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MedicalTuesday
refers to the meetings that were traditionally held on Tuesday evenings where
physicians met with their colleagues and the interested business and
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In
This Issue:
1.
The Health-Choice Headache
2.
Evidence-Based Medicine Examined
3.
Cost of Open-Ended Health Care
4.
Saving Social Security – It's Simple: Social Security Is Very Complex
5.
Medical Gluttony Can Only Occur in a Non-Market-Based Environment
6.
Medical Myths: Every American Has a Right to Medical Care
7.
Overheard in the Medical Staff Lounge - New Year's Eve Crises - argaiV
8. The MedicalTuesday Recommendations for Restoring Accountability in HealthCare, Government and Society
*
* * * *
1.
The
Health-Choice Headache
David
Wessel, a reporter for the Wall Street
Journal, (WSJ) writes in the
Wessel
sat down at the dining-room table with summaries of the three health-insurance
options that the publisher of his newspaper offers its employees and the two
options that his wife's employer offers. Wessel's goal was to pick the deal best
for him, his wife and their two teenagers.
Wessel
majored in economics in college, has always done his own tax returns and
scrupulously checks those "explanation of benefit" forms to be sure
they're correct. But after staring at the grids their employers provided, he
surrendered: There was no way he could make a rational choice, and it's not just
because it's impossible to predict if someone in the family will get sick next
year.
Wessel's
plan covers routine physicals only for kids up to age 13. His wife's covers
physicals for the whole family. His plan charges $8 for a generic-drug
prescription and $15 for a brand-name. Hers has six different charges from $5 to
$100, depending on where the drug is purchased, whether it's generic and, if
not, whether it's on the plan formulary.
Wessel's
plan has a $400 per-person deductible for in-network care and $475 for
out-of-network care. But they're combined: If he runs up a tab above $475,
there's no deductible left. Hers has separate deductibles: If she uses $500
out-of-network, and then sees an in-network doctor, she's starts from scratch.
His plan expects employees to know the difference between "co-payment"
and "co-insurance."
When
you shop for an auto loan or a mortgage, every lender has to calculate the
"annual percentage rate" similarly so you can compare apples to
apples. Health insurance doesn't work that way. Each big employer has its own
way of presenting information and crafting benefits; so does each health
insurer. And employers and insurers have sometimes conflicting goals: saving
money, putting health benefits in the best light to boost worker morale, and
devising co-pays and other incentives so workers use health care more wisely.
But if health plans become so intricate that few workers understand them, then
the incentives to be smart shoppers won't work.
Wessel concludes: "Choice and competition create complexity. It's almost always worth it. We don't want auto makers to restrict their offerings to three models of cars -- small, medium and large. But, gosh, help us make a smart choice. All we are saying is: Give us a chance to become smarter shoppers for health insurance, which is what you say you want us to be.” http://online.wsj.com/article/0,,SB110255187733595080,00.html
*
* * * *
2.
Evidence-Based
Medicine Examined
Twila
Brase, the President of the Citizens' Council on Health Care in
One
of the most powerful arguments in the paper discusses the validity of practice
guidelines, and notes, "In 2000, a group of researchers determined that
more than 75 percent of the guidelines developed between 1990 and 1996 needed
updating." Ms. Brase says that "they discovered that half of the
guidelines were outdated in 5.8 years." Yet the development of guidelines
is slow, cumbersome and expensive, taking as long as two years and costing as
much as $100,000 - unless the government does it, in which case it costs
$800,000.
The
guidelines themselves are based on "research" that may be biased,
incomplete or self-interested. Certainly we have seen numerous examples of
research not getting published because it contradicts the claims of the sponsors
of the research. Even the decision of what research to fund is often made for
political, not medical, reasons.
Research
is often contradictory. Hormone Replacement Therapy was found to lower the risk
of heart disease in the Nurses Health Study, while the Women's Health Initiative
study found that it increased heart attacks by 40%. But neither study can tell a
clinician how to treat one particular woman with one particular genetic profile
and one particular set of risk factors and co-morbidities. Population-wide
information may be interesting, but it is no substitute for individual diagnosis
and treatment. Relying on averages never works when dealing with individuals.
In
fact that may be the biggest problem with EBM - it is trying to standardize
medicine at the very time when we should be customizing medicine so that each
patient gets precisely the treatment that is best for his or her particular
needs.
Still,
research and guidelines for all their flaws can be very valuable in growing the
knowledge base. The danger is not the research, but how the bureaucrats want to
use the research. They want to control physicians who comply and punish those
who do not through the use of financial incentives, malpractice exemptions, and
even hospital privileges and licensure, all tied to compliance with EBM
guidelines.
This
is the polar opposite of consumer empowerment and choice. EBM advocates want
only to empower themselves, and we all owe Twila Brase a hearty congratulations
for bringing this to the attention of the American people.
SOURCE: http://www.cchconline.org/pdfreport.
*
* * * *
3.
Cost of Open-Ended Health Care
Shari
Roan, health writer for the Los
Angeles Times, recently discussed PET scans as an emerging vital tool to
diagnose Alzheimer's. She quotes a number of directors of PET centers at
Universities who feel that PET scans (Positron
Emission Tomography),
which have been used by pioneers in neurology for 10 years, are under utilized.
They are 91 percent effective in diagnosing the disease about three years sooner
than relying on medical examination, including psychological and cognitive
testing. Some neurologists feel that starting therapy early helps to slow the
process. Roan gives incidence of having Alzheimer's as 10 percent of people over
age 65 and 50 percent of people over age 85. The current cost is $1500 per exam.
Other statistics have estimated that there are 14 million Americans with
Alzheimer's. If everyone had a PET exam, this would add $20 billion to our
health care costs. This is down from the estimated $40 billion ten years ago,
when the test cost was $2800.
If
only those patients with Alzheimer's received the test, that would indicate that
clinical judgement has a degree of accuracy approaching 100 percent. That would
mean the test would only be an expensive confirmation of the diagnosis and would
be unnecessary. To find everyone with a disease, one must screen far more than
the anticipated number or many will be missed.
For
instance, if a patient has a lung nodule, which has a 10 percent chance of being
malignant, the pulmonologist of several decades ago would have to refer 20
percent of the most suspicious cases to the thoracic surgeon to be sure there
weren't any missed. Hence, the surgical literature in the 1960s report a 50
percent malignant rate for lung nodules removed since it was 50 percent of those
referred to the surgeon. However, the pulmonary literature which referred to all
lung nodules seen in a pulmonary practice reported a 10 percent malignant rate
since they included the 80 percent that were considered benign by standard
criteria and were not referred to the thoracic surgeon. With modern bronchoscopy
and imaging techniques, the pulmonologist of today evaluates essentially all
lung nodules to a diagnosis, which means the surgeon only sees the ones that
need resection (removal).
The
corollary in evaluating demented people would be similar. When memory fades,
every son or daughter is convinced that their parent has Alzheimer's. The
physician receives an inordinate amount of pressure from families to make an
accurate diagnosis, even if the treatment doesn't change. Using the
aforementioned pulmonary nodule example, one could estimate that 28 million,
rather than 14 million, people could justifiably be screened with PET scans if
there weren't some restraints in place.
What restraints are effective and patient sensitive? In Medicare, Medicaid, HMOs and most insurance plans, one must traverse a formidable bureaucracy before the test will be approved. In HSAs, with a several thousand dollar deductible, the patient and family will evaluate the need for the test and proceed only if the physician can convince them that it is needed in order to proceed with effective and helpful treatment. In pay-as-you-go practices, the patient and his family constantly evaluate any medical recommendations on a cost-benefit analysis. Thus, only those tests are done that are really necessary. In the HealthPlanUSA working draft, based on anecdotal evidence, it has been determined that most outpatient medicine will return to the Medical MarketPlace with a 30 percent copayment. In this example, the patient and the family, in consultation with their physician, will balance the need for a PET scan with a 30 percent copayment or $450 copayment for the $1500 test, which prevents excessive utilization. HealthPlanUSA is only directed to that part of society without a government-sponsored health plan such as Medicaid and Medicare. But it also eliminates all bureaucratic overseeing, as well as all billing and bookkeeping costs. It is expected to reduce overhead in the same fashion as pay-as-you-go health care, which has reduced expenses in half and thus decreased professional fees by half. It has also reduced the malpractice problem because patients that pay only for necessary services don't pay if they are not satisfied and thus the medical liability problem is essentially resolved.
*
* * * *
4.
Saving Social Security – It's Simple: Social
Security Is Very Complex
Bert
McLachlan, author of Saving
Social Security (from Congress), comments on Susan Lee's Wall
Street Journal article, "All You Need to Know About Social
Security" (http://online.wsj.com/article/0,,SB110117497648381576,00.html)
that it is not nearly that simple. First you really need to know about the
mythical "trust fund," and then about the way it invalidates
"actuarial balance" calculations, which in turn invalidate the
conclusions of the Presidential Commission's Model Two, along with all
"costing" of congressional plans to "save Social Security"
(politically, but not financially). Those who do not understand these
"little details," which are perpetuated mainly by the Social Security
Administration and its trustees, will unfortunately come up with bad proposed
solutions because their understanding of the problems is based on
misinformation. But that's where we are headed.
Herbert
F. Reilly III also comments on Susan Lee's
article. She did
Shouldn't
the poor be entitled to accounts of their own to use as they see fit, and pass
on to family if they die early? Selling the concept of Social Security private
accounts should be simple.
URL for this article: http://online.wsj.com/article/0,,SB110238266088492781,00.html.
*
* * * *
5.
Medical
Gluttony Can Only Occur in a Non-market-Based Environment
Last
week, we were deluged with a number of patients who could not see their usual
doctor because the physician’s affiliated hospital had been blacklisted by a
major insurance carrier. In evaluating these patients, it was helpful to review
their previous records to see how their doctor had handled their medical
problems. Many of these patients were surprised at some of the recorded
diagnoses because they had never been discussed. These included major items such
as hypertension, hyperlipidemia and diabetes. One record cited elevated lipids
ranging from triglycerides of 400 to 800 (normal about 100) that had been
dutifully measured and recorded every six months for a number of years, but
never treated. Although transparency of laboratory charges are difficult at
best, this is about a $75 to $100 test in some laboratories.
*
* * * *
6.
Medical Myths: Every
American Has a Right to Medical Care
Madeleine
Pelner Cosman, PhD, JD, Esq, in her
upcoming book, Who Owns Your Body,
gives Nine Myths of American Medicine. Today we review Myth
6: Every American Has a Right to
Medical Care. For the previous five, see http://www.healthplanusa.net/MC-WhoOwnsYourBodyIntro.htm.
This
chapter presents the legal background of Americans’ medical rights of privacy
and physical autonomy. It explores perceived rights to Medicare and to Medicaid.
Congressmen, medical experts, and the media constantly refer to health care
rights. They describe monies and surpluses in our Medicare Trust Funds. With
Trust Fund money Congress offers to pay for generous prescription drug benefits
for all American seniors. Despite impassioned political rhetoric asserting
rights to medical care, four critical questions provide alarming answers.
a.
Is there a right to medical care?
b.
Is there a right to Medicare?
c.
Does any American have a Medicare Trust Fund?
d.
Is there a right to Medicaid?
If
medical care, Medicare, and Medicaid are not rights, what are they? What is the
difference between a liberty right
and a welfare benefit? What
distinguishes a substantive right
from a mere procedural right?
There
is no right to medical care in any of the seven articles of the U.S.
Constitution, or in the first ten amendments called the Bill of Rights, or in
the seventeen subsequent amendments. No state provides a right to medical care.
Likewise, there is no Constitutional right to food, to clothes, or to housing.
The Constitution guarantees such rights as to vote, to speak freely, and to be
fairly compensated if the government takes our private property for public use.
Our rights prevent government and other people from taking our freedom and our
goods. No right provides free goods.
Welfare
benefits are free goods. Our rich, compassionate nation provides welfare food
benefits, housing, clothing, and medical benefits for those who cannot provide
for themselves. Those benefits are not rights. If they were rights then you, I,
and your wealthy aunt Jeannie could collect a monthly check for food. Or rent.
Or clothes. We cannot. We should not. Why should we get free medical care? We
cannot and we should not.
For
every right, someone or some government entity has a legally enforceable
responsibility to assure the right. If there were a right to food, every
restaurant owner and every farmer would be obligated to provide food to anyone
who demanded it. If medical care were a right, every physician and surgeon would
be obligated to provide medical goods and services. Suppose a doctor was not
willing or not able to treat a patient. Suppose the pay was too little to cover
costs and expenses. Under a system with a right to health care the government
could compel the physician to supply services under threat of prison.
Medicare
Trust Funds violate the legal and linguistic meanings of "trust." Each
payday working Americans pay into a Medicare Trust Fund money withheld from
their paychecks. The implication is that each employee has a personal account
invested for his benefit. Medicare Trust Funds are brutal deceptions. No
Americans who paid into the Medicare program at any time from 1965 until today
have paid into a Medicare Trust Fund for themselves or for others. No one owns a
Medicare Trust Fund. None of the money they paid has been invested for their
future or anyone else’s future medical care. They
paid for anonymous retirees claiming Medicare benefits. Medicare always has
been a pay as you go program. There
is no money in the two Medicare Trust Funds now and there will be none later
except for withholdings from future paychecks of future
workers. While in 1965 the ratio of workers to retirees was 7 to 1, now it is
fewer than 4 to 1, and soon will be 2 to 1. In fewer than a dozen years, the
41,000,000 people currently on Medicare and the 47,000,000 on Medicaid will
suffer a tidal wave of new fervent competitors for "free" medical
care. The first wave of 77,000,000 Baby Boomers hits shore in 2010. Who will be
left working to pay for Medicare?
Now
in 2003 Medicare is functionally bankrupt. It is running a deficit that
according to the Congressional Budget Office (CBO) exceeds $1.1 trillion
dollars. We neither see that number nor hear about it because CBO keeps the
sinking Medicare ship afloat with general tax revenues. Accountancy tricks split
the costs and revenues of the two sections of Medicare (Part A devoted to
hospital costs is called Hospital Insurance and Part B dedicated to medical
office expenses is called Supplemental Medical Insurance). The result is
mythical trust accounts that have mythical revenues that generate mythical
surpluses. Even the most fervent mythmakers will be shocked at the projections
of the Medicare Trustees in their Annual Report of 2003. If current financial
manipulations continue, our grandchildren will pay 71% of each paycheck to
support Medicare’s aged and disabled. Medicare’s hazardous financial antics
are far more pernicious than current, prosecuted corporate frauds and
deceptions.
Americans
who understand the perilous truth will act prudently, logically, and responsibly
or suffer inevitable exploding costs, crushing taxation, and savage benefit
cuts.
TRUTH
6: There is No Enumerated or Implied Constitutional Right to Medical Care
(To save Social Security and Medicare, we must make sure that those 77 million baby boomers don’t hit shore at age 65. Benefits which started at age 65 in the 1930s when life expectancy was less than 65, should have been indexed to the current increased life expectancy of age 75. We only have five years to complete this indexing or a Tsunami wave will hit our shores.)
*
* * * *
7.
Overheard in the Medical
Staff Lounge - New Year's Eve Crises - argaiV
A patient called on New Year’s Eve day wanting an urgent refill for his "argaiV." (We must spell this medical word backwards otherwise this newsletter will be rejected by more than 500 Medical Tuesday members who receive this newsletter at their corporate address and email from our URL may be permanently banned. Increasingly, many spammators do the same). My staff tried to get him to come in. He said he couldn't make it and he would need the medication that evening. So, understanding the seriousness of the matter, we made an exception to our “no between-office-visits phone refills” and obliged.
*
* * * *
8.
MedicalTuesday Recommends the Following
Organizations for Their Efforts in Restoring Accountability in HealthCare,
Government and Society:
$
The National
Center for Policy Analysis, John C
Goodman, PhD, President, issues a weekly Health
Policy Digest, a health summary of the full NCPA
daily report. You may log onto http://www.ncpa.org
and register to receive one or more of these reports. MedicalTuesday members and
readers are knowledgeable with Twenty
Myths about Single-Payer Health Insurance which we reviewed in this
newsletter the first twenty months of its existence. Please read a review of
their new book, Lives at Risk, http://www.healthcarecom.net/JGLivesAtRisk.htm,
the definitive work on Single-Payer National Health Insurance Around the World.
It shows that the
$
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
onto their website at http://www.galen.org.
This week, she discusses the December White House economic summit that set an
agenda for the next year and beyond that will begin with a debate over Social
Security and move into tax reform and tort reform. Will health care fall by the
wayside? To read her most recent newsletters, "Off and Running" on
prescription drugs, go to http://www.galen.org/pdrugs.asp?docID=759.
$
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 informative and well-outlined
newsletter that is distributed every Tuesday by logging onto http://www.galen.org
and clicking on Consumer Choice Matters.
Archives are now located at http://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 Medical Savings Accounts (MSAs) which recently
became Health Savings Accounts (HSAs). He reports that this has been An
Interesting New Year - For Hospitals. To read the entire newsletter on
"Ownership of Insurance," go to http://www.galen.org/ownins.asp?docID=757.
$
The Heartland Institute, http://www.heartland.org,
publishes the Health Care News, Conrad
Meier, Managing Editor Emeritus. Richard Rahn, reports last week on a speech
given at the Finance Ministry in
$
The Foundation for Economic
Education, www.fee.org, has been publishing
The Freeman - Ideas On Liberty,
Freedom’s Magazine, for over 50 years, has 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, read an article by Editor Richman,
"The Shady Origins of Social Security" at http://www.fee.org/vnews.php?nid=6531.
$
The Council for Affordable Health
Insurance, http://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
To
eliminate the uninsured problem, the politicians should pass just one law -
eliminate all mandates and all community ratings - and then get out of the way
of the problem so the solution can occur.
$
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 at http://www.factcheckers.org/.
Be sure to read the Daily Medical Follies: “Woeful Tales from the World of
Nationalized Health Care” at http://www.factcheckers.org/showArticleSection.php?section=follies.
$
The Independence Institute, www.i2i.org,
is a free-market think-tank in Golden,
$
The National Association of
Health Underwriters, http://www.NAHU.org,
$
Martin Masse, Director of
Publications at the Montreal Economic Institute, is the publisher of the
webzine: Le Québécois Libre.
Please log on at http://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 Martin Masse's editorial http://www.quebecoislibre.org/04/040615-2.htm.
The Department of Fisheries and Oceans recently advertised a
100,000-dollar-a-year position that was restricted to non-whites. "DFO
believes it is important to ensure that our senior management team represents
diversity," they wrote. "Competitions such as this one are aimed to
help increase the involvement of Canadians within specific demographic
groups…" To read this month’s OpEd article by Jayant Bhandari,
“Racism, old and new,” or call it whatever you want: racism, reverse racism,
or corrective racism, go to http://www.quebecoislibre.org/04/041215-15.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 http://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 http://www.fraserinstitute.ca/health/index.asp?snav=he.
The Institute reports on the American Medical Savings Accounts and recommends
them as Universal, Accessible, Portable and Comprehensive Health Care for
Canadians. The literature in the
$
The Heritage Foundation, http://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. Be sure to read
yesterday’s editorial “Bitter Pills #12: Can You See The Big Picture in
Medicare Spending?” at http://www.heritage.org/Research/HealthCare/bp12.cfm.
Every year, the Heritage Foundation and the Wall
Street Journal publish the Index of Economic Freedom. 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 http://www.mises.org
to obtain the foundation’s daily reports. To read Thomas J. DiLorenzo’s
article on the Tsunami disaster, “A Foreign Aid Disaster in the Making,” go
to http://www.mises.org/fullstory.aspx?Id=1715.
You may also log onto 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 http://www.lewrockwell.com/rockwell/sickness.html;
or to find out why anyone would want to be an MD today, see http://www.lewrockwell.com/klassen/klassen46.html.
$
CATO. The Cato Institute (http://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 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. Please see http://www.ethanallen.org/index2.html
and click on “links” to see the other 41 free-market organizations
throughout the
$
*
* * * *
Stay
Tuned to the MedicalTuesday.Network and Have Your Friends Do the Same
The
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Del
Meyer
Del
Meyer, MD, CEO & Founder
Words
of Wisdom
James
Bryce, (1914): Medicine is the only
profession that labors incessantly to destroy the reason for its own existence.
P.
J. O'Rourke: When buying and selling are
controlled by legislation, the first thing to be bought and sold are
legislatures.
Mark
Twain, (1866):
There is no distinctly native American criminal class save Congress.
Will
Medical
Aphorisms
In
medicine, the more practice a doctor has, the less practice he needs.
Only
a fool would make his doctor his heir.
Some
Recent Postings
Lives
at Risk: Single-Payer National Health Insurance Around the World
shows that national single-payer health care systems in countries such as
Terrorism’s
Next Target, by David Gibson, MD, http://www.healthplanusa.net/DGTerrorism'sNextTarget.htm.
Midlife
Bible - A Woman’s Survival Guide by
Michael Goodman, MD, http://www.healthcarecom.net/bkrev_MidlifeBible.htm.
On
This Date in History - January 11
On
this date in 49 B.C., Caesar crossed the Rubicon,
committing himself irrevocably to war against Pompey and the Roman Senate. This
phrase caught on and we may have a Personal
Rubicon to cross, and countries have a National
Rubicon to cross. Some think we are in it now.
On
this date in 1935, Amelia Earhart Putnam became the first woman to fly solo
across the Pacific from
On
this date in 1755, Alexander Hamilton was born.
Although he was important in American History, and his likeness is on a $10
bill, he lost his life in an "affair of honor," a victim of a duel
with Aaron Burr.