MEDICAL TUESDAY . NET

NEWSLETTER

Community For Better Health Care

Vol IV, No 17, Dec 13, 2005

 

In This Issue:


1.                  Featured Article: Paperwork is 21 Percent of Health Costs

2.                  In the News: Limits of Genetic Tinkering

3.                  International Medicine: European Report

4.                  Medicare: Medicaid Welfare Program Seems to Be Forever, Even If You're Wealthy

5.                  Medical Gluttony: Many Patients are Unaware of Their Gluttonous Behavior

6.                  Medical Myths: Government Can Control Costs

7.                  Overheard in the Medical Staff Lounge: Did the Bee Really Mean Investigate Congress?

8.                  Voices of Medicine: Physician Opinions in the Various Local and Regional Medical Journals and in the Press. The Black Box, by Gil N. Mileikowsky, MD

9.                  From the Physician Patient Bookshelf: Healthy Competition: Part II – Misdiagnosis: How Not to Reform Health Care

10.              Hippocrates & His Kin: Government Is a Way Of Not Having to Think

11.              Organizations for Restoring Accountability in HealthCare, Government and Society

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The 3rd Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case study data. The 2006 conference will be held from April 17–19, 2006, in Washington, DC. For more information visit www.worldcongress.com.

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1.      Featured Article: Paperwork is 21 Percent of Health Costs

Paperwork is 21% of health costs - $26 billion goes to administration each year in state By Victoria Colliver, Chronicle Staff Writer, Friday, November 11, 2005

The study, published in the current issue of the journal Health Affairs, investigated the cost to insurance companies, doctors and hospitals of billing and other administrative tasks, such as referrals and appeals.

That translates into about $26 billion a year in California, according to the study's main author, Dr. James G. Kahn, professor at the Institute of Health Policy Studies at UCSF.

Many health experts believe that the huge amounts spent on administration is a major source of inefficiency in the U.S. health care system, diverting resources from activities that directly help patients. The United States devotes a far higher percentage of its economic resources to health care than any other developed country and much of that money never goes to medical care. [Please see Healthy Competition in the Book Review link on left or Section 9 below for an alternate opinion from Michael Cannon and Michael Tanner.]                                                                                                                                                                                                                                                                                                                                                                                 

"If you extrapolate our results nationally, you get about $230 billion a year being spent for these insurance administration expenditures," Kahn said. "This is money that, in my view, would be better spent on health care."

. . . The study concluded that 21 percent was spent on insurance administration and an additional 13 percent was used to cover other administrative tasks, such as maintaining medical records. "What you're left with is that 66 cents (out of every dollar) is spent on health care," Kahn said.

The three-year, $100,000 study was funded by the California HealthCare Foundation, a philanthropic group based in Oakland.

Kahn's research bolsters the conclusion of two Harvard Medical School researchers, who determined that $45 billion, or 28 percent, of the nearly $163 billion spent on health care in California in 2003 went to administrative costs. Nationally, the study put that figure at nearly $399 billion.

The Harvard study, which compared health care spending in the United States and Canada, looked at the total cost of medical bureaucracy, including some things not included in Kahn's work, such as profits of private health care companies. . . .

Many physicians are frustrated by the amount of time they have to devote to insurance paperwork.

"If you have 10 different insurers, you don't know which one covers what. For every medication you give you have to check the formulary," said an East Bay internist, Dr. Marion Guyer, referring to the list of drugs each insurer will cover.

Guyer said she decided to work for Kaiser Permanente, a membership organization that does not contract with multiple private insurers, to avoid the time and hassle associated with billing.

To read the entire article, please go to www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/11/11/BUGM8FM8I11.DTL&type=printable.

"The Cost of Health Insurance Administration in California" is available at www.chcf.org.

www.chcf.org/topics/healthinsurance/index.cfm?itemID=110000

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2.      In the News: Limits of Genetic Tinkering

Biohazards: Advances in biological science raise troubling questions about what it means to be human - Wesley J. Smith, Sunday, November 6, 2005

"By the end of the 21st century," writes Reason magazine science editor Ronald Bailey in his book "Liberation Biology," http://reason.com/lb/, "the typical American may attend a family reunion in which five generations are playing together. And great-great-great grandma, at 150 years old, will be as vital ... as her 30-year-old great-great grandson with whom she's playing touch football."

UCLA futurist Gregory Stock predicts in "Redesigning Humans" that the genetic engineering of progeny for health, intelligence, physical beauty, even sociability, will be so successful that procreation through intercourse will be deemed "too unpredictable," making "laboratory conception ... obligatory rather than optional."

Princeton biologist Lee Silver believes fervently, as described in "Remaking Eden," that the wonders of human redesign will eventually lead to a "special point" where our posterity will create themselves into a "special group of mental beings who" are as different from humans as humans are from primitive worms. ...'Intelligence' will "not do justice to their cognitive abilities. 'Knowledge' does not explain the depth of their understanding. ...'Power' is not strong enough to describe the control they have over technologies that can be used to shape the universe in which they live."

The prospect of a 150-year-old living human being sounds fantastical. So does pre-designing children or future generations with godlike powers. But many futurists and scientists say we humans are about to seize control of our own evolution.

If the impeders of scientific progress can just be pushed out of the way, they predict, the wonders of science and biotechnology will re-create us into superior beings who will live longer, look better, play harder and think smarter than any of us can even dream of doing today.

Others (including this writer [Wesley Smith]) see such scenarios as more hype than hope.

Some of us also worry that advocates of unfettered research are changing science from a means into an end, a belief system rather than a method. . . .

Look out America: The trajectory of science is coming into conflict with venerable human values. Which side prevails will depend less on what scientists can do than upon the ethical principles that govern society in an era of biological control.

In the United States today, every human being who is born possesses full moral and legal rights. But this is under pronounced assault. Influential philosophers, such as Princeton University's Peter Singer, assert that basing an individual's moral value on humanhood is irrational and grounded in outdated religion.

In place of humanness as the criterion for ultimate value, these advocates offer "personhood theory," in which rights belong to "persons," a status earned by any organism or machine possessing minimal cognitive capacities.

If personhood theory ever governs society, the impact would be incalculable, for as futurist James Hughes writes in "Citizen Cyborg," "Persons don't have to be human, and not all humans are persons."

Opponents of personhood theory warn that it would lead to the most vulnerable humans being exploited as mere objects.

They note that some supporters of personhood theory already advocate infanticide for profoundly disabled babies and organ harvesting from people diagnosed to be in a persistent vegetative state.

The already simmering humanhood versus personhood controversy is going to boil over as our scientific and biotechnological capacities advance.

For example, what if it becomes technologically feasible to create cloned human embryos and gestate them in real or artificial wombs to fetal stage for use in drug testing or for organ procurement? (Such experiments have already been conducted successfully in cows.)

Those who believe that humanhood provides intrinsic value argue that such "fetal farming" should be prohibited because it reduces nascent human life to the status of a mere harvestable commodity.

Personhood theorists, on the other hand, would tend to support using cloned fetal nonpersons to save the lives of persons and to reduce the suffering of animals currently used in medical research, which are seen as having greater moral value because they possess higher cognitive capacities.

New Jersey has already legalized the creation of cloned embryos and their gestation through the ninth month.

Another issue touching on the meaning and importance of human life is the creation of animals called chimeras that have been genetically engineered to contain some human DNA. . . .

Once having children was generally conducted in a simple way: Men and women got married, made love, and had babies -- although not always in that order. . . .

Infertile couples now conceive through in vitro fertilization. Women who can't carry a child can arrange to have their baby gestated by a surrogate birth mother. . . .

But critics worry that our growing mastery over reproduction could slide from liberty into license and even into reproductive anarchy. Look for these issues to cut through the body politic like a laser in the coming decades:

-- Is there a right to reproduce?

This issue strikes at core beliefs about the importance of natural limits, age, gender, sexual orientation, feminism, traditionalism, normality and the purposes of becoming a parent. . . .

How all of this will turn out, nobody knows. But as Leon Kass, former chairman of the President's Council on Bioethics, has said: "All of the natural boundaries are up for grabs. All of the boundaries that have defined us as human beings, boundaries between a human being and an animal on one side and between a human being and a super human being or a god on the other. The boundaries of life, the boundaries of death. These are the questions of the 21st century, and nothing could be more important."

Wesley J. Smith is a senior fellow at the Discovery Institute and a special consultant to the Center for Bioethics and Culture. His current book is "Consumer's Guide to a Brave New World." Contact us at insight@sfchronicle.com.

Read the whole article at

www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/11/06/INGKGFGTEG1.DTL&type=printable.

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3.      International Medicine: European Report 

Health Care Cuts in Europe by Paul Belien, The Brussels Journal, Wednesday, November 23, 2005.

When conversations turn to health care, I am always reminded of my grandfather. He was 91 when he died. He had never been ill. He had never needed medical treatment in his whole life. Upon reaching his nineties, however, he required prostate surgery.

Like all Belgians, my grandfather had paid wage-related contributions to cover health insurance throughout his entire professional life. The Belgian health care system is a so-called pay-as-you-go system. Today's young and healthy do not set money aside for their own future needs, but are compelled to pay for today's sick and elderly. As my grandfather had never needed much health care, he had been a net contributor to the system. Now was the first time he was going to claim something back.

He had his operation in May. In November he was dead. The prostate operation had gone fine, but afterwards the hospital had given him an antibiotic drug that caused complete deafness. Though there were other, but costlier, drugs available, the hospital gave the old man the cheapest one. They knew about the side-effects, but it did not strike them as an unreasonable and unjust thing to do. Why should it? A man who has already had 90 healthy years of life surely has no right to complain about deafness when some people get more seriously ill or die at a far younger age. When my grandfather left the hospital he was completely deaf. He lost his will to live. Six months later, he was dead.

In many Western European countries, health care is the fastest growing segment of government spending. Over the past forty years there has been a significant increase in health-care spending. According to the latest OECD figures (2003), Western European countries spend between 7.3 and 11.5% of their gross domestic product on health care. Ten years ago it was between 6.9 and 9.9%. In 1960 it was only around 4%.

Much of the rise in Europe's health-care costs is caused by factors beyond government control, such as demographic evolution. Another important cause of rising expenditure, however, is the advancement of better and newer – but more expensive – medical technology.

There are only two ways to keep the present government-run European health-care systems going. One can either drastically increase the financial burden on those at the paying end of the system – the young and healthy of today – or one can drastically limit the quality and the availability of health care for those at the receiving end – the sick and the elderly.

For decades governments increased the financial burden on the working population. When this burden became intolerable, they shifted their policies towards cutting back quality. In Europe there are medical treatments, operations or drugs, which are not available to persons above a certain age, or to persons who are considered too sick, or to anyone at all. Political authorities, claiming to be the guardians of solidarity in society, decide who is allowed to get what kind of treatment, operation or drug. Soon euthanasia might be the price the solidarity principle of the welfare state imposes on those people whose health care is costing society the most. Politicians in Belgium and the Netherlands have already granted their citizens a "right to die" by means of a lethal (and cheap) euthanasia injection. Is this a new "freedom" that the state, which is constantly restricting every other aspect of our lives, generously bestows on us? Or does it boil down to "economic euthanasia," which enables governments to save money by eliminating those that cost the welfare state too much?

Other ways in which many governments in Europe have tried to control health-care spending has been by drawing up "negative lists" of drugs which doctors are not allowed to prescribe. Drugs are put on the "negative" list not because they are harmful, but because they are high-quality goods that are deemed too expensive.

For almost a decade now, governments have been stifling medical innovation in Europe. Last month the American drug company Pfizer decided not to build a new plant in Belgium because the Belgian government has been constantly raising taxation on pharmaceuticals. The government wants to reduce pharmaceutical expenditure by limiting drugs. They reckon that by limiting supply, demand will go down. In the same way, European governments discourage young people from becoming doctors, dentists or nurses. Many countries allow only a limited number of people to study for a medical profession, despite the fact that, due to the demographic development and the growing number of elderly, more doctors and nurses will be needed in the future. . . .

As is often the case, many of continental Europe's policies are of German origin. In the early 1990s the German government, in a move designed to cut health-care costs, limited – and in some cases completely blocked – access to new drugs and medical technology. Since 1993 the German government has set separate budgets for each segment of the health-care market, with provisions of heavy sanctions if these budgets are exceeded. The 1993 pharmaceutical budget was set at $15 billion – a 9.1% cut from 1992. The government ruled that money spent over the budget would be taken out of doctors' incomes. This caused a 25% drop in spending on medicine. . . .

While these measures were successful in the field of cost control, they had devastating consequences for the pharmaceutical industry. The German pharmaceutical companies, no longer keen on developing new drugs, saw their world-wide share of drug patents drop to 8% from 16%. Doctors, afraid that they would have to pay the pharmaceutical bills out of their own pockets, started to refer their patients to specialists and hospitals. Patients with minor illnesses, requiring common and cheaper medicines were helped, but the doctors would "dump" their more serious cases instead of treating them in more costly ways. As a result, in 1993 Germany saw an increase of 10% in hospital patients and 9% in referrals to specialists. . . .

"Money is being saved – even if it costs lives to do so. Whenever possible many hospitals are turning away expensive patients covered by the sickness funds. The only good patient is a cheap patient."

Unfortunately, the German system has become the European model. Politicians in neighbouring (sic) welfare states, noticing the drop in German health expenditure, started to follow the German example. The only thing that mattered in their eyes was cost control. Many adopted the policy of adding drug volume control to price control and finally to prescription control. France introduced so-called negative recommendations, telling doctors what they are allowed to prescribe and what not. These recommendations have been made compulsory and doctors risk heavy financial penalties if they go against them.

At the root of these decisions is the understandable desire of governments to control health-care costs. But rationing is clearly not the answer. What many governments in Western Europe have overlooked is that there is nothing wrong with a society devoting more of its resources to health care. This even appears to be an indication of prosperity. The higher and the more developed a society becomes, the more its citizens are willing to spend on keeping healthy. Modern technology makes everything cheaper except the highest quality of medical care, which is constantly improving. To try to limit access to this technology in the name of "cost-control" is irresponsible.

Meanwhile, the larger and more fundamental problem of how to finance the health-care systems is not adressed. Instead of funding the provisions of today's sick with taxes from today's healthy and young, people should be building up reserves for their own future liabilities. What Europe needs is to replace its pay-as-you-go systems by privatized and capitalized health-care systems. This, however, would imply that the governments relinquish control over the system, which is the very last thing they are willing to do.

To read the entire report, please go to www.canadafreepress.com/2005/brussels112305.htm.

Paul Belien is the editor of the Flemish quarterly Secessie and the editor-in-chief of The BrusselsJournal. He is a columnist at the Flemish weekly Pallieterke and at the Flemish monthly Doorbraak and a regular contributor to the Flemish conservative monthly Nucleus, which he co-founded in 1990.

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4.      Medicare: Medicaid Welfare Program Seems to Be Forever, Even If You're Wealthy

My homeless patient came in last week for his annual exam. I have been seeing him since 2002. Some may recall that he lived in boxes behind a bar when he was out of jail for substance abuse. In 2003, he started living in his car and obtained drinking water, showered and shaved at the YMCA. Low and behold, people started being friendly with him. In 2004, he obtained a job driving a truck and was able to keep body and cell phone together in an apartment.

Last week, he came in well dressed, his beard neatly trimmed, and could have passed for a mid-level executive. He announced that he was now driving an 18-wheeler, sometimes a 30-wheeler, truck interstate. He said the money was good, real good. After checking his pulmonary function and finding that his asthma was improved, partly due to living in a clean environment, he stated that he had been taking his standard bronchodilators and had not suffered from asthma attacks in the past year. He also decreased his cigarette smoking. After writing his prescriptions for the next year and escorting him to the door, I noted that he was still covered by Medicaid insurance, government healthcare for the poor and destitute. I looked surprised. He said he still had two more years to go before his next review of the disability he obtained for being on drugs.

 Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5.      Medical Gluttony: Many Patients are Unaware of their Gluttonous Behavior

One of my patients, a 72-year-old lady, came in for an office visit to obtain a health statement so she could continue substitute teaching in her school district. In reviewing her medical history since her last visit three months earlier, I found she had gone to the hospital Emergency Room because of elevated blood pressure. On the previous Saturday it was elevate to 210/112 at 4 PM. When asked why she didn't take one of her two blood pressure medications, she said it wasn't time until 5 PM to take them. Why didn't you take them early? She said, "I didn't know I could."

Her emergency record noted that no medications or treatment was given. She stated that she took her pill bottles with her and when the nurse interviewed her, she was advised that she should take her 5 PM medications even though it was an hour early. She was then allowed to occupy an expensive ER bed for two hours, after which her blood pressure returned to the usual 130/80 range.  When reminded of the ER cost, and the daily newspaper reports concerning excessive health care costs, she said she had no idea that ERs are so expensive. If she had to pay a portion of the ER costs, say what an average physician office visit cost (about $100) and the rest of the ER cost would be paid by Medicare (about $600), would she have gone to the ER? She acknowledged that she would have either called me or taken her high blood pressure medications on her own.

How can this gluttonous behavior be stopped? Was Medicare able to stop it with their massive restrictive and oversight programs? No, this happened under Medicare's watch. Would health insurance carriers or managed care companies have been able to stop this with their massive restrictive and oversight programs? No, this happened under health plan co-insurance managed care watch.

This type of gluttonous behavior can only be controlled through patient responsibility. It is not a classroom learnable experience – not even by this teacher after 50 years of teaching. This behavior can only be corrected through financial responsibility. Patients with no health insurance shop wisely and reduce their costs to about half. Patients with a percentage co-payment also shop wisely and reduce their health care costs, by estimates of 30 percent to 50 percent. Patients with a fixed or no co-payment, simply use their health plan financed by taxpayers or the pool of insured premium payers with no regard for its cost. This lady increased her health care costs by 600 percent because it was there. There was actually a disincentive to save costs since the $100 office call would have cost her a $10 co-payment, while the $600 ER visits had no co-payment because it was construed as an emergency, which it wasn't.

Single-payer or socialized medicine by any other name has never worked and will never work. Human gluttony will always exceed human need. Medical responsibility will never occur with third-party health care with no or fixed co-payment plans. It will only occur with a graduated deductible and graduated co-payment system. To think that non-economic incentives or a police state can control one of the largest items in a family's budget is unrealistic thinking.

To paraphrase the warning of Paul Revere:

Beware: The Socialists are Coming – The Socialists are Coming

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6.      Medical Myths:  Government Can Control Costs

Retiring manager gets raise: Sacramento council also awards 10% pay increases to other top administrators. By Terri Hardy -- Bee Staff Writer Published Wednesday, November 23, 2005.

Sacramento can forget about a gold watch for City Manager Bob Thomas, who retires Dec. 31.

The City Council that pressured Thomas to step down earlier this month quietly gave him an even nicer send-off Tuesday - a 10 percent pay raise and potentially a higher pension for life.

The decision boosts Thomas' salary to $208,900 from $189,901. The council made the increase retroactive to July 1, the beginning of its fiscal year.

 

The council was generous to its other top administrators as well, giving them identical retroactive 10 percent salary increases. City Attorney Sam Jackson's salary rose to $182,800 from $166,148, City Treasurer Tom Friery's to $169,900 from $154,502 and City Clerk Shirley Concolino's to $122,000 from $110,946.

Jackson also is retiring soon, although the date has not been announced. The new city attorney will be Eileen Teichert, a supervising deputy city attorney in Riverside. After an executive session Tuesday, Mayor Heather Fargo announced that Teichert will assume the post Jan. 1.

The timing and the substantial amount of the pay increases could trigger a review by the California Public Employees Retirement System, according to spokeswoman Pat Macht. . . .

If a pay raise was given as part of a final settlement, was listed as special compensation or would not be used to calculate the pay range for the city manager in the future, Macht said, it might not be allowed in a pension calculation.

"It would raise a red flag - the compensation experts would take a look at it," she said.

However, Macht said, if the raise was given to other key managers, was recommended after a compensation survey, or would be used to set the salary for a replacement candidate, the pension increase would be more in line with CalPERS requirements.

 

In a written report to the council, Dee Contreras, director of the city's labor relations office, said the recommended raises were based on performance and in comparison with several other cities in California and the West.

Contreras said the raises will place Sacramento's top administrators above the average, but not at the top, and ensures the city can attract good employees. . . .

On Tuesday, the council unanimously approved the salary increases with no discussion. It was included as part of the consent agenda, usually reserved for noncontroversial items. . . .

Theis Finlev, policy advocate for California Common Cause, said salary discussions such as these should always be discussed in public on the regular agenda.

"Sacramentans were not given enough opportunity to weigh in on this," Finlev said.

 Read the entire article at www.sacbee.com/content/politics/local_government/v-print/story/13895924p-14734780c.html.

About the writer: The Bee's Terri Hardy can be reached at (916) 321-1073 or thardy@sacbee.com.

Also see: Documents Show He'll Receive $80,000 To Retire Early By Terri Hardy at www.sacbee.com/content/politics/local_government/story/13900001p-14738680c.html.

Reality: No Branch of Government Can Control Costs or Make Accurate Financial Projections. They Use Myths Justify Their Gluttonous Behavior.

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7.      Overheard in the Medical Staff Lounge: Did the Bee Really Mean Investigate Congress?

Dr Milton was reading the editorial in the November 30, 2005, Sacramento BEE, stating that Rep Randy Cunningham is about to move from his big house, a Mansion, to a much bigger house, the prison. This was graphically illustrated by Rex Rabin in an adjacent cartoon. Rep. Randy "Duke" Cunningham's admission that he took bribes to help a defense contractor secure contracts ends one political career but should ignite a deeper investigation of Congress, according to the BEE.

"Though unsavory, it is not unusual for members of Congress on powerful defense committees and subcommittees to receive campaign donations from defense contractors or to be recruited for lucrative lobbying and defense industry jobs after they leave elected office. From Congress to the school board, proving that contributions are made with the specific intent to influence an official act or received because of an official act is what's difficult to pin down.

"But that wasn't the case for Cunningham, R-Rancho Santa Fe, and his quid pro quo. Cunningham blatantly and shamelessly took private favors in exchange for steering contracts to his benefactor. Cunningham admitted in U.S. District Court that he used his position on the House Appropriations Defense Subcommittee to steer government contracts to a defense contractor in exchange for personal favors. . . . All told, Cunningham admitted in court to receiving at least $2.4 million in bribes."

Dr Rosen: But won't investigating bribes decimate Congress?

Dr Milton:  Hopefully. And wouldn't that be the biggest step in restoring freedom in our country?

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8.      Voices of Medicine: Physician Opinions in the Various Local and Regional Medical Journals and the Lay Press. The Black Box.

White Paper For Patient Safety: In Search Of The "Black Box" For Reliable And Cost-Effective Quality Control Of The Delivery Of Medical Care. By Gil N. Mileikowsky, MD

The reason airline transportation is the safest of all transports is due to the famous "black box" that provides the necessary first step, i.e. the accurate "diagnosis." Without that reliable "forensic" analysis, the "blind lead the blind." 

The reason the Federal Aviation Agency (FAA) is effective is because it has jurisdiction over every aspect of the airline industry, including pilots, mechanics, flight attendants, management and manufacturers.  It can prevent disasters because it has the power to act immediately, without the intervention of any other agency, e.g. the U.S. Department of Justice and its lengthy process.  The FAA can ground, at once, a particular type of plane or an entire airline company, with good cause.  Without it, planes would crash daily.

There is no such equivalent in the healthcare industry, however the taxpayer is spending billions of dollars on multiple layers of county, state, federal and not-for-profit agencies that are defective by design. On November 24, 2002, Dennis O'Leary, M.D., President of JCAHO (Joint Commission on Accreditation of Healthcare Organizations) said, "There are some who believe that this whole system has to be blown up and start over again, I happen to be one of those advocates."1 In 2004, the GAO (Government Accountability Office) provided its own devastating analysis.2

Is it possible to have a "black box" in the health care industry? 

Absolutely, yes.

In clinical research, to evaluate new treatments we use randomized "double-blind" studies, where neither the physicians nor the patients know which pill is a placebo and which pill actually contains the drug. We can do the same when evaluating any error or complication in the health care industry, whether it's in the hospital, the doctor's office, the pharmacy, the manufacturer of a medical device, etc.

We have about 900,000 licensed physicians in the US and 100,000 of them are in California. That's a terrific, diversified pool to serve in a "black box."

Whenever any error or complication is reported, it could be submitted anonymously, i.e. without the patient's name, the physician's name, the hospital's name, the city or state, to an odd number (7 to 11) licensed individuals who will also remain anonymous to the patient, physician and hospital. This anonymity will assure an unbiased, impartial opinion, void of any possible conflict of interest. Such an approach also eliminates any concern of "immunity," as the identity of those individuals will never be known. 

A "black box" method of investigation should combine multiple disciplines, i.e. physicians, pharmacists, nurses, administrators, medical device manufacturers, laboratory technicians, etc., because errors and complications in the health care sector can result from various sources in a hospital, a laboratory, a pharmacy, a doctor's office, etc. "It's the system stupid," as R.M. Wachter, M.D. and K.W. Shojania, M.D., point out in Internal Bleeding – the truth behind America's terrifying epidemic of medical mistakes.3

Such a "black box" could be consulted in lieu of "experts" by state medical boards, hospitals' peer review, medical malpractice cases, Medicare investigations, etc., since their "experts" are at times the weak link or "Achilles tendon" of the system. 

Such a "black box" could also prevent future errors and complications because the opinions of each member of such a "black box" could be reviewed and a physician, a pharmacist, a nurse, or an administrator whose professional opinion may fall below the acceptable standard of practice could be identified and educated in such a proactive "two way" analysis. Isn't the whole purpose of peer review to learn from our colleagues' mistakes so that we can reduce errors and complications in our industry by not repeating them.

Such a "black box" participation should be mandatory as a part of maintaining and renewing the licenses' of physicians, nurses, pharmacists, hospitals, etc., in the same way that participation in peer review is mandatory under the bylaws of hospitals for members in order to maintain their "active" status. We could save the taxpayer a lot of money by merging all state boards - medical, nursing, pharmacists, tissue bank, laboratory, hospitals -, into a single state and federal oversight agencies. Thus, their investigative capabilities would be merged into one single comprehensive unit, much like our multiple intelligence agencies are coordinated through the "Homeland Security" Department. This is the only way to achieve a uniform quality control across the country. See articles in the Washington Post regarding the disparate effectiveness of various state medical boards.4 

To read the entire article, please scroll down at http://www.delmeyer.net/HMCPeerRev.htm.


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9.      Book Review: HEALTHY COMPETITION - What's Holding Back Health Care and How to Free It by Michael F Cannon & Michael D Tanner, Cato Institute, Washington, DC © 2005, ISBN 1-930865-81-3, 173 pp, $10. Part II – Misdiagnosis: Chapter 3: How Not to Reform Health Care

With America's health care system presenting such symptoms, few would deny the need for reform. However, as many of the preceding criticisms indicate, the underlying condition is poorly understood. This misunderstanding has led to various prescriptions that would be far worse than the disease. As in the practice of medicine, the guiding philosophy of health policy should be, First, do no harm.

The authors begin with a popular subject of the "Right" to Health Care as claimed by Physicians for a National Health Program, a group that claims to represent more than 10,000 doctors and medical students. (about one percent of physicians) Sen. Edward M. Kennedy (D-Mass.) has remarked, "We have it in our power to make the fundamental human right to health care a reality for all Americans.” His colleague Sen. John F. Kerry (D-Mass.) has said, "I'm committed to universal health care coverage because, in America, health care is not a privilege, it's a right."

The authors respond: "Medical care can be as essential to survival as food. But does it follow that people have a right to medical care? Would recognizing a right to health care solve America's health care difficulties or add to them? We can answer these questions with a thought exercise. Suppose Congress and the states were to amend the U.S. Constitution by adding a legally enforceable right to health care. Even if such a measure could win approval, the debate would not and could not end there. The first difficulty would be to define the ''right.'' What health care do Americans, by right, deserve? Do Americans have a right to preventive care? What types of preventive care? Should mammograms be made available to all women, regardless of their likelihood of developing breast cancer? Health care researcher J. D. Kleinke notes that if government recommendations were followed, the number of Americans on drug regimens for hypertension, asthma, obesity, and high cholesterol would increase anywhere from 2- to 10-fold. Spending on pharmaceuticals would explode. With the wide variety of medical tests and treatments that consumers may claim as their right, someone at some point must decide where the right to health care ends, lest the nation be bankrupted. That debate is currently taking place over a proposed constitutional right to health insurance in Massachusetts.

"Whoever has the power to make these decisions will exercise enormous power over who does and does not receive medical care. Who should have that power? In most nations that have tried to guarantee universal access to medical care, politicians allocate specified funds to local bureaucracies, which in turn decide how medical care will be rationed. This is typically achieved by making even seriously ill patients wait for care.

"A second and related difficulty is the question of who pays. A right to health care by definition would not be conditioned on one's ability to pay. Enforcing the right would require increasing taxes in proportion to how generously one defines the ''right.''

"A third difficulty is the incentives such a system creates. Patients would have little reason to constrain their consumption because additional consumption would cost them little. Higher tax rates would discourage work and productivity, yielding less economic growth and wealth. Pushing down the compensation of medical professionals would discourage many (and many of the brightest) candidates from entering the field of medicine. Divorcing their compensation from the satisfaction of their patients would reduce the quality of care. Since innovations that increase medical productivity also increase spending, policymakers would discourage innovation because every new discovery puts them in the uncomfortable position of either increasing taxes or saying ''no'' to patients. The paradox of a ''right to health care'' is that it discourages the very activities that help deliver on that ''right.''

"A final difficulty is how to deliver the medical care to which all are now entitled. Declaring health care to be a right does nothing to solve the problem of getting the right resources to the right place at the right time. Where are doctors most needed? Where will we place hospitals? Who will produce surgical tools? How much will they be paid? These decisions must be made through the political process. Not only has the political process proven slow and imprecise at meeting shifting needs, but those with political power would enjoy a greater ''right'' to health care than others by virtue of their ability to affect the allocation of health resources. That has largely been the experience of countries that have tried to enforce a right to health care. . . .

"Fundamentally, creating a legal 'right' to health care is incompatible with the idea of individual rights. People cannot legitimately claim a right to something if that claim infringes on the rights of another. Smith's right to free speech takes nothing away from Jones. The only obligation Jones owes to Smith is not to interfere with Smith's exercise of her rights. The same is not true of a right to health care, which would turn the concept of rights from a shield into a sword by imposing an obligation on Jones to provide health care to Smith.

"The underlying goal of creating a legal right to health care is to provide medical care to the greatest number possible. The fact that this approach would reduce the amount of medical care available to most or all Americans suggests that we should look for other ways of achieving this goal."

"Government-Run Health Care . . . as is done in Canada, Europe, and elsewhere go by the names single-payer, universal coverage, national health insurance, or national health care. The details of these proposals vary, but in general they would finance the provision of health care through higher taxes. . . .  

"A government-run health care system would come at enormous cost to American taxpayers. One proposal championed by Representative and former Democratic presidential candidate Dennis Kucinich was estimated to cost as much as $6 trillion over 10 years. Supporters argue that some of this cost would be offset by savings from reduced administrative costs and insurance company profits. However, research suggests that government provision of health care leads to higher administrative costs. Patricia Danzon has estimated that administrative costs under Canada's single-payer health care system equal more than 45 percent of claims, while the figure for private health insurance in the United States is less than 8 percent of claims. She writes, "The rough empirical evidence tends to confirm that overhead costs in Canada, adjusted to include some of the most significant hidden costs, are indeed higher than they are under private insurance in the United States." On the one hand, supporters of national health insurance also predict savings from preventive care that the uninsured currently do not receive. On the other hand, most cost estimates do not include the increased demand that would follow the reduction or elimination of copayments and deductibles. . . .

"Whatever its powers, government cannot repeal the laws of economics.  When individuals perceive health care to be free, the quantity demanded increases. Faced with the choice of bankrupting their economy to pay for the virtually unlimited demand, or reducing the amount of health care provided, these countries opt for the latter. 

"Even with rationing, however, government-run health care systems do a poor job of controlling the rising cost of health care. When such factors as population growth, general inflation, exchange rates, growth in elderly populations, investment in research and development, and rates of crime, poverty, AIDS, and teen pregnancy are taken into account, Canadian health spending is much closer to that of the United States, and actually rose faster over much of the 1970s and 1980s.

"Universal health care is not free. Citizens of countries with national health care systems pay a heavy price in taxes. Canada's government-run health care system is one of the major reasons why the average Canadian family pays 47 percent of its income in taxes. . . .

"One step removed from government management of the health care marketplace is the concept of 'Managed Competition'" That idea would leave the provision of health care in private hands, but would create an artificial marketplace run under strict government control. Managed competition saw its fullest rendering in the failed Clinton health care plan. . . .

University of Chicago law professor Richard Epstein has noted that managed competition "is not so much a coherent government plan as an oxymoron. It is possible to have either managed health care or competition in health care services. It is not possible to have both simultaneously" Even advocates agree that, in the words of one of its originators, Alain Enthoven, "Managed competition is not a free market.'' In many ways, managed competition simply builds a layer of government control on top of all the worst features of the current system. . . .

To read the rest of Part II, Chapter 3 – How Not to Reform Health Care, please go to the Cato Bookstore: www.catostore.org/index.asp?fa=ProductDetails&method=cats&scid=33&pid=1441272. The price is only $10. At that rate, consider purchasing two or three and do your friends, who don't understand the ideas above, a favor with a gift that keeps on giving. There are also excellent other recent titles you may want to consider.

Next month, Part III: Underlying Diseases, Strong Medicine, Chapter 4: Too Much of a Good Thing Can Be Very Bad

To read some of the other book reviews that are available, please go to www.delmeyer.net/PhysicianPatientBookshelf.htm.

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10.  Hippocrates & His Kin: Government Is a Way Of Not Having to Think

Harry Browne: Out of the mouths of nurses: During a recent hospital stay, I had an interesting conversation about government with a nurse, Kathleen Brazil. In the middle of the dialogue, she suddenly said, "Government is a way of not having to think." And in those eight words, she wrapped up neatly the seduction of government for so many people. www.harrybrowne.org/

Goodness, I hope she thinks when she's taking care of the sick and dying.


Vioxx Verdict: In the battle between sound science and the trial bar, it was probably too much to hope that Merck would win the lawsuit whose verdict came down Friday [August 19]. There was no direct causal link between Vioxx and the arrhythmia that the autopsy showed had caused the death of a Texas man whose wife brought the suit. The only evidence for such a link was the speculation from the medical examiner that Vioxx had caused a heart attack that she had not been able to detect and had not bothered to put on the death certificate. http://online.wsj.com/article/SB112466735410219175.html?mod=todays_us_opinion

How can you have a heart attack that can't be confirmed on the autopsy? So now attorneys, judges, and juries can hand down verdicts based on speculation rather than evidence?


A MedicalTuesday member writes about a college friend diagnosed as mentally ill by the psychologists at the euphemistically named student-counseling center. Ended up locked up in mental institution for some months. Finally her advisor heard about it. She was a chem major and had been working with selenium. Symptoms of excessive selenium exposure are, well, apparently similar to those of mental illness. They were so tuned to seeing everything as a psychological problem that they never even considered a physical cause until the professor started raising Cain.
It's always hazardous to allow allied medical fields to make a medical diagnosis. Before long, we might even hear of administrators of insurance carriers or even government practicing medicine by telling doctors how to diagnose and treat.

George Washington's Thanksgiving Prayer "Whereas it is the duty of all nations to acknowledge the providence of Almighty God, to obey His will, to be grateful for His benefits, and humbly to implore His protection and favor . . .that great and glorious Being who is the beneficent author of all the good that was, that is, or that will be." http://online.wsj.com/article_print/SB113287973488606161.html

If George Washington were alive today, he may never have become president.


Joshua Wolf Shenk, author of Lincoln's Melancholy: How Depression Challenged a President and Fueled his Greatness states: Modern clinicians agree that Lincoln suffered from depression. It's instructive to see how he collapsed, but even more so to see how his collapses led him to a signal moment of self-understanding.

Had Abraham Lincoln lived today in our current milieu of political correctness, he could never have been elected president and slavery may have lasted another generation or more.

To read more HHK columns, please go to www.healthcarecom.net/hhk2000.htm.

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11.  Organizations for Restoring Accountability in HealthCare, Government and Society:


 

•                      The National Center for Policy Analysis, (www.ncpa.org) John C Goodman, PhD, President, who along with Devon Herrick wrote Twenty Myths about Single-Payer Health Insurance, reviewed in this newsletter during our first twenty months. John C Goodman, Gerald R Musgrave and Devon Herrick, have recently published Lives at Risk. Read a chapter at www.ncpa.org/pub/lives_risk/livesrisk_24.pdf. Read a review at www.healthcarecom.net/JGLivesAtRisk.htm. You may log on at www.ncpa.org/sub/ and register to receive the weekly Health Policy Digest, a health summary of the full NCPA daily report, Executive Alerts, New NCPA publications, and a number of other fine reports. Be sure to visit their new Consumer Driven Health Care website at http://cdhc.ncpa.org/ for the latest on Market Competition Improving Quality while reducing costs and the value of Medical Research.

•                      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 subscribe at www.pacificresearch.org/pub/hpp/index.html or access their health page at www.pacificresearch.org/centers/hcs/index.html. This month, be sure to read The Acute Nature of Chronic Problems: Why the AARP drumbeat on costs won't help cure a single patient. www.pacificresearch.org/press/opd/2005/Medical_Progress_10-05.pdf.

•                      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 their Global Prosperity Initiative at www.mercatus.org/globalprosperity/subcategory.php/213.html.  

•                      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. Be sure to read her current report on Too Many Choices at www.galen.org/medicare.asp?docID=846.

•                      Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to www.chcchoices.org/publications.html. To join, go to www.chcchoices.org/join.html. To read the current issue, go to www.chcchoices.org/publications/cpr6.pdf.

•                      The Heartland Institute, www.heartland.org, publishes the Health Care News founded and edited by Conrad F Meier in 2001. Conrad passed on unexpectedly earlier this year. Be sure to get his latest book at the CAHI site below. This month, read Why Government Failed in New Orleans at www.heartland.org/Article.cfm?artId=17876. They emphasize that corruption is more pervasive and more difficult to root out in the public sector than it is in the private sector. In the private sector, competition among producers and freedom of choice exercised by consumers cause markets to punish and squeeze out corruption. In government, congressional oversight committees and the occasional whistleblower attempt, often with little success, to do what markets do naturally and well.

•                      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. Having bound copies of this running treatise on free-market economics for over 40 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 fifty years ago. This month, be sure to read another classic on Political Accounting by James Bovard who is the author of Freedom in Chains: The Rise of the State and the Demise of the Citizen, www.fee.org/publications/the-freeman/article.asp?aid=4854. "Since government is coercion, politics is largely the exercise of deception regarding the intended use of coercion. . . . If a politician camouflages his plans, people may fail to resist the increased power until it is too late. This is the thumbnail history of Social Security, a program that illustrates the natural combination of paternalism and political fraud."

•                      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." Get the latest HSA and other health insurance issues directly from the opening index page.

•                      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/. This week, read the Daily Medical Follies: "Woeful Tales from the World of Nationalized Health Care" at www.factcheckers.org/showArticleSection.php?section=follies, or just review the list of common myths and what is reality.

•                      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 at www.i2i.org/healthcarecenter.aspx. Read the latest posting by senior fellow Mike Krause:  WHEN POLICY GOES TO POT: It's time to change Colorado's strategy in the war on drugs to see the positive side of losing federal dollars (tax dollars extracted by the federal government) at www.i2i.org/article.aspx?ID=1181.

•                      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 and accessible on the opening page. Make this your guide to insurance, whether Individual, Group, Long Term Care or information on HSAs. www.nahu.org/consumer/HSAGuide.htm. 

•                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quιbιcois 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. This month, read Bradley Doucet's  "Native Poverty: Why Relying On Government Is A Poor Solution" at www.quebecoislibre.org/05/051115-8.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 some good news from the Mideast with a report that Lebanon and Oman are the most economically free people in the Arab world.  www.fraserinstitute.ca/shared/readmore.asp?sNav=nr&id=699

•                      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. The Medicare Maladies at www.heritage.org/research/healthcare/mm.cfm and Bitter Pill series at www.heritage.org/Research/HealthCare/bp18.cfm contain a wealth of basic health care information. This month, be sure to read Ed Feulner, PhD's, latest commentary on Medicare and Social Security "Entitlement Fix Not an Option for Uncle Sam" at www.heritage.org/Press/Commentary/ed120505a.cfm.

•                      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 might want to read this month on "The Rise and Fall of the City" by Hans-Hermann Hoppe at www.mises.org/story/1959. 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 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 at www.cato.org/people/cannon.html. Michael F Cannon and Michael D Tanner have recently written on Healthy Competition – What's Holding Back Health Care and How to Free It. Read a review of Chapter 3 by clicking on Book Reviews at the left. Order your copy at the Cato Bookstore. www.catostore.org/index.asp?fa=ProductDetails&pid=1441272&method=search&t=healthy&a=&k=&aeid=&adv=&pg

•                      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 Heartland Institute is featured by clicking on "Links."

•                      The Free State Project, 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. You may obtain copies of The Quill, the Free State Project's monthly newsletter at http://freestateproject.org/news/thequill/. 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 in our own state.]

•                      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. 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 it's national rankings in the USNews College rankings. Last year, 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. Read President Arnn's comments at www.hillsdale.edu/arnn/usnews.asp. Also read his comments on Ronald Reagan, RIP, at www.hillsdale.edu/newimprimis/default.htm. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. To read Dr Arnn's November Imprimis "Whatever Happened to the Ownership Society" go to www.hillsdale.edu/Imprimis/. The last ten years of Imprimis are archived at www.hillsdale.edu/imprimis/archives.htm.

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Stay Tuned to the MedicalTuesday.Network and Have Your Friends Do the Same.

Please note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

Del Meyer

Del Meyer, MD, Editor & Founder

DelMeyer@MedicalTuesday.net

www.MedicalTuesday.net

6620 Coyle Ave, Ste 122, Carmichael, CA 95608

Words of Wisdom

George Orwell: Political language . . . is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.

Ruth Grant: Hypocrisy and politics are inextricably connected on account of the peculiar character of political relationships.

Social Security Commissioner Stanford Ross, 1979: The mythology of Social Security contributed greatly to its success.

P. J. O'Rourke: When buying and selling are controlled by legislation, the first things to be bought and sold are legislatures.

Mark Twain, (1866): No man's life, liberty, or property are safe while the legislature is in session.

Unknown Author: Talk is cheap – except when Congress does it.

Some Recent or Relevant Postings

Medicare Reform: Pharmacy Benefit Program—What Must Be Done – A Clinician's Point of View www.delmeyer.net/hmc2005.htm

The Tipping Point - How Little Things Can Make a Big Difference - by Malcolm Gladwell www.delmeyer.net/bkrev_TheTippingPoint.htm

THE TYRANNY OF GOOD INTENTIONS - How Prosecutors and Bureaucrats are Trampling the Constitution in the Name of Justice, Paul Craig Roberts & Lawrence M Stratton http://healthcarecom.net/bkrev_TyrannyofGoodIntentions.htm

On This Date in History – December 13

Sir Francis Drake set out to sail the world on this date in 1577.

Abel Tasman discovered New Zealand on this date in 1642.

Dartmouth College was chartered on this date in 1792, formerly the Moor's Indian Charity School.

Robert E Lee spoke a few wise words on this date in 1862: It is well that war is so terrible, or we should grow too fond of it.