Some compression fractures are painful
and some are not.

Osteoporosis 4


Patients lose height and develop a stooped posture.

Osteoporosis 3

The change in patients’ posture causes a change in the patients’ center
of gravity. The change in the center of gravity causes a change patients’
ability to balance herself against a fall.

If patients with osteoporosis fall they can put torsion on their hips.
The bone in the hip is thinned by the long process of developing osteoporosis.
Their hips can fracture.


The mortality rate after a hip fracture is more than 20%. The morbidity rate
post- op is 40-50%. Very few patients return to having a normal quality of

Patients may be forced to live in nursing homes.

If we look at elderly people around us we will notice that as many as 60%
of people over 70 years old have lost height and are have stooped posture. They
have osteoporosis.

Early osteoporosis starts manifesting itself at about 50 years in women
and 70 years old in men.   

Modern medicine can prevent the onset of osteoporotic fractures. Modern
medicine can also prevent further fracture by treating women and men after they
have developed osteoporotic fractures.

Preventing hip fractures would save the healthcare system billions of
dollars a year in healthcare expenditures. Prevention of further fractures
would also increase the quality of life in elderly osteoporotic patients.

Much has been written about the IPAB (Independent Physician Advisory
I have written about the
potential defects in the structure of this board and the defects and
functioning of its existing precursor the USPSTF (United States Preventative Services
Task Force).

The USPSTF recommendations are created from its review of the published
literature. Most of the committee members are non-specialists.  They do not have medical experience in
treating osteoporosis. The committee ignores the consideration of the natural
history of the disease.

Yet, the USPSTF recommendations have resulted in a yearly decrease in the
reimbursement by both private insurers and Medicare for bone densitometry (DXA).

In some cases private insurers and Medicare do not pay. This is the way
to restrict access to care and devalue physician' judgment.

Physicians have not done a good
job detecting and treating osteoporosis. The decrease in DXA reimbursement will
further decrease physicians’ interest in treating osteoporosis preventively.

A small short-term cost savings will result in increased long-term expenditures.
The result will be an increase in cost to the healthcare system.

This is the contradiction in Obamacare’s promise of prevention.

Prevention is the key to healthcare savings.

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