MEDICAL TUESDAY . NET

NEWSLETTER

Community For Better Health Care

Vol VIII, No 19, Jan 12, 2010

 

In This Issue:


1.                  Featured Article: There are 280 Million Americans without Legal Care Coverage

2.                  In the News: Medicare Rationing Begins in One Year!

3.                  International Medicine: The weekly crises in government medicine throughout the world

4.                  Medicare: Extremists in Control

5.                  Medical Gluttony: Mudaany activity that adds cost, but does not add value

6.                  Medical Myths: What's Democratic about Obama's pseudo healthcare reform

7.                  Overheard in the Medical Staff Lounge: What's next for Doctors & Patients?

8.                  Voices of Medicine: Health is Politics, big Politics

9.                  The Bookshelf: How Medicine is Changing and What it Means to You

10.              Hippocrates & His Kin: Who has Time to read a thousand-page bill before we Vote on it?

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

Words of Wisdom, Recent Postings, In Memoriam . . .

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The Annual World Health Care Congress, a market of ideas, 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 7th Annual World Health Care Congress will be held April 12-14, 2010 in Washington D.C. For more information, visit www.worldcongress.com. The future is occurring NOW.

Keep in touch with evolving healthcare by subscribing to HPUSA . . .

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1.      Featured Article: There are 280 Million Americans without Legal Care Coverage!

LegalCare: It is Time to Lower Legal Costs and Ensure Affordable, Accessible Legal Coverage for All by Matthew S. Rice, M. D., Journal of American Physicians and Surgeons, AAPS

According to the American Bar Association, thousands of innocent working Americans are wrongfully convicted of crimes every year, in part due to negligent or poorly trained lawyers, careless judges, and prosecutorial misconduct. Samuel R. Gross, Professor of Law at University of Michigan, estimates that between 3.3 percent and 7 percent of convictions are erroneous, meaning that between 60,000 and 140,000 innocent Americans are incarcerated.

With attorney-legislators scrutinizing and planning the reform of medicine and the health insurance industry, it is only fitting that physicians apply the most current progressive healthcare reform principles to the legal profession. Attorney-legislators and other politicians and appointees are strongly encouraged to use the present healthcare reform momentum to simultaneously reform the legal profession. Doing so would greatly add to their credibility among constituents and other stakeholders, since they know essentially nothing about medicine and everything about law. Legal reform: it is time.

IllustrativeAnecdotes

·         Cameron Willingham was convicted of murdering his children by arson in 1992. Due in part to poverty, inadequate representation by legal counsel, and an inefficient, haphazard, paper-dependent Legalcare system based on medieval principles and practices, he was executed in 2004. The Texas Forensic Science Commission has been examining the flawed investigation that contributed to the execution of this man, thought by many arson experts to be innocent . . .

·         Eddie Lloyd was wrongfully convicted of rape and murder in 1985. Contributing factors to this tragic injustice included representation by a court-appointed attorney, poor hand-off between defense attorneys prior to trial, and the fact that another state-appointed attorney failed to meet with Lloyd or file a claim of ineffective assistance of counsel. Lloyd was exonerated after spending 17 years in prison, and died two years later.

Scope and Severity of the Problem

Legalcare costs in the U.S. are skyrocketing, with tort costs alone draining Americans of $865 billion dollars annually, a sum greater than the entire combined gross domestic products of New Zealand, Hong Kong, Ireland, Vietnam, Qatar, Ecuador, and Luxembourg. Billions more are wasted by fearful business owners complying with dubious regulations drafted by lawyers. Are we getting our money's worth? Is the United States anymore safe, just, or lawful than Japan or Great Britain, where the legal-cost burden is half of what we pay? According to The Times of London, our legal system is worse than that of either Russia or China.

The prohibitive costs of lawsuits and liability insurance are smothering small business owners and working Americans, who bear almost 70 percent of business tort liability costs. 

Class-action lawsuits result in multi-million dollar payouts to lawyers while consumers end up with nothing of value. David de Alba, a California Superior Court Judge, awarded attorneys who filed a class-action lawsuit against Ford Motor Company $25 million. What did the plaintiffs receive? Coupons they could apply toward the purchase of a new vehicle.

Expenses related to defensive medicine practices add $124 billion annually to healthcare costs, more than enough to give a $10,000 health insurance premium to each chronically uninsured American. 

The burden of lawsuits in America is an unseen "tax" of $9,827 on each working family of four. Unless you're Warren Buffett or Bill Gates, your family or small business is just one serious legal bill away from bankruptcy, and all bankruptcies in America involve at least one expensive legal bill. . .

While half of all Americans will require Legalcare services in any given year, almost 280 million Americans lack legal insurance. For those few Americans who do have legal insurance coverage, most plans only cover a limited number of attorney visits and fail to provide coverage for preexisting situations such as divorce proceedings, custody cases, bankruptcy, or cases involving alcohol or drugs, thus exposing hardworking families to unlimited financial liabilities. Even those Americans with coverage are struggling to cope with soaring legal expenses. As a nation we can no longer afford to accept the status quo. The cost of inaction is simply too much to bear. . .

Racial minorities, the poor, non-citizens, and men receive longer prison sentences than whites, the wealthy, citizens, and women, respectively. Recent studies by the American Bar Association estimate that half of all poor Americans suffer from at least one serious legal problem each year, but 75 percent of them have no access to Legalcare services. While the average profit per partner of the most successful law firms soared to $755,000 annually over the past 10 years, these same attorneys only provided eight minutes per day of pro-bono Legalcare services to the needy and helpless who suffer from serious legal conditions. Clearly, perverse profit motives have hindered the ability of many attorneys to reach their potential in providing low-cost or free Legalcare services to the poor.  Imagine an America in which disenfranchised socioeconomic groups and disparity ethnic groups had access to the same quality Legalcare afforded to the wealthiest Americans!

Too many Americans go without high-value preventive Legalcare services such as professional income tax preparation and reviews; estate, will, and trust planning; legal risk reviews; precrime legal mitigation assessments; and other critical legal services available only to the wealthiest Americans. Routine use of preventive legal services could help Americans avoid future liabilities, but owing to prohibitive costs, many working American families forgo such counsel only to suffer the far greater consequences of future legal or regulatory noncompliance. Our legal system has become a criminal and civil system, and the time for reform is well overdue.

Lower Costs to Make Our Legalcare System Work for People and Businesses— Not Just for Lawyers.

Inefficient and poor-quality Legalcare costs the nation hundreds of billions of dollars every year. Billions more are wasted on administration and overhead, and this problem will only worsen as legal spending increases over the next decade. We must redesign our Legalcare system to reduce inefficiency and waste, and improve Legalcare quality, driving down costs for families and businesses. We can do this by: (1) adopting state-of-the-art legal information technology systems; (2) ensuring that clients receive, and attorneys deliver, the best possible counsel, including preventive legal services and chronic-offender management services; and (3) liberating attorneys from perverse profit incentives by implementing a national single-payer Legalcare system.

Legal costs and quality can vary tremendously among firms and attorneys; however clients have limited access to this information.  We must require firms and attorneys to collect and publicly report measures of legal costs and quality, including data on hourly fees, legal errors, miscarriages of justice, attorney-to-client staffing ratios, overruled motions, reversed verdicts, and conviction rates.

We must align incentives with excellence. Sadly, many attorneys collect fees based on the volume of services provided rather than on the quality of those services. For example, a working parent might take her obese child to an attorney to sue a school for damages arising from chronic illnesses caused by the federally funded school lunch program. The attorney might think to himself, "I could make a lot more money by taking this case and billing these people $400 per hour, rather than telling them that the case is futile."

Enter Legalcare, a national single payer legal system that would set reimbursement rates for attorneys and link quality legal counsel with incentives. Legalcare would cover all Americans and drive down legal costs across the board. Legalcare would be administered by a Department of Legal Services (DLS). Reimbursement rates would be modeled on the highly successful Medicare program, and would range from $12.56 to $170.65 per attorney-client session, based on coded documentation of the complexity and quality of Legalcare services provided.

Tackling the Disparities in Legalcare

Although all Americans are affected by this crisis in our Legalcare delivery system, an overwhelming body of evidence indicates that certain populations are significantly more likely to receive lower quality Legalcare than others.

Do not all Americans deserve access to the best available Legalcare? Could a poor working member accused of drug possession simply walk into the office of a politically connected trial lawyer, and receive the Legalcare he needed and deserved at an affordable price? Of course not! Lawyers demand cash retainers, ranging in the thousands to tens of thousands of dollars for criminal defense. He would likely end up with a poorly trained, non-connected public defender, and spend years languishing in prison. According to a damning 2002 report, many public defenders are "unqualified, irresponsible, or overburdened and do little if any meaningful work for [their] clients." It is our nation's moral duty to ensure that attorneys and law firms provide affordable counsel to all Americans, especially our most vulnerable and disenfranchised; and to end the practice of "cherry-picking" easy clients or lucrative cases. . .

Attorneys must be required to keep electronic legal records (ELR) for their clients, the benefits of which are substantial: improved administrative efficiencies, improved quality of Legalcare, elimination of legal errors, reduction of redundancies and paperwork, and lower Legalcare costs, among others. The ELR should be modeled after the functional and efficient Department of Defense electronic medical record, AHLTA, which is arguably the "Porsche" of electronic medical records. The National Coordinator of Legal Information Technology would ensure that attorneys who fail to be meaningful users of the approved ELR  (Attorney Hypermetric Longitudinal Technology Application) by 2015 face reduced payments and other financial penalties from the DLS. In a general sense, meaningful users of the ELR are defined as attorneys who demonstrate to the government that they are using electronic documentation, that their technology is connected in a manner that provides for electronic exchange of legal data to improve quality of legal services, and those attorneys who submit information to the government on legal outcome measures.

The National Institute of Comparative Legal Effectiveness would monitor attorney-client decisions via the ELR to make sure that lawyers do what the DLS deems appropriate, fair, and cost-effective.  The goal is to reduce costs and guide attorneys' decisions, with the aim of standardizing and improving legal outcomes for all Americans. . .

Affordable, Accessible Coverage for All

We must guarantee affordable and accessible legal counsel for all Americans. Currently, with nearly 280 million Americans lacking legal insurance, rising costs are a burden on working families and small businesses. It is simply too expensive for individuals and families to buy the Legalcare they need and deserve on the open market, and is impossible for many with ongoing or preexisting legal problems.

We must require law firms and attorneys to accept clients with pre-existing legal problems (to include recalcitrant criminal behavior, drug and alcohol addictions, and civil problems such as complicated divorce and custody battles), at fair reimbursement rates set by the DLS. We can no longer allow attorneys and firms to accept easy or lucrative cases while dismissing those who cannot pay, or who suffer from challenging legal conditions.

Legalcare would be budget-neutral if it were funded with a small addition to the existing Federal Insurance Contributions Act tax (FICA), and a federal tax of 75 percent on all tort awards and on all court filing fees. Legalcare will enable all deserving Americans to get the comprehensive and quality legal benefits they need and deserve at a fair and stable price. It will eliminate the two-tiered Legalcare system currently in place, keeping courthouse doors open for all, regardless of economic status or race.

Read the entire Legalcare proposal at www.jpands.org/vol14no4/rice.pdf.

Matthew S. Rice, M.D. is a family physician in Tacoma, Wash. Contact:

matthew_s_rice@yahoo.com. Also see www.SinglePayerLegal.org.

© The Association of the American Physicians and Surgeons, Jane M Orient, MD, Executive Director, Managing Editor; Winter issue of JAPS, Lawrence R Huntoon, MD, PhD, Editor-in-Chief, editor@Jpands.org 

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2.      In the News: Medicare Rationing Begins in One Year!

"Medicare Rationing Begins in January, 2011," by AAPS Director Richard Amerling, M.D., Medical Progress Today.

House and Senate Democrat leaders, and President Obama, argue that they can "pay for" health insurance "reform" by cutting $500 billion from Medicare spending over the next decade—largely through arbitrary reimbursement cuts,— without reducing the quality of care delivered to beneficiaries.

Yet, in January, 2011, Medicare will implement a new payment system for patients receiving dialysis for end stage kidney disease that will severely ration care to this vulnerable (and largely minority) population based on equally arbitrary payment reductions. These patients will be the unfortunate canary in the Medicare coal mine: "reform" legislation will expose millions of Medicare patients to rationing and reduced quality of care.

Read the entire article: www.medicalprogresstoday.com/spotlight/spotlight_indarchive.php?id=1835
Click here to listen to audio podcast with Dr. Amerling.

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3.      International Medicine: The weekly crises in government medicine throughout the world.

Health of UK's seriously ill babies is threatened by funding crisis

Doctors say research is jeopardised by concentration on more profitable adult medicine

Anushka Asthana in The Observer, Sunday 3 January 2010

Research into health conditions affecting babies and older children is facing a funding crisis, say leading doctors who warn the shortfall is seriously hampering the development of new medicines.

Paediatricians from prominent hospitals, including Great Ormond Street and the Royal Marsden in London and "Jimmy's" – St James's Hospital in Leeds, accused the government of failing to fund its "fair share" of research. They said pharmaceutical companies were also paying too little attention to funding drug research for children because it was "much less profitable" than investing in medicines for adults.

The specialists fear the recession will worsen the crisis by cutting funds from charities – on which some children's units are heavily dependent.

Their views have emerged from a poll of leading paediatric medical professionals commissioned by Sparks, the children's medical research charity, and carried out by Populus. Almost four out of five respondents said the economic crisis will "harm seriously clinical care and research" into paediatric medicine. A similar number said the development of new medicines for babies and children had become a serious problem.

One professor said: "Lack of available funding is beginning to have a huge, negative impact on the quality and quantity of research which is paramount to the health and general wellbeing of our children." Another said: "Gaining funding, in particular from the commercial or pharmaceutical sector which has little interest in children's diseases, is a serious challenge, given the decline in paediatric research departments in the UK." . . .

Dr Simon Newell, a senior lecturer in paediatrics at St James's, said the poll indicated that children's medical research was badly underfunded. The situation was so serious that 50% of "good research projects that are up and ready to go" failed to receive funding. . .

Newell, a neonatal medicine specialist, said his unit used money raised by a golf tournament to fund a therapy for babies starved of oxygen at birth.

He pointed out that many children's units were funded by charities and expressed alarm about an NHS accounting change that will make hospitals list donations on their balance sheets. Critics say the move could be used as a smokescreen for budget cuts. . .

"The reliance on charities for funding cutting-edge paediatric medical research projects has never been greater."

Professor Neena Modi, of the Royal College of Paediatrics and Child Health, said: "Children's research funding has always taken second place to adult research funding. Also, research into newborn health has received even less funding. The importance of medical research to benefit infants and children can't be over-emphasised."

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The NHS does not give timely access to healthcare, it only gives access to a waiting list.

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4.      Medicare: Extremists in Control

Obama Passed Up Opportunity for Real Reform - Health Care News

Commentary by John C Goodman December 22, 2009, Source: The Heartland Institute

No one really likes any of the various health care reform proposals passed by Congress. Why would the majority of Members of Congress vote for bills that no one really likes and no one thinks will control costs or improve quality and possibly not even improve access to care?

The health care reform legislation is much worse than it ever needed to be, because of two decisions by President Obama: Not to take a principled approach to health care reform, and not to try for bipartisan legislation.

Unwieldy Coalition

If you propose a bill that isn't going to get a single Republican vote, you need every single Democrat vote to pass the Senate. If you can't afford to lose even a single Democrat, that means you have to start bribing the holdouts-$300 million for Sen. Mary Landrieu's (D-LA) vote, for example.

It also means you can't afford to lose a single special interest. You need the doctors, the hospitals, AARP, the drug companies, the insurance companies (at least the large ones), the medical device companies, Medicaid constituencies, and more. More precisely, you need the organizations that claim to represent doctors, hospitals, insurers, and the elderly. [Since the AMA does not represent American Doctors, using their support is pure subterfuge on the part of Obama. –Editor]

So whatever bill you start with has to be modified again and again, until you line all these folks up. Since almost all those special interests benefit from wasteful spending, the end product will have no possibility of controlling costs. And since all those interests are threatened by fundamental quality improvements, the end product is not going to improve quality, either.

And given that opening up the market to improve access would likewise threaten a lot of interests you have to keep onboard, very little can be done to increase supply and improve access to care.

Extremists in Control

The fact that you can't lose a single Democrat vote also means you must satisfy the left wing of the Democratic Party. And what the left hates the most in health care is anything that even hints of free markets. So, at a minimum keeping the left onboard means no economic incentives, no price competition, no entrepreneurship, no patient power, no consumer-driven health care-at least, no more than what we have now.

Of course, almost all the special interests that are on board-even the ones running TV ads in support-will tell you privately the current version of health care reform is far from perfect.  In fact, reform is likely to make things worse, not better.

The interest groups have signed on because the administration confronted them with a threat: If you don't stay at the table, you are going to be the meal.

Avoiding Real Reform

How could reform have been different? Obama could have started with the Wyden-Bennett bill, a bipartisan measure that has 15 Senate cosponsors, including 5 Republicans. This bill isn't a timid approach to health reform. It even has an individual mandate and a health insurance exchange.

Obama might also have taken an approach that is both bipartisan and principled. He could have started with Sen. Tom Coburn's (R-OK) bill, under which the federal subsidy for health insurance to all Americans is the same, and which is close to revenue-neutral.

This is an approach that would command support from a wide spectrum of health economists. Besides being a Republican, Coburn is a respected medical doctor, and given that Sen. John McCain (R-AZ) ran on a similar plan in 2008, it would have been very difficult for any Republican senator to vote "no."

Of course, a Coburn-McCain approach probably could not pass in its pure form-especially given labor union opposition. But it could serve as a starting point from which modifications could be made in order to bring enough special interests and recalcitrant Democrats on board to pass a bill.

What might have been is what people thought they were voting for in the last election: A nonpartisan, get-things-done-the-right-way, no-special-interest approach to health reform. What we got instead was politics as usual.

- John C. Goodman (john.goodman@ncpa.org) is president, CEO, and Kellye Wright fellow of the National Center for Policy Analysis.

www.ncpa.org/commentaries/obama-passed-up-opportunity-for-real-reform2

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

- Ronald Reagan

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5.      Medical Gluttony: Mudaany activity that adds cost, but does not add value.

In our recent issue, we discussed the Toyota success story wherein Toyota eliminated all activity in their company that did not increase value—thus producing the world's largest car company. In applying this to the practice of third party medicine, it was astounding how much MUDA we have in health care where the government is the fiscal intermediary. Many are also hazardous to your health and possibly your life.

There are seven categories of health care muda or waste:

·         Delay: Idle time spent waiting for something, such as pre-certification approval. (Patient with a hot appendix was denied surgery for three days while the pre-certification approval process ran its course. I plied the patient with antibiotics and was successful in preventing sepsis during the three-day wait.)

·         Movement: Unnecessary movement of products, people, or information, such as requiring patients to see a primary care physician, before being referred to the specialist they knew they wanted to see in the first place. (The hospital demanding a prescription for Durable Medical Equipment for a patient who has not been seen since the last hospital admission.)

·         Oversight: Having one worker, such as a case manager, watch another worker do his job. If a worker can't be trusted to do a job, an efficient enterprise either retrains or replaces the worker, or redesigns the task. (HMOs routinely send contract workers to every doctor's office to copy a selection of charts, usually forty or sixty, and then take them to the HMO's office for inspection and review. When the top clinician is subjected to this type of review and scrutiny, it becomes clear that no one in the health care field is or can be trusted.)

·         Inspection: Having one worker inspect the work of another after it has been completed, as in retrospective reviews.  The goal of worker autonomy is self-control and self-inspection.  If someone is unable to determine whether his work is acceptable, then he is not competent to do the job, and should be replaced. (Hospital charts are routinely inspected by lower staff members and sent for retrospective review to competing physicians where punitive action is then taken.)

·         Rework: Performing the same task a second time, such as giving a needless second surgical opinion, or re-filing a claim. (With the advent of hospitalists who manage our hospitalized patients, the primary personal physician must approve the discharge orders even though s/he has not had a chance to examine the patient or review the medical chart. This not only increases medical error, but causes a huge increase in medical liability which adds significantly to health care costs.)

·         Overproduction: Manufacturing of products that aren't needed, such as defensive medical tests, or processing of unnecessary claims information. (This is a common billing process to delay payment.)

·         Defective Design: Design of goods that do not meet customer needs, such as CPT, DRG and ICD-9 coding schemes, which were designed for the convenience of third party payers, not for the treatment of sick patients. . .  (Furthermore, these codes take time to access, giving room to errors in diagnosis and coding, which could lead to further diagnostic errors and reporting of false data.)

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Medical Gluttony thrives in Government and Health Insurance Programs.

It Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6.      Medical Myths: What's Democratic about the pseudo-reform being ramroded by Obama?

Myth 13. "Health care reform" is being enacted through a democratic process.

© The Association of the American Physicians and Surgeons, Jane M Orient, MD, Executive Director,

If "democracy" means a nationally televised speech by the Leader, the expenditure of tens of millions of dollars by pressure groups, and a frenzied process of voting on a short deadline, then this is a Democratic process—with a capital "D" for the Party in power.

The level of spending by advocacy groups is unprecedented. Through mid-July, the Campaign Media and Analysis Group (CMAG), which monitors the airwaves, identified $9.7 million in advertising in support of Obama's position, $4.7 million opposed, and $19.7 million by groups staking out a position. MoveOn will be sending activists to every town hall, as well as buying ads. Healthy America Now will add $12 million to what it has already spent on ads favoring legislation that "expands health coverage."

MoveOn is deploying its "strong, practiced field infrastructure." Spokeswoman Ilyse Hogue said that during August recess, the full force of the progressives' pressure will be "brought to bear on those who are on the wrong side of history" (Politico 7/26/09).

The "democratic process" does not involve reading the bills. Rep. John Conyers (D-MI), chairman of the House Judiciary Committee, asked what was the point in reading the bill, when it's 1,000 pages long, and "you don't have two days and two lawyers to find out what it means."

It does not involve responsiveness to letters, emails, or calls from constituents, reportedly running 15 to 1 against the government takeover.

It does not involve hearings or serious consideration of amendments, much less legislation drafted by the minority party. A representative of the Republican Study Committee reported that 200 amendments had been blocked. House Republican Leader John Boehner listed 31 common-sense amendments that were defeated.

These include what might be called "stop loss" provisions: a $1 trillion deficit cap, delaying spending for "disease prevention" measures such as bicycle trails until the budget deficit drops below the cap; a repeal of the government-run plan if wait times exceed those in private plans; suspending the job-killing employer mandate if unemployment reaches 10%; and waiving the employer mandate if it causes layoffs, pay cuts, or reductions in hiring.

Also killed were freedom amendments, such as: barring bureaucratic interference in treatment decisions; preventing medical professionals from being forced into a government-run plan; preventing tax funding of abortions (which is opposed by 70% of Americans); protecting health savings accounts and their accompanying high-deductible plans; shielding employer-provided coverage from complex, costly new mandates; and repealing the prohibition against new enrollees in individual plans.

An amendment to require members of Congress to immediately enroll in the government-run plan was approved by voice vote in the Education & Labor Committee, but killed in Ways & Means at the behest of Speaker Pelosi and Chairman Rangel.

Also nixed were tort reform; protecting workers who earn less than $200,000 from tax increases, and prohibiting unfair advantages for the government-run plan.

What is really happening, according to high-level inside sources, is back-room deal-making by power brokers unknown to the public.

The process resembles that which passed the "cap and trade" energy bill. It was not passed because Congressmen bought into flawed science or listened to climate Rasputins. "The terrible truth is much worse than that," writes Arthur Robinson. "The truth is that Congress has become so corrupt that it is incapable of acting on principles—even misguided principles."

Congressmen do not care whether the bill is a good one or not. "This past month I watched an awful spectacle—chronicled approvingly in the press—while the cap and trade bill moved forward, picking up votes as its sponsors bought one Congressman after another with provisions that would enhance their careers. It was reported that the last major hurdle was cleared by giving farm state Congressmen a few goodies for farmers."

There was essentially no discussion of science or of the revocation of human freedom in the bill. "The entire process was one of trading favors." Bribery in the form of handouts to constituents is far less cost-effective than simply handing the legislator a suitcase full of money.

Additional information:

"Democracy," AAPS News, December 2007, p 2.

"Republic v. Democracy"

www.aapsonline.org/newsoftheday/00394

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Medical Myths originate when someone else pays the medical bills.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

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7.      Overheard in the Medical Staff Lounge: What's next for Doctors & Patients?

Dr. Dave: Well, it looks like Obama Care is fait accompli.

Dr. Rosen: Don't be so sure.

Dr. Ruth: It passed the House and now the Senate. That's pretty final isn't it?

Dr. Sam: It has to come back to the House and Senate after the conference revisions. That will create a significant challenge for Obama, Reid and Pelosi. I don't think they can pass it a second time with all the Representatives and Senators having been home for Christmas.

Dr. Ruth: I guess I hadn't focused on that. Do you think it will make all that much difference?

Dr. Rosen: Remember it only passed the House by 220 to 215. It would only take three liberals to get cold feet to change the course of history.

Dr. Dave: Now that you bring that up, you have a valid point. It looks like some of the "yea" votes come from districts that disagree with that vote by 5 to 1. I wonder if the unhappy constituents stormed their offices over the holidays?

Dr. Sam: From what I read, many have stormed and voiced a stern warning to their congressmen. One poll has already indicated that 11 "not so radical" Representatives are already wavering. With only three having to maintain their courage, the outcome is still up in the air.

Dr. Rosen: I think the outcome is fairly well determined. I think the vote will be reversed - maybe 215 for and 220 against wouldn't surprise me.

Dr. Michelle: Then what? It won't just disappear into history, will it?

Dr. Sam: Our forefathers warned us in the 18th Century, we have given you freedom, if you can keep it. Every generation has to re-commit to freedom. So it's a constant and never-ending battle.

Dr. Rosen: One of the serious problems surfacing is that we've had 75 years of socialistic public education and many have lost sight of the cause of freedom. Do they even teach economics in high school any longer?

Dr. Sam: When you talk to some of the younger generation about the Market System or in our case the Medical MarketPlace that can bring down the price of health care, they think you're stupid.

Dr. Yancy: I can't believe the Medical MarketPlace can lower the price of surgery any more that it has already. I already do gallbladders for one-third the price I did years ago. Going any lower would not be in my interest.

Dr. Sam: The insurance carriers have been successful in forcing down the price of operations. But they've done it in such a way that patients have lost sight of the value of surgery. They'll still pay for value.

Dr. Edwards: Everything would readjust in a free Medical MarketPlace like any open market. Some may go up and others go down. In Communist Russia with the state setting a price on all goods, no one knew the value of anything. It took the market to restore the real value.

Dr. Yancy: The Blue Cross insurance carrier once warned me that if I didn't accept the reduced fee for surgery, he knew he could go down the block and find a couple of other surgeons that would accept his price. He said doctors and surgeons have too. There is no free market place left.

Dr. Rosen: Open Medical MarketPlace would get all of health care in sync with each other.

Dr. Edwards: I received a notice from AT&T that my year contract for my office phones was up for renewal. When I called back, it was after the deadline and AT&T said "not to worry" since Comcast had made such inroads into their business that AT&T was lowering their prices by 10 to 20 percent. And if I bring my Cingular cell phone into a business cell phone, which it basically is, they would give me another 10 percent off on the combined billing.

Dr. Rosen: That just shows what free enterprise or the Medical MarketPlace would also do. It would make health care so readily affordable, that health insurance would be relegated to what insurance should be—a hospital and surgery plan. Routine office or ambulatory health care is not insurable and by paying with cash or credit care, would be vary affordable.

Dr. Edwards: Can you imagine if 800,000 physicians and surgeons were allowed to compete with each other, what that would do to affordable heath care? Just what AT&T experienced. It made my phones including my cell phone less costly. And they threw in another cell phone free of charge with unlimited calling.

Dr. Paul: But don't we already compete with each other? That's not helping.

Dr. Edwards: We are not competing. Each HMO pays all of us the same whether we're good or incompetent. So the fixed fees from above reduce quality in addition to making health care unaffordable.

Dr. Paul: I don't get it. You're saying the free market is more effective than the government?

Dr. Edwards: Certainly. Remember, just ten years ago we all carried pagers and then had to scramble to find a phone and later our cell phones. The pagers became cheaper and cheaper and eventually were replaced by the cell phones.

Dr. Rosen: If 800,000 doctors were competing with each other outside the hospital system, since we only need the hospitals for about 20 percent of health care, we would all be able to do our own x-rays. Orthopedic and neurosurgical groups could afford to invest in their own CT and MRI scanners. It's been well shown that doctors charge less than hospitals by a factor sometimes of ten to one.

Dr. Paul: You've got to be kidding.

Dr. Edwards: Last week an internist sent his patient without insurance to the hospital for an ECG and was asked to fork over $450. The patient went home. Another internist did it for $80 since Medicare now only pays $20 for an ECG.

Dr. Rosen: I think most of us are catching on as medicine becomes more horizontal like the mainframe computer revolution. With the advent of the PC in the 1980s, the price of computers dropped from a $5 million mainframe to $500 PC. Computers became very affordable. Some mainframe companies went out of business and hundreds of other companies made a fortune. With the practice of medicine being transformed into an outpatient industry, since we only need the hospitals for 20 percent of our work, medicine will become revolutionized, cheaper and better.

Dr. Edwards: So Congress can do whatever regressive thing they want to, their looking backwards will not change the stampede of innovation and efficiency in the Medical MarketPlace.

Dr. Rosen: Our future is Rosier than most think - for both our Patients and Us.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8.      Voices of Medicine: A Review of Local and Regional Medical Journals and Articles

Rationing of Health Care, By Richard L. Johnson, MD

Dr. Johnson, the former editor of Sacramento Medicine, was the Medical Society's president in 1978. He recently uncovered a cassette tape about a film he reviewed in August of that year. It was on rationing of health care, and shown at a conference at Sutter General Hospital. The more things change…

This is an excellent film. It is disquieting and provocative. It gives answers and asks questions; many more questions than answers. Probably the best commentary I can make on this film is to ask more questions. Health is politics, big politics, and we, as physicians, must be more interested in politics.

The ever-increasing cost of health care has become a leading concern of many politicians. There are demands for cost containment. Organized medicine prefers the voluntary approach. Certain politicians, including our President, feel mandatory controls are needed. So far Congress has opted for the voluntary approach.

Before we go any farther, let us ask one question, are we spending too much money for health care? After all, health care is one of the leading growth industries. A few years ago health care took three or four percent of the gross national product. Now, it approaches ten percent. It is a labor rich industry, probably the only one hiring more and more people each year. If the auto industry doubled its sales, it would be applauded, but, if it doubled its employees it would be demonized.

Are we spending too much for health care? No one has the answer. At some point in time, society will decide that health care costs too much. What will happen then? Health care will be rationed. Who will do the rationing? Will it be physicians, hospital administrators, health care specialists or just plain bureaucrats? We don't know but the answer will come eventually.

David Mechanic, a professor of sociology at the University of Wisconsin, published a most lucid discussion of rationing of medical care in the current Center Magazine, a publication of the Center for Study of Democratic Institutions. He describes three basic types of rationing of medical care.

Fee for service rationing puts an economic barrier on the consumer. Some devices used by this means are co-insurance and deductibles.

Implicit rationing establishes limitation on the available resources. That is by restricting budgets, limiting the number of beds, restricting specialists or specialty physicians. Examples are the National Health Services of England and HMOs, especially closed panels like Kaiser.

Explicit rationing refers to direct administrative decisions that lead to exclusions of coverage in health care plans, restrictions to particular sub-populations, limitations on specific procedures, pre-review of certain procedures and utilization review at intervals during provision of services. This sounds like a PSRO. Ours was probably based on the concept of explicit rationing.

The author of this article stresses that in any type of rationing, the sophisticated recipient gets much more than his or her share of services. . .

drrlj@colusanet.com

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9.      Book Review: How Medicine is Changing and What it Means to You

THE AMERICAN WAY OF HEALTH - How Medicine is Changing and What it Means to You by Janice Castro, Back Bay Books, (Little, Brown, & Company), Boston, 1994, x & 282 pages, including glossary, notes, & index, $9.95, Paperback.

Janice Castro, senior health-care correspondent at TIME who interviews professionals, patients, and others, opens with "Ask most people what they think about the state of American medicine, and they will tell you about their own doctors, or about something that happened to them during an illness. Chances are, if they see a need for health-care change, it will be very specific, based on personal experience. On the other hand, listen to American leaders discussing health-care reform. They speak of providers. Access. Alliances. Competition. Mandates... The concepts seem impossibly complicated and remote from the experience of one sick person needing help."

She continues, "This book will help the general reader understand how the American health system works, why it costs so much... Medicine is too important, too personal, to be left to economists and politicians... After all, the health-care debate is really about life and death. It is about those times when people need help and about whether it will be there, about one sick patient at a time and the doctor or nurse who provides care... It is fundamentally a moral problem. Viewed in that light, the challenge... begins to come more clearly into focus. It is not really that complicated. We know what we need to do. We need to take care of old people... Children should see doctors and dentists. A pregnant woman should be able to check in with a doctor as the baby grows. People should not be dying in the street... Families shouldn't lose their home over the cost of coping with medical disasters. Breadwinners should not quit good jobs in order to qualify for poor people's insurance... People should take responsibility for their own health and for their family's. Children should not be having children..."

And, "If we are going to ensure that every American has access to decent health care, while also controlling the burgeoning costs, all of us must curb our medical greed. All of us must stop pretending that someone else is paying the bills. 'What do you think most people would say if one of their parents called up and said they needed a hundred and twenty-five thousand dollars for an operation?' asks one economist. 'Do you think that son or daughter would think twice and wonder whether that operation was really necessary? Of course they would. But none of us think we pay for medical care. And of course we all do.' All of us must pay our share..."

Castro then takes us on a tour de force of health-care about our country. She starts at Kaiser Walnut Creek's two delivery rooms where 4,000 infants, mostly delivered by midwives, take their first breath each year. She interviews a midwife who feels that midwives can deliver most women in tents, a practice which is prevented by organized medicine. She then takes us inside the delivery room where the midwife has a complication with a stuck shoulder. Within seconds, an obstetrician and pediatrician come through the delivery room doors and deliver a healthy infant two minutes later. Castro feels it was fortunate this baby was not born in a tent and that the pediatric ICU is only twenty steps from the delivery room.

In the next chapter, "Condition Critical," Castro guides us on a tour of hospital care. . . .

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10.  Hippocrates & His Kin: The Government's incompetence with computerizing Data

The local newspapers have reported over the years the struggles California has in getting new computers. Today a patient reminded me of the problems with government programs. Her department, the state Department of Motor Vehicles (DMV), spent $45 million on new computers to update their system before they abandoned the project and returned to using the previous computers to continue registering cars and trucks with no difficulty. I was reminded of a $62 million upgrade of the Employment and Development Department (EDD) computer system before it was abandoned and the old computers reinstated to manage millions of accounts, receiving millions of payments and getting checks sent out on time. We were reminded that Child Support Services went through a computer upgrade and spent $54 million before they abandoned that project and continue to provide their child support services quite well. What was the problem? These people seem to think that the state sent out their request for proposals and each company had different ideas about what each department does and thought they could do it better. Only it turned out to be worse. And after spending more than $150 million in these three departments, they all are functioning well using their existing computers.

This is a small window into what the Feds will be up against in their takeover of American Healthcare. Only the problems will be larger and the results more catastrophic.


Who has Time to read a thousand-page bill before we Vote on it?

Rep. John Conyers (D-MI), chairman of the House Judiciary Committee, asked what was the point in reading the bill, when it's 1,000 pages long, and "you don't have two days and two lawyers to find out what it means."

Isn't this more than incompetence? Isn't this also unethical?


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

                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. This month, read the What's New in Medicaid . . . We have placed the NCPA on Freedom Watch because of a feature on Mitt Romney. Should they support him for President after his introducing socialized medicine into Massachusetts, we will remove them from this list of freedom-loving organizations!

                      Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. Must Read: And so it begins to unravel. The Mayo Clinic - "praised by President Barack Obama as a national model for efficient health care" - stopped accepting Medicare patients as of January 1, "saying the U.S. government pays too little."

                      The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This month, be sure to read what's on the federal horizon Federal Entitlement Spending Multiplies.

                      The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

                      The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. This month, you might focus on Reform Will Be an Albatross Around Democrats' Necks . .

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumer Power Report. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

                      The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?. This month, be sure to read The Ponzi Nation . . .

                      The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 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. Be sure to read the current lesson on Economic Education. . .  Belated Happy New Year! You may have seen this list of resolutions elsewhere on the web, but we found them on the Advocates for Self-Government website and thought they would be a fitting tribute on this first Monday of the New Year. Enjoy…

                      The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

                      The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. This month, you may want to read: Defend Colorado from Obama Care . . .

                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read Why Government Bailouts Only Make Things Worse . .  

                      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. Be sure to keep up with the institute's new President: Dr. Brett J. Skinner . . .

                      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. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, they have lost site of their mission and we will no longer feature them as a freedom-loving institution and have canceled our contributions.

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports.  Be sure to read . . .  The link between classical liberalism and present-day Socialism is often still misnamed liberalism . . . You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

                      CATO. The Cato Institute (www.cato.org) was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at www.cato.org/people/cannon.html. Read about Obama's grade point average: Obama Flunks His First Year . . .

                      The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

                      The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

                      The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars. Congratulations to Hillsdale for its national rankings in the US News College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read Education, Economics, and Self-Government. . . The last ten years of Imprimis are archived.

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Please note that sections 1-4, 6, 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. We respect copyright as exemplified by George Helprin who is the author, most recently, of "Digital Barbarism," just published by HarperCollins. We hope our highlighting articles leads to greater exposure of their work and brings more viewers to their page. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.


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Del Meyer, MD, Editor & Founder

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Words of Wisdom

Democracy is the greatest revenge. -Benazir Bhutto, twice elected Prime Minister of Pakistan, assassinated on December 27, 2007, as she defeated the forces of military dictatorship, freed all political prisoners, ended press censorship, legalized trade and student unions, built 46,000 primary and secondary schools, and appointed the first female judges in their history, teaching women that they must accept no limits on their abililty and opportunity to learn, to grow and to lead in modern society.


Just in case you think times are bad . . .

If you're going through Hell, keep going. -Winston Churchill

Some Recent Postings

HealthPlanUSA January Newsletter . . .

David Gibson, MD: Politicians Cannot Manage a Health Care System . . .

In Memoriam

Alan G. Zacharia, MD

By Philip Alper, MD

By the time of his death in August 2009, Alan Zacharia had published more than two dozen articles in the San Mateo County Medical Association Bulletin. For a time, he authored a column that, with tongue in cheek, he titled, "Curmudgeon's Corner." More recently Alan served as an active member of the Bulletin's Editorial Board. 

Dr. Zacharia was not a person who could easily be ignored.  Blessed with incredible energy and an interest that encompassed many domains, his mind was constantly occupied. Alan would be the first to admit that he felt his reading entitled him to comment on a vast range of subjects pretty much any time and any place. As might be imagined, this made him a colorful, one-of-a-kind individual.  

Though Dr. Z could talk a lot, he was not just a talker. I knew him, in part, as the Chairman of the By-Laws Committee and Member-at-Large of the Peninsula Hospital's Executive Committee. Over the years, Dr. Zacharia demonstrated a steadfast allegiance to the rights and prerogatives of physicians, which he felt were being steadily abridged by requirements of the Joint Commission and the increasing corporatization of health care, including at the local level.  He became a controversial figure as the medical staff seemed, to him, to become less vibrant and assertive and indifferent to his most passionate concerns.

I am going to comment on two of Dr. Zacharia's articles in the Bulletin. The first is titled, "Perceptions." It was originally published as the January 1997 Curmudgeon's Corner offering and reprinted in September 2003.

Here, Zacharia gives an overview of managed care's contribution to the unhappy state of medical care. Patients are discontented and so are doctors. Too many choose insurance plans that, as lower-cost options, cede too much control to the insurance carriers. Flawed perceptions of what constitutes good medical care contribute to their doing so.

Patients expect nearly everything, even in bargain plans.  Third-party payers don't fund care at that level and leave any perception of fault with the physician. Regulators confuse what is easy to measure with what is important.  Doctors' perceptions are more complex and expectations of themselves are largely based on medical ethics and tradition and not on economics.

But people buy insurance when they are healthy and expect to remain so without considering that they are giving the carrier a power of attorney that can ultimately restrict the care they receive. Doctors must explain and attempt to intervene with the insurer when coverage is denied. The doctor-patient relationship suffers accordingly because the doctor cannot entirely fix the consequences of the patient's choice.

This article was written when HMOs were all the rage. It was before patients rebelled and insurers responded with a return to less-restrictive PPOs. Dr. Zacharia was prescient.

The second article, published in the Bulletin in May 2004, is called "Societal Leadership, Ethos, and Erudition." It deals with grand philosophical themes and the sweep of history areas that fascinated Zacharia. He points out that not so long ago, doctors couldn't actually do that much, "but held a special and honored place in society." Our advice was sought in matters both philosophical and medical.  Underlying it all was the expectation of broadly based erudition.

One cannot properly deal with the forces of life and death without the art as well as the science of medicine. Zacharia says, "The public needs physicians to be reservoirs of humanistic cultural evolution because we carry with us the results of millennia of critical thought and inquiry." The great physicians of old were proficient in numerous disciplines as well as in medicine. These included architecture, astronomy, mathematics, and philosophy. Hippocrates, Galen, and Maimonides were all the products of a classical education.  Living in different eras, each was nevertheless a Renaissance man who brought great and broad erudition to bear on the care of his patients.

Today, such breadth of learning is rare in medicine. The authority of the learned man has been replaced by technical expertise. Instead of Aristotle, we have the medical ethicist, perhaps one like Ezekiel Emmanuel who believes that physicians take the Hippocratic Oath too seriously and should, in the future, serve society at the same time as the individual patient. Medicine additionally has the obligation to offer services that we believe people need, even though it is not necessarily what they want. This role has been compromised by contemporary medical corporate behavior of all kinds.

Zacharia goes on to discuss Plato and yin and yang. Both seek to find balance in human affairs, the essential quality for stability. Zacharia tells children of the fun of knowing when they ask why their teachers aren't more entertaining.  He ends his essay by posing a list of difficult problems facing the world and comments, "I lament the demise of physicians as effective societal thinkers and thought leaders." It is these qualities we must regain if we are to help guide society in the future.

In revisiting these words, I see Alan Zacharia before me.  His words came through unfiltered, whether in print or in person. On many an evening, I verbally sparred with Alan at Editorial Board meetings. He even made differences of opinion fun. And he was never mean.

This unusual doctor died far too soon. Those of us who had a sense of what Alan Zacharia was all about will miss him greatly.

Retrospective By Philip R. Alper, M.D.

Member, SMCMA Editorial Committee

Dr. Zacharia articles from the last decade: Perceptions, Societal Leadership, Ethos, and Erudition, and It's the Process, Stupid, as well as his obituary are in the San Mateo Medical Society Bulletin.

On This Date in History - January 12

On this date in 1990, Astronauts aboard the space shuttle Columbia retrieved an 11-ton floating science lab. It was the rescue mission that kept the faltering satellite from lunging to earth.

On this date in 1737, John Hancock was born in Braintree, MA. Signing one's "John Hancock" to an important document wouldn't mean much if John Hancock had not become the first signer of the nation's Declaration of Independence.  Unwavering dedication to his beliefs spurred him to make a big statement and write his name legibly for all to see.

After Leonard and Thelma Spinrad

Always remember that Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people's welfare.

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