MEDICAL TUESDAY . NET                         NEWSLETTER

Community For Better Health Care                   Vol IV, No 8, July 26, 2005

In This Issue:

  1. Featured Article: A Victory for Freedom: The Canadian Supreme Court's Ruling on Private Health Care by Jacques Chaoulli, M.D.

  2. In the News: Health Insurance for All Californians B less Expensive than You Think B Let's See Now, Where Have We Heard That Before?

  3. Medicine Around the World: Healthcare Systems in Europe by C Hartung

  4. Government Medicine: What You Can Expect in Medical Expenses After You Retire

  5. Medical Gluttony: The Hospice Program Is a Revenue Gold Mine

  6. Medical Myths: More Regulations and Laws Improved Health Care - Lessons from Colorado on How to Feed the Lawyers: Make More Criminals

  7. Overheard in the Medical Staff Lounge: Don't Send Me a Bill Doctor, If My Insurance Says It's Not a Covered Benefit, That's Not My Problem.

  8. Voices of Medicine: New Physician ID Number Replacing Current Physician ID Number

  9. Book Review from the Physician/Patient Bookshelf:  MARKET DRIVEN HEALTH CARE

  10. Hippocrates & His Kin: Health Care Pork - Now That's Really Unhealthy Fat

  11. Related Organizations: Restoring Accountability in Medical Care and Society

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1.    Featured Article: A Victory for Freedom: the Canadian Supreme Court's Ruling Condemning the Canadian Single-Payer Health Care System for Causing Situations in Which Patients Suffered and Died on Waiting Lists, in Violation of the Rights to Life, Liberty, and Security by Jacques Chaoulli, M.D. Heritage Lecture #892, July 22, 2005.

INTRODUCTION BY ROBERT E. MOFFIT: Ladies and gentlemen, I am happy to join my co-host, Grace-Marie Turner, President of the Galen Institute, in welcoming you to The Heritage Foundation. We are honored to have with us Dr. Jacques Chaoulli, whose recent case before the Canadian Supreme Court ended in a major victory for health care freedom in Canada.

In Canada, patients have long been legally prohibited from spending their own money to purchase medical care privately if that care was also provided under the Canadian government's health care program. Many Canadians who did not want to endure the wait for treatment under the government program, or suffer the pain or inconvenience of these restrictions, would often have to travel to the United States to get the care that they wanted or needed. That is why Dr. Chaoulli's victory in the Canadian Supreme Court, allowing patients to secure private care in Canada, is historic.

The Canadian case has relevance for Americans. While ordinary Americans would consider government restrictions on their ability to spend their own money on legal medical services to be a shocking violation of their personal freedom, they should be reminded that the Clinton Administration and Congress enacted a similar restriction in the Balanced Budget Act of 1997 for the Medicare population. . . . Since the enactment of this bizarre law, subsequent litigation and regulatory modifications have softened its impact, but it nonetheless remains on Medicare's books.(1)

The Canadian Supreme Court decision is a landmark case for one reason: It reaffirms that personal freedom is the key value in health care policy. In the continuing debates over health care access, cost, and quality, American policymakers should not lose sight of why America exists.

- Robert E. Moffit is Director of the Center for Health Policy Studies at The Heritage Foundation.

INTRODUCTION BY GRACE-MARIE TURNER: Bob and I are honored to host Dr. Jacques Chaoulli, the courageous physician who challenged restrictions in Canada's government‑run health care system--and won. The Supreme Court of Canada struck down on June 9, 2005, a Quebec law that had banned private health insurance and private payment for services covered under Medicare, Canada's socialized health care program.

Dr. Chaoulli was joined in the case by his patient, Montreal businessman George Zeliotis, who was forced to wait a year for hip replacement surgery. Zeliotis, 73, tried to skip the public queue to pay privately for the surgery but learned that was against the law. He argued that the wait was unreasonable, endangered his life, and infringed on his constitutional rights. The two fought their case all the way to the Canadian Supreme Court, which voted 4‑3 that they were correct.

"Access to a waiting list is not access to health care," the court said in its ruling.

The case involved the Quebec Hospital Insurance Act and technically applies only to that province, but it is a wake up call to the other provinces, where private insurance also is banned. "This is indeed a historic ruling that could substantially change the very foundations of medicare as we know it," Canadian Medical Association president Dr. Albert Schumacher said after the ruling. The ruling means that Quebec residents can pay privately for medical services, even if the services also are available in the provincial health care system. . . .

The United States has been a safety valve for Canadians unwilling or unable to tolerate the long waits for medical care in their country. Now, the Canadian government must face directly complaints about the long waiting lines, lack of diagnostic equipment, and restrictions on access to the latest therapies, including new medicines.

In an almost laughable defense, lawyers for the government argued the Canadian Supreme Court should not interfere with the government's health care system, considered "one of Canada's finest achievements and a powerful symbol of the national identity." Dr. Chaoulli had persevered in spite of two lower court rulings against him. They had ruled the limitation on individual rights was justifiable in order to prevent the emergence of a two‑tier health care system.

Dr. Chaoulli was born in France and obtained his medical degree from the University of Paris, before moving to Canada in 1978. He has practiced medicine in Quebec since 1986. Welcome, Dr. Chaoulli.

- Grace-Marie Turner is President of the Galen Institute.


JACQUES CHAOULLI, M.D.: I am happy to be with you today, and I would like to thank The Heritage Foundation and the Galen Institute for hosting this public briefing.

What I did in Canada, anybody willing to do it could have done. My background is quite simple.

I was born in France. During the time I was studying medicine there, I never heard about patients suffering or dying on a waiting list. After graduating in 1978 from the Paris University school of medicine, I moved to Canada. To my great surprise, while practicing as a physician during the 1990s, I saw patients suffering and dying on waiting lists under the Canadian single‑payer health care system. Although I didn't have any knowledge of law at the time, I already felt it was unacceptable. Actually, I was even more surprised to see that nobody stood up against the government to claim that those patients were victims of an infringement upon their human rights.

I also felt the Canadian legal community was not up to speed. So, I studied the law, I studied the health care systems from around the world, and I studied more in the field of some medical and surgical specialties for which I noticed important problems of access to timely and quality health care services in Canada.

I launched the court case you know about, representing myself all along, and invited a patient, Mr. Zeliotis, to join me in the legal proceedings as a co-plaintiff, until my legal arguments eventually prevailed before the Canadian Supreme Court.

Astonished Elite

Up to the end, most of the commentators thought I would fail. But on June 9, 2005, I won. Across Canada, the elite was astonished.

The Dean of Canada's Osgoode Hall law school, Patrick Monahan, was quoted by Canada's National Post three days ago as saying, "I didn't expect a majority of the court to uphold Chaoulli's claim."

A constitutional law professor from the same law school, Jamie Cameron, was quoted as being "surprised at the judges' activism.... It's a huge step for Section 7 [of the Canadian Charter of Rights and Freedoms}. I think that the constraints that used to apply to Section 7 have pretty much blown out of the water."

It is significant that I won against a number of lawyers and top expert witnesses representing the government side. For example, during the trial I cross‑examined Professor Theodore Marmor from Yale University. Justice Deschamps, concurring with the majority, rejected his testimony, on paragraphs 63, 64 and 67 of the judgment.

For many years, in survey after survey, a majority of Canadians said that they were in favor of private health care alongside the public system. After my victory, ordinary people felt a sense of relief to hear that, for the first time ever, the highest court in the land condemned the Canadian single-payer health care system for causing situations in which patients suffered and died on waiting lists, in violation of the rights to life, liberty, and security protected by Section 7 of the Canadian Charter of Rights and Freedoms.

As a result of this historic judgment, Canadian legal scholars have now classified Canada's legal history about rights and freedoms into two distinct periods: before Chaoulli and after Chaoulli.

For many years, I have been studying constitutional law, most of the time alone, and during a short period of time, in year 2000, as a full‑time law student in Canada. As a law student, I argued against most of my Canadian professors of law, whose interpretation of the Canadian Charter of Rights and Freedoms was opposed to my own interpretation. Ironically, five years later, in 2005, the Canadian Supreme Court upheld my own interpretation of that Canadian Charter of Rights and Freedoms.

To my knowledge, it is the first time that a court has invalidated a government health care action that had effectively resulted in the suffering or deaths of individuals.

The Canadian Supreme Court ruled that a state may not force an individual to endure poor quality health care services or unreasonable waiting times for medically required services, and it cannot prevent average individuals from getting access to private health insurance.

Opportunity for Private Health Care

This Canadian Supreme Court ruling was like the fall of a second Berlin Wall. It opens up a unique opportunity, in the United States and in several OECD countries, to counter what is called in the United States "liberal," and what I call "socialist," lobbies that are pushing their agenda for socialized medicine.

Some commentators believe that this ruling would apply only to Quebec and not to the rest of Canada. I respectfully disagree with their opinion. In my view, a proper reading of the judgment leads to the conclusion that similar legislation in other Canadian provinces may already be considered as violating Section 7 of the Canadian Charter of Rights and Freedoms, which protects the right to life, liberty, and security. For that reason, in my view, there is no need to launch additional legal challenges in other Canadian provinces.

About private hospitals, I was asking the court to declare my right to establish a private hospital in Montreal. The majority of the Canadian Supreme Court gave me the green light to go ahead in establishing a private hospital, when Justice Deschamps, concurring with the majority, ruled at paragraph 51 of the judgment that: "the Minister may not refuse to issue a permit solely because he or she wishes to slow down the development of private institutions that are not under agreement," and when at paragraph 54, she said: "Not only are the restrictions real but Mr. Chaoulli's situation shows clearly that they are."

Practically speaking, that ruling opens the door for a parallel private health care system in Canada running alongside the continuing socialized and compulsory Medicare program run by the "States" or "Provinces," as in other countries of Northern and Southern Europe, Australia, and New Zealand.

Obviously, in terms of public health policy, such a result is not good enough. Those who are unable to pay twice, through general taxation and the additional cost of parallel private health care services, will continue to fall through the cracks of a deficient Medicare program.

For a long time, several experts have suggested that legislators should permit individuals to opt out of a state's compulsory Medicare program. But as you well know, legislators from around the world, including here in the United States, have to deal with a potato which is not only hot, but also burning!

Lessons for the U.S.

This victory is particularly important for American people, since they are facing important health policy issues, both at the federal level, regarding the Medicare program, and at the state level. The states of Vermont and California have engaged, or are engaging themselves, in the process of establishing a single-payer health care system which--there is no doubt in my mind--shall lead, like in Canada, to a situation whereby some patients will suffer and die on waiting lists.

I believe that, were it not for particular interest groups pushing for their own agenda, most people around the world would reject such a health care system that inevitably leads to suffering and to death.

In 2002, particular interest groups thought they could introduce a single-payer health care system in Oregon, through the initiative and referendum called Measure 23. But three-quarters of the population of Oregon rejected that model. Then, legislators in Vermont passed a bill establishing a single-payer system.

A few weeks ago, the Senate of California passed a bill that is even more extremist, in the sense that, like in Quebec, it bans private health insurance covering services already covered under a new California State Universal Medicare program. That bill is likely to pass the Assembly as well. Maybe the governor of California will use his veto power to block that bill, but such a veto would last only as long as that same governor would remain in power. What about the people of California if the bill is passed again and the next governor fails to the veto that bill?

In Canada, in the United States, and elsewhere, liberal groups should be confronted with the failure of socialized medicine, which the four majority justices exposed in the so‑called Chaoulli judgment. Moreover, and even perhaps more importantly, they should be confronted with the terrifying opinion of the three dissenting justices. Although the dissenting justices acknowledged that some patients die as a result of the state monopoly, they went on to say that the state monopoly is necessary in order to avoid what they call an unfair situation, whereby those able to pay in a parallel private health care system would save their own life, while those unable to pay would have to wait in the public sector.

For the first time in Canada, a Supreme Court Justice criticized publicly a dissenting colleague sitting on the same bench. Justice Deschamps, about whom I have spoken, wrote at paragraph 16 of the judgment: "The debate about the effectiveness of public health care has become an emotional one.... The tone adopted by my colleagues Binnie and Lebel JJ. is indicative of this type of emotional reaction."

Also, she clearly challenged the view of the three dissenting justices, when at paragraph 85, she said: "It must be possible to base the criteria for judicial intervention on legal principles and not on a socio-political discourse that is disconnected from reality."

But make no mistake about it. Although the Berlin Wall fell in 1989, many groups driven by a socialist ideology are still very active in all the OECD countries, including here in the United States, and they share the view of the three dissenting justices I have mentioned.

You might hear from the legislators of Vermont that the Chaoulli judgment is irrelevant to them since the bill they passed doesn't ban private health insurance. They would be right to say that their bill doesn't ban a parallel private health care system. Still, down the road, like in Canada, in the UK, and in several other OECD countries, I believe some patients from Vermont shall inevitably suffer and die on waiting lists if the single‑payer health care system is to be implemented in that state.

Justice Deschamps had it right when she wrote, at paragraph 96: "Given the tendency to focus the debate on a socio-political philosophy, it seems that governments have lost sight of the urgency of taking concrete action. The courts are therefore the last line of defence for citizens."

I suggest her comment applies as well to the United States and to many countries around the world. I suggest the time has come to take advantage of this historic judgment in order to inform people in Canada, in the United States, and elsewhere about the consequences in terms of human suffering from letting legislators adopt, or maintain, single-payer health care systems.

Conclusion

I feel close to the American people because of our common love for liberty and responsibility.

A long time ago, in 1776, the Virginia Declaration of Rights, drafted by George Mason and Thomas Ludwell Lee, showed the world what liberty means. I am afraid, within Western democracies, many people have forgotten the true meaning of liberty.

I have a dream. My dream is to show the world how to get rid of a new and subtle form of tyranny hidden under the cover of a Welfare State's compulsory health care program.

My dream is remind the world of the original sense of liberty that the founding fathers of the United States of America envisioned for generations to come, not only for American people, but also for people around the world.

Thank you.

- Jacques Chaoulli, M.D., is a Senior Fellow at the Montreal Economic Institute.

 

To read the full introductions and the entire Heritage lecture, go to www.heritage.org/Research/HealthCare/hl892.cfm.

For an account of the Medicare private contracting legislation and subsequent litigation, see Robert E. Moffit, Ph.D., "Congress Should End the Confusion Over Medicare Private Contracting," Heritage Foundation Backgrounder No. 1347, February 18, 2000, at www.heritage.org/Research/HealthCare/BG1347ES.cfm.

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2.    In the News: Health Insurance for All Californians - Less Expensive than You Think -  Let's See Now, Where Have We Heard That Before?

Gerald F. Kominski,
in his Tuesday, July 19, 2005 article, states "the number of Californians without health insurance is growing rapidly. According to the California Health Interview Survey, in 2003, 6.6 million Californians (including 2.6 million undocumented immigrants) were uninsured at some time during the year, an increase from 6.3 million in 2001. Not only do these high numbers indicate a tremendous amount of needless suffering, but they also signal even greater fiscal pressure on federal, state and local governments.

"Still, conventional wisdom tells us that even once the state's budgetary crisis turns around, there just won't be enough money to solve this problem. Considering the billions being spent to provide health care to the uninsured, however, it is clear that money isn't really the issue. . . .

"It will cost $9.8 billion in 2005 to provide health care to California's uninsured, including $4.2 billion from out-of-pocket payments, $2.6 billion from government sources and $3 billion from charitable organizations, according to a report from the UCLA Center for Health Policy Research. Federal, state and county governments will spend an additional $3.6 billion in subsidies to safety-net providers to cover indirectly the costs of caring for the uninsured, mostly in hospitals and community-health centers. Combining these direct and indirect expenditures means that a combined total of $13.4 billion will be spent to care for uninsured Californians in 2005, including a total of $6.2 billion in federal, state and county subsidies and $3 billion in charitable contributions.

"According to our recent calculations at UCLA, the uninsured would use approximately $14.3 billion in health-care services if fully insured, because having insurance always increases spending. This is a staggering amount of money -- equal to recent deficits in the state budget. But given that Californians already spend $13.4 billion to care for the uninsured, our state is looking at a gap of only about $900 million.

"This $900 million represents less than $150 additional dollars for each uninsured individual in California. To place this number further in context, $900 million represents an increase of about 6 percent in current total spending for the uninsured and an increase of less than 1 percent of overall health-care spending in the state. So, if health care for all Californians really is so affordable, why can't we solve this persistent problem?

"One barrier is combining the diverse funding streams for the uninsured into a single program. Facilities that currently receive subsidies are not willing to give them up. However, if all uninsured Californians were provided with health insurance, the indirect subsidies provided to safety-net facilities to care for the uninsured could be reduced, because subsidies to safety-net providers would be largely replaced by insurance payments. . . .

"Our research indicates that current expenditures from all sources for the uninsured in California, if combined into a single program and supplemented with modest additional expenditures, could provide sufficient funding to provide health insurance for all of California's uninsured. Isn't it time we solved this problem once and for all?"

Gerald F. Kominski, Ph.D., is associate director of the UCLA Center for Health Policy Research and professor of health services and associate dean of the UCLA School of Public Health. Read the entire article at www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2005/07/19/EDG4PDP10A1.DTL.

And if California Single-Payer Actuaries are as smart as the Medicare Actuaries, there should not be more than a 400% error in the above calculations.

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3.    Medicine Around the World: Healthcare Systems in Europe

C Hartung of Hannover in a study on the development of the German Healthcare Systems, gives an overview of the German and Dutch system and compares them with the EU. He states, "There are basically two types of healthcare systems in Europe:

    a "Beveridge-system", primarily financed by taxes, which you will meet with in Northeuropean countries, in Ireland and the UK. Since the eighties, the Southeuropean nations like Spain, Greece and Portugal have joined.

    a "Bismarck-system", primarily financed by social insurances income related, which is introduced in Middleeuropean countries and since the late nineties in Easteuropean countries as well.

"Countries of the EC, like Holland and Germany, however, meanwhile finance their healthcare by a mix of taxes, social and private insurances. Altogether the private contribution in all states of the EC is increasing, . . . Thus an approach of both systems is expected within the next decade, a further reason that our European Societies should be joined under a European roof. Though the funding in our countries, Holland and Germany, is almost identical, still little deviations can be detected. The figure reveals that Holland's healthcare is less financed by taxes and more by social insurances and private provisions. . . .

"Admittance of competition as ruling control element

"The healthcare sector is increasingly understood as part of our competitive society. Health performance is controlled by our pluralistic system by application of competitive principles B a feature, which we have not been witnessing to that extent. Competition has become the fundamental principle for all, who render health services: i.e. health insurances and hospitals.

"Public control is increasingly considered as a restraint counteracting against a free development in healthcare.

"Reduction of public structures

"The healthcare sector is still impaired by quite a number of antiquated regulations. This becomes evident, when focusing on hospital corporations. Particular public hospitals are still liable to public authorities. Since this corporate form is by far less competitive on the market than the form of a private company with limited liability the number of public hospitals is reducing. Either they disappear or - what actually happens - they are changing their corporation. . . ."

To read the entire report on Financing of Healthcare Systems in German, Holland and the EU by C Hartung, go to www.wgkt.de/download/NVTG-NL-2004-04-xx.pdf.

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4.    Government Medicine: What You Can Expect in Medical Expenses After You Retire

In his monthly newsletter, "From Inside Personal Finance," Ric Edelman gives us a view of what health care will cost when we retire.

"As you estimate the expenses you are likely to incur after you retire, pay attention to the costs of medical care, especially medical insurance. You are likely to spend $3,500 to $11,000 annually on medical insurance - and that's before you visit a doctor or hospital, before you even fill a prescription, see a dentist, or visit an optician.

"Your primary defense is Medicare. Sign up for it three months before your 65th birthday. Medicare consists of Part A and Part B. Sign up for both; if you delay signing up for Part B until after you lack coverage, the premium for Part B increases 10% for every year you defer. Note: If you are still employed and covered by health insurance at work, defer signing up for Part B until you are no longer covered at work.

"Let's see what each part covers:

"Part A is free - thank you, Uncle Sam - and it pays part of the expenses for inpatient hospital charges. It also pays for skilled nursing facility care. However, it pays nothing for the first 20 days, but for day 21 through 100, it pays up to $114 per day. Part A also pays a very small amount of home health care costs.

"Under Part A, you will pay the following for each benefit period. (Benefit periods start the first day the Medicare client is provided inpatient hospital, skilled nursing, or rehabilitation services and ends when the Medicare client has not been an inpatient of a hospital or other facility for 60 consecutive days.)

"A deductible of up to $912 for a hospital stay of 1-60 days. $228 per day for days 61-90 of a hospital stay.  $456 per day for days 91-150 of a hospital stay. After 150 days, you pay all costs. 

"Did I say Part A is free? Well, that's because you've been paying for it via Social Security payroll taxes. Oh, you didn't have an earned income or accumulate 40 quarters of Social Security coverage? Well, in that case, you will have to pay the Part A premium, and it's expensive ($375 per month). So it's worth staying - or getting - employed so you can rack up those 40 quarters (that's 10 years) under the Social Security "system. 

"Part B, by contrast, is not free. The monthly premium for one person is $78.20. Thus, married couples will pay $1,876.80 this year. Part B pays for some physician charges, outpatient hospital services, certain home health services, and durable medical equipment. There's a $110 deductible this year, and you pay 20% of the Medicare-approved amount for services after that.

"But even used together, Medicare Parts A and B don't cover everything. Unfortunately, there are lots of gaps between what care costs and what Medicare pays. For example, after 150 days in a hospital and 100 days in a skilled nursing facility, Medicare pays little to nothing.

"Because of these 'gaps,' the insurance industry offers a solution: So-called 'Medigap' policies help cover what Medicare itself does not.

"There are 10 versions of Medigap insurance, labeled A to J. Look at all 10 and decide which you like best - A offers the least benefits and is the least expensive; J is the opposite - and then shop around for the best price. You'll pay $800 to $10,000 or more a year per person. To learn more about the policies and the costs, go to www.medicare.gov and click on 'Medicare Personal Plan Finder.'" www.ricedelman.com/planning/healthcare/medicalexpenses.asp

If you think that health care is expensive now, wait until you see what it costs when it's free.

P. J. O'Rourke

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5.    Medical Gluttony: The Hospice Program Is a Revenue Gold Mine

Margie, one of our 94-year-old patients with Alzheimer's Dementia, had three very doting daughters who each swore that their mother would never go to a convalescent hospital. On several admissions over the past decade, the home health-care team tried to persuade the daughters to allow them to assume care of their mother. The daughters respectfully declined. Margie was never left alone without one of them always at her side.

On this last admission, which I didn't attend since I've retired from the hospital portion of my practice, the home health-care team finally prevailed and began making home visits resulting in five pages of orders for me to sign. The more I read the document, the more I realized that this was a significant mechanism to milk the Medicare system.

On page one, problem 001 was Pain, Acute/Chronic with expected outcomes. The taxpayers were funding someone to assess the emotional factors; instruct in the causes of pain; perform therapeutic touch; instruct in comfort measures such as position changes, cool room, music, and touch; instruct on premedication for activities (Note: the patient is senile, contracted, cannot talk, or perform any activities), and notify appropriate supervisors if goals were not attainable.

Problem 003 was Anticipatory Grief. Funding would apparently be provided for being able to verbalize grief-related thoughts and emotions, to demonstrate understanding of grief processes, to encourage the expression of feelings about loss, to encourage life review, and instruct on stages of grief.

These were two problems of those listed on the first of four pages. They all had three digit numbers ranging from a selection of more than 500, suggesting there were at least 500 ways to obtain Medicare money. All are worthwhile ideals, but many were irrelevant to this patient.

It reminded me of the monthly home visits I made for one of my respiratory-failure patients who was on liquid oxygen. I received $72 of my $120 home visit charge from Medicare. The patient showed me the Medicare notice of payment. The hospital was paid $148 (as I recall) for the nurse visit, which the patient stated was of shorter duration than mine. A colleague, Dr Davis who was the editor of Private Practice, wrote Medicare as to why they paid the hospital nurse twice as much as the doctor. Medicare replied that the hospital had to provide the car and overhead expenses for the nurse to make the visit. When he wrote back outlining the overhead expense for his care, he was ignored.

Which just goes to show that given the opportunity to enhance any source of revenue, a large hospital with unlimited resources will be able to obtain huge reimbursements compared to solo or group practitioners. Government Medicare and other bureaucratic forms of medicine will always allow this inequity, which has no quality of health care or quality of life value. It just depletes health care resources for honest hard-working Americans.

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6.     Medical Myths: More Regulations and Laws Improved Health Care - Lessons from Colorado on How to Feed the Lawyers: Make More Criminals

Last week at the Independence Institute, Mike Krause and Chelsea Johnson in their Opinion Editorial report that New Crimes Mean More Criminals: Colorado has plenty of both already.

"On July 1, several dozen of the more than 400 new laws passed by the 2005 Colorado Legislature went into effect. Some of these laws are changes and updates, while others actually advance personal freedoms. But the Legislature also managed to create more new crimes where no actual criminal behavior exists.

"The Legislature's expansion of 'public welfare' lawmaking, which criminalizes conduct not inherently wrong, but wrong due to a legislative declaration (malum prohibitum) has increased dramatically over the last 50 years. The Legislature should put the crime creation business on hold for at least a couple of sessions.

"Colorado already has some 30,000 laws taking up a dozen volumes of statutes; more than enough to ensure no one knows if one is in compliance or not. This in turn has placed excessive burdens on the criminal justice system. Colorado's prison population has more than doubled over the last decade, and local jails operate beyond capacity throughout the state.

"Police agencies from the Routt County Sheriff's Office to the Denver Police Department, claim to be under‑staffed and overworked, while the court system is overburdened and backlogged; in 2004, there were over 10,700 adult criminal case filings in Colorado courts just for drug cases, still only one quarter of criminal case filings.

"There are plenty of crimes and criminals in Colorado. So why does the Legislature insist on creating yet more of both?

"All the basic violent crimes--murder, rape, assault and robbery--have long been on the books, as have theft, trespassing, and other property crimes, and while technology has created new ways to commit fraud or embezzlement, the basic elements of these financial crimes have remained unchanged from the days of common law.

"Since real crimes against people and property have long been codified, legislators now have to satisfy themselves with passing 'public welfare' laws in pursuit of some perceived public benefit.

"The creation of yet more crimes, however, has failed to bring about an end to these old, most important crimes. In fact, major crimes in Colorado increased by almost 9 percent in 2004. Homicide alone increased by 18.5 percent.

"New crimes do however increase demands on police, the courts, and the public; creating new criminals, while at the same time delivering often dubious benefits.

"For instance, Senate Bill 36 makes it a crime in Colorado for newly licensed teenaged drivers to carry passengers under the age of 21 (except siblings) for the first six months. They can carry just one teenaged passenger during the next six months.

"In reality, criminalizing teenagers riding in cars will actually create new scofflaws (those teens who will certainly ignore the new law), while at the same time ensuring that there will be more inexperienced teenage drivers on the road than ever before.

"For example, where a group of four 16-year-old friends might carpool to high school, or several teens ride‑share to part time jobs at the local mall, the law now demands they all drive separately, or find another means of getting to class or work. If the Legislative logic behind the law holds true, the new school year will actually mean less safe roads for the rest of us. . . .

"The sheer number of such 'public welfare' laws on the books makes it impossible to enforce these laws consistently. And since a sense of right and wrong is no longer a guide to remaining a law-abiding citizen, the average Coloradoan has no hope of complying with all of them. This breeds a lack of respect for the rule of law itself.

"Next time someone tells you, 'There ought to be a law,' remind them that there probably already is one."

To read the entire OpEd article, go to www.i2i.org/article.aspx?ID=1167.

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7.    Overheard in the Medical Staff Lounge: Don't Send Me a Bill Doctor, If My Insurance Says It's Not a Covered Benefit, That's Not My Problem.

Dr Edwards was commenting on a patient that he had evaluated in consultation, obtained an ECG, CXR, and PFT, spending over an hour with the patient. He thought it had gone well, when a month or two later his CMA (Medical Assistant) informed him that the patient had called with inflammatory insults. She had received a statement for the charges that her insurance wouldn't pay. She alleged it was not her problem. "That's the reason I have insurance to pay all my medical expenses. Don't ever send me another statement."

Dr Edwards had been surprised that day when he saw her in the office. He was very cordial and took care of her medical needs. When she left, she looked him in the eye, saying, "Doctor, I hope you get paid for this one."

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8.     Voices of Medicine: New Physician ID Number - NPI (National Provider Identification) to replace the Current Physician ID Number - UPIN (Unique Provider Identification Number) Another Bureaucrat with Too Much Time on His Hands

In their Bulletin, The Humboldt-Del Norte County Medical Society (HDNCMS) reminds physicians to begin submitting applications for their unique National Provider Number (NPI) because over the next two years, it will replace the existing Unique Provider Identification Number (UPIN). Health plans are required to use them by May 23, 2007. The NPI will be a ten-digit number unique to every provider and is expected to stay with the physician regardless of practice location. The Centers for Medicare and Medicaid Services (CMS) is tying this closely to the HIPAA confidentiality requirements for electronic transfer of health-care information. CMS is expecting to have a system in place that will allow a physician to apply on-line.

The cost of switching to the new system will not be cheap for CMS or for any of the health plans. Small plans that can't make the two-year transition will be given an extra year before they must begin using the new NPI number. See http://www.humboldt1.com/~medsoc.              

This should make it easier for the government to police and control us ever more tightly. The patients may not be sophisticated enough to know that the noose is also around their necks.

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 9.    Book Review: MARKET DRIVEN HEALTH CARE - Who Wins, Who Loses in the Transformation of America's Largest Service Industry by Regina Herzlinger. Addison-Wesley Publishing Company, Inc. Reading, Mass, 1997, xxviii & 379 pages, (includes index) $25. ISBN: 0-201-48994-5

Dr Herzlinger, Professor of Business Administration, Harvard Business School, suggests by her title "how the market--not managed care... will provide the solution to the deep problems that plague the American health care system." Consumers in the United States are ambivalent about medical care--bemoaning high costs and inefficiency while applauding research advances and individual health care providers such as doctors and pharmacists. The abundant information that is available for other sectors--prices, cost, quality, availability--is stunningly absent in health care... Even prices are generally quoted "a la carte" not for the full episode of care. Herzlinger's book intends to help remedy "the contradictions in the American health care system: to keep what is so good about it and to purge what is so bad."

In Part One of this four-part book, Herzlinger looks back twenty-five years to studies that found disparity in patient care. Women in Maine underwent hysterectomy four times more often than those in New Hampshire, implying that some back woods docs were a "greedy lot." Nevertheless, providing equitable care to women seemed easy. Allow a few smart doctors to routinize medicine and then tell the rest what to do and how to do it. Quality would improve, and the cost of health care would plunge--one of the cornerstones of today's powerful for-profit managed care movement.

Herzlinger finds this strategy puzzling when compared to recent changes in most sectors of the American economy. She points to manufacturing's innovations in organizational structure, technology, information, and employee empowerment. The author describes "focused factories," where cleaving vertically integrated firms and "outsourcing" goods and services have proved beneficial, both in costs and customer service. These successful ideas have eluded much of the health care system, which continues to replicate the mistakes of long-gone manufacturing giants--believing that "big is beautiful" and that direction should come from the top.

By 1986, fifteen years after Herzlinger's initiation into the maddening contradictions of the American health care system, she was convinced that the forces that had revitalized manufacturing could reshape the health care system. A revolution was on its way. However, unique barriers--complex technology, multiple professional roles, and daunting legal requirements--had to be overcome. To prepare potential medical care managers, Herzlinger developed an MBA course at the Harvard Business School, "Creating New Health Care Ventures," proposing lower priced specialized medical care, "available before and after working hours, in easy-to-reach locations like work sites, shopping malls, homes, and schools," much as the eyewear sector and chain of cancer centers are doing right now. There will be winners, healthier, better-informed patients and health care providers no longer having to answer to bottom-line-oriented managers, and losers, providers who do not value customer convenience over their own and who also enjoy being in complete control.

In Part 2 , Dr Herzlinger, using examples found in managed care and horizontal integration, analyzes why the two popular remedies for the health care system--downsizing, or managed care, and upsizing, or "big is beautiful," fail in most cases. She gives examples that merged hospitals have increased their costs disproportionately.

In Part 3, the author applies two industry proven ideas, the focused factory and the technology concept, to the "resizing" of health care systems, a fundamental change in structure--exchanging fat for muscle--which is the most difficult.

She points to Toronto's famed Shouldice (Hernia) Hospital, a "focused factory" where 20 surgeons only do herniorrhaphies, as a lesson in efficiency. This privately owned, for-profit facility, charges $2,000 for a procedure that is otherwise essentially free in Canada (after a long waiting period) and costs between $2,400 and $15,000 in American hospitals. Birthing centers, already part of the medical landscape, are another form of the focused factory. She reminds us that clinical pathways are not equivalent to focused factories. She presents data about the inefficiencies of diabetic, asthmatic, and hypertensive care and why they are ripe for the cure: focused factories. The Wilkerson Group, a consulting firm, speculates that HMOs will not invest in a focused factory program because their large membership turnover of 20-25% per year causes them to cast a dubious eye on programs that require intensive efforts in the present to avoid massive costs in the future. "The last thing they want to do is to attract more people with these diseases."

Industry uses technology to lower costs; medicine does not. Further, the present proliferation of needless technology raises costs, enabling health care institutions to raise prices.

Lastly in Part 4, Herzlinger discusses reimbursement systems that encourage focused factories' growth and how technological innovations, convenience, and information will improve our health and reduce our health care costs.

Physicians concerned about the evolution of health care should consider taking this "MBA course" by reading Professor Herzlinger's text, which is succinctly written. Although the book reads well and presents a total picture, we must always speak with the physicians in the trenches. Herzlinger quotes the Shouldice hernia recurrence rate as less than 1%. Two surgeons have told me they have repaired several Shouldice recurrences. Statistics in clinical medicine may be less scientific fact than clinical impression. However, Herzlinger has presented this total picture for our continued dialogue of health care issues. Healthcare leaders will read and study these ideas which will guide them as they plan for health care's future. If physicians take that leadership role, it will empower our profession by making our patients health care more cost effective.

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10.   Hippocrates & His Kin: Health Care Pork - Now That's Really Unhealthy Fat - Class Action Pays Doctors $135 Million - or One Dollar per Patient Visit - Who's Giving Us this Adverse Publicity - How Can We Get Our Professional Organizations to Stop this Professional Homicide?

WellPoint, the nation's largest for-profit health insurer, said Monday that it will pay up to $198 million to settle class-action lawsuits brought by physician groups in California and more than a dozen other states accusing the company of underpaying doctors.

As part of the settlement, WellPoint agreed to pay $135 million to physicians. The company also agreed to pay legal fees up to $58 million. WellPoint has more than 28 million members nationwide. On average that would be slightly less that five dollars per patient or about one dollar per patient visit if the patient made five office visits during the years in question. Can you believe spending $58 million on attorneys to get five dollars back in reimbursement? I don't anticipate ever seeing my five dollars. It would cost me ten times that amount in bookkeeping fees and paper work to try to collect. No matter if you win or lose, your attorney always wins.

One-third of the $25 billion awarded each year goes to the lawyer.

- Jess Brallier in Lawyers and Other Reptiles courtesy of my attorney.

Stroke Center Concept Is Mostly Medical Pork

Dr Gershon replies to the editor of the Wall Street Journal, "If your reporter offers only one side of the story with regard to the stroke center juggernaut it isn't his fault ("Doctors Push Stroke Hospital Network," June 17). Within the U.S. academic medical community there is little voice in opposition to stroke centers. I believe this is mainly because the most motivated authors and speakers are those with the most at stake professionally and, unfortunately, financially in the development and funding of stroke centers.

"I am one of the "interventional endovascular neuroradiologists" referred to in your article, and I am speaking up to say that, in all honesty, the stroke center concept is the fattest lump of pork ever hoisted on the American taxpayer by the medical community.

"In a society with unlimited resources I think it would be a good idea to financially support every medical endeavor with good intentions. But in the U.S., where we are discussing how long Medicare can remain solvent, it is revolting to see self-serving and frequently financially conflicted academic stroke neurologists pushing the stroke center juggernaut."

Abner S. Gershon, M.D., Assistant Clinical Professor, University of Connecticut Medical School, Avon, Conn. http://online.wsj.com/article/0,,SB112122039641684170,00.html?mod=todays_us_opinion

How about Doubling the Health Care Costs in the Name of Quality That Patients Wouldn't Recognize?

Laura Landro reports in the WSJ that "the largest federal program to improve the nation's medical practices is coming under fire, as critics question whether it is effective in fixing some of the most persistent and costly gaps in health-care quality.

"The multibillion-dollar program aims to address the enduring problem that many patients don't get the most effective and up-to-date treatment. In fact, research shows that patients in the U.S. receive only half the care recommended by medical evidence."

What an interesting technique to double the cost of health care from $17 trillion to $34 trillion overnight in the name of quality by making a bureaucratic correction that most patients wouldn't even recognize as an improvement in health care but as something less than they would like? How do we improve the quality of medical bureaucrats?

Read the whole story at http://online.wsj.com/article/0,,SB112060369315777806,00.html?mod=todays_us_personal_journal.

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11.   Restoring Accountability in Medical Practice, HeathCare and Government

Special Offer for Medical Tuesday readers: Receive a free gift subscription to the Newsletter and Journal of the Association of American Physicians and Surgeons (AAPS). "Each month we report on our actions promoting free market and ethical medicine. In the past year AAPS has helped defeat the California Medical Board, the FDA, the DOJ and currently has briefs pending in multiple federal circuits. Learn how to opt out of insurance and succeed with a cash practice. Benefit from our network of thousands of like-minded physicians, and legal support."

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Stay Tuned to the MedicalTuesday.Network to Maintain Your Perspective of HealthCare and Have Your Friends Do the Same

 

Del Meyer                                                              

Del Meyer, MD, CEO & Founder
DelMeyer@MedicalTuesday.net
www.medicaltuesday.net/
6620 Coyle Avenue, Ste 122, Carmichael, CA 95608


Words of Wisdom

Dwight D Eisenhower: There are a number of things wrong with Washington. One of them is that everyone has been too long away from home. May 11, 1955.

Voltaire (1764): The art of government consists of taking as much money as possible from one party of citizens to give to the other.

Jacques Chaoulli, M.D.: My dream is to show the world how to get rid of a new and subtle form of tyranny hidden under the cover of a Welfare State's compulsory health care program.

On This Date in History - July 26

On this date in 1908, the Federal Bureau of Investigation was established by Attorney General Charles Bonaparte.

On this date in 1947, the United States Department of Defense was established under the Armed Forces Unification Act. This signaled the recognition that, in an era of the totality of war, there had to be one combined overall military command.