1.
Featured
Article: New Approach to Human History: DNA from an Ossified Mummy
2.
In
the News: The Massachusetts Mandate Update: The Slippery Slope
3.
International Medicine: I Wouldn't Trust This System to Water My Plants
4.
Medicare: Why Medicare Will Never Work
5.
Medical Gluttony: Why Should I Treat Myself When Insurance Will Pay For It
6.
Medical Myths: Government Health Care Will Reduce Costs
7.
Overheard in the Medical Staff Lounge: Motorized Wheelchairs Replacing Cars?
8.
Voices of Medicine: Why
Doctors Do Not Earn Like Other Highly Trained Professionals
9.
From the Physician Patient Bookshelf: DENIAL OF THE SOUL
10.
Hippocrates & His Kin: How to be Relevant!
11.
Related
Organizations: Restoring Accountability in Medical Practice and Society
MOVIE AGAINST
SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE
Logan Clements,
a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the
truth about socialized medicine. Clements' strategy is to release the
documentary this summer on the same day that Michael Moore's pro-socialized
medicine movie "Sicko" is released. This movie can only be made
in time if Clements finds 200 doctors willing to make a tax-deductible donation
of $5K each by the end of March. Clements is also seeking American doctors
willing to perform operations for Canadians on wait lists. 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:
New Approach to Human History: DNA from an Ossified Mummy.
Modern
Technology Reveals Mummy's Past
ST. LOUIS (AP) -- The baby
mummy had a European mom, and likely came from a wealthy family. But where he
lived and why he died - and at such a young age - remain a mystery. The mummy,
exhibited for the first time Thursday at the Saint Louis Science Center, has
been the year-long focus of an international team of investigators. The museum
said it may be the most extensive research project ever undertaken on a child
mummy.
Acquired by a Hermann,
It sat in a museum
warehouse until Al Wiman joined the Science Center as vice president two years
ago and suggested that modern medical technology could unlock its secrets.
He spearheaded efforts
to get medical, science and art institutions in St. Louis, the U.S., and Egypt
to discover the mummy's past. . . To read
more, please go to www.medicaltuesday.net/index.asp.
A team of radiologists
and geneticists from Washington University studied the mummy. Salima Ikram, an
Egyptologist and mummy specialist at The American University in Cairo;
anthropologist Dean Falk at Florida State University; and conservator Emilia
Cortes of The Metropolitan Museum of Art in New York also agreed to help.
A small snippet of the
mummy's wrapping tested for carbon dating suggested the child had lived between
30 B.C. and 130 A.D., in Egypt's Roman period around the time of Mark Antony
and Cleopatra.
Three-dimensional images
from CT scans of the child's bones, skull, teeth and body cavity suggested the
child lived to be seven or eight months. The CT scans revealed a long wooden
rod against the child's back that supported the mummy wrapping. All of the
scans were done without having to remove the wrap.
Scans detected a hole in
the child's skull. The brain, like jelly, would have drained through the hole
and out through a nostril as part of the mummification process, Washington
University dentist and anthropologist Charles Hildebolt said. The scans also
identified small incisions on the left side of the body through which the
child's internal organs were removed and placed in jars.
One of the most
interesting finds was a series of amulets or charms in the boy's body cavity
and in the wrapping, suggesting his family was well-off. "The wrapping was
a protective cocoon for the body," Hildebolt said. "Prayers and
amulets were a protective cocoon for the metaphysical soul."
Corpses prepared for
mummification were soaked in a salt and baking soda solution for 40 days, then
kept in oils for 30 days.
Washington University
geneticist Anne Bowcock said she feared the DNA would have undergone chemical
changes or been "contaminated" by those who handled the corpse. But
that wasn't a problem.
The challenge was boring
into the mummy, which had petrified, to get three samples of degraded muscle,
tissue and bone. She succeeded by inserting a thick needle into the chest and
shoulder. After that, she extracted DNA using routine methods. Tests showed the
boy's mother was European. She plans more tests to determine his father's
ancestry. To read the entire story, please go to
http://news.wired.com/dynamic/stories/M/MUMMY_CHILD?SITE=WIRE&SECTION=HOME&TEMPLATE=DEFAULT.
On the Net: Saint Louis
Science Center: www.slsc.org/
* * * * *
2. In the News: The
Massachusetts Mandate Update: The Slippery Slope
Slippery Slope to Expanded Private Health Insurance? by Ronald
Bailey | Reason |
Health
care is the top domestic political issue for the upcoming 2008 presidential
election. In a recent New York Times/CBS poll 64 percent of Americans
said the government should guarantee health insurance for all. Not quite a
majority (47 percent) favored a national health insurance program covering
everyone, administered by the government and financed by taxpayers. Is there
any way to stop the rapidly accelerating slide toward universal
government-funded health care?
Today,
employers purchase health insurance for 153 million workers and their families.
Why is that? Because ridiculous federal tax laws allow employers, but not
individuals, to purchase health insurance with pre-tax dollars. Rather than
paying an employee $1,000 more in wages, of which $400 will be taxed away,
companies purchase $1,000 in additional health insurance tax-free. In this way
companies funnel more than $140 billion a year in federal tax breaks to their
workers. One more obstacle prevents health insurance from being tied to
individuals rather than to jobs-the feds require that employers purchase group
insurance.
At
first glance, the mandate adopted by Massachusetts in April 2006 that every
state resident carry a health insurance policy looks like just one more
slippery step down the slope to nationalized health care. But is it? The
seductive idea behind this individual mandate is that responsible Massachusetts
policyholders and taxpayers should no longer have to pay $1 billion per year in
uncompensated care for free riding uninsured individuals. Under the mandate,
residents with incomes under the federal poverty level ($9,804 in annual income
for an individual and $20,004 for a family of four) are enrolled in
Massachusetts' version of Medicaid, called MassHealth. They
may choose among four private health management organizations (HMOs) that
already provide health care services financed by Medicaid. This is just more of
the same. .
. To read more, please go to www.medicaltuesday.net/news.asp.
But
what does the
A
state health insurance exchange like the Connector could address many of the
distortions of our current system of third party payments for insurance. First,
as they suggest, any resident could buy coverage through the exchange. Second,
all of the plans sold through the exchange would effectively become individual
policies. That means they are no longer linked to specific employers. Workers
could take their health insurance with them as they pursue their careers with
various employers. Third, employers could designate the exchange as an employer
group plan. Why does this matter? Recall that in order to qualify for the
health insurance tax break, employers must buy group health insurance. . .
The
second core concept is the shift from subsidizing providers to subsidizing
consumers. As previously described, the Mass Mandate transforms $1 billion paid
out to providers for uncompensated care into subsidies for insurance premiums
of lower income citizens who are not eligible for Medicaid or State
Children's Health Insurance Program
(SCHIP). Haislmaier and Owcharenko note that subsidies don't have to stop
there. "Other states might consider a broader reform strategy that uses
the exchange to cover some Medicaid or SCHIP enrollees," they suggest. . .
The
Massachusetts mandate has plenty of critics. Michael Tanner, director of health
and welfare studies at the libertarian Cato Institute, argues that the mandate is unlikely to actually achieve
universal coverage. He cites the fact that 47 states mandate car insurance, yet
more than 14 percent of drivers are uninsured. Massachusetts intends to enforce
the mandate by withholding state income tax refunds. Tanner is right that
attempts to enforce a mandate through monitoring, withholding or fines will be
problematic.
However, enforcement will be much less difficult if lower income Americans are
subsidized by means of vouchers with which they purchase their own health
insurance. Vouchers will tend to be self-enforcing since they cannot be spent
on other products or services. Tanner also argues that determining the proper
subsidies for individuals will be complex and thus engender new intrusive
bureaucracies. However, this difficulty might be avoided in part by establishing
an annual open enrollment period in which Americans seeking vouchers would
qualify based on their current incomes.
Tanner
is also rightly concerned about "mandate creep." As 1800 current
state insurance mandates show, various disease and provider lobbies will
continue to seek to get politicians to mandate coverage of their specialties
and diseases. Tanner argues that as more "benefits" are added to the
mandated insurance package, costs will rise. In turn, politicians will be
pressured to increase subsidies to keep up with the rising costs. He believes
that this public choice dynamic would lead inevitably to price controls. Tanner
further suggests, "Since consumers would have little or no leverage over
insurers (they can no longer refuse to buy their products), they can eventually
be expected to turn to the only entity that can hold down their costs-the
government." In fact, the left-leaning Foundation for Taxpayer and
Consumer Rights is already calling for government cost controls on
Massachusetts health care plans.
While consumers must buy some coverage, they can refuse to buy any particular
insurers' product. Under a universal mandate in which all insurance is
purchased privately by individuals using their own money or dedicated vouchers,
competition among insurers will tend to keep costs down. Unfortunately,
Massachusetts has not chosen to use vouchers yet.
The Massachusetts mandate is far from perfect but it has set up the pre-conditions-a
state health insurance exchange and consumer subsidies--for enabling the
expansion of private health insurance. Given the growing clamor for national
health care, individual mandates may be the only politically viable way to
preserve private health care.
Ronald Bailey is Reason's science correspondent. His book Liberation Biology: The Scientific and Moral Case for
the Biotech Revolution is now available from Prometheus Books.
Disclosure: I am looking at individual mandates as a second-best
alternative to what is likely to occur politically. The rationing and cost
controls that come with nationalized health care would be the death of
biomedical innovation. By the way, my friends over at Cato lump me in with the Republicans for Big Brother on this issue. Instead I would argue that I'm trying
to figure out how to keep Big Brother from becoming Big Nurse.
Oh yes, I don't own any stock in any health insurance companies.
To
read the entire article, go to www.reason.com/news/printer/119147.html.
* * * * *
3.
International Medicine: I
Wouldn't Trust This System to Select Someone to Water My Plants
Telegraph columnist Dr
Max Pemberton is one of the lucky junior doctors to have been granted an
interview under the Government's controversial Medical Training Application
Service. However, the experience has left him demoralized [sic].
So, I think to myself as
I sit in the small, characterless room. This is it. Chairs are arranged around
the edge, and everyone is sitting in silence, staring at the floor feeling
uncomfortably close. A woman outside can be heard crying down the telephone.
And then some grey man
in a grey suit walks in, stops and calls out my name. I stand up and he takes
me away.
I am one of the lucky
ones. I am here for one of the much coveted Medical Training Application
Service (MTAS) interviews, the farcical scheme introduced by the Government to
assess and recruit doctors for specialist training. As a result of its
implementation, all the junior doctors in this country will, from August this
year, have their contracts terminated and must re-apply for the jobs they have
being doing perfectly competently up until now.
The new scheme, which
has cut drastically the total number of training posts (there were 30,000
applications for 22,000 positions) has failed in every way possible, and is
disrupting the lives of young doctors on an unprecedented scale. Many of those
who have spent nearly a decade in training are seeing their planned careers
evaporate.
. . To read more, please go to www.medicaltuesday.net/intlnews.asp. .
In the waiting room, the
fear is palpable. So much depends on the next few hours.
Any doctor awaiting an
interview and hoping that the interview process will in some way be superior to
the ludicrous, Kafkaesque application form should be warned: it isn't.
The grey man led me into
a room filled with work stations manned by confused, bewildered looking
interviewers. Some of them were doctors, some, I learned later, were not. None
was properly introduced to me. It was clear they hadn't read my form and knew
nothing about me. Each asked a series of formulaic questions to which I had a
few minutes to provide equally formulaic answers.
There was no provision
for me to discuss anything, to show my strengths and qualities, or to talk
about the things that interest me. The bland questions were designed to elicit
responses that could be ticked off on a form.
In all honesty, I
wouldn't trust this system to select someone to water my plants, let alone look
after me when I'm sick.
I left the interview
feeling desperate: desperate for my colleagues who hadn't been selected for
interview; desperate for those who had; desperate for the chance to continue in
a career I have worked so hard to be a part of.
But I felt more
desperate for the future state of health care in this country. What is
happening now matters to every one of us.
Not only have our taxes
paid for the training of every doctor who now faces unemployment, the system as
it stands is failing to select the best doctors of the future.
This is a clear attempt
to undermine the medical profession; to ensure that we become compliant, unquestioning
automatons in a system that can be presided over by managers and politicians.
Doctors
are notorious for being apathetic when it comes to fighting their corner. .
. To read the entire article, go
to www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/03/12/ndocs112.xml.
Information appearing on
telegraph.co.uk is the copyright of Telegraph Media Group Limited.
The National Health Service
does not give timely access to healthcare, it only gives access to a waiting
list.
* * * * *
4.
Medicare: Why
Medicare [and fixed co-payment insurance] Will Never Work
The Market for Medical Care: Why You Don't Know the
Price; Why You Don't Know about Quality; And What Can Be Done about It. by Devon M. Herrick and John C. Goodman, NCPA.
Executive Summary
In most markets, prices and quality indicators are
transparent - clear and readily available to consumers. Health care
is different: Prices are difficult to obtain and often meaningless when
they are disclosed. Many patients never learn the cost of their care.
The primary reason why doctors and hospitals typically
do not disclose prices prior to treatment is that they do not compete for
patients based on price. Prices are usually paid not by patients
themselves but by third parties - employers, insurance companies or
government. As a result, patients have little reason to care about
prices.
And it turns out, when providers do not compete on
price, they do not compete on quality either. In fact, in a very real
sense, doctors and hospitals are not competing for patients at all - at least
not in the way normal businesses compete for customers in competitive markets.
This lack of competition for patients has a profound
effect on the quality and cost of health care. Long before a patient
enters a doctor's office, third-party bureaucracies have determined which
medical services they will pay for, which ones they will not and how much they
will pay. The result is a highly artificial market which departs in many
ways from how other markets function. . . To read more, please go to www.medicaltuesday.net/medicare.asp.
In health care markets where third-party payers do not
negotiate prices or pay the bills, the behavior of providers is radically
different. In the market for cosmetic surgery, for example, patients are
offered package prices covering all aspects of care - physician fees, ancillary
services, facility costs and so forth. Not only is there price
competition, but the real price of cosmetic surgery has actually declined over
the past 15 years - despite a six-fold increase in demand and enormous
technological change. Similarly, the price of conventional LASIK
vision correction surgery (for which patients pay with their own money) has
fallen dramatically, even as procedures become more technically advanced.
Increasingly, cash-paying "medical tourists"
are traveling outside the United States for treatment or surgery. In
contrast to the typical American hospital stay, a package price includes all
the costs of treatment, and often air fare and post-operative hotel
accommodations. Prices are one-third to one-fifth as much as treatment at
a U.S. hospital and the quality is typically high.
Retail walk-in clinics in drugstores, shopping malls
and big-box retailers are another example. Originally established to bypass
traditional health insurance, they post prices for procedures and minimize
waiting times. . .
Like walk-in clinics, a growing number of medical
practices offer discounts for patients who pay bills directly and avoid
third-party insurance. These entities almost always post their prices,
and many store records electronically and offer e-mail and telephone
consultations. Patients can also go outside their health insurance
plan and arrange for telephone-based consultations with companies like TelaDoc
Medical Services. A similar service, Doctor On Call, claims 70
percent of what physicians do can be done by phone! These services also
store medical records electronically and "write" electronic
prescriptions.
The marriage of the computer and telecommunications
has also led to innovations that can increase economic efficiency and improve
quality. Several new tools are now available to help physicians and
patients find the most appropriate treatments using information on
evidence-based protocols. Information on price and quality is available
on the Internet to patients in some health plans. And objective,
independent third parties often provide data for a fee.
The Internet is also transforming the market for
prescription drugs. For example, when a patient logs on to Rxaminer.com
and enters information about his or her prescription medications, the Web site
produces a report including therapeutic and generic substitutes and
over-the-counter alternatives for brand-name drugs. The drug-rating Web site
AskAPatient.com lets patients compare experiences with drug therapies.
Furthermore, ordering prescriptions online improves quality.
Patients paying with their own money can also use
Internet services to order numerous lab tests on samples collected in convenient
settings for fees that are nearly 50 percent less than tests ordered by
physicians' offices.
We are likely to see more of these challenges to
traditional health care in the future. The reason? Increasingly, patients
are paying more costs out of pocket. Deductibles for the average plan,
for example, have nearly doubled over the past decade. And due to recent
changes in the tax law, employees are increasingly managing their own health
care dollars through personal health accounts, usually coupled with
high-deductible health plans. In 2006, of the approximately 12 million
high-deductible health plans, about one-quarter were accompanied by Health
Reimbursement Arrangements (HRAs) and about 3.2 million were coupled with
Health Savings Accounts (HSAs). This consumer-driven health care
revolution gives individuals the opportunity to benefit financially from
consuming health care wisely.
Although the medical marketplace is changing, legal,
regulatory and cultural barriers to competition, innovation and transparency
remain. . . .
The biggest obstacle to transparency is a tax system
that favors third-party insurance over individual self-insurance. For a
middle-income employee, government is effectively paying almost half the cost
of health insurance. This has encouraged consumers to use third-party
bureaucracies to pay every medical bill.
Transparency is the natural product of a market in
which patients control their own health care dollars and providers compete for
those dollars. Thus, transparency will emerge as we fundamentally change
the way we pay for health care. Some of these changes are already
occurring, but government can speed the transition to greater transparency by
removing obstacles to competition and innovation.
To read this rather extensive treatise, please proceed
to www.ncpa.org/pub/st/st296/#a. It's well
worth the study to becoming much better informed.
Government is not the solution to our problems,
government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
Why Should I Treat Myself When Insurance Will Pay For It.
I've been tracking the patients coming into my office
for a variety of complaints. Many are for common problems that bring patients
to any physician's office: cough, colds, shortness of breath, wheezing, head
aches, back aches, foot aches, nausea, vomiting, diarrhea, the usual maladies
that beset humans. What amazes me is the numbers that do not even think of
self-care, which should be the biggest item in the health-care system. Before
the advent of Medicare and the government intrusion into medicine, it was
stated by my professors in Medical School that 95% of health care was
self-care—patient directed treatment of the common ailments.
That made a notable change in 1966 with the advent of
government health care. Much of inexpensive self-care was converted into
Medicare. Well, that would be expected, wouldn't it? Why should one even bother
taking care of the simple things in life if the government is ready to pay? To read more,
please go to www.medicaltuesday.net/gluttony.asp.
To evaluate a backache when the patient has not even
tried routine aspirin, Tylenol, Motrin, Aleve, etc, does not allow effective
treatment. If a patient has not obtained any relief from full doses of one or
more of these anti-inflammatory drugs, the evaluation and treatment will be
different from someone who has not even made any attempts and doesn't know if
an aspirin alone might be effective. Since many patients are insulted if
aspirin or Tylenol is suggested, I have a box of Tylenol packets in my exam
rooms containing two ES Tylenols. I can give a patient two of these, busy
myself with another patient and in 20 or 30 minutes re-evaluate the backache.
I'm always amazed at the number of backaches cured in that half hour. Then
treatment regimen becomes amazingly simple.
The ingenuity of Medicare recipients has no bounds. My
chief of medicine in training told the story of a couple who had found love in
their golden years after each had lost his spouse. They came in requesting that
they use his examining table for making love. Since they had gotten rusty in
the procedure, perhaps the professor could give them some pointers as he
observed them in the act. The professor reneged and asked what was the real
reason. Well, if they went to the lady's house, her children all had keys and
would on occasion drop in. If they proceeded to his house, he would lose face
with his neighbors who might think he was shacking up. If they went to a motel,
it was rather costly on a social security budget. But they reasoned if they
could do it in the doctor's office, he could charge Medicare an office visit
for each of them and it would only cost them a co-pay, which was a fraction of
a motel room charge.
Ingenious Americans will always find a way to utilize
Congress' government programs in ways they never imagined. Congress should
focus on the five departments necessary to run the country—State, Defense,
Treasury, Justice and Public Health—and restore freedom to the rest of the
country. Especially in health care so the cost could come down.
See Medicare, section 4 above.
* * * * *
The United States spends more on health care than any
other country in the world, both in dollars per person and as a percent of
gross domestic product (GDP). Does this mean that the US, with a predominantly
private system, is less able to control health care spending than are developed
countries with national health insurance? John Goodman does not think so.
Health economist Joseph Newhouse found that 90 percent of the variation in
health care spending among developed countries is based on income alone. As
people have more income, they spend more on health care, whether their spending
takes place through the Medical MarketPlace, the political system or
quasi-public institutions. In countries with a national single-payer health
system, the government can, in principle, limit health care dollars and force
hospitals and doctors to ration services. But, that power is more apparent than
real as politicians who exercise it risk being replaced by their competitor. In
all political systems, just as in the U.S., there is unrelenting pressure to
spend more on health care. To read more,
please go to www.medicaltuesday.net/myths.asp.
Most
international statistics on health care spending are produced by the
Organization for Economic Cooperation and Development (OECD). However, Goodman
contends that these statistics are not always reliable because the various
countries use widely different methods of reporting costs. For instance,
Germany includes nursing home care as part of the total health expenditures and
Britain does not. Some countries report hospital beds by counting bed frames,
whether or not in use, while others count a bed only if it is staffed and
operational. The U.S. has a lower inpatient rate (12) below the OECD average
(16), because the U.S. figures do not count outpatient procedures, whereas OECD
statistics include them. In the 1990s, health care spending in 12 of 15 OECD
countries grew at the same rate or higher than the U.S. while expenditures on
hospitalization and physician services actually decreased in the U.S. well
below the OECD mean. Goodman contends that this is surprising since the U.S.
has less rationing of care and greater access to medical technology with a
wider range of health problems; AIDS is 10 times more prevalent in the U.S.
than in Canada and obesity is a greater problem in the U.S. than in other
developed countries. The U.S. has more health care costs related to war
injuries, teenage pregnancies with a high premature baby rate, and twice as
high a pregnancy rate.
Canada achieved the impressive feat of limiting the
real rate of health care growth to about half that of the U.S. by cutting
funding for services; however, it did so in ways that caused people to suffer.
There were draconian cuts in facilities and services. The Canadian federal
government reduced block grants to provinces for health care in 1986, 1989, and
froze expenditures in 1990 for five years. They then made further cuts through
the last half of the 1990s. The provincial governments reduced funds to
hospitals, severely limiting purchase of new technology and removed some
services from coverage. Many smaller hospitals were closed–50 in
Goodman
concludes that unfortunately, these reductions in the availability of medical
services had more to do with budgetary shortfalls than lack of medical need,
meaning that patients often must do without needed care. Satisfaction with the
Canadian health care system has fallen throughout the 1990s as the waiting
lists have increased.
Oregon
rejected the Canadian-style socialized medicine initiative by a 4 to 1 margin.
They decided that there were already enough Guinea Pigs around the world who
confirm that government medicine does not work, and only privatization is
saving their system from disaster. Bill Virgin, a business columnist with the Seattle
Post Intelligencer was impressed by the defeat of Single Payer in Oregon.
He says "defeat" isn't the right word. The result, "requires
more action oriented verbs such as shredded, pummeled, clobbered."
Single-payer systems control health-care costs, not by
efficiency, but by eliminating services.
* * * * *
7.
Overheard in the
Medical Staff Lounge: Motorized Wheelchairs Replacing Cars?
Sacramento has a street called Sunrise Blvd. which
connects I-80 (a route to North Lake Tahoe) and US 50 (a route to South Lake Tahoe).
Halfway between is a cross street called Sunset. It was known as a very safe
intersection with a long safety record. Then one day it happened. There was an
auto accident at the corner of Sunrise and Sunset, which made the front-page
headlines and all the news programs. Now electric wheelchairs are traversing
the sidewalks and crossing intersections with the same right-of-way of any
pedestrian. Instead of MVAs (motor vehicle accidents) we are seeing MWCA
(motorized wheelchair accidents).
Dr. Sam: On going
home last night to To read more, please go to www.medicaltuesday.net/lounge.asp.
Dr. Milton: Last
week, coming off the freeway towards my office, I saw a MWC roll over—rather
like a single-car accident. She also was able to right herself before I could
offer assistance.
Dr. Edwards: I had
a patient request a prescription for a MWC. As I was evaluating the medical
need, the patient casually remarked that he would be able to do his shopping
and go to the coffee shop, since all of these were within a block or two of his
house. In fact, he had decided to sell his car when he obtained the MWC, which
he thought was the only vehicle he needed.
Dr Yancy: My
neighborhood is lousy with the electric wheelchairs. Some use the sidewalks,
some the bike walks and some the street.
Dr. Sam: Looks
like the DMV should get involved and begin licensing these disabled drivers.
Dr Rosen: These
items that allow people to cash in on their cars and get vehicles from Medicare
should have a significant co-pay since they replace items that are not part of
healthcare.
Dr Edwards: The
same logic applies to hospital beds. These replace other beds which no longer
have to be purchased by the family, and thus should only be partially
reimbursed by Medicare, or rather taxpayers.
Dr Rosen: I
think what we're all saying is that most durable medical equipment, instead of
being free Medicare benefits, basically replaces other durable goods, and thus
should have a significant co-payment, something on the order of 40 to 50
percent. Why should patients or their families make a profit by selling their
cars or their beds while insurance picks up the replacement?
Dr. Milton: And
please, no DMV involvement. The most disabled need the MWC the worse.
* * * * *
8.
Voices of
Medicine: A Review of Local and Regional Medical Journals
Alan
G. Zacharia, M.D., discusses R - E - S - P - E - C - T: What Does It
mean To Thee? in the January 2007 issue of The Bulletin of the
As a profession, medicine earned respect
by evolving from its religious origins to early medical science tempered with altruism.
Along the way there were periods of light and dark. After the patent medicine
era, around the turn of the 20th century, there was a significant
ethical correction that freed the science from much of the historical dogma.
What was primarily art tempered with a bit of science became a science tempered
with reasonable comity and compassion. Respect must be earned, and it was a
renaissance approach to science and philosophy that earned it.
What Are You Worth?
Contrary to persistent media and government-reinforced
misconceptions, doctors do not earn like other highly trained professionals
(bankers, lawyers, and other real businessmen). Few, if any, of the
latter work as many hours per week for as many years to grind out a living through
direct personal hourly labor. Fewer still serve the society as well.
There are two rewards for people who do
things, wage-salary and psycho-salary, and the balance is different for each of
us. Too much of one or the other is unsatisfying. Altruism begets love, but
rarely gets you paid. If you persist in it, your services will be taken for
granted. If your position is that your services are the public's right
to have, you will be treated like other entitlements, with more duty than
respect for your needs. A person whose services are another's right to
have is ultimately a slave. You may love your slave, but love does not pay the
bills. To
read more, please go to www.medicaltuesday.net/voicesofmedicine.asp.
Except for priests, missionaries, and
entitlements, profit drives a "free-market" democracy and motivates
productivity. Physicians are increasingly taken for granted because we continue
to tell the public that we want to be. It is a subtle economic truism, but an
indentured servant (real or perceived) is never a legitimate player in the
"free" market.
We are marketing ourselves into a
miserable corner by supporting blind entitlement to our services believing that
once the people are entitled to our services, they will be fair! It may seem
like good public relations, but the more they think you love what you do and
that your work is its own reward (with an oath, no less), eventually it will
become public policy. Promising our services to the public gets politicians
elected. Liberal support of short-sighted or naive legislation, such as the
governor's recent proposal, seems philanthropic, but the message to the public
and their representatives is that we will support whatever their politicians
promise them, regardless of our own welfare. When those who should be grateful
bite your helpful hand, you must defend yourself.
Schwarzenegger Initiatives
What's worse than taking your services for
granted? Taxing you for the privilege of providing them. A wealthy gentler,
kinder society can offer help to the less privileged, but when the amenity is
the service of others, the burden must not be inequitably borne by the
providers. I have no problem with voluntarily helping the poor as we always
have, but MediCal rates are and will continue to be charity; and high-overhead
specialty practices have to limit treatment of this population as an economic
necessity.
The "Governator" has taken
disregard of us to a new low by proposing a 2 percent indenture tax on
physicians ostensibly to create more MediCal patients and increase what we
are paid to treat the poor. He claims that the increased volume generated by
providing universal health coverage will be a boon to physicians, but the fact
that something is paid for in a fixed-market government plan does not mean that
the payment is profitable or even covers the provider's costs. The cost of
providing care to this population has always been underfunded. One cannot gain
weight by eating one's own feet. This preposterous concept ignores our risks
and overhead and may even be unconstitutional in California.
Government plans are not really
"insurance." The amount paid for a service is set not by the market
but by budget constraints and political wrangling in a one-sided contract. The
governor has bought into the insurance lobby fallacy that we can lay off our
charity losses on the insured population and has conveniently ignored the fact
that in the era of Medicare/MediCal, PPOs, HMOs, regardless of our usual and
customary charges, our choices are few: see only cash patients or be bound to
accept what the payer reimburses after the fact. Health insurance is not
health care–it is a profit-making enterprise with profits made by charging
patients more (hindered by a free market) and paying us less (unimpeded by real
antitrust exposure). Worse, the "unanticipated consequence" is that
insurance companies will try to make the government charity rates a standard
that will only reduce our average reimbursement.
Even were these kinds of initiatives to go
forward, it would be foolhardy to believe that anything would stop future rate
reductions or indenture tax increases. The basis of a market is supply, demand,
negotiation, and contracting that represent a "meeting of the minds."
When there is no contract, every other service provider "balance
bills" the beneficiary or refuses to provide the service until a
negotiated price is settled. The insurance lobby and the governor even begrudge
us this. Even if the governor's proposal is a "straw man" raised to
intimidate us into a less heinous compromise, his brazen attempts to abrogate
our contract rights is indicative of the slave-owner mentality.
The Story of MICRA
When there was less hard science to know,
we spent more time on developing an educated ethos and a place as leaders in
our society. We had "the respect due the principled." But there is a
more "practical" kind of respect, and the hard, cold fact is that it
is spelled in two somewhat related ways, M-O-N-E-Y and F-E-A-R. We still get a
fair amount of "principled" respect for what we do, but we are
rapidly losing the "practical" kind, and it is getting harder to live
in the narcissistic fantasy that what we do is so important that we
can't hold out for financial respect like the other professions who are paid so
well. For those of you younger than I, we were once pushed far enough to
respond, and that response yielded a salubrious result for California and its
physicians.
In the 1950s and 1960s patients were the
beneficiaries of physician largesse when we could in fact do little. The
subsequent era of defined and expected outcomes was heralded with the new
concept of malpractice. Raised in the cordiality of honest scientific endeavor,
we continued to naively voice the "patient welfare before doctor welfare"
morality even when the patient side (government, the legal profession, and
insurance companies) saw that there was money to be made.
But our adversaries miscalculated and
ramped up the pressure on physicians so quickly in California that the
ramifications of apathy became painfully clear. In May 1975 high-risk
specialists responded with a minor rebellion—only urgent and emergent surgical
care was rendered for a month. People were inconvenienced, but no one was
hurt. The result was the first durable model of professional liability tort
reform. Many physicians in other states provided little support for what
was assumed to be a purely California phenomenon. Physicians in other states no
longer laugh and now seek our support for their travails. . .
Denouement
Before we assume that it is hopeless, we
must remind ourselves of the vigor we displayed in 1975. There needs to be no
less than a complete retraction of the very concepts of physician indenture
taxation and exclusion from balance billing. To the extent we are
successful, we will know how much the society really values our services in
terms of measurable wage-respect. Perpetual, retroactive, and one-sided or
implied contracts must be abolished and our contract rights reasserted. We need
a level playing field with health insurance companies who enjoy enough
antitrust immunity to collude against us to "low-pay, slow-pay, and
no-pay." Insurers must be liable for at least "treble" damages
when they repetitively "accidentally" defraud us so that we can get
their attention.
And there are other ways to reach
progressive goals. We can increase support for the county hospital system or
allow physicians a reasonable tax deduction for services rendered below
reasonable cost. Because we have become policy-irrelevant, these and other
better ideas never seem to get to the table.
If they are smart, they will back off, but
if we wish to reestablish respect, we will have to go through a work action
anyway. Just as in 1975 we must remind those who would treat us badly that
we still own the weapon. The only thing worse than involuntary indenture is to
accept it as inevitable.
To read the entire article, go to www.smcma.org/Bulletin/BulletinIssues/Jan07issue/RESPECT.html.
Dr. Zacharia is an orthopaedic surgeon in Daly City.
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9.
Book Review:
Reflection on a current debate from our archives.
DENIAL OF THE SOUL - Spiritual and Medical
Perspectives on Euthanasia and Mortality, M. Scott Peck, MD, Harmony Books, New York, 1997,
242 pp, $23, ISBN: 0- 517-70865-5.
Physician, psychiatrist, theologian, and author of the
best-seller, The Road Less Traveled, F Scott Peck, MD, gives us an
in-depth look at the current euthanasia movement and its origins in the
inability of physicians to "pull the plug." Peck states that although
Dr Kevorkian gives him the shivers, he must credit him more than any other
individual for the genesis of this book. Almost single-handedly over the past
five years, Kevorkian has turned the debate over euthanasia into a national
issue within the United States.
But Kevorkian didn't inspire Dr Peck to write this
book–it was the public response to his behavior. Peck was surprised by the
number of people who admire Kevorkian. He was even further surprised by the
larger number who, though they feel no affections for Kevorkian, nevertheless
deeply approve of what he has been doing in assisting the suicides of those who
are ill. Most of all, Peck has been surprised by the huge number of Americans
who do not find Dr Kevorkian's work particularly objectionable. To read more,
please go to www.medicaltuesday.net/bookreviews.asp.
The whole debate is strangely passionless and
seemingly simplistic. But the subject of euthanasia is far from simplistic–it
involves questions about who, if anyone, has a right to terminate a life;
whether it's the same as or different from suicide or homicide; whether it
differs from merely "pulling the plug;" and what role does pain, both
physical and mental, play in euthanasia decisions. Among the stories he tells,
is one about Tony, a patient of his when he was a psychiatric resident. He felt
Tony's craziness was organic and referred him to neurology where he was found
to have a large frontal brain tumor. The tumor was inoperable and failed to
respond to radiation treatment.
Weeks later when Peck rotated on the neurology
service, Tony, now unresponsive and on a ventilator, reentered his life. He
wondered why anyone would decide to place Tony on life support. Was this
"heroic" medicine, or just a measure to prolong a life that had lost
its essence? Peck asked his chief of neurology at
Recalling the anguish of the family in waiting, Peck
looked at Tony for the next 15 minutes, cut the levophed drip in half, went to
the doctor's lounge, smoked a cigarette, returned 10 minutes later, found Tony
dead, and informed the family. As they wept, speaking to each other in Italian,
he could not tell whether they were weeping in grief or relief. He concluded,
probably both. He, of course, had the presence of mind not to tell anyone about
what he had done.
Peck wishes that he could have shared his solo
decision 30 years ago. If he had, he would have opened himself to court-martial
for unacceptable medical behavior. His actions would have been considered
euthanasia or physician suicide. Today the decision to "pull the
plug" is made in conjunction with the family and other physicians and
occasionally the ethics committee.
Peck then takes us on a journey of inadequately
treated pain, which is now a precursor to physician-assisted suicide. Nothing
fuels the euthanasia debate so much as the fear of intractable pain. Peck
states that if there were such a thing as intractable untreatable agonizing
pain, one could make a case for physician-assisted suicide. In his entire
professional life, Peck has never found one case in which pain could not be
controlled with the appropriate type of morphine cocktail. Peck gives the fear
of pain a lengthy treatment because he feels that many people look to
euthanasia as a cure for physical pain they believe they will have to endure
during the natural process of dying. But according to Peck, it is emotional–not
physical pain that is the center of the euthanasia debate.
Once Peck establishes that it is emotional, not
physical pain that is the center of the euthanasia debate, he then turns to
mental illnesses, to suicide, natural death, and murder. Although he believes physician-assisted
suicide should be illegal, he points out that not all people can obtain Hospice
care to relieve pain and suffering and there are many unsympathetic physicians
out there. He wishes there were a vigorous discussion in religious congregations,
but feels they will do almost anything to avoid open debate. The author
contends feels that all of these issues must be adequately explored before the
underlying simplicity of the spiritual perspective will be accepted. We must
become articulate in the Euthanasia–Physician Assisted Suicide debate before
it's too late.
The review can be found at www.healthcarecom.net/Denial_of_the_Soul.htm.
To read other reviews on Medical Ethics, please go to www.healthcarecom.net/bkrev_MedEthics.htm.
To read reviews on Medical Practice, please go to www.healthcarecom.net/bkrev_MedicalPractice.htm.
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10. Hippocrates & His Kin: How to be Relevant!
Two Senators on the Senate Health Care Committee went
to the Senatorial Dining Hall for lunch. One noted that the saltshaker
contained pepper. As he was surveying the problem and pondering the solutions,
the other senator noted that the pepper shaker contained salt. This created a
real problem, in their estimation, of great magnitude. What to do? One Senator
suggested that they empty the pepper and salt into two saucers and then refill
the shakers with the right ingredient. The other suggested that they need only
to empty one shaker, transfer the contents into the other and then empty the
bowl into the other.
The waitress, being sensitive to not interfere with
matters of state that are of grave concern to Senators, allowed the discussion
to proceed. When she noted the discussion slowing, she decided to proceed to
the table to obtain the order. She asked the Honorable Senators if she could
help them.
The Senators replied that they noted the saltshaker
had pepper in it and the pepper shaker had salt.
The waitress replied, "I'm so sorry," as she
proceeded to take the cap off of each and reverse them. As she smiled over the
ease of the solution she again asked, "Have you decided what you'd like to
have?"
The Senators replied that they had been so busy
discussing matters of great importance to the country that they had not yet had
a chance to review the menu.
Now we know that we best not look to Washington to
solve any health-care issues. They might put internists in the operating room
and surgeons in the TB Clinics.
To read more, please go to www.medicaltuesday.net/hhk.asp.
Doctor, I Haven't Found
Myself?
Patients come in saying,
they haven't found themselves. I don't believe the Cecil or Harrison (two basic
textbooks of medicine) ever discussed this. How do you find yourself? Well,
checking the news recently, we've found some suggestions.
Yoko Ono: She found herself
in health. She proposes a global day to focus on health care for all people. It
must be nice to solve the world's health care problems by meditating.
Al Gore: He found himself in
Global Warming. He proposes that we all reduce our greenhouse gas emissions. He
excludes himself, since he's emitting excessive greenhouse gases from his
20-room mansion and heated swimming pool. He assures us that he has networked
with some people that are reducing their emission to balance for his excesses.
It's like polluting industries buddying up with a clean air plant so that their
combination meets OSHA requirements. Isn't it great to be committed?
Movies
Star: She found herself during the water crises some years ago when she
suggested that we all put a brick in our
toilet water closets to reduce each flush by the volume of one brick. When
someone went to check her home, they couldn't find any bricks in any of her ten
bathrooms. Wealthy movie stars shouldn't have to inconvenience themselves,
should they?
Congress, which is designing
the health care system for the rest of us, have the world's most luxurious
health plans for its own members.
Isn't It Great to Be
Revolving in Isolation from Society While Solving Society's Problems?
So We Know in Advance That Anything
They Design Won't Work.
The ten countries with the
highest health spending in terms of the GDP: United States, Switzerland,
Germany, Cambodia, Iceland, Norway, Lebanon, France, Canada and Greece.
I Would Certainly Hope We'd
Be at the Top Of This Group.
To read more vignettes,
please visit our archives at www.healthcarecom.net/hhk1998.htm.
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11. Physicians Restoring Accountability in Medical
Practice, Government and Society: