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MEDICAL TUESDAY . NET |
NEWSLETTER |
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Community For Better Health Care |
Vol XII, No 11, Feb, 2014 |
In This Issue:
1. Featured Article: : POTOMAC WATCH
2. In the News: What Doctors Can Learn From Business Leaders - Forbes
3. International Medicine: Health Care Reform: Do Other Countries Have the Answers?
4. Medicare: Uses two obsolete models for coverage.
5. Medical Gluttony: ICD 10 replacing ICD 9 codes on October 1, 2015
7. Overheard in the Medical Staff Lounge: Benghazi
8. Voices of Medicine: A Doctor Leaving Solo Practice
9. The Bookshelf: What Doctors Feel: How Emotions Affect the Practice of Medicine,
10. Hippocrates & His Kin: Telehealth
11. Restoring Accountability in Medicine, Government and Society
12. Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .
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The Annual World Health Care Congress
In April, the most forward-thinking health insurance, employer, hospital and health system executives and top health care thought leaders will come together to discuss transformative trends such as consolidation, transparency , quality metrics, engagement and procedural costs, payment model innovations.
As the national leadership forum to transform health care costs and quality, the 11th Annual World Health Care Congress www.worldhealthcarecongress.com drills down to find solutions to the challenges and issues facing health care executives in an unprecedented, peer-driven forum of open discussion and debate.
SEVEN dedicated, educational Summits provide focused presentations, along with interactive discussion on emerging trends and solutions. Join many organizations already sending their executive teams to cover all seven summits that include: www.worldhealthcarecongress.com
· Health Insurer and Payer Summit for VP, SVP, and C-Level Executives
· Health Reform & Policy Summit on Exchanges, Duals, Medicaid, & Medicare
· Network & Contract Management Summit for Providers & Insures
· Hospital, Health System & Physician Executive Summit for VP, SVP, C-Level Executives
· Health Information & Technology Summit for Insurers & Providers
· Business of Women’s Health Summit for Provider Marketing, Sales, & Strategy Executives
· Benefits, HR, & Wellness Executive Summit on Improving Employee Engagement, Health, & Wellness
These Summits take place April 7-9, 2014, at the 11th Annual World Health Care Congress (WHCC) in National Harbor, Maryland – the only health care meeting that simultaneously convenes all stakeholders to share global strategies and offers targeted summits focused on each health care sector. Please take a moment to download the printable agenda (PDF).
The 12th Annual World Health Care Congress will take place on March 23-25, 2015 at the Marriott Wardman Park in Washington, DC. Please check the website at least monthly to keep apprised of the updates.
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1. Featured Article: POTOMAC WATCH
Strassel: The IRS Scandal Started at the Top | WSJ
Was the White House involved in the IRS's targeting of conservatives? No investigation needed to answer that one. Of course it was.
President Obama and Co. are in full deniability mode, noting that the IRS is an "independent" agency and that they knew nothing about its abuse. The media and Congress are sleuthing for some hint that Mr. Obama picked up the phone and sicced the tax dogs on his enemies.
But that's not how things work in post-Watergate Washington. Mr. Obama didn't need to pick up the phone. All he needed to do was exactly what he did do, in full view, for three years: Publicly suggest that conservative political groups were engaged in nefarious deeds; publicly call out by name political opponents whom he'd like to see harassed; and publicly have his party pressure the IRS to take action. Read more . . .
Mr. Obama now professes shock and outrage that bureaucrats at the IRS did exactly what the president of the United States said was the right and honorable thing to do. "He put a target on our backs, and he's now going to blame the people who are shooting at us?" asks Idaho businessman and longtime Republican donor Frank VanderSloot.
Mr. VanderSloot is the Obama target who in 2011 made a sizable donation to a group supporting Mitt Romney. In April 2012, an Obama campaign website named and slurred eight Romney donors. It tarred Mr. VanderSloot as a "wealthy individual" with a "less-than-reputable record." Other donors were described as having been "on the wrong side of the law."
This was the Obama version of the phone call—put out to every government investigator (and liberal activist) in the land.
Twelve days later, a man working for a political opposition-research firm called an Idaho courthouse for Mr. VanderSloot's divorce records. In June, the IRS informed Mr. VanderSloot and his wife of an audit of two years of their taxes. In July, the Department of Labor informed him of an audit of the guest workers on his Idaho cattle ranch. In September, the IRS informed him of a second audit, of one of his businesses. Mr. VanderSloot, who had never been audited before, was subject to three in the four months after Mr. Obama teed him up for such scrutiny.
The last of these audits was only concluded in recent weeks. Not one resulted in a fine or penalty. But Mr. VanderSloot has been waiting more than 20 months for a sizable refund and estimates his legal bills are $80,000. That figure doesn't account for what the president's vilification has done to his business and reputation.
The Obama call for scrutiny wasn't a mistake; it was the president's strategy—one pursued throughout 2012. The way to limit Romney money was to intimidate donors from giving. Donate, and the president would at best tie you to Big Oil or Wall Street, at worst put your name in bold, and flag you as "less than reputable" to everyone who worked for him: the IRS, the SEC, the Justice Department. The president didn't need a telephone; he had a megaphone.
The same threat was made to conservative groups that might dare play in the election. As early as January 2010, Mr. Obama would, in his state of the union address, cast aspersions on the Supreme Court's Citizens United ruling, claiming that it "reversed a century of law to open the floodgates for special interests" (read conservative groups).
The president derided "tea baggers." Vice President Joe Biden compared them to "terrorists." In more than a dozen speeches Mr. Obama raised the specter that these groups represented nefarious interests that were perverting elections. "Nobody knows who's paying for these ads," he warned. "We don't know where this money is coming from," he intoned. . .
The IRS is easy to demonize, but it doesn't exist in a vacuum. It got its heading from a president, and his party, who did in fact send it orders—openly, for the world to see. In his Tuesday press grilling, no question agitated White House Press Secretary Jay Carney more than the one that got to the heart of the matter: Given the president's "animosity" toward Citizens United, might he have "appreciated or wanted the IRS to be looking and scrutinizing those . . ." Mr. Carney cut off the reporter with "That's a preposterous assertion."
Preposterous because, according to Mr. Obama, he is "outraged" and "angry" that the IRS looked into the very groups and individuals that he spent years claiming were shady, undemocratic, even law breaking. After all, he expects the IRS to "operate with absolute integrity." Even when he does not.
Read the entire article in the WSJ . . .
A version of this article appeared May 17, 2013, on page A13 in the U.S. edition of The Wall Street Journal, with the headline: The IRS Scandal Started at the Top.
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2. In the News: What Doctors Can Learn From Business Leaders - Forbes
Physicians of the future will require a very different skill set and a lot more creativity.
The first time I set foot on my medical school campus, I realized I would have to check my creativity at the door. For the majority of medical students and residents in training today, that experience remains unchanged.
The goal of medical education is to teach aspiring doctors “the right way” to provide medical care. For most patients – and for many physicians – there is comfort in the definitive answers doctors are taught to provide. But the world is changing.
Knowledge creation is speeding up and medical problems are becoming more complex. Physicians of the future will require a very different skill set and a lot more creativity. Read more . . .
To better understand these needs, let’s compare medical education to the business school approach. I have the privilege to teach at both the Stanford School of Medicine and the Stanford Graduate School of Business. These two schools are very close in geographic proximity, but their cultures are worlds apart.
Medical students learn by rote – memorization based on repetition. But for business students, education happens through case study, analysis and discussion.
In business school, stories about a particular company or leader force students to analyze a dilemma and provide their own solutions. Diversity of thought is valued and back and forth discussions are common. Students point to their own prior experiences and knowledge as the basis for their claims. They’re challenged by classmates to defend their solutions – and there is rarely just one right solution.
The class I teach in the business school, “Leading Strategic Change in the Healthcare Industry,” encourages students to think big and without boundaries. I spend minimal time presenting students with “the facts.” Students can read about those on their own time. Instead, students push each other to develop new ideas that could transform the health care industry.
Business students understand that the entrepreneurial path is entirely merit based. Only knowledge, hard work and creativity matter. Failure is accepted and even embraced. The heroic stories are often about people who founded several startups that went bankrupt before creating a successful one. That’s how industry-changing companies like Nike, Sun Microsystems and StubHub were formed.
Medical school couldn’t be more different. The learning process during the first two years predominantly involves memorization. One day, students memorize the bones of the wrist. The next day, they memorize the steps in the Krebs cycle. There is a solid rationale for this. Medical students need this information to provide the best care for patients. No one would be comfortable with a beginning surgeon who decides to employ a new, “creative” surgical approach that hadn’t been tested.
But the singular focus of this instruction model inhibits alternative thinking. And the hierarchical system of medical educations ensures that yesterday’s truths remain tomorrow’s answers. Failure is not tolerated, creativity is discouraged and aspiring doctors are taught to protect themselves by accepting the wisdom handed down by their professors. Medical students know they can’t go wrong by adhering to “community standards.”
The process by which professors teach medicine stifles creativity. Decades after their schooling, doctors are influenced as much by their institution as by advances in their field of specialty. Worse, this process stifles the innovative spirit required to transform health care. It is no wonder few physicians are comfortable “thinking outside the box.” . . . .
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3. International Medicine: Health Care Reform: Do Other Countries Have the Answers?
John C. Goodman | National Center for Policy Analysis
Linda Gorman | Independence Institute
Devon Herrick | National Center for Policy Analysis
Robert M. Sade | Department of Surgery and Institute of Human Values in Health Care,
Medical University of South Carolina
Many arguments for the superiority of other health care systems have been repeated often: the United States spends more than any other country, but its health outcomes are often worse. Whereas no one is ever denied care because of an inability to pay in countries with universal coverage, as many as 18,000 people in the U.S. die each year because they are uninsured and more than half of all bankruptcies are caused by medical debts. Also, other countries avoid our high administrative costs.
Yet these and other assertions are debatable. Some are demonstrably false. Read more . . .
The health care systems of all developed countries face three unrelenting problems: rising costs, inadequate quality, and incomplete access to care. Much analysis published in medical journals suggests that other countries have found superior solutions to these problems.
This conclusion is at odds with economic research that is published in journals physicians seldom read, using methodologies that are unfamiliar to physicians. In this essay, we attempt to shed light on topics frequently discussed in proposals for health care reform, drawing on the relevant medical and economics literature.
Does the United States Spend Too Much on Health Care?
International statistics show that 2005 United States (US) per capita health care spending was 2.3 times greater than the median Organization for Economic Cooperation and Development (OECD) country ($6,401 vs. $2,759, based on purchasing power parity) and 1.5 times larger than Norway, the country that followed Luxembourg in the spending ranking.2 However, normal market forces have been so suppressed throughout the developed world that purchasers rarely see a real price for any medical service. As a result, summing over all transactions produces aggregate numbers in which one can have little confidence. In addition, other countries more aggressively disguise costs, especially by suppressing provider incomes.
Economists have long known that international health care spending comparisons are fraught with potential error. Even for uncomplicated dental fillings, reimbursement data underestimate total costs by 50% in nine European countries.3 Countries account for long term care and out-of-pocket spending differently. The accounting treatment of overhead and capital costs also varies.4 An OECD project to harmonize national accounting methods began in 2000, but even when methods are harmonized, the choice of a price adjustment method can alter hospital cost estimates by as much as 400%. The US compares more favorably when real resources are measured rather than monetary accounts. Per capita, the US uses fewer physicians, nurses, hospital beds, physician visits, and hospitals days than the median OECD country.
Even taking the monetary totals at their face value, the US has been neither worse nor better than the rest of the developed world at controlling expenditure growth. The average annual rate of growth of real per capita US health care spending is slightly below OECD average over the last decade (3.7% vs. 3.8%), and over the past four decades (4.4% vs. 4.5%).7 Despite common perceptions, a country’s financing method—public vs. private financing, general revenue vs. payroll taxes, third-party vs. out-of-pocket spending—is unrelated to its ability to control spending.
For the US, the practical question is, can the adoption of another country’s health care system offer a reasonable chance of improving US private sector methods? An answer in the negative is suggested by a comparison of the British National Health Service and California’s Kaiser Permanente found that Kaiser provided more comprehensive and convenient primary care and more rapid access to specialists for roughly the same cost.
Finally, international spending comparisons typically ignore costs generated by limits on supply. In 2002-2004, dialysis patients waited 16 days for permanent blood vessel access in the US, 20 days in Europe, and 62 days in Canada.10 Waiting for care has economic costs in terms of sick pay and lost productivity, as well as negative health consequences. In the late 1990s, an estimated 5 to 10% of English waiting list patients were on sick leave. Norway is trying to reduce waiting times for patients “in order to reduce the cost of sickness benefits.” Finland calculates that the cost of waiting (sickness benefits, medicines, and social welfare expenses) can exceed the cost of treatment.
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Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.
--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791
http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html
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4. Medicare: Uses two obsolete models for coverage.
NCPA – Goodman, et. al.
The modern era has inherited two models of health insurance: the fee-forservice model and the HMO model. Neither is appropriate to the Information Age.
Both models assume that (1) the amount of sickness is limited and largely outside the control of the insureds, (2) methods of treating illness are limited and well defined, and (3) because of patient ignorance and asymmetry of information, treatment decisions will always be filtered by physicians, based on their own knowledge and experience or clinical practice guidelines. Read more . . .
However, an explosion of technological innovation and the rapid diffusion of knowledge about the potential of medical science to diagnose and treat disease have rendered these assumptions obsolete. In this chapter, we briefly outline the type of insurance we believe would emerge if we rely on markets, rather than regulators, to solve our problems.
WHY TECHNOLOGICAL CHANGE AND THE DIFFUSION OF KNOWLEDGE HAVE MADE
TRADITIONAL HEALTH INSURANCE MODELS OBSOLETE
Although the HMO model is often viewed as the more contemporary, it is actually the less compatible with the changes the medical marketplace is undergoing. The traditional HMO model is fundamentally based on patient ignorance. The basic idea is a simple one: make health care free at the point of consumption and control costs by having physicians ration care, eliminating options that are judged “unnecessary” or at least not “cost effective.”
But this model works only as long as patients are willing to accept their doctor’s opinion. And that only works as long as patients are unaware of other (possibly more expensive) options.
As we argued in the Introduction, we could spend our entire gross domestic product on health care in useful ways. In fact, we could probably spend the entire GDP on diagnostic tests alone—without ever treating a real disease.
The information reality is that patients are becoming as informed as their doctors—not about how to practice medicine, but about how the practice of medicine can benefit them. Combine the potential of modern medicine to benefit patients with a general awareness of these benefits and zero out-of- pocket payments, and the HMO model is simply courting disaster. The fee-for-service model is only a slight improvement. It tries to control demand by introducing deductibles and copays. But even it offers strong incentives for patients to over consume health care.
Some believe that managed care can solve these problems. They are wrong. Imagine grocery insurance that allows you to buy all the groceries you need; but as you stroll down the supermarket aisle, you are confronted with a team of bureaucrats, prepared to argue over your every purchase.
Would anyone want to buy such a policy? Traditional health insurance isn’t designed to work much better.
Stay tuned . . .
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Government Medicare is not the solution to our problems, it is the problem.
- Ronald Reagan
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5. Medical Gluttony: ICD 10 replacing ICD 9 codes on October 1, 2015
International Classification of Diseases
Using numbered codes for diagnosis make cataloging disease and coding the cause of death easier and more accurate. These are the ICD codes (International Classification of Diseases). ICD 1 began in 1900 and the current ICD 9 is scheduled to be replaced by the ICD 10 in October 2015. The magnitude of the changes can be seen in the ICD 9 having about 16,000 diagnostic codes and the ICD 10 will have about 68,000 diagnostic codes. This was to be effective in October 2014. Because insurance companies, medical billers for large medical groups could not meet the deadline, Obamacare delayed the implementation to October 2015. The possibility for error has increased dramatically. Errors in coding can be interpreted as fraud, especially if there is a financial incentive, and can be prosecuted and lead to stiff fines or sanctions. Hence, the one year delay has added an additional year of practice for many physicians and surgeons who will close their offices on the date of implementation. Read more . . .
When he was reviewed, as he faced the medical reviewer, a US attorney, and a peace officer, he was told that he used the wrong CPT codes and therefore, his reimbursement was greater that it should have been. He stated that he did not understand the new codes and left it to his staff to figure out which to use and he continued to do the same amount of work and continue the same charges he had used prior to the code changes.
He was then asked if he understood the codes after their explanation and he said “yes” and he was sorry and would not do that again. According to this physician he was then asked to sign an agreement that he indeed had used the wrong codes and would use the correct codes in the future. As he explained it to me some two or three later, he signed the admission of having used the wrong codes, and was promptly handcuff by the officer, and led off to jail. He spent the next 22 months in prison. Although he was relatively young, he should have been able to practice for another 20 or 30 years, except now as a felon, he lost his license, his home, and all his assets to attorney’s fees.
He did not think it was gluttony since his charges and work were the same, but the FEDS did. And he did time, is considered a felon, and no longer is a physician and no longer can vote.
Some physicians felt he did nothing wrong, he charged his usual and customary fee for his service, both before and after the code changes, did not commit fraud, but still became a government manufactured white crime criminal losing at least a half million dollars his father invested in his education and ended up as a day laborer.
Tune in next month for a continuation of coding in Section V.
So if you’re near the time to close your practice, seriously consider closing it on Oct 1, 2015.
I will be closing mine on the date that ICD 10 is implemented.
I don’t want to spend the last decade of my life in prison.
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Medical Gluttony thrives in Government and Health Insurance Programs.
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6. Medical Myths: Cigarettes
The Economist | From the print edition | Jan 11th 2014
It was the report that showed, without a whiff of doubt, that cigarettes kill. On January 11th 1964—a Saturday, so to not roil the stockmarket—Surgeon-General Luther Terry released a 387-page document entitled “Smoking and Health”. Ten scientists (all men; half smokers) analysed 7,000 studies to assess the effects of tobacco on the human body. Its conclusions were incendiary. “Cigarette smoking is causally related to lung cancer in men,” it said. (“The data for women,” it added, “point in the same direction.”) Read more . . .
The report clearly showed how smokers died younger (see chart 1). A year later, Congress required health warnings on every packet. Public understanding of the risks of smoking changed even faster. Ads in the 1950s had claimed that tobacco was good for you; after the report millions of Americans quit puffing. In the past 50 years cigarette consumption per adult has fallen by 72% (see chart 2). The report called smoking a habit, not an addiction. But apart from that, it hit the coffin nail on the head. Read the entire article in The Economist, subscription required . . .
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Medical Myths are hard to repudiate . . . sometimes at great cost
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7. Overheard in the Medical Staff Lounge: Benghazi
Dr. Rosen: A Retired Air Force Col told me in my private office the real story of Benghazi.
Dr. Edwards: The Benghazi story has really been hitting the news recently.
Dr. Milton: I wonder why this sudden interest is surfacing again. Read more . . .
Dr. Ruth: Aren’t they going after our Secretary of State?
Dr. Edwards: Going after? Or just trying to get at the truth as to whether she was derelict in her duties. This would give us some indication whether she was fit for higher office.
Dr. Rosen: Did you know that the White House has a Diarist?
Dr. Yancy: Is this a replay of the Nixon tapes? He wanted every word recorded to make the most complete and authentic record of a presidency ever?
Dr. Michelle: Those tapes did leave the Nixon White House and Nixon left the Office of the Presidency. But these records of the Obama White House would never leave the White House. How could they?
Dr. Edwards: There was a reporter who stated that someone had acquired a copy of the Diary. The President allegedly was in the Situation room on September 11, 2012, when there was a call about 10 PM. It was reported as being to or from the Secretary of State while our Diplomat in Libya was being sodomized by the attacking Muslims.
Dr. Rosen: Although we had jet aircraft on alert within one hour of Benghazi, the President and Secretary of State felt this assault on our Ambassador was retaliation for the anti-Muslim film that was shown that the Muslims felt was offensive.
Dr. Edwards: The Secretary of State felt this was an expected reaction to the film and it was probably best to low key this as she signed off and the president left for a political engagement.
Dr. Dave: Didn’t they realize that this was on the Anniversary of 9-11-01? Shouldn’t that have set off an alert like other anniversaries of 9-11-01 did?
Dr. Kaleb: Isn’t it criminal on the President’s part not to protect an official representative of his government?
Dr. Dave: Well, isn’t it criminal on the part of our Secretary of State to brush this off as our being offensive to Muslims and their response was appropriate?
Dr. Michelle: How can gang sodomizing ever be appropriate?
Dr. Edwards: After being in the situation room monitoring our international Ambassador being sequentially and repeatedly sodomized by the 50 or so Muslim intruders, could the President be so cold and non-caring that he could leave the situation room for an election debate?
Dr. Rosen: My ranking retired military officer stated that an estimated 50 Muslims sodomized Mr. Christopher repeatedly until he was near dead and then shot him so he wouldn’t suffer any more.
Dr. Ruth: I can’t even think they were that sensitive to his condition or show any compassion to his suffering.
Dr. Michelle: I can’t even think that our Secretary of State would be so insensitive to such cruelty. How could anyone ever think of voting for this incompetent inhumane woman for President?
Dr. Rosen: Don’t you think she feels so aloof from the average citizen that she feels she can masquerade herself as sensitive, caring person fit for public office?
Dr. Michelle: She’s not running for New York Senator, but for the Presidency of the United States of America. Doesn’t that require a higher ethical standard?
Dr. Rosen: I would certainly hope so.
Dr. Dave: And if she won, wouldn’t that tell the world we’re no better than the Muslim attackers and anal rapists?
Dr. Rosen: What is this country sinking to?
Dr. Edwards: When did criminal behavior in the civilized world become acceptable behavior?
Dr. Rosen: Maybe the world is getting less civilized.
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The Staff Lounge Is Where Unfiltered Opinions Are Heard.
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8. Voices of Medicine: A Review of Local and Regional Medical Journals
A Doctor Leaving Solo Practice
by Marsha McKay DO
I am one of the docs who decided that medicine is not fun anymore, and more importantly is no longer tolerable with all the documentation, coding, referrals, prior authorizations, begging insurance companies to “let me” prescribe necessary medications and so forth. I can’t practice medicine anymore as an Authentic Doctor so I closed my private solo rural practice five days ago and will now just work 8 hours a week in small county jails. I am tired of spending my days clicking templates on an EMR so that if I get audited I don’t have to go bankrupt paying back Medicare or being accused of fraud when I just forgot to document that someone has a gun in their house or doesn’t wear their seatbelt. I did the EMR incentive program for a year, got my $14,000 and then realized it was a loser financially and time wise and added nothing to good patient care. Read more . . . Ditched the program the next year. Then it was time to cope with ICD 10, ACO’s, patient centered medical home, an electronic health record at the local hospital which is completely unusable and adds hours to hospital work.
I really loved my patients, my little office and wonderful staff but I am completely exhausted and done with the struggle of trying to be a good doctor when the forces out there seem to be determined to wear me down. So now about 1500 people have to find a new doctor and I will retire from active family practice at the age of 59. Pretty stupid waste of my training and compassion to be done so early. I am also tired of being perceived as the rich greedy doctor who only wants to make money and is the source of all the health care problems in this country. I am anything but that. Life is too short to work so hard, sacrifice being with family and friends and spend all my time servicing the insurance industry.
I’m not tired of being a physician, I’m just done with all the unnecessary garbage that comes along with it. I agree that doctors are wimps and in our defense, we are just too busy most of the time to get organized and do something about this mess. Most of us are just trying to do some good in a complicated world. Now I’m going to take care of myself, my family and have a real life. Yahoo!
Read the original in Authentic Medicine. . .
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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about
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9. Book Review: What Doctors Feel: How Emotions Affect the Practice of Medicine,
by Danielle Ofri, MD
Sonoma Medicine | The magazine of the Sonoma County Medical Association
CURRENT BOOKS: Hoping for More: a review by Deborah Donlon, MD
It seems the American public is yearning to figure out what makes doctors tick. First came How Doctors Think (2008) by Dr. Jerome Groopman, followed by What Doctors Feel (2013) by Dr. Danielle Ofri. According to Amazon.com, these two books are “frequently bought together.” They represent the ying and the yang of the physician psyche, one a guide to how our minds work, and the other a road map to our innermost feelings. From a patient’s perspective, there should be some powerful insights offered here. Based on the coordinating titles, one wonders if Drs. Groopman and Ofri got together over coffee one morning to decide who should publish first. His quote graces the cover of her book, endorsing it as the place “where science and the soul meet.” Read more . . .
Dr. Ofri has an MD and a PhD, and she completed a residency in internal medicine. She is the mother of three children, a working physician and writer, and an associate professor at New York University School of Medicine. Her inspiration for What Doctors Feel comes from patients she has cared for as a faculty member at NYU’s internal medicine residency at Bellevue Hospital. From her writing, it is clear that she has charged herself with teaching the psychosocial side of medicine to her students and residents. Rather than treating a patient with alcohol and drug withdrawal as just another admission, she probes to discover the exact moment in the past when the patient knew he was an addict, and she gets a moving response. Her underlings treat the patient with more concern and compassion as a result.
To a primary care physician in the trenches, Dr. Ofri’s book has enormous potential and appeal. How do we feel, anyway? Every 15 to 20 minutes, we walk into the next patient’s exam room. Each one has a chief complaint, or more likely, many complaints. It is our job to elicit information, show compassion, cure, heal, fix. And in family medicine, which many of us practice and teach in Sonoma County, there is always more than one patient in the room. The accompanying child, parent or partner also has a complaint, but not an appointment. How do we feel? Rushed, overwhelmed, concerned, altruistic, and often fortunate to be doing such challenging and beautiful work. Surely this book can offer us a road map for how to get in touch with our emotions, avoid burnout, remember the psychosocial perspective in caring for patients, and carry on . . .
What Doctors Feel seems to be written more for the lay public than for a physician readership. There is a lot of detail about the process of medical school and residency training. We physicians remember those days like they were yesterday, and the memories are visceral. But residency, as intense and exhausting as it was, had a finite aspect that made it survivable. The practice of medicine over decades is something else entirely.
Here are four examples of what I hoped to get out of reading What Doctors Feel, but didn’t. First, when I see the name of my most challenging patient on my schedule for the day, or on a telephone message, I have an unpleasant internal reaction. However, I still need to provide the best care possible for this person and to put my feelings about them aside. Is this possible? Second, my clinic has just adopted a new patient portal, through which all my patients can contact me via email. What if a patient emails me with an urgent concern when I am not close to the computer? Also, do I wish to spend my leisure time, already limited, responding to emails from my patients? Third, there are work-hour restrictions for residents, but not for attending physicians. When one has been up all night working in the hospital, it is nearly impossible to show empathy to patients by the next afternoon. Fourth, our healthcare system has incentives in all the wrong places, leading to poor outcomes, poor care and poor morale among physicians. What will it take to turn this around? . . . Read the entire book review. . .
Dr. Donlon, a Santa Rosa family physician, serves on the SCMA Editorial Board. debbied@swhealthcenter.org
This book review is found at . . .
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The Book Review Section Is an Insider’s View of What Doctors are Reading about.
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10. Hippocrates & His Kin: Telehealth
Will Telehealth replace the traditional office visit?
A new study from MDLIVE, a telehealth software provider, has found the vast majority (82 percent) of young adults age 18 to 34 say having a consultation with their physician via a mobile device is the best option for them.
Everet Taylor, MA, MPM, PMP© Clinical Project Manager at Independent Contractor
Very interesting! The 18 to 34 age group are not alone, I have met with seniors that rave over telehealth as well. The evidence of its value can be seen in the very rural areas once it gets there.
Ramsey Carol VP of Rehabilitation at Pinnacle Healthcare Inc.
As a PT with a disabled husband at home, telehealth would be an excellent option for his frequent physician visits! Often the working spouse must take off work, and assist with transport and this is taxing the spouse and their employer when a telehealth option could even be a 3-way conference and allow me to join that visit from my workplace, and my husband from the comfort of his home. If I can remotely monitor him at home via the internet, the physician should be able to as well for routine visits.
What is the biggest obstacle to Telehealth? How would we pay for it? --Editor’s comment
There are essentially two ways to pay for health care. One is to personally pay for it in a Free Enterprise fashion. As more physicians would do this and competition increases, the cost would decrease. It would then be affordable. The cost is estimated at about one-half our present health care costs.
The other method is to try to convince CMS, Medicare, Medicaid, Blue Cross, and Blue Shield, to pay for Telehealth. This would set up a bureaucracy in each of the above payment schemes with the cost being added to the basic cost of a physician responder who would conduct the medical interview and prescribe the treatment. This could only be done on patients calling their personal physician since having a valid medical file is a requirement of most licensing boards. In California, this is defined as having a recorded medical history and physical examination within the past one year. With the bureaucracy of numerous insurance companies, each would have to verify that this medical visit had occurred. This would create a huge burden on each physician’s office. In our studies on the time involved to provide this data, it would come to about one-half of an office visit charge or about 10 minutes.
With the advent of hospitalists, their obtaining medical data from our office on our patient’s admission plus our obtaining of the hospital medical data on our patient’s discharge, reviewing the medical information and incorporating this into the patient’s electronic medical records also takes about one-half of an office visit or 10 minutes of a 20 minute appointment. Since this is also not a reimbursable expense; it is a cost reduction in the physician’s income.
From the data obtained from physicians who do not accept insurance and thus eliminate billing, the savings is about 50%. From the patient’s perspective, having insurance, which eliminates market forced efficiencies, doubles the cost of health care which is painless to the patient.
The majority of patients, as well as physicians cannot remember the one and two dollar office calls of the 1950s and sixties, and thus can’t comprehend personalized health care. In the UK with the NHS now being nearly 60 years in existence, there are no physicians who have been in practice that long. Hence, to propose private practice efficiency would be considered pure lunacy, not only by the patients, but also by the physicians having no longer experienced such an efficient system.
The return to personalized private cost-effective healthcare is no longer a goal of current practicing physicians or the current patients or public. It could only happen if the initial startup funding was outside of the public or physician’s purse since the opposition would be nearly universal. Current physicians even in the United States would fear the risk.
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Hippocrates
and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow
* * * * *
11. Restoring Accountability in Medical Practice, HealthCare, Government and Society:
• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports.
We could spend our entire gross domestic product on
health care in useful ways. In fact, we could
probably spend the entire GDP on diagnostic tests alone—without ever treating a
real disease. --Goodman
• Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog.
• The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government.
• To read the rest of this column, please go to www.medicaltuesday.net/org.asp.
• The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.
• The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels.
• Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.
• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?
• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 50 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter sixty years ago. Be sure to read the current lesson on Economic Education.
• The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."
• The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter.
• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis.
• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section.
• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission was to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, and was used by some as a justification for the Obama plan, they have lost sight of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions.
• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.
• CATO. The Cato Institute (www.cato.org) was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at www.cato.org/people/cannon.html.
• The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.
• The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]
• The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.
• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month: Choose recent issues. The last ten years of Imprimis are archived.
In this critical year for America, it’s more important than ever that EVERYONE understand our Constitution and its importance to liberty. That’s why Hillsdale College is offering a new, absolutely free, online course:
Constitution 101: The Meaning and History of the Constitution
Register at https://online.hillsdale.edu/course/con101/register
• John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to www.zhcenter.org and check out their history, mission statement, newsletter, and a host of other information
• Medi-Share Medi-Share is based on the biblical principles of caring for and sharing in one another's burdens (as outlined in Galatians 6:2). And as such, adhering to biblical principles of health and lifestyle are important requirements for membership in Medi-Share. This is not insurance. Read more . . .
• PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist, practices. To read his story and the background for naming his clinic PATMOS EmergiClinic - the island where John was exiled and an acronym for "payment at time of service," go to www.patmosemergiclinic.com/ To read more on Dr Berry, please click on the various topics at his website. To review How to Start a Third-Party Free Medical Practice . . .
• PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. (http://home.earthlink.net/~doctorlrhuntoon/) Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law.
• FIRM: Freedom and Individual Rights in Medicine, Lin Zinser, JD, Founder, www.westandfirm.org, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance. Read Lin Zinser’s view on today’s health care problem: In today’s proposals for sweeping changes in the field of medicine, the term “socialized medicine” is never used. Instead we hear demands for “universal,” “mandatory,” “singlepayer,” and/or “comprehensive” systems. These demands aim to force one healthcare plan (sometimes with options) onto all Americans; it is a plan under which all medical services are paid for, and thus controlled, by government agencies. Sometimes, proponents call this “nationalized financing” or “nationalized health insurance.” In a more honest day, it was called socialized medicine.
• Michael J. Harris, MD - www.northernurology.com - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis."
• David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.
• Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, which would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at www.peerreview.org.
• Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848, no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment. Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD. To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to www.semmelweissociety.net.
• The Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. Be sure to read News of the Day in Perspective: Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. Browse the archives of their official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents.
•
The AAPS California
Chapter is an unincorporated
association made up of members. The Goal of the AAPS California Chapter is to
carry on the activities of the Association of American Physicians and Surgeons
(AAPS) on a statewide basis. This is accomplished by having meetings and
providing communications that support the medical professional needs and
interests of independent physicians in private practice. To join the AAPS
California Chapter, all you need to do is join national AAPS and be a physician
licensed to practice in the State of California. There is no additional cost or
fee to be a member of the AAPS California State Chapter.
Go to California
Chapter Web Page . . .
Bottom line: "We are the best deal Physicians can get from a statewide physician based organization!"
• PA-AAPS is the Pennsylvania Chapter of the Association of American Physicians and Surgeons (AAPS), a non-partisan professional association of physicians in all types of practices and specialties across the country. Since 1943, AAPS has been dedicated to the highest ethical standards of the Oath of Hippocrates and to preserving the sanctity of the patient-physician relationship and the practice of private medicine. We welcome all physicians (M.D. and D.O.) as members. Podiatrists, dentists, chiropractors and other medical professionals are welcome to join as professional associate members. Staff members and the public are welcome as associate members. Medical students are welcome to join free of charge.
Our motto, "omnia pro aegroto" means "all for the patient."
* * * * *
12. Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .
Words of Wisdom
Public speaking is an audience participation event; if it weren’t, it would be private speaking.
A good speech is like a pencil; it has to have a point.
Great public speakers listen to the audience with their eyes.
No good speech ever came to a bad end.
Do not open your mouth until your brain is in gear.
When a speaker is on too long, his audience may get short with him.
--Anonymous aphorisms.
Some Recent Postings
In The January Issue:
1. Featured Article: There Oughta Be a Law
2. In the News: The Biggest Mistake Doctors Make: Misdiagnoses
3. International Medicine: Canadian-Style Health Care System
4. Medicare: Ten Steps to Achieve Health Care Reform
5. Medical Gluttony: Medical Autonomy
6. Medical Myths: Just give me some good cough syrup so I can sleep.
7. Overheard in the Medical Staff Lounge: Medicare Restrictions because of Obama Care
8. Voices of Medicine: Retaliation against a Physician Whistleblower
9. The Bookshelf: Principles Of Health Care Reform
10. Hippocrates & His Kin: Ants, Scars, and Corkscrews
11. Restoring Accountability in Medicine, Government and Society
12. Words of Wisdom, In Memoriam, Today in History . . .
From The Economist | the print edition | Jan 30th 2014
THERE was, said Claudio Abbado, a certain sound to snow. It did not come from walking on it. If you stood on a balcony, too, you could hear it. A falling sound, fading away to nothing, pianissimo, like a breath. . .
Read the entire obituary in The Economist, subscription required . . . http://www.economist.com/news/obituary/21595387-claudio-abbado-conductor-died-january-20th-aged-80-claudio-abbado
In This Month in History -
Lincoln was born on February 12, 1809.
Washington was not really born on February 22, 1732. When he was born, the country was still on the old calendar. He was actually born on February 11; but then we adopted the Gregorian calendar, which added 11 days. After many years of celebrating his birthday on February 11, Washington himself finally changed it to February 22.
But now we don’t celebrate either day. The Labor Unions changed it to a Monday to make sure that they had another day off with pay for not working.
After Leonard and Thelma Spinrad
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Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, any single payer initiative, Social Security was born for the benefit of the state and of a contemptuous disregard for people’s welfare.
We must also remember that ObamaCare has nothing to do with appropriate healthcare; it was similarly projected to gain loyalty by making American citizens dependent on the government and eliminating their choice and chance in improving their welfare or quality of healthcare. Socialists know that once people are enslaved, freedom seems too risky to pursue.