1.
Featured Article: The Neuroscience of Dance
2.
In
the News: A Welcomed Sea Change in Sharing Health Data
3.
International Medicine: Are Drugs Really Cheaper in Canada?
4.
Medicare: Change of Address Harassment
5.
Medical Gluttony: Telephone Calls
6.
Medical Myths: Government health care will save money.
7.
Overheard in the Medical Staff Lounge: Hospitals Practicing Medicine
8.
Voices
of Medicine: Inside Health Care: Crisis of Faith?
9.
From the Physician Patient Bookshelf: Physician-Assisted Suicide
10.
Hippocrates
& His Kin: Can Government Ever Do Anything Right?
11.
Related Organizations: Restoring Accountability in Medical Practice and
Society
MOVIE EXPLAINING SOCIALIZED
MEDICINE TO COUNTER MICHAEL MOORE's SiCKO
Logan Clements,
a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the
truth about socialized medicine. Clements is the former publisher of
"American Venture" magazine who made news in 2005 for a property
rights project against eminent domain called the "Lost Liberty
Hotel."
For more information visit www.sickandsickermovie.com or email logan@freestarmovie.com.
* * * * *
1. Featured Article: The Neuroscience of Dance
The Neuroscience of Dance; Scientific American Magazine; by Steven Brown
and Lawrence M. Parsons; July 2008; 6 Pages
Dance is the most
synchronized activity people perform. Neuroscientists are trying to discover
not only how but why we do it.
So natural is our capacity for rhythm that most of us
take it for granted: when we hear music, we tap our feet to the beat or rock
and sway, often unaware that we are even moving. But this instinct is, for all
intents and purposes, a . . . novelty among humans. Nothing comparable occurs
in other mammals nor probably elsewhere in the animal kingdom. Our talent for
unconscious entrainment lies at the core of dance, a confluence of movement,
rhythm and gestural representation. By far the most synchronized group
practice, dance demands a type of interpersonal coordination in space and time
that is almost nonexistent in other social contexts.
Even though dance is a fundamental form of human
expression, neuroscientists have given it relatively little consideration.
Recently, however, researchers have conducted the first brain-imaging studies
of both amateur and professional dancers. These investigations address such
questions as, How do dancers navigate though space? How do they pace their
steps? How do people learn complex series of patterned movements? The results
offer an intriguing glimpse into the complicated mental coordination required
to execute even the most basic dance steps.
I Got Rhythm
Neuroscientists
have long studied isolated movements such as ankle rotations or finger
tapping. From this work we know the basics of how the brain orchestrates simple
actions. To hop on one foot—never
mind patting your head at the same time—requires
calculations relating to spatial awareness, balance, intention and timing,
among other things, in the brain's sensorimotor system. In a simplified version
of the story, a region called the posterior parietal cortex (toward the back of
the brain) translates visual information into motor commands, sending signals
forward to motion-planning areas in the premotor cortex and supplementary
motor area. These instructions then project to the primary motor cortex, which
generates neural impulses that travel to the spinal cord and on to the muscles
to make them contract [see box on next page].
At the same time, sensory organs in the
muscles provide feedback to the brain, giving the body's exact orientation in
space via nerves that pass through the spinal cord to the cerebral cortex.
Subcortical circuits in the cerebellum at the back of the brain and in the
basal ganglia at the brain's core also help to update motor commands based on
sensory feedback and to refine our actual motions. What has remained unclear is
whether these same neural mechanisms scale up to enable maneuvers as graceful
as, say, a pirouette.
To explore
that question, we conducted the first neuroimaging study of dance movement, in
conjunction with our colleague Michael J. Martinez of the University of Texas
Health Science Center at San Antonio, using amateur tango dancers as subjects.
We scanned the brains of five men and five women using positron-emission tomography,
which records changes in cerebral blood flow following changes in brain
activity; researchers interpret increased blood flow in a specific region as a
sign of greater activity among neurons there. Our subjects lay flat inside the
scanner, with their heads immobilized, but they were able to move their legs
and glide their feet along an inclined surface [see box on page 81].
First, we asked them to execute a box step, derived from the basic salida step
of the Argentine tango, pacing their movements to the beat of instrumental
tango songs, which they heard through headphones. We then scanned our dancers
while they flexed their leg muscles in time to the music without actually
moving their legs. By subtracting the brain activity elicited by this plain
flexing from that recorded while they "danced," we were able to home
in on brain areas vital to directing the legs through space and generating
specific movement patterns.
As anticipated, this
comparison eliminated many of the basic motor areas of the brain. What
remained, though, was a part of the parietal lobe, which contributes to spatial
perception and orientation in both humans and other mammals. In dance, spatial
cognition is primarily kinesthetic: you sense the positioning of your torso and
limbs at all times, even with your eyes shut, thanks to the muscles' sensory
organs. These organs index the rotation of each joint and the tension in each
muscle and relay that information to the brain, which generates an articulated
body representation in response. Specifically, we saw activation in the
precuneus, a parietal lobe region very close to where the kinesthetic
representation of the legs resides. We believe that the precuneus contains a
kinesthetic map that permits an awareness of body positioning in space while
people navigate through their simply walking a straight line, the precuneus
helps to plot your path and does so from a body-centered or
"egocentric" perspective.
Next we compared our dance scans to those
taken while our subjects performed tango steps in the absence of music. By
eliminating brain regions that the two tasks activated in common, we hoped to
reveal areas critical for the synchronization of movement to music. Again this
subtraction removed virtually all the brain's motor areas. The principal
difference occurred in a part of the cerebellum that receives input from the
spinal cord. Although both conditions engaged this area—the anterior
vermis—dance steps synchronized to music generated significantly more blood
flow there than self-paced dancing did.
Albeit
preliminary, our result lends credence to the hypothesis that this part of the
cerebellum serves as a kind of conductor monitoring information across various
brain regions to assist in orchestrating actions [see "Rethinking the
Lesser Brain," by James M. Bower and Lawrence M. Parsons; Scientific
American, August 2003]. The cerebellum as a whole meets criteria for a good
neural metronome: it receives a broad array of sensory inputs from the auditory,
visual and somatosensory cortical systems (a capability that is necessary to
entrain movements to diverse stimuli, from sounds to sights to touches), and
it contains sensorimotor representations for the entire body.
Unexpectedly,
our second analysis also shed light on the natural tendency that humans have to
tap their feet unconsciously to a musical beat. In comparing the synchronized
scans with the self-paced ones, we found that a lower part of the auditory
pathway, a subcortical structure called the medial geniculate nucleus (MGN),
lit up only during the former set. At first we assumed that this result merely
reflected the presence of an auditory stimulus—namely, music—in the
synchronized condition, but another set of control scans ruled out this interpretation:
when our subjects listened to music but did not move their legs, we detected no
blood flow change in the MGN.
Thus, we concluded that MGN activity related
specifically to synchronization and not simply listening. This finding led us
to postulate a "low road" hypothesis that unconscious entrainment
occurs when a neural auditory message projects directly to the auditory and
timing circuits in the cerebellum, bypassing high-level auditory areas in the
cerebral cortex. . .
Tantalizing Tango
Finding
In a
study published in December 2007, Gammon M. Earhart and Madeleine E. Hackney of
the Washington University School of Medicine in St. Louis found that tango
dancing improved mobility in patients with Parkinson's disease. The condition
stems from a loss of neurons in the basal ganglia, a problem that interrupts
messages meant for the motor cortex. As a result, patients experience tremors,
rigidity and difficulty initiating movements they have planned.
The
researchers found that after 20 tango classes, study subjects "froze"
less often. Compared with subjects who attended an exercise class instead, the
tango dancers also had better balance and higher scores on the Get Up and Go
test, which identifies those at risk for falling.
Ballet for
Better
Balance?
Roger W. Simmons of San
Diego State University has found that, when thrown off balance, classically
trained ballet dancers right themselves far more quickly than untrained
subjects, thanks to a significantly faster response to the disturbance by
nerves and muscles. As the brain learns to dance, it also apparently learns to
update feedback from the body to the brain more quickly.
To read the rest of this report, charts and
illustrations, go to www.sciamdigital.com/index.cfm?fa=Products.ViewIssuePreview&ARTICLEID_CHAR=5F4F2FE1-
3048-8A5E-105D5AF1137F48F3.
* * * * *
2. In the News: A Welcomed Sea Change in Sharing Health
Data
HealthBlog: A possible
sea change on how to share health data by Bill Crounse, Director, Worldwide
Health, Microsoft Corporation, July 23, 2008
I'm writing today from Boston, Massachusetts, where I
just delivered the opening keynote at the World Congress Leadership Summit. The
conference is being held at the new and very lovely Renaissance Waterfront
Hotel.
If you've noticed a nautical theme on HealthBlog from
time to time there's a very good reason for it. I grew up in the Pacific
Northwest in a fishing village on the waters of Puget Sound. The sea is very
much in my blood. I find that whenever I'm near a seaport and can smell the
ocean air or hear the cry of a gull, I not only get nostalgic about my boyhood
but I have an almost uncontrollable desire to get down to the water. So after
my keynote this morning, I took a long walk. That's
when it hit me; the connection (at least metaphorically) between today's topic
on HealthBlog and the sea. The theme at
this year's Leadership Summit is "The Road to Interoperability". My
keynote on global healthcare industry trends was followed by a "reactor
panel" moderated by Janet Marchibroda, CEO of the eHealth Initiative.
Panelists included Bill Beighe, CIO of Physicians Medical Group of Santa Cruz;
Barbara Blakeney, RN, Innovation Specialist at Mass General Hospital and Past
President of the American Nurses Association; and G. Daniel Martich, MD, CMIO
and Associate CMO, at the University of Pittsburgh Medical Center.
In my presentation I had discussed the 5 global
trends; increasing personal responsibility, "retailization" of health
services, "commoditization" of services and providers, information
everywhere, and globalization. The panel reacted to my keynote by giving
examples of how their organizations are being impacted by these global trends and
what they are doing to address them. The conference continued with a number of
other presentations and breakout sessions on how to achieve interoperability in
our health system, and what it will take to get us there.
In 2004, George Bush proclaimed that most Americans
would have an electronic health record by 2014. So here we are 4 years later,
and despite a lot of focus on establishing the Office of the National
Coordinator for Health IT, promoting the concept of a National Health
Information Network and seeding Regional Health Information Organizations with
millions of dollars in federal and foundation grants, one could argue that we
aren't much closer to getting where we need to be than we were four years
ago. However, in those four years
something else has emerged that is proving to be truly disruptive. It's the
idea of aggregating health information around the consumer as perhaps a better
and certainly less costly solution than trying to interconnect every hospital,
clinic, doctor's office, imaging center, lab, payer and other player in our
complex ecosystem of care. And what is at the center of this change? It is patients and healthcare consumers
themselves and the emergence of new technology models such as HealthVault,
Google Health, Medical Record Banks, Dossia, and other solutions that appear to
be leapfrogging the need for NHIN, RHIO's, or other efforts to hard wire a
connection between every health facility. If there is a buzz in the air at this
conference it is that bow wave of new ideas. This truly represents a "sea
change" in our thinking on how to achieve a portable, always available,
and interoperable "electronic record" for most Americans by 2014. In
fact, I now believe we may get there well before that date rolls around.
www.worldcongress.com/events/HL08014/pdf/news/RTI-healthblog-072308.pdf
* * * * *
3.
International
Medicine: Are Drugs Really Cheaper in Canada?
Canada's Drug Price Paradox 2008 by Brett J. Skinner, Mark Rovere
This study regularly
(since 2005) compares Canadian and American retail prices for an identical
group of the 100 most commonly prescribed brand-name (mostly patented) drugs
and the 100 most commonly prescribed generic drugs in Canada. In 2007, this
sample of drugs represented approximately 70% of the entire brand-name market and
approximately 55% of the entire generic market.
The results confirm that, in 2007, Canadians continued
to pay more than double the prices that Americans pay for identical generic
drugs because government policies in Canada distort the market for prescription
medicines. Meanwhile, Canadian prices for brand-name drugs remain more than
half as expensive on average as American prices for identical drugs and are
declining over time relative to prices in the United States.
In currency-equivalent terms, Canadian retail prices
for generic prescription drugs in 2007 were on average 112% higher than retail
prices observed in the United States for identical drugs (see figure 1). Last
year's study found similar results; generic prescription drugs in Canada were
on average 115% higher than American prices in 2006.
This year's findings indicate that average generic
drug prices in Canada have slightly declined relative to American prices, yet
Canadians are still paying too much (more than double US prices) for their generic
medicines. A previous analysis of Canadian and American drug prices found that
average prices for generic drugs were 78% higher in Canada in 2003, indicating
that over a five-year period the average cost of generic drugs in Canada has
risen substantially relative to US prices.
This year's study also found that in 2007 Canadians
paid on average 53% less than Americans for identical brand-name drugs; in 2003
the average price for brandname drugs was 43% lower in Canada. For Canadians,
this means that since 2003 the cost of brand-name drugs has decreased relative
to US prices for identical drugs.
The American market for prescription drugs is not
distorted by the same public policies that are observed in the Canadian market.
Canadian government policies insulate generic drug companies and pharmacy
retailers from normal market forces that would put downward pressure on prices
for generic drugs. A relatively freer market in the United States produces
lower prices for generic drugs. Lower prices in the
United States give consumers incentives to substitute
generic drugs for comparatively more expensive brand-name drugs at higher rates
than the rates seen in Canada. If the Canadian market for prescription drugs
was at least as free as the US market, we would expect Canadian prices for
generic drugs to eventually fall to US levels. Over time, lower prices would be
expected to lead to an increased substitution of generic drugs for brand-name
drugs in Canada, as they have in the United States.
In 2007 alone, federal-provincial-territorial policies
regulating prescription drugs cost Canadians an estimated $2.9 to $7.5 billion
in unnecessary spending due to a combination of inflated prices for generic
drugs and inefficient substitution of medicines. Canadians would be much better
off if federal and provincial governments repealed policies that distort the
market for prescription drugs.
Findings
Adjusting for the purchasing power parity of the
Canadian and US dollars, retail prices for the 100 most commonly prescribed
Canadian generic drugs in 2007 were 112% more on average than prices for the
same generic drugs in the United States. Of the top 100 generic drugs in Canada
that were available in both markets,
- 75% were priced higher in Canada than in the
United States: Canadian prices for
these drugs averaged 161% higher than US prices
- 25% were priced lower in Canada: Canadian prices
for these drugs averaged 36%
lower than US prices.
By comparison, retail prices for the 100 most commonly
prescribed Canadian brandname drugs cost, on average, 53% less in Canada than
in the United States. Of the 100 most commonly prescribed brand-name drugs in
Canada in 2007 that were available in both markets,
- 97% were less expensive in Canada than in the
United States: Canadian prices for these drugs averaged 56% lower than US
prices
- 3% were more expensive in Canada than in the
United States: Canadian prices for these drugs averaged 37% higher than US
prices.
American consumers also substitute generic versions of
drugs for their brand-name originals at higher rates than do consumers in
Canada. Lower prices for generic drugs driven by market pressures in the United
States create positive incentives for American consumers to make rational
cost-benefit choices regarding their use of medicines. By contrast, Canadian
public policies often try to force generic substitution by government edict and
yet fail to achieve rates of substitution as high as a relatively freer market
in the United States. In 2007, Canada-US generic substitution rates, measured by
the percentage of total prescriptions dispensed in the year were,
- Canada: 48% generic; 52% brand name
- US: 67% generic; 33% brand name.
Conclusion
If Canada repealed policies that distort the market
for prescription drugs, net savings for Canadians could reach between $2.9
billion and $7.5 billion (2007) annually for total retail pharmacy sales of
generic and brand-name drugs. The savings would result from greater competition
for sales of generic drugs leading to much lower prices and greater voluntary
use of generics. In the absence of massive cross-border demand from American
consumers, Canadian prices for brand-name drugs should remain significantly
below US prices for identical drugs. . . .
To read the entire report, go to www.fraserinstitute.org/commerce.web/product_files/CanadasDrugPriceParadox2008.pdf.
Canadian Medicare does not
give timely access to healthcare, it only gives access to a waiting list.
--Canadian Supreme Court
Decision 2005 SCC 35, [2005] 1 S.C.R. 791
http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html
* * * * *
4.
Medicare: Change
of Address Harassment
We ran a series
on Medicare Harassment of doctors who have been in practice for many years who
simply change their office address, frequently in the same zip code, sometimes
on the same street and sometimes just a suite number change in the same
building. Medicare treated these physicians in a very demeaning manner making
them reapply as if they were interns applying for the first time, not physician
members of Medicare for many decades. We thank all who have written concerning
similar experiences.
We thought the
following letter was a little different but illustrative of the arrogance of
government programs and what to expect should the government ever gain a total
monopoly on healthcare.
Medicare did the
same thing to me that they are currently doing to you. Prior to opting out of
Medicare, I was always a Non-Par in Medicare.
When I moved and
opened a new office, I notified Medicare, via U.S. Mail, of my new address.
They wanted me
to fill out a 30-page form just to change my address!! The form was basically an initial enrollment
form in Medicare which contains all sorts of things that I would not agree to
and sign as a Non-Par physician. I had
been "enrolled" in Medicare as a Non-Par physician for 18 years at
that point.
I refused to
fill out and sign their abusive 30-page form.
Medicare
retaliated by refusing to pay what they owed (i.e. they force assignment on
physicians who treat dual eligible patients - Medicare + Medicaid). Medicare owed me a substantial amount of
money.
I stood firm,
and would not fill out and sign (agree to) their abusive "enrollment"
form.
Within a few
months, I opted out of Medicare under Sec. 4507 of the BBA of 1997.
As a result of
opting out of Medicare, Medicare was forced to accept the change of address
notification that I previously supplied to them - no 30-page form had to be
filled out.
After Medicare
was forced to acknowledge and accept my notification of change of address, they
were then forced to send all the money they owed me.
This is the
"standard operating procedure" for this highly abusive and coercive
government bureaucracy.
The bureaucracy
seeks to punish those physicians who refuse to "voluntarily" sign up
with their abusive Medicare program which degrades and devalues physicians on
an ever increasing basis.
LRH, 10-4-07
Government is
not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
Telephone Calls
The telephone is an important item in the
business/professional world. Many businesses have resorted to automatic
answering programs with automatic direction of the calls to the desired party.
Even automatic systems have become expensive. AT&T no longer provides the
time of day for free. They can't afford to tie up the number of lines required
to give out time even if it is totally free of human intervention.
Lawyers were the first professionals to develop a
system of charging for calls or any other interface with their client. They can
charge the same hourly rate whether at home, on the road, in the office, or
indisposed. They have even developed a mechanism to charge for information
relayed in unobtrusive fashion. I once reported some information on a case to
my attorney in a Christmas card. Her secretary opens all mail and screens for legal
information and is able to electronically insert the time into the attorney's
time card on any case. Most attorneys have a minimum charge of one-sixth or
one-fourth an hour. In the above case, the junior attorney's rate was $200 an
hour; her supervisor, who always managed to get in one hour of consulting on my
case monthly, it seemed, was at $320 an hour. The minimal rate in the firm was
one-fourth hour. Therefore, a one- to 15-minute phone call to my personal
attorney was $50 and to the senior attorney it was $80. Hence, the secretary
entered a quarter-hour fee for the information entered in the Christmas card
and it showed up on my statement the next month. In this way, attorneys are
able to charge for any time spent, whether in your presence or on your behalf.
Physicians spend a lot of time on the phone often in
many non-remunerative activities on behalf of their patients. Many of my
colleagues estimate time spent on completing charts, making phone calls,
discussing with consultants, and reviewing lab and x-ray reports for one
patient takes about two to three hours a day. There is no mechanism to charge
for these services with a third-party system such as Medicare, Medicaid,
insurance carriers, and HMOs who all feel this would add to the cost of health
care.
Charles Krauthammer, a physician columnist, once
stated that if doctors charged even $2 for every phone call, this would reduce
phone work to the absolute minimum. However, most insurance carriers, Medicare,
and Medicaid will not let a doctor put through any additional charges. Thus,
reasonable cost accounting for time spent cannot happen with current fiscal or
insurance intermediaries.
Even charging $5 a phone call would be cost effective
for the patient. Sometimes a $5 phone call would reduce the need for a $100
office call. The free market economy would work this out to the most
cost-effective solution saving everyone money and making the professional's
life more comfortable and palatable.
Likewise, a $25 email consultation on an established
patient may also be cost effective for the patient if it saves a $100 office
call. The physician's income wouldn't drop since this would work out as the
process develops a schedule. The fluidity of office calls interspersed with
paid phone calls and with paid email medical evaluations could make a
wonderfully challenging practice environment. Health care costs would probably
decrease.
Pharmacies are becoming a huge drain on a medical
practice. Physicians give enough refills to last until the next designated
appointment plus one in case of a schedule change. However, pharmacists have
added to their practice the job of securing prescriptions from the doctor
without the patient being present with the doctor. To treat without the medical
chart or the patient in front of you, if it isn't malpractice, certainly is
very poor medical practice. It is the pharmacist's job to inform the patient of
his last prescription refill and encourage them to make an appointment with
their doctor for their next evaluation and Rx renewals. Perhaps the pharmacists
want to insure that they get the next prescription rather than have the patient
shop around with an open or live prescription.
I called my pharmacist to request a refill. However, I
never reached the pharmacist but their phone menu. I had no refills remaining
and the recording said that they would call my doctor. However, I could not
interrupt the system to tell them thank you for reminding me that this was the
last refill and certainly not put my own physician to this unnecessary expense;
I would see my doctor for reevaluation of my therapeutic program. They
automatically called and interrupted my busy doctor for which he didn't get
paid.
I made a trip to the pharmacy and asked the
pharmacists not to call my doctor again. If I had no refills, just tell ME, NOT
MY DOCTOR; it is my job to get the new prescription to them. I pointed out that
such a simple call to my attorney would cost $50 to $80 and I objected to their
calling my doctor at his expense. Phone calls are expensive. The challenge is
to work them into the mainstream practice of medicine to economize everyone's
valuable time, not into an additional two or three hours to a ten-hour work
day.
The technology is here to incorporate phone calls and
emails into the practice of medicine. This integration would be cost effective
for the patient. It would also put health care costs on a more realistic basis.
The patients and insurance companies’ expectation for doctors to do this
additional time without remuneration will eventually collapse. We must have the
system ready before this happens.
* * * * *
6.
Medical Myths:
Government health care will save money.
Court rejects California's Medi-Cal reimbursement cuts
By KEVIN YAMAMURA and JIM SANDERS, Sacramento Bee August 20, 2008
A federal judge has ordered a temporary halt in the
California's 10 percent reduction in Medi-Cal reimbursement rates, improving
access to care for 6.5 million low-income patients but throwing a new wrench in
already-difficult budget negotiation.
The U.S. District Court decision forces the state to
reimburse most Medi-Cal providers at rates prior to the 10 percent cut, which
lawmakers and Gov. Arnold Schwarzenegger made effective July 1 as a
cost-cutting measure to help resolve a $15.2 billion budget shortfall this
year.
The move increases reimbursement rates the state pays
to doctors, dentists, pharmacists, adult day-care centers and other providers
who serve Medi-Cal patients. It excludes some hospitals who do not contract
with the state and do not provide emergency care.
"There's no question this is good news,"
said Anthony Wright, executive director of Health Access California, a consumer
group. "We already have more than half of doctors not taking Medi-Cal patients
because of low reimbursement rates, so the additional rate cut was going to
further reduce access to care for millions of children, parents, seniors and
people with disabilities."
But the injunction comes as lawmakers remain divided
because they cannot agree whether to bridge the budget spending gap with new
taxes, borrowing or spending cuts. If the state ultimately loses the Medi-Cal
reimbursement case, it could face an additional $575 million hole on top of the
$15.2 billion deficit, according to Schwarzenegger's Department of Finance. . .
The state is now 51 days into the new fiscal year
without a budget, and some Medi-Cal providers stopped receiving payments in
late July because the state does not have a spending plan in place. . .
"It looks like the judge recognized that these
people have no access, and certainly not equal access to services, at least not
the way the (federal) program was envisioned." To read the entire report,
go to www.sacbee.com/111/v-print/story/1170735.html.
With state revenues at an all time high, that we have
a budget deficit just points out the inability of our legislature to manage
revenue and control spending. In these difficult times for taxpayers with loss
of income, foreclosures, bankruptcies, that the liberal legislators can even
think of raising taxes is cruel and inhumane. In the absence of a budget, we
should reduce every legislator and their staff to a zero income. We should then
recall every legislator that shows this total lack of regard for their fellow
human beings so they can get a real job and understand income and expenses.
Lawmakers' fiscal irresponsibility would destroy our
health care if they were given a chance.
* * * * *
7.
Overheard in the
Medical Staff Lounge: Hospitals Practicing Medicine
Dr. Edwards: The
medical practice act has limited the practice of medicine to physicians. Why
are hospitals competing with us?
Dr. Milton: I
remember it was a big thing in Medical School to point out that the practice of
medicine should always remain in medicine. Most states had laws against the
corporate practice of Medicine with physicians as employees.
Dr. Ruth: But
we have always had large groups. Look at the Mayo Clinic.
Dr. Edwards: But
that was group practice. The physicians of the clinic were always in charge.
Mayo uses several hospitals but the doctors are solely responsible for their
practice and the quality of health care. The hospitals are only the environment
in which the very sick are treated. The rest were treated in the clinic.
Dr. Rosen: Then
there was Kaiser. Although the Kaiser Health Plan and the Kaiser Foundation
Hospitals were non-profit corporations, the Permanente Medical Group was always
a physician-controlled group. They had a mutually exclusive contract with each
other.
Dr. Milton: Then
other large clinics developed all over the country maintaining the physician’s
independence in the practice of medicine. The physician never had to answer to
a corporate overlord. The primary responsibility was to the patient.
Dr. Dave: It
seems that more and more hospitals are putting doctors on salary to practice
administrative medicine which then controls the medical staff which in effect
puts them under hospital control.
Dr. Rosen: This
seems to be a hot issue throughout the country - how the independent hospital
staff is gradually coming under the hospital thumb and is no longer
independent. There are many articles in the medical practice journals speaking
to this issue.
Dr. Milton: The
hospitals have similarly created foundations that, though allegedly
independent, seem to be beholden to the hospital corporation.
Dr. Dave: The
veneer of the hospital foundation is so thin, that the doctor’s salary and
practice patterns are quite well controlled. Have you noticed how short the
physician’s stay is if he or she gets too independent?
Dr. Michelle: I
rather like being a physician with the hospital practicing medicine. I think it
makes me feel more secure than threatened.
Dr. Dave: You
like the hours?
Dr. Michelle:
That’s very important to a woman who has a family and a home to manage. I can’t
work until 7 or 8 o’clock like you guys. You have someone at home that does all
those things for you.
Dr. Joseph:
Being a retired surgeon doing surgical assisting part time, I’m of a mixed
mind. The hospital pays me directly for assisting in surgery at all hours
several days a week. I train their family practice residents in surgery. Most
of these residents are then hired by the hospital to practice on their staff.
Dr. Dave: So
you are training the competition that will put the private practicing surgeons
out of work?
Dr. Joseph: You
got that right. But I’ve come to the conclusion that I don’t care who pays me.
I just work my hours, take my pay, and enjoy life.
Dr. Dave:
Sounds like that’s what all these residents you’re training plan to do also?
Dr. Joseph:
That’s my conflict. These doctors will never have to hustle to make a living.
It’s just a job from 8 to 5.
Dr. Dave: Just
like any other day laborer?
Dr. Joseph:
Isn’t that what we are? Laborers?
Dr. Dave: Will
we have any more Christiaan Barnard’s who, after working a thirteen-hour day,
had a heart available and then worked another nine hours doing the first heart
transplant?
Dr. Joseph: I
really don’t think so. There won’t be any innovations in America anymore than
there are innovations in Sweden and elsewhere.
Dr. Rosen: I
remember a discussion with a Swedish physician in Amsterdam once. He agreed
that there was a complete homogenization in their country and he didn’t think
that they would ever have another Nobel Prize winner in any scientific field
again. There was no drive towards excellence.
Dr. Joseph:
Maybe Nobel Prizes and innovations are no longer important. We’ll all just be
cogs in a wheel and hopefully no one will be absent some day so that a patient
misses an important cog in his trying to get well or get a transplant.
Dr. Dave: With
the emphasis on dying and cost containment, who’ll care if the patient goes to
the morgue instead of the heart surgical operating theater?
Dr. Michelle: I’ll
care. But I have to admit that I won’t make any moves to change the modus
operandi.
* * * * *
8.
Voices of
Medicine: A Review of Local and Regional Medical Journals and the Press
SONOMA MEDICINE, the
Magazine of the Sonoma County Medical Association, Spring 2008
EDITORIAL: Inside
Health Care: Crisis of Faith? By Rick Flinders, MD
I've never begun an editorial in these pages with more
misgiving. This won't be a "feel good" piece. The profession I've
served and loved for over 30 years has provided me livelihood, fulfillment and
inspiration. With rare exception, my colleagues have been diligent and
dedicated professionals, committed to caring for the patients we mutually
serve. To my colleagues, I say it is still a pleasure and privilege to work
with you all. But we work inside a lousy system. In fact, it is no system at
all. So if I seem critical, please understand that my complaint here is a
lover's quarrel.
Medicine is a mess. We spend $2.2 trillion a year for
health care in the United States, and it's not as good as we thought.
"Best health care in the world" now refers to isolated islands of
medical excellence in a sea of mediocrity. By the best health metrics our
outcomes rank 37th in the world. Among the 13 industrial economies of the world
we rank last. We can transplant organs and keep people alive through the
terminal stages of chronic illness, but we can't immunize many of our children,
guarantee adequate care to all our pregnant women, or provide basic care and preventive
services for the estimated 45 million people in our population who are
uninsured.
Not a pretty picture. Few want it this way, but the
problem is complex, and it touches every level of values around which societies
organize. Health care has been described by one bioethicist as "the
largest social reform issue in the U.S. since the abolition of slavery."
For starters, health-care dollars comprise nearly a fifth
of our domestic economy. President Eisenhower left office in 1960 with his
famous warning of a vast "military-industrial complex." When Dr.
Arnold Relman retired as editor of the New England Journal of Medicine
in 1983, he warned: "Beware the medical-industrial complex." The
financial juggernaut of the Big Three—pharmaceuticals, private insurance, and
the medical technology marketplace—drives the current practice of medicine with
an undue influence that has distorted our science, distracted us from the
reason we practice medicine, and threatens a stranglehold on any meaningful
reform. If you doubt this influence, consider our Congress, where drug
lobbyists outnumber legislators two to one.
Congress is where the 2003 story of Medicare's
"drug benefit" unfolded. Medicare Part D, which provides prescription
drugs for the elderly at drug-company prices, was written by drug lobbyists.
The bill forbids Medicare from negotiating the price it pays for drugs. As
Billy Tozan, the Louisiana congressman who steered the bill through the House,
boasted, "Not one word was written by Congress." Just six weeks after
pushing the bill through Congress, Tozan took a $2-million-a-year position as
president and CEO of PhRMA, the lobbying conglomerate of 12 major drug
companies, including Abbott, Lilly, Bayer, Pfizer and Merck.
Tozan is not alone. Fifteen other representatives who
voted the bill into law are now lobbyists for the drug industry. Thomas Scully,
Medicare's top administrator at that time, now represents a half-dozen drug
firms through a contract he negotiated while the bill was being debated. When
his chief actuary, Richard Foster, found the cost-analysis to be almost twice
the original estimate, Scully threatened to fire him if he disclosed the
information before the congressional vote.
The result of Part D is a pharmaceutical windfall that
requires Medicare to pay up to 10 times the price charged to others for the
same drug. For example, Medicare pays $1,485 for a year's worth of Zocor, while
the VA—which negotiates its price—pays $127. We're talking $800 billion over 10
years, up to 60% of which is a "gouge." Since the passage of Part D
in 2003, the drug industry has raised its prices to Medicare by 30%. Who
"benefited" the most?
The influence of drug companies extends well beyond
Congress. Seventy percent of academic drug trials are sponsored by the drug industry,
and the industry determines what gets published—and what doesn't. For example,
Merck (the same company that brought us Vioxx) has now disclosed data that
their lipid-lowering drug, Zetia, has no benefit in cardiovascular outcomes,
despite reducing levels of LDL. They knew this two years ago and sat on the
data, while they generated more than $4 billion each year in sales.
I'm not saying that drug companies are evil. I think,
like any capitalist enterprise, they're trying to make a buck. And I believe
they're honestly trying, along the way, to even help some people. But I no
longer trust their judgment, or what we see of their data. I can no longer
trust that their judgment of what's best for my patients is not compromised by
what's best for their profits, conscious or otherwise. Would you buy a used car
from Merck? And if not, why would you trust their judgment of what's best for
your patient?
Unlike the pharmaceutical industry, which actually
produces drugs that work, the insurance industry produces nothing. This
Byzantine bureaucracy of 1,300 different companies, dealing over 27,000
different health plans, charges us a 15-30% "administrative fee"
depending on whether the company is investor-owned or
"not-for-profit." Compare this fee to Medicare's administrative cost
of 3%. Most single-payer systems, worldwide, operate at under 10%
administrative costs. Annually, the difference in the United States would mean
an additional $300 billion for actual health services.
Recently, Blue Cross of California placed its member
physicians in yet another new role, sending them copies of their patients'
insurance applications and asking their help in canceling policies of patients
who fail to disclose "material medical history" or other pre-existing
conditions. Physician as informant: who are we working for?
Finally, there is the cost of technology. It is hard
to deny the modern daily miracles, but I would ask that the words technology
and appropriate be merged in medicine into one: approtechnology.
Last year 62 million CAT scans were ordered in the United States. By September
there will be more MRI scanners in Sonoma County than acute psychiatric beds.
Most Medicare dollars are spent in the last 30 days of life.
I recently saw a 14-year-old gymnast who received plain films, CT and MRI of
his sore knee before ever getting a history or physical exam. He turned out to
have Osgood-Schlatter disease, a common condition among teenagers that can be
diagnosed with your thumb on the tibial tuberosity. Let's be reasonable. We
should use our clinical skills first and only apply our technologies when they
should be done, not just because they can be done.
Our medical heritage, passed on from the professors who
taught us, by lecture and example, is that the practice of medicine, at its
purest, is guided by science and driven by compassion. Money matters. But it
has distorted the methodology of our science and has distracted us from the
motive of our practice. As a professional, all I ask to know is what's best for
my patient. I've been a good soldier who's preached the gospel of
evidence-based medicine for 30 years. And now I learn that the evidence may be
tainted.
Forty years ago, while I began studying for a career
in medicine, a popular American songwriter declared, "I ain't gonna work
on Maggie's Farm no more." Maggie's Farm was the perfect, modern metaphor
for the classic relationship of serf to landlord. The laborer pours passion and
sweat into his work, only to learn he's really working for someone else. The
oath we took when we became physicians binds us as privileged servants to our
patients, not to Pfizer, Blue Shield or General Electric. We need to assure
ourselves—and the generation of young men and women now entering medicine—that
we still work for the patient, not for some new-age corporate rendition of
"Maggie's Pharm."
www.scma.org/magazine/scp/SP08/flinders.html
Dr. Flinders is a clinical professor
of family and community medicine at UCSF and teaches in Santa Rosa's Family
Medicine Residency Program.
To read more VOM, please go to www.healthcarecom.net/voicemed.htm.
To read HMC, please go to www.delmeyer.net/HMC.htm.
* * * * *
9.
Book Review:
Physician-Assisted Suicide
FORCED EXIT - The Slippery Slope From Assisted Suicide to
Legalized Murder, by Wesley J Smith, Times Books, div of Random House,
New York, 1997, xxvi, & 291 pp. ISBN: 0-8129-2790-7
Wesley J Smith, author of No Contest: Corporate
Lawyers and the Perversion of Justice in America, opens his prologue of Forced
Exit with the story of a dear friend who spent years planning her suicide
and after inviting friends to the event, none of whom came, exited this life
quietly. Smith, an Oakland attorney, contacted the executrix and obtained her
suicide file wherein he found newsletters and other scurrilous documents from
the Hemlock Society that thoroughly sickened him.
This motivated Smith to research into death, the
inventing of the right to die that is driving people to embrace the death
culture, and euthanasia's betrayal of medicine. He finds that a society that
believes in nothing can offer no argument even against death. Seen in this light,
support for euthanasia is not a cause but rather a symptom of the broad
breakdown of "community" and the ongoing unraveling of our mutual
interconnectedness. The consequences of this moral Balkanization can be seen in
the disintegration of family cohesiveness; in the growing nihilism among young
people that has led to a rise in suicides, drug use, and other destructive
behaviors; in the growing belief that the lives of sick, disabled, and dying
people are so meaningless that helping them kill themselves can be countenanced
and even encouraged.
Smith calls acceptance of euthanasia "terminal
nonjudgmentalism." He finds a good example in A Chosen Death by
Lonny Shavelson, an emergency physician, who describes "Gene" who has
had strokes and depression but is not terminal. Sarah, from the Hemlock
Society, is given the task of assisting in his death. Sarah found her first
killing experience tremendously satisfying and powerful, "the most
intimate experience you can share with a person... More than sex. More than
birth." Sarah gives Gene the poisonous brew as if she were handing him a
beer. Gene drinks the liquid, falls asleep on Sarah's lap who then places a
plastic bag over his head and croons, "See the light. Go to the
light." But Gene, suddenly faced with the prospect of immediate death,
changes his mind and screams out . . . and tries to rip the bag off his face.
Sarah won't allow it, catches Gene's wrist and holds it. Gene's body thrust
upwards and Sarah lays across Gene's shoulders. . . pinning him down, twisting
the bag to seal it tight. Gene's body stops moving.
Smith says what happened to Gene is murder. He
further feels that the ethical thing for Dr Shavelson to have done was to knock
Sarah off the helpless man and then dial 911 for an ambulance and the police.
Shavelson describes his thoughts on whether to act or observe the death, and
Smith calls this non-decision "terminal nonjudgmentalism," or TNJ. He
feels that what Shavelson and other death fundamentalists miss is that
so-called protective guidelines for the "hopelessly ill" are
meaningless; they provide only a veneer of respectability. Once killing is
deemed an appropriate response to suffering, the threshold dividing
"acceptable" from "unacceptable" killing will be
continually under siege. But the fiction of control, essential to the public's
acceptance of euthanasia, will have to be maintained, so the definition of what
will be seen as "legitimate" killing will be expanded continually.
I personally observed this attitude at the last
international meeting of my professional society as I spoke with pulmonologists
from The Netherlands, Belgium, and other Western European countries who
admitted that "killing patients" occurs rather frequently - sometimes
the sickest in the hospital is killed simply to open a bed for a new admission.
As we are beginning to comprehend the holocaust; as
African Americans are searching for the relics of their slavery, like the neck
irons with their torture springs and who say that this was the real holocaust;
when doctors are able to kill thousands of the millions that lie on beds of
mercy every day, we will see the epithet of Shindler's List, when doctors
directed those whose lives weren't worth living into lines toward the chambers.
What was thought to be the efficient killing by the Nazis and the communist
doesn't hold a candle to what a free misguided society can do as we open up
Pandora's box for doctors to kill patients whose only crime was being ill, or
alive with a life not thought to be worth living, We must act before it is too
late. Otherwise, those who do act will be considered alive, but will not be
after their first accident or illness that brings them in contact with ruthless
bureaucratic state-controlled doctors, a horror we can't imagine or a thrill
that not even Stalin or Hitler could envision.
To read more reviews on medical ethics, go to www.healthcarecom.net/bkrev_MedEthics.htm
To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.
* * * * *
10. Hippocrates & His Kin: Can Government Ever Do
Anything Right?
Sacramento Library can't add up the Fines that are
Due!
Since the Sacramento County grand jury issued a
scathing report that it found a major problem with uncollected fines totaled by
the library at $2.5 million, which in fact totaled $4.6 million, the library
responded by authorizing a $300,000 contract for a "performance
audit" and is considering paying another $30,000 for a survey of how well
it serves it customers.
Only a government entity can spend money like that
when they're losing money already. The problem is that government has an
unlimited supply of money - taxpayers.
Man denied treatment but offered Physician-Assisted
Suicide
A reader writes that on Fox News at 11 PM on July 28,
a man in Oregon who applied to Medicaid for cancer treatment was denied
treatment but offered PAS (Physician-Assisted Suicide) by the state.
Looks like Oregon found a new way to cut health care
costs - kill the patient.
California's Little Hoover
Commission recommends state prisons for juveniles go out of existence.
State prisons for youthful
offenders have been an expensive failure. A lawsuit filed on behalf of juvenile
inmates in 2003 documented horrific conditions in what was then called the
California Youth Authority. Violence was rampant and lockdowns so common that
educational or counseling programs could not operate effectively. It's hard to
conceive of a juvenile justice system that would be more costly and less
effective than the one now in place. Three of four youths who leave state-run
prisons commit new crimes within three years of release.
The CYA was an effective
training program to prepare juvenile offenders for a lifetime of crime.
Inmate Care to cost an extra
$8 billion for seven 1500-bed hospitals.
Frustrated and showing signs of temper, California's
prison medical receiver on Wednesday asked a federal judge to give him what the
governor, the controller and the Legislature have not - enough money to fix the
state's correctional health care crisis.
The bill will be $8 billion over five years, J. Clark
Kelso said at his downtown Sacramento office. It would go toward building seven
new chronic-care facilities to house 10,500 inmate patients and upgrading
medical units at all 33 state prisons.
In the legal motion filed in U.S. District Court in
San Francisco, Kelso blasted ahead in what amounted to the receivership's
boldest move yet in the 2 1/2 years since it was created by judicial mandate. .
.
Besides the money, Kelso's motion also asked that Gov.
Arnold Schwarzenegger and state Controller John Chiang be held in contempt of
court for failing to provide the prison medical fix-it financing. The receiver
wants Judge Thelton Henderson to fine them $2 million a day until they come
through with the cash. . .
Kelso acted under authority granted to him by
Henderson, the federal judge who ruled in 2005 that California is violating the
Eighth Amendment of the U.S. Constitution by failing to provide adequate
medical care to its prison population. The judge said in his fact findings that
one inmate a week was dying due to medical neglect, a figure that has remained
substantially unchanged, according to later surveys conducted by the receiver's
office. . . Read the entire story at www.sacbee.com/capolitics/v-print/story/1155728.html.
"I think Mr. Kelso got their attention,"
political consultant Ray McNally said.
To read more HHK, go to www.healthcarecom.net/hhk2001.htm.
To read more HMC, go to www.delmeyer.net/hmc2005.htm.
* * * * *
11. Physicians Restoring Accountability in Medical
Practice, Government and Society: