1.
Featured Article: Do-not-resuscitate: A Revolution Now 30 Years Old
2.
In
the News: New Drugs for Rare Diseases
3.
International Medicine: Unequal Health Care Under Canadian Medicare
4.
Medicare: Unequal Health Care Under Medicare
5.
Medical Gluttony: MediGap Insurance
6.
Medical Myths: Congress can control Health Care costs. Shall we start
with big OIL?
7.
Overheard in the Medical Staff Lounge: Professionalism in Dress Code
8.
Voices
of Medicine: Medical Professionalism: Society's
Expectations, Our Expectations
9.
From the Physician Patient Bookshelf: Health Care Co-Ops
10.
Hippocrates
& His Kin: Everybody's Practicing Medicine Except Doctors
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: Do-not-resuscitate: A Revolution Now
30 Years Old by James Murtagh, MD
"Because all the sick do not recover does not mean that there
is no art of medicine." - Cicero, 143-06 BCE De Natura Deorum
"And thus it seems a conspiracy of silence has descended . . . We all pretend
toward our neighbor that the possibility of his death could never happen."
- Albert Schweitzer
This month marks the 30-year anniversary of a fundamental
revolution in America's approach to end of life care. Thirty years ago, it
was impossible to issue a legal Do-Not-Resuscitate order. Then, on June 30,
1978, came a legal decision that remains the bedrock of a new legal, ethical
and moral consensus that has guides medicine today.
"In the matter of Shirley Dinnerstein" Dinnerstein,
380 NE2d, 134,135 (Mass App 1978) made clear that Do-not-resuscitate (DNR)
orders can be issued without court intervention, because the decision to
resuscitate or not resuscitate "is a question peculiarly within the
competence of the medical profession."
Before Dinnerstein, doctors believed that they had to go to court
to stop extraordinary life support. Doctors felt a "technological
imperative" to do "everything possible," regardless of whether
an intervention could work, and regardless of whether a patient wanted a futile
intervention.
Two years previous to Dinnerstein, a New Jersey court in 1976 had
ruled in the Karen Ann Quinlan case that all persons had the right to refuse
treatment. But the Quinlan court did not make clear how this right could be
implemented without court review on a case-by-case basis.
I was a first year medical student at University of Michigan in
1978, and remember the immense relief when Dinnerstein was issued. The
hospital attorney, Ed Goldman, and noted philosopher Carl Cohen, hailed the
decision as common sense: decisions at the end of life were personal, and had
to be made between doctor, patient and family. Courts did not need to involve
themselves.
Father Richard McCormack, the theologian from the Quinlan case
(and, by coincidence, a friend of my family), wrote in 1978 "The Quality
of Life, The Sanctity of Life," reflecting a quote from Martin Luther
King that "The quality, not the longevity, of one's life is what is
important."
Earlier, Pope Pius XII condemned in 1952 "extraordinary
means" to maintain life against the will of patients. All of the major
religions remain in agreement. Doctors now work with chaplains and rabbis of
all faiths to help patients make these decisions.
Dinnerstein
became the basis of the President's commission on Standards for
cardiopulmonary resuscitation (CPR) and was adopted by the American Medical
Association Report on Standards for Cardiopulmonary Resuscitation, declaring,
"The purpose of cardiopulmonary resuscitation is the prevention of sudden,
unexpected death. Cardiopulmonary resuscitation is not indicated in certain
situations, such as in cases of terminal irreversible illness where death is
not unexpected or where prolonged cardiac arrest dictates the futility of
resuscitation efforts. Resuscitation in these circumstances may represent a
positive violation of an individual's right to die with dignity."
Most medical societies followed suit, and Dinnerstein
became embedded into medical standards throughout the country, and in other
countries.
It is now realized that doctors should not prolong dying, but
instead promote dignity. The physician must weigh the concepts of benefit and
burden, and realize that such decisions are value judgments and moral
decisions. The physician must always consider the quality of life of his/her
patient, to which the patient can hopefully enlighten him/her.
Over the past 30 years, the nation has witnessed debates over
Terry Schiavo, and in popular culture in such movies as "Whose Life Is It
Anyway?" "Sea of Life," and "Million Dollar Baby." But
no one seriously denies that a patient has the right to refuse treatment, and
that futile or inhumane treatment should be discouraged. Margaret Edson's
Pulitzer prize winning play "Wit" became the basis of new medical
school initiatives to discuss the need for end of life dignity. Bill Moyers had
a famous series on this topic.
We may take the need for the concept of dignity and for the need
for DNR orders almost for granted in 2008. Certainly, grey areas remain, and
public discussion remains needed. But we need to remember that today's
discussion, and today's law, remains grounded in the 1978 Dinnerstein.
Is this still a "Brave New World?" In reality,
questions of our mortality have always been with us, and are "only new to
thee." This year, in the wake of Schiavo, and in the turbine of other
medical reforms, we need to continue the discussion that was begun 30 years
ago, in the case of Dinnerstein.
James Murtagh has
spent 20 years as an intensive care unit physician. He was associate professor
of internal medicine at Emory University until 2001.
To read other articles by Dr. Murtagh,
please go to www.healthcarecom.net/JM_Profile.htm.
* * * * *
2. In the News: New Drugs for Rare Diseases
The Orphan Drug Act Has Been a Huge
Success, By ED RENSI , WSJ, June 23, 2008;
In more than 32 years with
McDonald's, I worked my way up from grill man to president and CEO by focusing on
providing shareholder value while fulfilling a need. In that vein I'd like to
recognize the 25th anniversary this year of a groundbreaking piece of
legislation that has made it easier for drug companies to do exactly that.
The Orphan Drug Act, signed into
law President Ronald Reagan in 1983, made it possible for companies to invest
hundreds of millions of dollars in the development of potential treatments for
rare diseases. A rare, or orphan, disease is defined as one that affects fewer
than 200,000 Americans. By offering tax incentives for clinical trials of these
treatments and granting seven years of patent exclusivity once the drug is
approved – compared to an average of five years with most new drugs – the
Orphan Drug Act gave hope to the collective millions of Americans living with
these horrible diseases.
One of its most notable
achievements has been to make the capital markets less risky for biotechnology
investors. It has allowed companies to secure financing for research and
development, and created opportunities for scientists and entrepreneurs to make
important advancements in treating these rare diseases.
Prior to this legislation, it
was prohibitively expensive for a company to develop a drug for a disease that
affects so few people. In fact, in the decade before the law was passed only 10
new drugs for rare diseases were developed. In the 25 years since, more than
1,100 new treatments for orphan diseases have entered the research pipeline,
and over 300 new orphan drugs have been approved by the Food and Drug
Administration.
The Orphan Drug Act fosters
collaboration between for-profit corporations and nonprofit organizations –
something I have not only encouraged, but also practiced. As regional vice
president of McDonald's USA in Philadelphia, I was approached about the need
families of children with cancer had for affordable housing so that parents
could be close while their child was undergoing treatment. I decided in 1974
that the Philadelphia market of McDonald's would join in the building of the
first Ronald McDonald House, by making it possible for many committed people to
take the risk and raise money through our restaurants.
Using nothing but philanthropic
funds, we helped to build Ronald McDonald House Charities into what it is
today, with 276 Ronald McDonald Houses scattered around the globe. I strongly
believe that it is important for a corporation to stand for something and
contribute to society in a way in which its employees can be proud.
This isn't always easy for
companies to do. The Orphan Drug Act has made it easier for many nonprofit
organizations to partner with companies to find treatments for rare diseases.
That includes the Scleroderma Foundation, which is celebrating its 10th
anniversary this year. . .
I often hear people talk about
fighting the terrible diseases that cause Americans pain and suffering, but I
rarely hear about real solutions. The visionary leaders who helped to pass the
Orphan Drug Act 25 years ago are an exception to the rule. They backed up the
talk by creating incentives for companies to innovate and fulfill an unmet
need, making it less risky to build a business on treating or curing a rare
disease. As we celebrate the anniversaries of the Orphan Drug Act and the
Scleroderma Foundation, let's follow their example and move from talk to action
by supporting legislation and organizations that make it easier for companies
to innovate and solve problems.
Mr. Rensi is the former
president and CEO of McDonald's USA and current co-owner of Team Rensi
Motorsports.
To read the entire report, go to http://online.wsj.com/article_print/SB121417838559995535.html.
* * * * *
3.
International
Medicine: Unequal Health Care
Under Canadian Medicare
Waiting for new
drugs in Canada: Access to new medicines is delayed or blocked by government
policies and drug plans, By Mark Rovere and Brett Skinner
Before a new drug is
introduced for sale in the Canadian market, Health Canada must approve it as
safe and effective. Thereafter, patients who are dependent on public drug
programs1 must wait for the province in which they reside to determine if the
cost of the drug will be covered by the public plan.
The recently
released second annual edition of the Fraser Institute publication, Access
Delayed, Access Denied, measures the length of time patients must wait to
access new drugs in Canada. The report reviews the impact that Canadian public
policies and institutions have on lengthening the time that patients must wait
to have access to newly developed patented prescription drugs. The report also
compares consumer access to new drugs under government drug insurance programs
relative to access under private sector drug insurance plans. By measuring the
impact of government policies and programs on access to new medicines,
especially relative to private sector access, the report draws attention to a
significant failure of government intervention that could be alleviated by more
economically liberal policy approaches.
Access delayed
The total wait
time for accessing medicines in Canada is measured in two segments: the
national delay - the time spent waiting for Health Canada to certify the safety
and effectiveness of a new drug and authorize its use in Canada - and the
provincial delay - the time spent waiting for provincial drug insurance
programs to approve the public reimbursement of new drugs.
Figure 1 shows
the consolidated average wait time for access to new medicines in Canada,
broken down by each of the two segments described above. This wait time is
measured in days and is presented as an average of wait times for
pharmaceutical and biological drugs, 2 including all classes of non-generic new
drug approval submissions.
In 2006, the
average length of time taken by Health Canada to approve the use of new
medicines was 380 days. In the same year, the average subsequent delay
resulting from provincial approval of reimbursement for new drugs averaged 323
days (averaged across all provinces and drug submissions). Including both the
national delay and the provincial delay, the total average wait time for
patients dependent on public drug benefits for insured access to new medicines
was 703 days (1.9 years) in 2006.
International comparison
Access Delayed, Access Denied 2008 compares the time
spent waiting for government approval of new drugs in Canada, Europe, and the
United States.
The data indicate that from 2002 to 2004, Health Canada took longer on
average to approve new drugs than the European Medicines Agency (EMEA), its
European equivalent. However, in 2005, Health Canada's performance, on average,
improved significantly relative to its European counterpart, approving new
drugs 67 days quicker than the EMEA. Similarly, Health Canada took 379 days on
average to approve new medicines in 2006, compared to 399 days (on average) for
the EMEA (Skinner and Rovere, 2008).
When comparing
wait times for new drugs in Canada with those in the United States, the data show
that the wait times in Canada were shorter than those in the United States in
three of the five years studied (2002-2006). In 2006, Health Canada's median
approval time significantly decreased from the previous year and was below the
US Food and Drug Administration's (FDA) median approval time. The FDA's median
approval time in 2006 was 351 days, while Health Canada's median approval time
was 328 days. Health Canada took a shorter time than the FDA to approve new
drugs in 2002 and 2003, but a longer time in 2004 and 2005.5
These analyses
suggest that over the course of the period studied, Health Canada has been
improving its drug approval process relative to its international peers. Nevertheless,
delays in accessing new medicines caused by Health Canada's approval process
currently average more than one year.
Provincial comparisons
In addition to
the year-long average delay caused by Health Canada's new drug approval
process, the provinces create an additional delay of nearly one year while
deciding whether to reimburse the cost of the new drugs certified by Health
Canada. Data show that the provinces take 323 days (on average) to declare a
new drug eligible for public coverage after it has been approved by Health
Canada (figure 1). This means that patients who are dependent on their
province's public drug programs must wait almost two years in total before
having access to new medicines.
Access denied
To make matters
worse, many of the drugs that are approved by Health Canada as safe and
effective are not even declared eligible for reimbursement under most
provincial drug plans. Averaged across all provinces and public drug plans,
only 39% of new drugs that obtained market authorization from Health Canada in
2006 were declared eligible for public reimbursement under provincial drug
insurance programs as of October 20, 2007 (table 1).
This means
that, in 2006, patients who were dependent on public drug plans were covered
for less than half of the drugs that were approved for sale by Health Canada.
In contrast, our research indicated that patients who were covered by private
insurance plans or could afford to purchase medicine on their own would have
had access to virtually all of these drugs as soon as they were approved by
Health Canada (with rare exceptions for "lifestyle" drugs). . .
Universal private
drug insurance
The evidence
suggests that the scope of drug benefits coverage is demonstrably better under
private sector insurance plans than it is under government-run drug programs.
Policy makers should consider the merits of introducing means-tested, publicly
subsidized access to private insurance as a better mechanism for achieving
universal access to prescription drugs. Such a policy approach would be
expected to reduce or avoid the restrictions on consumer choice associated with central planning.
To read the entire articles
and well-designed charts, go to
www.fraserinstitute.org/Commerce.Web/product_files/WaitingforNewDrugsinCanada.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: Unequal Health Care Under Medicare
MORE BLACKS THAN WHITES MUST LOSE A LEG TO DIABETES
Blacks undergo leg amputations as a complication of
diabetes at a far higher rate than whites, according to a study by Dartmouth
College out today that also found blacks lag behind whites in breast cancer
screening and diabetic tests.
Researchers used data from Medicare to look at
amputations, screening rates and other measures of quality care among the 50
states and the District of Columbia. Other major findings:
·
Across the United
States, the rate of leg amputation is four times greater among black Medicare
recipients than white.
·
Black residents of
Louisiana, Mississippi and South Carolina had 6 amputations per 1,000 Medicare
enrollees, while black residents of Colorado and Nevada had fewer than 2 per 1,000.
·
Overall amputation rates
for both blacks and whites vary among states; Utah has the lowest rate at .5
amputations per 1,000 Medicare members, and Louisiana has the highest at 1.7
amputations per 1,000.
Blacks also were less likely than whites to get mammograms
to check for breast cancer, although the size of the gap varied widely among
states:
·
In Illinois, for
example, 63 percent of white female Medicare beneficiaries were screened for
cancer, while only 51 percent of blacks were.
·
In Massachusetts, the
gap was narrow: 71.9 percent of whites were screened, 71.5 percent of blacks.
With the exception of Arizona and Kentucky, black
diabetic patients were less likely to get a recommended annual blood test than
whites. The biggest gap was in Colorado, where 84 percent of whites and
only 66 percent of blacks were tested, according to the researchers.
Source: Julie Appleby, "More Blacks Than Whites
Must Lose a Leg to Diabetes," USA Today, June 5, 2008.
www.ncpa.org/sub/dpd/index.php?Article_ID=16624
For text: www.usatoday.com/news/health/2008-06-04-amputee_N.htm
For more on Health Issues: www.ncpa.org/sub/dpd/index.php?Article_Category=16
Government is not the solution to our problems, government is
the problem.
- Ronald Reagan
* * * * *
5. Medical Gluttony:
MediGap Insurance
Recently
we have had an influx of Medicare patients. The surprising thing has been the
number without MediGap insurance, the policy that Medicare provides through
private insurance at a nominal cost to pay for the yearly deductibles,
co-payments, and prescription drugs in order to make health care relatively
free and unrestrained.
The disparity in attitudes as well as health care
costs is striking when compared to the patient with MediGap insurance, usually
an HMO policy. The patient with MediGap insurance has a very large appetite for
anything with a potential health benefit at the expense of taxpayers, never
thinking they are "one of them."
The patient with Medicare as the primary insurance
without MediGap is always looking for a cheaper way to obtain the diagnosis and
be treated. This brings about a health discussion between the patient and
physician concerning the most economical way to get a diagnosis and treatment
for an illness. Various avenues in making diagnosis and treatment decisions
sharpen the focus not only for the patient, but for everyone on the health care
team.
In our experience, Medicare patients without MediGap
avoid excessive laboratory testing, reduce the extent of x-ray examinations,
and reduce to every other year rather than annually the preventive mammograms
and pap smears recommended by many authorities. They do not ask for PSA testing
after the age of 75 and reduce their doctor visits to those that are necessary
rather than for every ache and pain that is part of the human experience.
Estimates of costs savings might be construed as
conjectural, but it appears that there is a reduction in health care costs
approaching 30 percent to 50 percent.
Thus, if every Medicare recipient were denied additional
insurance, Medicare would be solvent today and remain solvent, since the
hospital and outpatient deductible and the outpatient 20 percent co-payment
would be self-policing. Medicare micromanaging and controls would not be
necessary.
Outlawing MediGap Insurance
Would Preserve Medicare.
* * * * *
6. Medical Myths: Congress can control Health Care costs.
Shall we start with big OIL?
Investigate Big Congress, Not Big Oil, By Alex Epstein
(Bucks County Courier Times, May 29, 2008; FrontPage Magazine,
May 30, 2008)
With gasoline prices exceeding $4 a gallon in some
states, politicians are responding as usual: Blame Big Oil First. Several
prominent senators have once again summoned industry leaders to Capitol Hill,
subjecting them to yet another barrage of rhetorical questions, interruptions,
accusations, and sermons. The lawmakers' goal, claims Sen. Patrick Leahy, is to
identify "causes of the rising price of oil on which Congress can
act." But the foregone conclusion is that "price gouging,"
"collusion," and "market manipulation" by Big Oil, or
speculation by financiers, is responsible.
The simple fact that such Congressional investigations
are designed to obscure is that the prices of oil and gasoline are determined
by supply and demand--which neither private oil companies nor speculators have
any power to dictate in their favor. If they had such market mastery, then why
didn't they use it in the 1990s, when gasoline was selling at a barely
profitable $1 a gallon? To be sure, speculators can bid up prices--but they
only do so when they believe that oil will become even more expensive in the
future, and only make money when they are right.
The question Congress should really be asking, then,
is: What nonmarket factors are distorting supply and demand? If they sought an
honest answer, they would discover that much of the blame lies with Congress
itself.
No one disputes that environmentalist laws passed by
Congress have cut off some of our most promising and plentiful sources of oil.
In the name of safeguarding a tiny portion of caribou habitat in the Alaskan
wilderness, drilling is prohibited in the Alaska National Wildlife Refuge--a
potential source of 1 million barrels a day, 5 percent of America's daily oil
consumption. Also off-limits is 85 percent of America's coastline, which Shell
estimates contains some 100 billion recoverable barrels--13 times America's
annual oil consumption--and the vast majority of oil shale in Colorado, which
Shell estimates at 1.5 trillion barrels. . .
And how about the effects of Congress's open hostility
toward the future of oil? Our politicians damn oil as an "addiction"
to be eliminated, and seek to cut--by up to 90 percent--the use of oil and
other vital fossil fuels that make our standard of living possible. Congress
should ask oil executives how this possible forced cut in demand affects their
industry. It should ask whether they feel safe to make the billion dollar
investments and decades-long plans that oil production requires when Barack
Obama, a leading presidential candidate, can uncontroversially proclaim that
"the country that faced down the tyranny of fascism and communism is now
called to challenge the tyranny of oil." Is it a coincidence that the
much-maligned speculators think oil will become even scarcer in the future, and
are acting accordingly?
In addition to investigating its own impact on
gasoline prices, Congress should investigate how its economic policy partner,
the Federal Reserve, has raised our gas prices by lowering the value of the
dollars we buy gasoline with. The Fed, along with the Treasury Department, has
for years had an inflationary policy that has caused the value of the dollar to
plummet relative to other currencies. Were it not for this devaluation of the
dollar, oil prices would likely be 40 percent lower--as they are for those on
the Euro. Why not call a free-market economist to the stand and ask how much
more expensive Alan Greenspan, Ben Bernanke, and Henry Paulson have made our
gasoline?
Americans deserve to know the story--in all its gory
detail--of what their government has done and is doing to cause high prices at
the pump, and to make gasoline--indeed, all energy--more scarce and more
expensive in the future. A congressional investigation of Congress would be a
great public service. www.aynrand.org/site/PageBuilderPreviewPage?category=1&pagename=reus_author_epstein
- top
Alex Epstein is an analyst at the Ayn Rand
Institute, focusing on business issues. The Institute promotes
Objectivism, the philosophy of Ayn Rand--author of Atlas
Shrugged and The
Fountainhead.
www.aynrand.org/site/News2?page=NewsArticle&id=18691&news_iv_ctrl=1021
* * * * *
7. Overheard in the Medical Staff Lounge: Professionalism
in Dress Code
Dr. Dave: A patient returned from a cardiology consultation
and asked me to send him to a real doctor.
Dr. Ruth: What was wrong with the consultant?
Dr. Dave: The patient said he didn't look like a doctor. He
was not dressed professionally.
Dr. Kaleb: I can understand that. I've been appalled by the
dress of many American doctors. No one in my country would have any respect for
a doctor who wasn't professionally attired.
Dr. Milton: I don't think we can dictate appropriate dress, but
I think many patients have more respect for doctors that look like
professionals.
Dr. Dave: I try to avoid sending patients to doctors that
don't look professional in my estimation, but this was the only cardiologist
available that evening.
Dr. Ruth: Do you think that most patients are more tolerant of
after-hours dress?
Dr. Milton:
Depends on the hour. Shortly after office hours, I think the daytime
professional dress is expected. Making a three a.m. call is somewhat different.
Dr. Rosen:
Maybe I'm from the old school. I would wear a coat and tie for a three a.m. call just the same as a three p.m. call.
Dr. Yancy:
As a surgeon, if I'm in the office, I would agree. In the hospital, I'll wear
greens. I'm not going to change several times a day between operations while on
the ward.
Dr. Rosen: I
think those of us from the old school would accept that. But dress also
reflects respect; both from the physician and the patient.
Dr. Dave:
Professionalism creates respect, which in turn improves the Doctor/Patient
relationship.
Dr. Patricia:
I think always wearing a White Long Coat is important in the Doctor/Patient
relationship as well. Since I'm wearing a nice starched coat, I'm more easily
recognized as a professional.
Dr. Dave: I
think it also decreases many calls after hours. If I get more respect during
the day, they treat me with more respect after hours.
Dr. Milton:
I think appropriate dress and decorum is extremely important and helps solve
many of the problems that plague us. We're being treated more and more like
school children.
Dr. Rosen:
Even school children on the continent wearing coats and ties to school seem to
be getting more respect than doctors being casual.
Dr. Dave: I
guess that pretty well tells the story. The first step in improving our image is
our dress. We can't afford to dress less than professionally at any time a
patient sees us.
Dr. Patricia:
Not even at the grocery store?
Dr. Rosen: I
think not even in a store, church or a lay meeting.
Dr. Ruth:
When I go grocery shopping, I don't think my patients would even recognize me
without my face on or hair done.
Dr. Milton: I
don't think any of us guys can judge a woman's dress or demeanor.
Dr. Michelle: But
I think a patient can judge a woman's dress and her demeanor.
To read more about how doctors think, go to www.healthcarecom.net/OpEd.htm.
* * * * *
8. Voices of Medicine: A Review of Local and Regional
Medical Journals
Vital Signs, Official Publication of the Fresno-Madera
Medical Society and Kern County Medical Society, March 2008
President's Message: Medical Professionalism:
Society's Expectations, Our Expectations, And the Role of FMMS by DAVID SLATER, MD
"There is no reason to doubt the
possibility that medicine may fall from the ranks of professions without
increased vigilance and a concerted effort to more clearly fulfill society's expectations of us." - William Norcross, MD, Clinical Professor of Family Medicine, UC San
Diego, speaking at the FMMS General Membership Meeting on February 6, 2008
Attendees
at our February general meeting heard a spirited presentation by Dr. William
Norcross. For 33 years he has guided physicians-in-training into
professionalism at UC San Diego, and for 12 years he has directed a program
there to address lapses in professionalism.
(During his presentation, he delivered a sidebar tragicomic lament about how
during his two recent hospitalizations at UCSD Medical Center, it became clear
how endangered is the art of the physical exam. The story drew nods of agreement
in the FMMS audience and went to the point of "competency assured" –
see below.)
At
the heart of Dr. Norcross' presentation was an enumeration of reciprocal
expectations that underpin the "contract" between society and its
physicians. The idea is that a contract can only remain stable and serve all
parties when the expectations underlying it are acknowledged and are met or at
least aspired to by all sides.
First the expectations
that society has of its physicians
(these are based on Cruess SR, Clin Orthop 2006; 449:170):
Service
as healer
Competence assured
Altruism
Morality and integrity
Accountability
Transparency
Objectivity
Promotion of the public good
Next,
the expectations we physicians have of society:
Trust
Autonomy
Self-regulation
Health care system is value-driven and adequately funded
Shared responsibility for healthcare
Monopoly if service is adequate to societal needs
Rewards: Commensurate status, respect, money. . .
The admonition at the
beginning of this article makes clear Dr. Norcross' opinion that, even at a
time when physicians can readily point to ways our expectations of society are
not being met, we must still equate society's expectations of us, with our
expectations of ourselves. The surest way to de-professionalize physicians -
perhaps irreversibly - is to devalue or ignore society's expectations of us as
a response to shortfalls in how society is currently meeting our expectations.
The best hope we have of society respecting its obligations to physicians, Dr.
Norcross maintained, is to meet what we know are society's expectations of us.
This plays into Dr.
Norcross' belief that physician organizations - from County Societies like
FMMS, to State and National Societies and hospital medical staffs - play a
critical role in fostering physician professionalism. Societies like ours offer
a framework to achieve much of what the public expects of us. They also offer a
way for us to interface with the public in ways that demonstrate our commitment
to societal expectations and to be reminded of what they are. This is precisely
what the "contract of medicine" needs now, and Dr. Norcross was
highly encouraging of our group. This was one of his closing slides:
Promote the Public Good:
Join your county, state, and national medical societies.
Participate in your hospital, professional societies, and the community.
Become involved in the "issues of the day" and work toward solutions
that benefit your patients and society.
It has always been FMMS's
mission to promote the public good. . . To read the rest of this editorial,
please go to www.fmms.org/pdf/MAR08_VS_FINAL.pdf.
* * * * *
9. Book Review:
Health Care Co-Ops
HEALTH CARE
CO-OPS IN UGANDA – Effectively
Launching Micro Health Groups in African Villages, by George C. Halvorson, The Permanente Press,
Oakland, CA; Portland, OR, © 2007,
ISBN-13: 978-0-9770463-1-7, 175 pp, $19.95, http://xnet.kp.org/permanentejournal/permjournal.html
http://xnet.kp.org/permanentejournal/tpjstaff.html
Before
accepting a position with the Kaiser Foundation Health Plan, George Halvorson
was the President and CEO of HealthPartners. Why did HealthPartners, a
multi-billion dollar United States health care plan head quartered in Minnesota
decide to help set up tiny health care co-ops in Uganda? Because HealthPartners
is, itself, a health care co-op - the largest health care co-op in the world.
Land
O'Lakes, a sister co-op for dairy farms also headquartered in Minnesota, has a
long history of going into developing countries to set up local dairy co-ops.
Uganda is one of more than a dozen countries that have benefited from the Land
O'Lakes outreach initiative over the past two decades.
Uganda
is a poor country full of brave people. Per capita income is a mere $270 per
year. AIDS, dysentery, malaria and parasitic infections are common. The infant
mortality rates are among the highest in the world. The health care
infrastructure is tiny, fragile, unevenly distributed, and functionally
uncoordinated. Almost no one is insured through the private sector, and the
government simply can't afford to provide care to every person who needs it.
The tiny health care co-ops HP set up in Uganda were really the only available
form of health coverage in the communities served.
About
eight years earlier, members of the Land O'Lakes African dairy co-op were doing
well - functioning cooperatively - collecting its milk together, processing it
together, protecting the quality together, and selling the milk together at a
good price. Farmers working together had better incomes. The local market had
better mild. The co-op was also importing carefully selected bull semen from
the United States to upgrade the local herds and increase the milk production
levels of its cows. Antibiotics were also being made available by the co-op to
help ailing members of the tiny cattle herds. The cows in that Ugandan village
had never been so healthy or so productive.
One
of the farmers at the meeting said to the Land O'Lakes staff, "We now have
good veterinary care for our cattle. Is there any way we can also get medical
care for our children?"
That
question intrigued the Land O'Lakes staff. When they returned to Minnesota,
they called HealthPartners and asked that same question. Could it be possible
to set up health care co-ops in a third world country, maybe starting with a
foundation of small, local dairy co-ops?
HealthPartners
decided to explore that possibility. A team from HealthPartners went to Uganda
to meet with the co-op leaders. Two doctors and two administrators made that
first trip. They met with dozens of rural Ugandan co-op leaders in half a dozen
locations, and they concluded that it was worth a try.
Halvorson
describes in this volume what the staff from HealthPartners has learned and
accomplished since that time. There are now working health care co-ops in Uganda.
They are serving thousands of people in a dozen villages and rural communities.
People are getting care that they wouldn't have gotten without the co-ops.
It
was the cooperative thing to do. Co-ops tend to be a bit evangelical in their
approach to the world. People who understand the co-op mentality know that the
Land O'Lakes efforts to support developing nations' dairy farmers are very much
in keeping with the worldwide tendency of co-ops to help other co-ops get
started.
The
approach HealthPartners is using in Uganda will not solve Uganda's health care
problems. It will make life better for some Ugandans, however. Much better.
Women will have prenatal care. Kids will survive dysentery and malaria. Disease
will be prevented for some people and cured for others. Some people will be
healthier. Not everyone - but some.
Is
that enough?
One
of Halvorson's favorite stories is of a man walking down a beach early in the
morning. As he looked down the shore, he saw another man in the distance
walking toward him. The other man was regularly stooping over picking something
up, and throwing it into the ocean.
As
the men drew closer, the first man saw that the stranger was picking up
shellfish and throwing them out to sea.
"What
are you doing? He asked. "Why are you throwing those shells into the
water?
"Because
the tide invariable catches some shellfish and washes them ashore," the
stranger replied. "They die on the shore, so I throw them back into the
water."
The
first man looked down the shore in both directions. There were shells far up
and down the coast.
"It's
hopeless," the first man said. "There are huge numbers of them.
You're just one person. You can't possibly make a difference."
The
second man bent over and picked up another shellfish. He held it for a second
and then he threw it far out to sea. He looked at the first man and said
softly, "Hey, it made a difference for that one."
What's
the value of one human life? What's the value on one surviving child? What's
the value of one mother being healthy enough to care for her family? What
HealthPartners is doing in Uganda won't change the world. But it is making a
difference. A real difference in real lives. That's good enough.
Before
Halvorson finished writing about what happened, he left HealthPartners to move
to Kaiser Permanente, the nation's largest non-profit health maintenance
organization (HMO). With other priorities, he put the draft on the shelf. After
two years, as more people were asking about the Ugandan co-ops and if there was
anything in writing, Halvorson took the draft and wrote this book.
This
is more than a story of what happened in Uganda or how co-ops work. It is an
excellent study of how health care works in many adverse circumstances,
including when budgets are meager. The chapter on trying to reach a ten-cent
Target was another illustrative example of "LEAN" as it is now
progressing to health care, especially in Non-Profit Health Care, as in Kaiser
Permanente, and being attempted in For-Profit HMOs. LEAN having been successful
in industry is now involving health care reducing costs without loss of
quality.
This review is posted at www.healthcarecom.net/bkrev_HealthCareCo-OpInUganda.htm.
To read more
reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
George C. Halvorson
Chairman and CEO
Kaiser Foundation Health Plans and Hospitals
George
C. Halvorson is chairman and CEO of Kaiser Foundation Health Plan, Inc. and
Kaiser Foundation Hospitals, headquartered in Oakland, California. Kaiser
Permanente is the nation's largest integrated health plan, serving more than
8.4 million members in nine states and the District of Columbia. He has more
than 30 years of health care management experience. He was formerly President
and CEO of HealthPartners, headquartered in Minneapolis. He is the author of
"Epidemic of Care" published in April 2003, and "Strong
Medicine." He is currently writing two new books, one about racial
prejudice around the world, and another about systematic reform of health care
in America.
www.worldcongress.com/speakerBio.cfm?speakerID=318&confcode=HR08000
To
read more about LEAN, go to www.superfactory.com/,
www.evolvingexcellence.com/, www.evolvingexcellence.com/blog/2004/12/excellence_thro.html.
* * * * *
10. Hippocrates & His Kin: Everybody's Practicing
Medicine Except Doctors
Colonoscopy
Many patients who just turned fifty are
bringing in a letter from their insurance company to obtain a colonoscopy. This
is not geared to the patient's medical history, the family history, or to any
colon symptoms. It is not cost effective but just for publicity to show that
the "insurance company really cares." But it will come back to haunt
them, and the fall out will be to the doctors because it's their signature that
ordered it at the behest of the insurance carriers. Many of the
gastroenterologists have been quite leery about doing colonoscopies without a
medical indication. They feel they are gouging the patient.
Doctors following HMO directives lower
the standard of care and their own standards.
Hemoglobin A1C
The prevailing test to assist in
making the diagnosis and then managing the patient with diabetes is for the
patient to do finger stick glucose determinations and a glycohemoglobin
(HgbA1C) test every 3 to 6 months. Many insurance carriers monitor this since
they can see if a charge of HgbA1C has come through as frequently as possible.
They put those numbers in the equation to determine how much of the 10 or 20
percent withhold they will return to the physician for obeying their
guidelines. Diabetics on diet only may not have any elevations. Thus, the
expensive HbgA1C tests are not medically necessary.
Insurance carriers practicing
medicine will lower the quality and increase the cost.
Glucose monitoring
Diabetes may be the worst disease that affects humans. As the disease progresses
to diabetic nephropathy, diabetic retinopathy, and diabetic neuropathy with
progression to leg ulcers, gangrene and amputations, the horrors manifest
themselves. Diabetics monitor their blood sugars by doing finger sticks before
meals and at bedtime. Medicare doesn't pay for more than one finger stick per
day unless the patient's on insulin. However, endocrinologists, the specialists
most expert in diabetes and other endocrine diseases, are now having patients
with a strong family history of diabetes in first degree relatives monitor
their finger stick glucose levels several times a day. If both parents have
diabetes, the children are all genetic diabetics from birth. The goal is to
never experience clinical diabetes by appropriate diet. One patient noted that
his finger stick was 30 points higher in the morning after eating a large baked
potato or large bowl of white rice or a large helping of pasta for dinner.
Thus, that patient avoided baked potatoes, white rice and pasta so as to never
get clinical diabetes. Doctors are very good at modifying care to each
individual patient.
Medicare
practicing medicine lowers the quality of care and increases the cost of health
care.
To read more medical vignettes, please go to www.healthcarecom.net/hhkintro.htm.
To read HMC, go to www.delmeyer.net/HMC.htm.
* * * * *
11. Restoring Accountability in Medical Practice,
Government and Society:
•
John and Alieta Eck,
MDs, for their first-century solution
to twenty-first century needs. With 46 million people in this country
uninsured, we need an innovative solution apart from the place of employment
and apart from the government. To read the rest of the story, go to www.zhcenter.org
and check out their history, mission statement, newsletter, and a host of other
information. For their article, "Are you really insured?," go to www.healthplanusa.net/AE-AreYouReallyInsured.htm.
•
PATMOS EmergiClinic - where Robert Berry, MD, an emergency
physician and internist practices. To read his story and the background for
naming his clinic PATMOS EmergiClinic - the island where John was exiled and an
acronym for "payment at time of service," go to www.emergiclinic.com. To read more on
Dr Berry, please click on the various topics at his website.
•
PRIVATE
NEUROLOGY is a Third-Party-Free
Practice in Derby, NY with
Larry Huntoon, MD, PhD, FANN. http://home.earthlink.net/~doctorlrhuntoon/.
Dr Huntoon does not allow any HMO or government interference in your medical
care. "Since I am not forced to use CPT codes and ICD-9 codes (coding
numbers required on claim forms) in our practice, I have been able to keep our
fee structure very simple." I have no interest in "playing
games" so as to "run up the bill." My goal is to provide
competent, compassionate, ethical care at a price that patients can afford. I
also believe in an honest day's pay for an honest day's work. Please Note that PAYMENT IS EXPECTED AT
THE TIME OF SERVICE. Private Neurology also guarantees that medical records in our office are kept
totally private and confidential - in accordance with the Oath of Hippocrates.
Since I am a non-covered entity under HIPAA, your medical records are safe from
the increased risk of disclosure under HIPAA law.
•
FIRM: Freedom and
Individual Rights in Medicine, Lin Zinser, JD, Founder, www.WeStandFirm.org,
researches and studies the work of scholars and policy experts in the areas
of health care, law, philosophy, and economics to inform and to foster public
debate on the causes and potential solutions of rising costs of health care and
health insurance.
•
Michael J. Harris, MD - www.northernurology.com - an active member in the
American Urological Association, Association of American Physicians and
Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry
practice in urology in Traverse City, Michigan. He has no contracts, no
Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally
recognized for his medical care system reform initiatives. To understand that
Medical Bureaucrats and Administrators are basically Medical Illiterates
telling the experts how to practice medicine, be sure to savor his article on
"Administrativectomy:
The Cure For Toxic Bureaucratosis."
•
Dr Vern Cherewatenko concerning success in restoring private-based
medical practice which has grown internationally through the SimpleCare model
network. Dr Vern calls his practice PIFATOS – Pay In Full At Time Of Service,
the "Cash-Based Revolution." The patient pays in full before leaving.
Because doctor charges are anywhere from 25–50 percent inflated due to
administrative costs caused by the health insurance industry, you'll be paying
drastically reduced rates for your medical expenses. In conjunction with a
regular catastrophic health insurance policy to cover extremely costly
procedures, PIFATOS can save the average healthy adult and/or family up to
$5000/year! To read the rest of the story, go to www.simplecare.com.
•
Dr David MacDonald started Liberty Health Group. To compare the traditional
health insurance model with the Liberty high-deductible model, go to www.libertyhealthgroup.com/Liberty_Solutions.htm.
There is extensive data available for your study. Dr Dave is available to speak
to your group on a consultative basis.
•
Madeleine
Pelner Cosman, JD, PhD, Esq, who has made important efforts in restoring accountability in
health care, has died (1937-2006).
Her obituary is at www.signonsandiego.com/news/obituaries/20060311-9999-1m11cosman.html.
She will be remembered for her
important work, Who Owns Your Body, which is reviewed at www.delmeyer.net/bkrev_WhoOwnsYourBody.htm. Please go to www.healthplanusa.net/MPCosman.htm to view some of her articles that highlight the
government's efforts in criminalizing medicine. For other OpEd articles that
are important to the practice of medicine and health care in general, click on
her name at www.healthcarecom.net/OpEd.htm.
•
David J
Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the
free Medical MarketPlace in speeches and writings. His series of articles in Sacramento
Medicine can be found at www.ssvms.org. Read his "Lessons from the Past."
For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.
•
Dr
Richard B Willner,
President, Center Peer Review Justice Inc, states: We are a group of healthcare
doctors -- physicians, podiatrists, dentists, osteopaths -- who have
experienced and/or witnessed the tragedy of the perversion of medical peer
review by malice and bad faith. We have seen the statutory immunity, which is
provided to our "peers" for the purposes of quality assurance and
credentialing, used as cover to allow those "peers" to ruin careers
and reputations to further their own, usually monetary agenda of destroying the
competition. We are dedicated to the exposure, conviction, and sanction of any
and all doctors, and affiliated hospitals, HMOs, medical boards, and other such
institutions, who would use peer review as a weapon to unfairly destroy other
professionals. Read the rest of the story, as well as a wealth of information,
at www.peerreview.org.
•
Semmelweis
Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD,
FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD,
Secretary-Treasurer; is
named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician
who has been hailed as the savior of mothers. He noted maternal mortality of
25-30 percent in the obstetrical clinic in Vienna. He also noted that the first
division of the clinic run by medical students had a death rate 2-3 times as
high as the second division run by midwives. He also noticed that medical
students came from the dissecting room to the maternity ward. He ordered the
students to wash their hands in a solution of chlorinated lime before each
examination. The maternal mortality dropped, and by 1848 no women died in
childbirth in his division. He lost his appointment the following year and was
unable to obtain a teaching appointment Although ahead of his peers, he was not
accepted by them. When Dr Verner Waite received similar treatment from a
hospital, he organized the Semmelweis Society with his own funds using Dr
Semmelweis as a model: To read the article he wrote at my request for
Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the
California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some
very interesting letters to the editor from the Medical Board of California,
from a member of the MBC, and from Deane Hillsman, MD.
To view
some horror stories of atrocities against physicians and how organized medicine
still treats this problem, please go to www.semmelweissociety.net.
•
Dennis
Gabos, MD, President of
the Society for the Education of Physicians and Patients (SEPP), is making
efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and
Responsibilities of Patients and Health Care Professionals. For more
information, go to www.sepp.net.
•
Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D,
write an informative Medicine
Men column at NewsMax. Please log on to review the last five weeks'
topics or go to archives
to see the last two years' topics. Have some fun this month and read New
Bio-Fuel: Non-polluting, Efficient and Aromatic.
•
The Association
of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943,
representing physicians in their struggles against bureaucratic medicine, loss
of medical privacy, and intrusion by the government into the personal and
confidential relationship between patients and their physicians. Be sure to read News of the Day in
Perspective: Sabotaging
health savings accounts. Don't miss the "AAPS
News," written by Jane Orient, MD, and archived on this site. This
month, be sure to read DOCTOR NURSE. Browse the archives of their official organ, the Journal of American Physicians and Surgeons,
with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief.
There are a number of important articles that can be accessed from the most current issue. Don't miss the
excellent articles and book reviews. Be sure to read Jane Orient's book review
of The
Criminalization of Medicine: America's War on Doctors by Ronald
T. Libby.