MEDICAL TUESDAY . NET NEWSLETTER
Community For Better Health Care Vol IV,
No 9,
In This Issue:
1. Featured Article: Health Insurance Choice - Avoiding Costly Mandated Benefits
2. In the News: California
Comes out Ahead Getting Husks at the Federal Feeding Trough
3. International Medicine: Healthcare in
Australia By Stephen Duckett, PhD - An Overview
4. Medicare: Physicians
Are Dropping Their Medicare Patients
with Immune Problems
5. Medical Gluttony: I Don't Care If It's Cheaper to Pay
for My Own Drugs, I Have Insurance
6. Medical Myths - You Can Fight a Lethal Disease by
Keeping Contacts in a Secret Code?
7. Overheard in the Medical Staff Lounge: Please Use the
Hyperbaric Chamber
9. Book Review: From
the Physician/Patient Bookshelf: HEALTH CARE CRISES
10. Hippocrates & His Kin: Maintenance Mania
11. Related Organizations: Restoring Accountability in
HealthCare, Government and Society
* * * * *
1. Featured Article: Health Insurance Choice -
Avoiding Costly Mandated Benefits
"Mandated
health insurance benefits are state regulations that require insurers to cover specific
services and specific providers. Currently, there are 1,823 state-mandated
benefits among the 50 states, and an additional 295 mandates are now being
debated in state legislatures," says Jack Strayer, a representative of the
"Mandates
cover services ranging from acupuncture to in vitro fertilization. They cover
providers ranging from chiropractors to naturopaths. They cover bone marrow
transplants in
In Strayer's
Brief Analysis, he points out, "A citizen who lives in any one state can
buy a toaster produced in any other state. The same citizen can also buy a
lawnmower, a sofa, an automobile or virtually any other product - regardless of
the state where the product is made.
"This same
freedom does not exist in the market for health insurance, however. Take
"Laws that
keep people who live in one state from buying health insurance sold in other
states balkanize the health insurance market and make it less competitive than
it could be. As a result, people pay higher prices and have fewer choices than
they would have if they could purchase insurance in a national marketplace.
"Consumers
will get some relief, however, if Congress passes a bill proposed by Rep. John
Shadegg (R-Ariz.). It would allow insurers licensed in any one state to sell
insurance (under the rules of that state) to individuals and small groups residing
in any other state. What difference will the Shadegg bill make?
"Avoiding
Costly Mandated Benefits. Mandated health insurance benefits are state
regulations that require insurers to cover specific services and specific
providers. . . .
"These laws
mean that if people buy insurance at all, they must purchase a bloated and
expensive package of benefits designed by politicians. They are forbidden to
buy insurance that reflects their own preferences, tailored to individual and
family needs. A family of teetotalers is thus forced to buy protection against
alcoholism, even though they neither want nor need such protection. A couple
well past child bearing years is forced to buy in vitro benefits they do not
plan to use. Catholics are forced to buy contraceptive coverage they find
morally objectionable.
", , , 11
states require insurers to cover marriage counselors, four mandate coverage for
naturopaths, three cover midwives, 11 cover acupuncturists and four require
coverage for massage therapists. Other states have mandated such procedures as
in vitro fertilization (15 states), port-wine stain birthmark removal (two
states), and treatments for morbid obesity (four states).
"Compared
to the costs of barebones insurance, these kinds of mandated benefits hike
premiums considerably, thus pricing otherwise healthy people out of the market.
In fact, studies estimate that as many as one of every four uninsured Americans
has been priced out of the health insurance market by mandates.
"If
mandates do so much harm, then why do they exist? Very few mandates have been
enacted because of patient pressure. Almost all are the result of the lobbying
power of special interest providers. And once a state-mandated health benefit
is enacted, it is almost impossible to get it repealed.
"Not all
states have been equally bad at limiting consumer choice and raising the cost
of insurance. For example, people who live on the
"Under the
Shadegg bill, Minnesotans, at least in principle, would be able to purchase
insurance licensed in
"Avoiding
Other Cost-Increasing Regulations. Another problem is the proliferation of
state laws that make it increasingly easy for people to obtain insurance after
they get sick. Guaranteed issue regulations (requiring insurers to take all
comers, regardless of health status) and community-rating regulations
(requiring insurers to charge the same premium to all enrollees, regardless of
health status) are a free rider’s heaven. They encourage everyone to remain
uninsured while healthy, confident that they will always be able to obtain
insurance once they get sick.
"Moreover,
as healthy people respond to these incentives by staying uninsured, the
premiums required to cover costs for those who remain in insurance pools rise
significantly. These higher premiums, in turn, encourage even more healthy
people to drop their coverage. In general, all such legislation prevents risk
from being accurately priced in the marketplace —that is, people cannot
purchase pure insurance against risk; rather, they must purchase a politically
designed package of specified medical benefits.
"Choosing
Consumer Protections. Not all regulation is bad for consumers. For example,
consumers have an interest in knowing that their insurer is solvent (that is,
can pay the patient’s medical bills as they come due). Regulators that oversee
solvency requirements, therefore, can perform a valuable service. Additionally,
consumers have an interest in making sure that insurance companies play fair
(for example, that they don’t cancel or raise rates for someone simply because
he has the misfortune to get sick). Under the Shadegg bill, consumers will be more
likely to get the benefits of these value-enhancing regulations without
suffering the cost of value-reducing ones.
"Creating
A Market for Regulation. What can we expect as a result of the Shadegg
bill? Currently we have 50 states with 50 different sets of regulations. If all
insurers licensed in each of the 50 states were willing to sell their products
in the other 49 states, the typical consumer would have an opportunity to
choose among 50 regulatory regimes.
"Defenders
of mandated benefits and other forms of regulation frequently assert that these
are “consumer protections.” Insurance companies, on the other hand, deride them
as “special interest” legislation whose costs exceed their benefits. The
Shadagg bill will allow these competing claims to be put to the market test.
Those regulations that enhance the value of insurance (for example, whose
benefits exceed their costs) are likely to win out in competition with those
that do not.
"The law
will also help better public policies replace inferior ones. A state that
subsidizes risk pools for people who are uninsurable through no fault of their
own will leave insurers free to charge lower and fairer prices to the healthy.
Insurers in such a state are more likely to compete successfully in a national
market than insurers in a state that attempts to help the uninsurable by
legislating rules that raise everyone’s premiums.
"Conclusion.
The Shadegg bill promises to usher in a new era in the evolving market for
health insurance. Consumers will be able to shop in a national market, as
opposed to 50 separate state markets. Regulatory regimes will compete against
each other and those that survive will be those that add value to the product.
Insurers will be able to offer products that meet individual and family needs without
the cost-increasing burden of inefficient regulations."
Jack Strayer is
a
Read the entire
report at www.ncpa.org/pub/ba/ba523/.
* * * * *
2. In the News:
California, the
richest of the 50 United States, with an economy that is seventh largest in the
international community of 192 countries, has 53 congressmen, the largest block
of votes in Washington. Each got a share of the transit money in the public
trough for their districts. Are there any lawmakers left in
Edward Epstein, Chronicle Staff Writer, headlined his report last
week: Highway bill puts state on high
road -
He reports:
"California came out a multibillion-dollar winner in the high-stakes
struggle over the new $286.4 billion federal highway and transit funding bill
finally making its way toward President Bush's desk after a two-year delay,
state representatives said Thursday. . . .
"'This is a good-news bill for California,'
said Rep. Ellen Tauscher, D-Walnut Creek, a House Transportation Committee
member who served on the conference committee that ironed out differences
between House and Senate versions of the bill.
"The final bill of several thousand
pages, which the House and Senate were expected to vote on today before
Congress recesses for its six-week summer break, means $4.4 billion more for
the state in highway funds, said Sen. Barbara Boxer, D-Calif. She was also a
member of the House-Senate conference committee. Under the old program,
"The new legislation also provides the
state with $4.6 billion for transit programs over the life of the bill, which
will expire in 2009. Mass transit across the country will get more than 18
percent of the bill's total money, or more than $50 billion, while $6 billion
is set aside for transportation safety programs.
"In addition, the state will get more
than $1 billion for specified road, bridge and transit projects across the
state that virtually every member of Congress got inserted into the bill, Boxer
reported. . . .
"Tauscher
said she got $51.9 million for five projects in Contra Costa, the biggest of
which is $36 million for the Highway 4 widening project. The biggest project in
the
"Boxer estimated that the bigger federal
highway and transit program will create 800,000 jobs. . . .
"In addition to California, whose 53
House members are by far the single biggest state bloc in the House, other
donor states include Illinois, home of House Speaker Rep. Dennis Hastert, and
House Minority Leader Rep. Tom Delay's Texas.
"Bush had initially proposed a $247
billion program to replace the transportation bill that expired in 2003. Since
then, Congress has passed extensions to keep construction going, but it has
become harder for state officials who rely on federal funds to provide a
matching portion of money for projects to plan new work.
"Congress consistently proposed a higher
amount, drawing a White House veto threat that provoked the deadlock. The House
Transportation Committee originally wanted a $370 billion program.
"As the House and Senate passed new
versions of their bills, Bush raised the limit on the amount of money he would
accept to $256 billion, then $275 billion and then $284 billion. He has
accepted the $286.4 billion figure that represents a compromise between the
House and a higher Senate-passed figure. . . .
"The
new highway bill also creates a commission to study ideas for raising more
money for highway and transit programs.
"Among
the ideas it will consider is basing fuel taxes on miles driven, not on the
amount of fuel purchased. The reason is that rising fuel prices are encouraging
motorists to buy more higher-mileage vehicles, which translate into less tax
revenue while not cutting congestion on roads that still have to be maintained
and eventually rebuilt. "
E-mail Edward
Epstein at eepstein@sfchronicle.com. To review the entire
article, go to
http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/07/29/BAGGADV8G41.DTL.
In Epstein's
report the following day when this windfall had passed, he quotes Bob McCleary,
executive director of the Contra Costa Country Transportation Authority,
"I feel like it's Christmas. It's twice what we had been led to expect we
would get." [Other California Representatives, however, reported the next
day that they still didn’t get enough. With Federal funding, is there ever
enough? Will 100 percent of all tax revenues come close to keeping the pigs at
the trough satisfied?]
Note: Be sure
to re-read and fully understand the last two paragraphs. There is a commission to
"study ideas for raising more money" from us taxpayers including how to
tax those individuals who are buying energy efficient cars, such as the popular
Hybrids, that travel more miles on the roadways and pay less taxes because they
don't drive gas guzzlers. The bureaucrats feel they are not paying their fair
share for the road upkeep. Are you ready to have another federal bureaucracy
monitor your mileage as well as every odometer in every car in the country?
Can you imagine
health care pigging out at the same government trough where those who conserve
health care costs will be taxed in a new and innovative way so that they don't
avoid Medicare and health care taxes for being judicious in their medical
costs?
Citizens and
responsible people can never win with government in the equation. The equation
should just be between the patients and their physician.
Government is not the
solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
3. International Medicine:
Healthcare in
Q: What kind of health system does
A: The Australian healthcare
system is mixed. Responsibilities for healthcare are divided between the
federal and state governments, and both the public and the private sectors play
a role. Australia spends about 8.5% of gross domestic product on healthcare, which
compares favorably to spending in countries such as the United States (13.7%), Canada
(9.5%), and England (7%).
Government
programs underpin the key aspects of healthcare. Medicare, which is funded out
of general tax revenue, pays for hospital and medical services. Medicare
Covers
all Australians, pays the entire cost of treatment in a public hospital, and
reimburses for visits to doctors.
There
is no limit on fees charged by doctors. There is, however, a government-set fee
schedule. Doctors can bill patients or send their bills directly to the
government insurance authority, the Health Insurance Commission (HIC). If sent
to the HIC, the payment is 85% of the government-set fee for out-of-hospital
expenses and 75% of the government-set fee for in-hospital services; the money
is paid directly to the doctor, and the doctor is not allowed to charge the
patient an additional fee. About 75% of family physician services are directly
billed to the HIC. If a doctor bills the patient directly, the patient then
applies for the rebate of the government set fee.
Public
hospitals are owned by the state. About 70% of beds are in public hospitals,
and major teaching hospitals are public hospitals. Budgets for public hospitals
are usually set on the basis of their case-mix, using an Australian version of
Diagnosis Related Groups. In the past, the majority of private hospitals were
owned by charitable organizations, but for-profit corporations – which are
listed on the stock exchange – now own an increasing proportion. Private,
freestanding surgical centers are a rapidly growing phenomenon. Few private
hospitals have emergency departments, so, in an emergency, most Australians
rely on the public hospital system.
Australia
has a Pharmaceutical Benefit Scheme (PBS), which subsidizes the cost of
medication. The scheme covers most prescriptions with some exceptions, such as
Viagra. (Before approving a drug to be listed on the PBS, the government
assesses its cost effectiveness.) Aged pensioners and people on low income pay
A$3.60 (US$1.94 at an August 2002 exchange rate) out-of-pocket for
pharmaceuticals, while others pay A$22.40 (US$12.07) per prescription. Both
schemes have "safety nets" on total expenditure for a patient or
family in a year: after 52 prescriptions, pensioners receive prescriptions at
no charge; all others after spending A$686.40 (US$369.94), pay A$3.60 (US$1.94)
per remaining script for that year. Pharmaceuticals (including nonprescription
medications) account for about 12% of total health expenditure compared to
about 19% spent on medical services.
Q. How is the healthcare system funded?
A:
Government pays about 70% of healthcare costs (approximately 47% from the
federal and 23% from state governments); the remainder is paid by non-government
sources, e.g., insurance and private pay.
The share of costs varies
significantly across service types. Public hospitals, for example, are about
48% federal, 45% state, and the balance private sector funded. Medical
services, on the other hand, are 82% federal funded with the balance paid
mainly by the patient.
Private health insurance
(which covers about 8.6% net of health costs) receives a 30% subsidy from the
federal government. Everyone is eligible for this subsidy. And 45% of the
population has private health insurance; for a family, it costs between A$1,000
and A$2,000 per year (US$539 to US$1,078). People buy insurance directly from
the insurance company (not via an employer). Insurance products are not
risk-rated.
Q: What is the quality of care in each system?
A.
Overall, quality of care in
Q: What are the current concerns among healthcare workers in the
country?
A: One of the worldwide
fallouts of September 11 has been escalating costs of insurance and
re-insurance arrangements, and this has placed pressure on the medical
malpractice insurance in
Longer-term issues include
concerns about the potential shortage of nurses in most states and the adequacy
of equipment and capital funding, and general questioning about the level of
financing of the system.
Q: What are the current concerns among patients?
A:
The Australian healthcare system is in relatively good shape. Out-of-pocket
costs are moderate and access to emergency care is good. However, there are a
number of concerns for people without access to the pensioner-level subsidy for
pharmaceuticals, especially for the chronically ill.
There are also extensive
waiting times for elective surgeries at public hospitals. Although waiting
lists for the most urgent elective surgery for heart disease and cancer are
almost nonexistent, there are long waiting lists for orthopedic surgery (median
wait for total hip replacement is 88 days; 10% of patients waited over 345 days
in 1999 to 2000), and cataract surgery (median is 73 days; 10% waited more than
316 days). One of the attractions of health insurance is the ability to bypass
public hospital waiting lists.
There are also problems of access
in rural
There is also a significant
problem of the health status of
To review the entire article
published on
* * * * *
4. Medicare:
Physicians Are Dropping Their Medicare Patients with Immune Problems
Andrew Pollack reports in
the New York Times that Medicare Law Impedes Flow of Immunity in a
Vial
"Linda Swim, who has a
serious immune deficiency, went through two frantic months this spring when she
was unable to receive the treatment she usually gets every month. Her doctor
stopped treating her when Medicare reduced its reimbursement. Then three
hospitals near her home in
"'If you've got
insurance and you've got a life-threatening illness, why the devil won't they
treat you?' said Ms. Swim, who faces an increased risk of serious infections
without the treatment.
"Ms. Swim and thousands
of others have been caught in a swirl of developments surrounding intravenous
immune globulin, a mundane product derived from donated blood plasma essential
for some people.
"Many private
physicians are dropping their Medicare patients, saying they can no longer
afford to treat them because of lower reimbursement rates. At the same time, prices
have risen sharply, and some hospitals say there is a shortage. Kaiser
Permanente, the big
"Used for people with
immune problems, immune globulin, also called immunoglobulin or gamma globulin,
is a collection of antibodies that provides sort of an immune system in a vial.
About 50,000 Americans have the deficiency, some 7,000 of them Medicare
patients, many younger than 65 because they are on disability, according to the
Immune Deficiency Foundation, an advocacy group. 'We've got patients all over
the country who are not getting treatment,' said Michelle B. Vogel, the group's
vice president for government affairs.
"The change in Medicare
reimbursement, mandated by the 2003 Medicare overhaul, appears to be intended
in part to prevent potential overuse of the drug, which can cost $20,000 to
$80,000 per year per patient.
"Medicare spent $300
million on immune globulin in 2004, its 10th biggest drug expenditure. That
figure was up from $180 million the year before, even though the reimbursement
rate had gone down.
"Much of the increased
demand appears to be for uses, like some neurological disorders, not approved
by the Food and Drug Administration. Varying degrees of evidence support such
uses. Some neurological uses require doses three to four times as great as
those for immune deficiency.
"'There's so much
profit to make,' said Dr. Daniel Suez of Irving, Ms. Swim's doctor, who treats
only immune deficiency patients. 'In the meantime, they drain all the
resources.'
"Medicare's new
reimbursement is based on "average selling price," which is supposed
to be close to what the manufacturers actually charge. The rate is now about
$42 a gram for the powdered product and $56 a gram for the liquid, down from
$66 last year for either type of product and from about $78 in October 2003. A
typical monthly infusion is 30 to 50 grams.
"Some doctors say
prices have risen well beyond that level. So they are shifting patients from
their offices to hospitals, which are still reimbursed under the old formula at
about $80 a gram.
"'My partners felt we
could not continue to sustain these kind of losses,' said Dr. Roger Kobayashi
of
"Dr. Robert Dracker of
"The infusion clinic at
"A similar change in
reimbursement occurred this year for cancer drugs, which are also typically
infused in doctors' offices. But according to Medicare and to some cancer
specialists, cancer patients have not been shifted en masse to hospitals,
despite warnings last year by some oncologists. . . .
"On top of the Medicare
issue, or possibly linked to it, is apparently a shortage that is making it
harder for even non-Medicare patients to get treatment. "We're on
allocation from every manufacturer," said Dr. Richard A. Wagner, director
of drug use management for Kaiser Permanente. "We're only getting about
two-thirds of what we normally purchase from them."
". . . There was a severe shortage in 1998 after
two companies took their factories out of production to meet new quality
standards. When those plants came back online there was a glut and plunging
prices that prompted three manufacturers - Aventis, Bayer and Alpha
Therapeutics - to exit the business. . . .
"Manufacturers insist
that the supply of immune globulin is adequate and is up 80 percent since the
1998 shortage. Some buyers may not be getting enough temporarily, they said,
because patients are moving from doctors' offices to hospitals.
"'You can't shift
radically with that kind of change,' said Larry Guiheen, head of Baxter's North
American biopharmaceutical business.
"Others said companies
were allocating supplies to keep customers from ordering more than they needed
in order to resell at higher prices.
"'It may be more
lucrative for a physician's office to sell the product than use it for a
Medicare beneficiary,' said Patrick M. Schmidt, president of FFF Enterprises, a
large distributor of immune globulin. He and others said some small
distributors were charging as much as $70 to $90 a gram. Most patients being
dropped by doctors appear to be finding hospitals. Some patients and doctors,
say, however, that hospital treatment is not ideal. Hospitals are a well-known
source of infections, a risk to those with weak immune systems. Hospitals can
take longer to do the infusion and actually charge Medicare more.
"'The first time I went
to the hospital was an absolute nightmare,' said Phyllis Glasser of
"Christina, 58, of
Boynton Beach, Fla., who asked that her last name not be used because neighbors
did not know she had immune deficiency, said her doctor forgave her 20 percent
Medicare co-pay, but the hospital did not. After being billed $940 for her
first two hospital infusions, she decided to forgo treatment, she said. . . .
"Ms. Vogel of the
Immune Deficiency Foundation said private insurers, which often take cues from
Medicare, were starting to cut reimbursements, meaning non-Medicare patients
may also have trouble getting treatment. And in January, the reimbursement paid
to hospitals will also be switched to the new formula."
To read the NCPA Health
Policy Digest, go to www.ncpa.org/newdpd/dpdarticle.php?article_id=2006.
To read the entire
editorial, go to www.nytimes.com/2005/07/19/health/policy/19immu.html.
Note: This article could
have been improved by a comparison with other countries’ government-run Medicare
plans. We know for certain that the $80,000 for immune shots would not occur on
a regular basis in either Canadian Medicare or the UK National Health Service.
I would seriously doubt if even a single injection would be available in very
many of the other 192 countries' government-run health plans.
* * * * *
5. Medical Gluttony: I Don't Care If It's Cheaper to Pay for My Own Drugs,
I Have Insurance
Most patients understand
that certain medications are cheaper than even paying their deductible and
running it through their insurance company. For instance, one patient told me
she could purchase 100 tablets of thyroid for $12 and her copayment for a
one-month supply of 30 tablets was $15, which would be more expensive each
month than the three-month cash price. Another patient told me she could
purchase 100 prednisone tablets for $9 and her copayment for 30 tablets was
$18. Thus a one-month supply through her insurance plan was twice what a three-month’s
supply was when paying cash. So when I write prescriptions for long-standing
common medications that only come in generics, I try to take the extra time to
explain that they might want to check the cash price before handing over their
insurance card.
Helen, who had been on
thyroid since some doctor treated her obesity as a teenager with thyroid and
thus destroyed her thyroid, sentencing her to a lifetime of medications, was
also on occasional prednisone for her asthma. I mentioned that she might price
those medications and find it best not to use her insurance card. She asked,
"How can you get medicine without an insurance card?" I suggested
that she could just pay cash if it's less than her copayment. "But how can
the pharmacist dispense the medication without my insurance card?" she
asked. I told her that the prescription I gave her was the authority for the
pharmacy to dispense the medication and reiterated that she should pay cash if
it's cheaper. "But how can that be, doctor?" she asked. After several
additional explanations, she finally said in exasperation, "I don't
understand you at all, doctor. I'll just keep using my HMO insurance card.
After all, I paid a lot of money for that."
Bureaucratic third party
medicine may be so entrenched in society that it will be difficult to get
people to think again of cost-effective, private health care.
* * * * *
6. Medical
Myths: You Can Fight a Lethal Disease by Keeping Contacts in a Secret Code?
This oddity is largely due to liberal
State and federal databases of reportable diseases are strictly
confidential and aren't available to insurance companies or the press. They are
used for internal research purposes, to track trends and to combat an outbreak.
Information can be the most potent weapon that public health officials have in
their arsenal.
But
The laboratory that identified the HIV case is supposed to concoct the
code for the patient based on elements of the patient's name and birth date.
The same goes for the doctor. The state is supposed to keep this information
together in a computer by linking the common codes. But when a finger hits the
wrong key, the code gets botched. The data become gibberish. The case of HIV,
in the eyes of the federal Centers for Disease Control and Prevention, cannot
be officially counted. And since some funding is based on a state's official
HIV case count, money to fight the disease may slip away. The state may lose as
much as $50 million by 2007 if
The same activist groups and legislators who backed this disaster of a
reporting system would normally be the first to complain about a federal cut in
funding to
URL: www.sacbee.com/content/opinion/v-print/story/13316331p-14158443c.html
Note:
Treatable infectious diseases, such as tuberculosis and syphilis, were brought
under control by appropriate reporting of cases and contacts to the public
health department, which in turn contacted, tested and treated those exposed.
The Public Health Department, responding to a powerful lobby that involved
about one percent of the population, lost all sense of health, reason and
direction, jeopardizing our nation's health, assuming that AIDS, a lethal and
initially incurable and un-treatable virus could be controlled in secrecy. This
lobby was so strong that initially blood banks did not test blood donors for
HIV because that would step on the civil rights of those blood donors with the
AIDS virus, not allowing them to give blood. Introducing this lethal virus into
the blood bank system disseminated the AIDS virus into the essentially
disease-free population of hemophiliacs, sickle cell anemics, cardiac surgery
patients, and those requiring frequent blood transfusions. The AIDS immune
deficiency epidemic has now increased the dissemination of syphilis and
tuberculosis, both now resistant to drugs. AIDS will never be brought under
control until every case and contact is identified, tested and treated if
necessary. Tuberculosis and syphilis will then also again be controlled.
* * * * *
7. Overheard in the Medical Staff Lounge: Please Use the Hyperbaric Chamber
Dr Edwards was discussing
the sign at the door of the medical staff lounge as we were eating lunch. The
sign stated that the HBO (Hyperbaric Oxygen Chamber) has immediate openings for
chamber treatments. It asked that doctors search their patients diseases for
approved indications for hyperbaric oxygen treatments such as wound healing,
skin grafts, osteomyelitis, delayed radiation burns, bas emboli, gas gangrene,
CO poisoning, decompression sickness, and the list went on. If you need help in
referring your patient, please call the nurse in charge at this number. If
you're not sure if your patient could benefit from hyperbaric oxygen, please
call Dr ID or Dr PM.
The doctors in this group
mostly viewed the large advertisement in a rather negative fashion. However,
most understood the challenges of running a hospital and did not think
negatively about the administrator, who happens to be well liked. They
understand he's running a business to make money.
What seems to be lacking in
all the discussion, as we mentioned last week in our Hippocrates column, is
that so much of health care is working at cross purposes. With some
interventionists saying Americans obtain only half as much health care as they
could use, the doubling of health care costs would paralyze and bankrupt the
entire system.
The question remains, “How
can we keep the interventionists from destroying American Health Care?"
* * * * *
8. Voices of Medicine: A Review of
Various Local and Regional Medical Journals: Return to Solo Practice - The
Young Female Athlete - The Trouble With Day Care - MICRA
Return to Solo
Practice
Eric Holmberg, MD, a
Holmberg states "... in
1992, most young physicians I knew would have been happy to open their own
offices or join existing practices to replace their happily retiring older
colleagues. Today, however, the ravages of managed care, and the advent of a
health system controlled by the insurance industry and neglected by government,
have left a barren landscape for new physicians."
He had for some time thought
about returning to a smaller model of care, "... and the shift finally
seemed right last year," he states. "I didn’t intend to practice
completely alone; but when partners did not readily materialize, I realized
that solo practice was quite doable and perhaps in some ways for the
best." After being on his own for almost a year and enjoying work once
again, he's been able to fix nearly everything he was unhappy about previously.
"With the exception of
a few out-of-town trips, I have taken all my own call during this time. Call is
much less burdensome than I thought it would be, other than the need to be
always available. Patients have both my home and cell phone, and they don’t
abuse them. I know the patients who are calling, and I can access their charts
and our appointment schedule over the Internet. I never have to quibble with
the on-call doctor’s decisions. My patients seem quite happy, and the practice
continues to grow steadily without the need for advertising."
He concludes that to be of
real value to patients, the private-practice community needs to offer something
unique. "We need to differentiate ourselves from the HMO model by being
more accessible, flexible, and caring, and by knowing our patients as well as
we possibly can. We have lost the early battles for information retrieval,
system organization, and pharmacy management; but as we strive to improve these
aspects of our practices, we should also offer the one alternative that
patients are most enamored of: the chance to know and be known by your
doctor." To read the featured article, go to www.scma.org/magazine/scp/sp05/holmberg.html.
A Gynecologic Perspective of The Young Female Athlete
Susan J. Spencer, M.D., who
practices obstetrics, gynecology and reproductive endocrinology in
"In 1992 The American
College of Sports Medicine coined the term 'Female Athlete Triad.' This
syndrome is defined as disordered eating, osteoporosis, and amenorrhea that
occurs in women engaged in regular strenuous exercise or sports activities. For
those of you accustomed to acronyms, I do not believe the authors wish to refer
to the syndrome as 'FAT.'
"In the young female
athlete, weight can become a preoccupation. Abnormal eating behaviors may arise
in young women, but most vulnerable are those involved in athletic activities
that are weight-bearing and favor leanness for performance, such as ballet and
gymnastics.
"By the age of 10 years
there is a demonstrable difference in concern about eating and weight between
girls and boys. One study showed that by fifth grade 31 percent of girls are
dieting, and by sixth grade, 62 percent are dieting to lose weight. Thus it
appears that attempts to diet in an effort to control weight are common in
prepubertal and pubertal girls. All it takes is a glance at Teen Vogue or Britney Spears’ latest
video to realize that young girls are bombarded with images that reinforce
abnormal eating patterns. Other factors thought to increase a young athlete’s
risk for the disordered eating component of this triad include frequent
weigh-ins, an overcontrolling parent or coach, and the social isolation of
individual sports compared with team sports."
In summary, Spencer states
there are potential health risks for young women in strenuous sports and
exercise programs. "Physicians and parents need to be cognizant of the
Female Athlete Triad. Supportive care for the adolescent, with collaboration
between pediatrician, gynecologist, orthopaedist, and parents, greatly enhances
recovery." To read the entire article, go to www.smcma.org/Bulletin/BulletinIssues/March05issue/A
GynecologicPerspective.html.
The Trouble With Day Care
The Reverend David Feddes,
in his Mother's Day radio message on the importance of motherhood, points out
that a Canadian kennel will not place a new puppy in a home with both parents
working. He states that equally damaging as a dog being at home with no master,
evidence is increasing that a child without either parent at home has a
significant chance of behavior problems.
Heide Lang, in a recent issue
of Psychology Today, discusses the
trouble with day care and questions whether scientists are telling parents the
whole truth? Stanley Greenspan, a
The raging debates around
maternal guilt, work/family balance, money and childrearing often drown out
scientific insights into the developmental pact of day care. But the latest
findings from a huge, long-term government study are worrisome. They show that
kids who spend long hours in day care have behavior problems that persist well
into elementary school. About 26 percent of children who spend more than 45
hours per week in day care go on to have serious behavior problems at
kindergarten age. In contrast, only 10 percent of kids who spend less than 10
hours per week have equivalent problems.”
“Developmental psychologists
are sweeping this information under the rug, hoping studies will churn out
better data soon,” argues Jay Belsky, a child development researcher at
Saving MICRA
Sonoma County Medical
Association President Heather Furnas, MD, notes, “In the CIA thriller Spygame, Robert Redford’s secretary bemusedly
questions his flurry of seemingly paranoid activity. He pauses a moment before
asking her, “When did Noah build the ark? Before the rain …… before the rain.”
“Dark clouds are presently
gathering over MICRA (the Medical Injury Compensation Reform Act that
“How lucky are physicians in
“What are we up against? A
whole lot of money. The No. 1 priority of
Furnas concludes: "All
of us need to pitch in to defend MICRA. If you specify MICRA on your CALPAC
donation, 100% of your contribution will go directly to the cause, with none
spent on administration. It’s going to take a lot of timber to build this ark,
and I think I hear some thunder in the distance." To read the entire
article, go to www.scma.org/magazine/scp/sp05/furnas.html.
* * * * *
9. Book
Review: From the Physician/Patient Bookshelf: HEALTH CARE CRISES
HEALTH CARE CRISES - The
Search for Answers, Edited by Robert I Misbin, MD, Bruce Jennings, MA, David Orentlicher,
MD, JD, and Marvin Dewar, MD, JD. University Publishing Group, Inc. Frederick,
MD, 1995.
This volume is a collection
of papers presented in
Section I, deals with
well-publicized cases in which family members insisted that artificial life
support be maintained indefinitely on patients who were permanently
unconscious. The courts sided with the families and against the health
providers who did not wish to be forced to provide futile treatment. Given the
millions of Americans who lack basic health care, it is hard to understand why
over $100,000 per year should be spent to maintain a patient who is permanently
vegetative.
The issues are tied to
considerable emotion. Rebecca D. Pentz, PhD, MD, discusses the surprisingly
strong statement by the
In section II, John H.
Fielder, PhD, has a chapter on Abusive Peer Review and Health Care Reform. Dr.
Fielder discusses three cases of Peer Review abuse: Dr Timothy Patrick formerly
of
Dr Fielder feels hospital
bylaws are fatally deficient in due process and fail to protect competent
doctors who are falsely accused. It provides a convenient means for
unscrupulous hospitals and physicians to remove doctors who are a threat to
their interest. He states that it is difficult for physicians who have received
unfair peer reviews to succeed in a lawsuit against the hospital because of the
extensive legal shielding of the peer review process by courts and
legislatures. Dr Fielder predicts that with the growth of managed care,
economic pressures on physicians will increase and we can expect to see a
corresponding growth in abusive peer review.
This glimpse at two of the
twenty chapters in this volume reflects the timeliness of the entire volume.
Every one of our organization's leaders needs to be conversant with the issues
at the forefront of medicine. I understand that Dr Fielder is spending his
entire year of Sabbatical leave researching Peer Review. If his research
supports his initial concerns, we should not only read this volume, but his
next volume as soon as it is available.
* * * * *
10. Hippocrates & His Kin: Maintenance Mania
National Public Radio had a
report on the success of Health Maintenance Organizations (HMOs). They
suggested that there were other things beside health care that were expensive
and we might apply HMO techniques to bring down their costs. The doctors in
turn have formed Independent Practice Associations (IPAs) to protect their
interests. I didn’t have my recorder in the car and so am describing this 100
percent from recall. My apologies to the author as I have probably missed a few
words, in addition to missing her name.
Car Maintenance Organizations (CMO)
Everyone knows the price of
cars is too high. To get the price down, we could form a car maintenance
organization (CMO). Our CMO executives would tell the dealers that they would
henceforth be re-imbursed at 60 percent of retail costs for the members of the
CMOs that purchase cars. The CMO would sign up potential car buyers, which
eventually would include almost everyone. The CMOs would enter into contracts
with the various dealers to acquire the cars. The dealers, in order to protect
themselves, would form Independent Dealers Associations (IDAs). As the number
of consumers joining these CMOs increase, the car dealers would not have enough
business to go solo and eventually would have to contract at the reduced price.
Americans would enjoy the pleasure of driving their automobiles at a 40 percent
savings.
Electric Maintenance Organizations (EMOs)
We also know that the price
electricians charge is too high. The charge of $65 to come to your house, plus
a labor charge of $65 for an hour or fraction thereof, can amount to $130 for a
ten-minute job. If 47 million unfortunate Americans with hazardous wiring in
their homes could not afford electrical upgrades, the need for an Electrical
Maintenance Organizations (EMO) would become obvious. The deserving public
living in electrically hazardous homes would join an EMO which would in turn
contract with the electricians for their services at $35 a hour (which just
happens to be what the latest data shows that doctors in the 25th percentile
income, working 3,000 hours per year, are making). As more and more Americans
sign up with an EMO, the electricians wouldn’t have any work unless they
contracted with our EMO and so we would be able to get the electrician’s hourly
rate down to $35 an hour. (Thus the EMOs would bring skilled labor down to the
same cost as professional labor.)
Jock Maintenance Organizations (JMOs)
Everyone agrees that
athletes are definitely making too much money and the charge to watch them play
is becoming obscene. In fact the cost of seeing professional sports live is so
high that deserving school kids have difficulty seeing their heroes in action.
Why should a jock get $3 million dollars for 20 weeks of work? That’s $150,000
for a 30-hour week--about the same as the 50th percentile for family physicians
for a 3000-hour work year. Sport fans should form a Jock Maintenance
Organization (JMO) and the public would join these JMOs for the purchase of
tickets to football, basketball, baseball, and hockey games that contracted
with our JMO. As the coliseums become emptier and as the jock salaries fall,
league managers would contract with our JMO to re-acquire fans. We and our
deprived children would then be able to see NFL, NBA, NHL, AL and NL games at
about 20 percent or $10 each, about the cost of seeing a doctor nowadays. And
the players would learn to live on a doctor’s salary.
Lawyer Maintenance Organizations (LMOs)
Now there is one area in
which I am sure we can all agree. Lawyers charge far too much. Not only do they
charge too much, but also they bill us for all time spent on our behalf, even
if not at work. They can be sitting at home on their toilet and reading our
file while defecating and bill us for the time spent reviewing the file. They
can be sitting in their office and call someone on our behalf while the
conversion digresses to other business ventures and charge us the whole amount.
I've personally experienced both. Once I had a
If all clients joined an
LMO, which would set the fee at say $40 an hour, about what the HMOs set the
doctors fee, there would be a mad rush to join the LMO. Within weeks, the
attorneys would sign up with the LMOs so they would at least have $40-an-hour
clients when no $320-an-hour clients came in, or they would be selling their
luxury cars and yachts. One attorney bragged that the best thing about a legal
partnership, is that you can double bill. But an LMO would see attorneys
charging for more than a 50-hour week and they would restrict the attorneys to
time actually spent with the client and no longer could charge reviewing the
file in the toilet or during lunch or while on their yacht in the absence of
the client.
When clients complain that
they were not receiving quality legal care, the LMO would start to come into
the office and copy the attorney's records just like the HMOs copy the doctor's
records. The LMOs would then get suspicious that a one-page handwritten scrawl
didn't justify two hours of legal care and they would develop legal guidelines.
They would then review the records a second time to see if quality had
improved. If it hadn't, they would reduce reimbursement from $40 an hour to
$35. If a second review three months later didn't show improvement, the LMO
would just reduce the reimbursement to $30 an hour and inform the attorney that
they could just keep going until he shaped up. (Exactly the words used by an
HMO in disciplining a physician.)
There is one strategic
difference between doctors and attorneys. If the reimbursement of attorneys
gets down to zero, the attorney just might go out and charge $320 an hour
again. At this point, so many clients are so unhappy that some would be willing
to pay the exorbitant fee to get good legal counsel. HMOs still haven't found
the bottom when doctors refuse to lose money. It's a morality play.
CEO Maintenance Organization (CEO-MO)
The HMO’s CEOs are
definitely making obscene amounts of money. Even our local boys are making
$5,000 ($5K) per hour. One national HMO CEO made $1 billion. Suppose he worked
real hard, maybe three-fourths as hard as some doctors, and put in a 3,000-hour
work year? That would be $333,000 per hour. (Even Bill Gates, the world’s
wealthiest man only makes $55,000 per hour.) What we need is a CEO-Maintenance
Organization (CEO-MO). People would join a CEO-MO, which in turn would purchase
their HMO insurance. But they would only purchase HMO insurance from those that
maintain a contract with our CEO-MO, which would require that their CEOs starve
themselves on a primary doctor's average salary. They would also be required to
keep their profit and overhead the same as Kaiser. This would mean they would
have to reduce the fat from 33% to 8%, a 25% health-care cost savings. The
shareholders would lose interest and the price per share would plummet. With
the price per share below a quotable price, there would be no further interest
in merger-mania with billion dollar CEO bailouts. The HMOs would then again
become nonprofit and would again compete on an even basis with Kaiser, preserving
the world's finest HMO structure, which would then be the best defense as an
alternative to private practice. This would give all Americans a choice for
private fee for service or real HMO care. Then with a few tweaks, we would be
close to universal health care in a free market environment. Nirvana!
* * * * *
11. Restoring Accountability in HealthCare, Government and
Society:
$ The National
Center for Policy Analysis, John C
Goodman, PhD, President, who along with Devon Herrick wrote Twenty Myths about Single-Payer Health
Insurance, which we reviewed in this newsletter the first twenty months,
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. This week read the report on New York Medicaid Fraud May Reach Billions of Dollars at www.ncpa.org/newdpd/dpdarticle.php?article_id=2004&PHPSESSID=8788111628edf4666f72764bafbe88ab.
When you spend other people's (taxpayers') money, there will always be fraud.
There are no laws that can prevent it.
$ The
$ 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. In last weeks issue, she
reports that a week after The New York
Times published a dramatic series of articles about waste and fraud in New
York's Medicaid program, The Washington Post had its own series about the
crying need for reform in Medicare. For example, the Post describes complaints
that
$ Greg Scandlen, Director of the “Center for Consumer-Driven Health Care” at the Galen Institute, has a Weekly Health
News Letter: Consumer Choice Matters.
You may subscribe to this newsletter that is distributed every Tuesday by
logging on at www.galen.org and clicking on Consumer Choice Matters. Archives are
now located at www.galen.org/ccm_archives.asp.
This is the flagship publication of Galen's new Center for Consumer-Driven
Health Care and is written by its director, Greg Scandlen, an expert in Health
Savings Accounts (HSAs).
$ The Heartland
Institute, www.heartland.org,
publishes the Health Care News, Conrad
Meier, Managing Editor Emeritus. Read the OpEd article by Dr Richard
Dolinar, “AMA Too Timid on Drug Advertising.” Dr Dolinar thinks that
advertising is a very efficient and ultimately cheaper way for this information
to be disseminated to patients. It allows patients to self-select and come to
the office to determine if the drug will be of benefit to them. To read his
entire line of logic, go to www.heartland.org/Article.cfm?artId=17490.
$ The Foundation for
Economic Education, www.fee.org,
has been publishing The Freeman - Ideas
On Liberty, Freedom’s Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Nelson
Hultberg has an excellent reprint on “Is Individualism Dead?” “Study any
account of the growth of
$ 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
$ The Health
Policy Fact Checkers is a great resource to check the facts for accuracy in
reporting and can be accessed from the preceding CAHI site or directly at www.factcheckers.org/,
where you reality check rumors.
$ The Independence
Institute, www.i2i.org is a
free-market think-tank in Golden,
$ 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. They have a new ethics course at www.nahu.org/education/NAHU_Ethics.htm.
$ Martin Masse,
Director of Publications at the Montreal Economic Institute, is the publisher
of the webzine: Le Québécois 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. Enjoy a digression into Randian prose by the Rational
Argumentator, Gennady Stolyarov II in his review of Gen Lagreca's Noble
Vision. She offers her devastatingly efficient critique of government
involvement in medicine, as she analyzes numerous broader questions. What do
politicians seek when they impose regulatory programs? Why do some people cave
in to the desire to conform at the cost of their selves and their values, while
others persist in their loyalty to principles? In the process of analyzing these
questions, she offers extensive rebuttals to the mentalities of collectivism,
altruism, conformity, and utilitarianism." Don’t miss it at www.quebecoislibre.org/05/050715-5.htm.
$ 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 at www.fraserinstitute.ca/health/index.asp?snav=he. Be sure to read the latest report in the wake of Dr Jacques
Chaoulli’s big Supreme Court win in
$ The Heritage
Foundation, www.heritage.org/,
founded in 1973, is a research and educational institute whose mission is 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. The Center for Health Policy Studies supports
and does extensive research on health
care policy that is readily available at their site. Read the current
research on
Health Policy: The Healthcare system in the
$ 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. Lew has a recent article on Decentralization that is worth reading at www.mises.org/story/1872. You may also log on to Lew’s premier
free-market site at www.lewrockwell.com to read some
of his lectures to medical groups. To learn how state medicine subsidizes
illness, see www.lewrockwell.com/rockwell/sickness.html;
or to find out why anyone would want to be an MD today, see www.lewrockwell.com/klassen/klassen46.html.
$ 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
$ 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) www.spn.org/newsite/main/.
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.
$
* * * * *
Stay Tuned to
the MedicalTuesday.Network and Have Your Friends Do the Same
Del Meyer
Del Meyer, MD, CEO & Founder
Words of
Wisdom
Jacques Chaoulli, M.D.: My dream is to show the world how to get rid of a
new and subtle form of tyranny hidden under the cover of a Welfare State's
compulsory health care program.
Pericles (430 BC): Just because you do not take an interest in politics doesn't mean
politics won't take an interest in you.
On This Date
in History - August 9
On this date in 1974, Gerald Ford succeeded Richard M Nixon, who resigned, as
President. This was the first time in American History that a man not chosen
even indirectly by the people became the President of the
Ten
years ago today, the Grateful Dead's Jerry Garcia died of a
massive heart attack. His last words were rumored to be: "Netscape opened
at WHAT?" Netscape, not having one profitable quarter, was rumored
to open at $28 a share. On this date ten years ago, Netscape didn't open
at $28, but at $71 ending the day with a $1.7 billion market cap. The great
Internet gold rush was on. It is still changing the world in thrilling
and still unforeseen ways, according to Rich Karlgaard, publisher of Forbes, as
reported in the Wall Street Journal today. It will also change
health care as doctors see the possibilities in caring for their patients more
efficiently.