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MedicalTuesday refers to the meetings that were traditionally held on Tuesday evenings where physicians met with their colleagues and the interested business and professional communities to discuss the medical and health care issues of the day. As major changes occurred in health care delivery during the past several decades, the need for physicians to meet with the business and professional communities became even more important. However, proponents of third-party or single-payer health care felt these meetings were counter productive and they essentially disappeared. Rationing, a common component of government medicine throughout the world, was introduced into the United States with Health Maintenance Organizations (HMOs), under the illusion that this was free enterprise. Instead, the consumers (patients) lost all control of their personal and private health-care decision making, the reverse of what was needed to control health care costs and improve quality of care.

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In This Issue:
1. How Business Can Save American Medicine - Get On the Hospital Boards
2. Lawmakers Want to Regulate Information - Another Horror Story
3. Our Nursing Colleagues Look to Lawmakers to Solve Their Hospital Problems
4. Government Medicine - Follow the Rules - Don't Worry About the Patient Dying
5. Medical Gluttony: The Value of Lab Work is Obtaining Them - Not the Results
6. Medical Myths - Health Insurance Improves Health Care
7. Medicine at the Bedside - Dying is Such a Risky Business - Challenge is the Family
8. The MedicalTuesday Recommendations for Restoring Accountability in HealthCare, Government and Society

1. How Business Can Save American Medicine - Get On the Hospital Boards
When Jack Stack, CEO of SRC Holding Corp and Inc contributing editor, penned a letter to President Bush about government and business in the January 2004 issue of Inc, he got an unexpected reply: Air Force One swooped over his factory in Springfield, MO, bringing the commander in chief for a personal visit. President Bush took their discussion one step further in his second term by making a simplified tax code one of his top priorities. But tax policy is just one (and perhaps not even the most crucial) area that the president can address to strengthen the nation's entrepreneurial economy. That's why Inc Editor John Koten asked Stack to write a second letter to the president last month, this time highlighting such issues as rising health care costs and increased foreign competition. Since Jack Stack sees his company as a business of businesspeople,1200 businesspeople altogether, he feels that last month's letter is one that more than one type of president should read - including not only business, but also health care executives and hospital boards.

Stack continues in the letter that virtually everything the federal government does, from welfare reform to environmental regulations, impacts businesses. It's all too easy for Congress and the administration to inadvertently create problems that will have ramifications throughout the entrepreneurial sector, with a potentially devastating effect on our nation's ability to meet the challenges ahead. It's possible for you, Mr President, to help remove some of the biggest obstacles that stand in our way. And that doesn't always involve passing a law. Sometimes we just need leadership more than legislation. We need your explanation of what businesses can do without getting the government involved.

Jack Stack then discusses the Health Care Crunch that forces more and more small companies to stop offering health insurance altogether. He suggests two steps that the president can take and neither involve legislation. First, he suggests that the president use his position to foster better understanding of why costs keep rising and to describe the terrible impact this is having on business. He should focus public attention on the need to make changes. He should use his position to ask the health providers to voluntarily restrain their costs as other businesses do. Start a national campaign.

Secondly, the president should encourage hospitals and clinics, which often have no connection to the market place, to put small-business owners on their boards. It's an inbred system. That's why Stack agreed to sit on the board of the local hospital that provides health care for his SRC employees. The other board members pay attention if Stack presents his case forcefully and makes sure that they have their ducks in a row before bringing up any new spending increase. He found that board members listen. The town surgeon assured Stack that they were working on keeping costs in line with inflation.

Because of Stack's efforts, it costs his company about $90 a month to provide a single employee with health-care coverage, compared with a national average of $308 a month according to the Kaiser Family Foundation.

To read the other suggestions that Stack outlines for President Bush and for presidents of companies in the February issue of Inc, go to http://www.inc.com.
 

2. Lawmakers Want to Regulate Information - Another Horror Story
When Bank of America lost tapes on 1.2 million federal employees' data, the Senator from Vermont called for more regulation of companies that buy and sell personal data. The previous week, ChoicePoint Inc., a data warehouser, had learned that personal information of as many as 140,000 consumers might have been compromised. It is difficult to see how this Senatorial knee-jerk reaction could prevent theft. But as alluded to in the previous section, regulation would have devastating effects on all other businesses that would be subjected to increased costs.

Bank of America took immediate major steps to reduce the injury by establishing a hot line, notifying all cardholders involved, replacing cards for the ones canceled, and offering free credit reports and fraud alerts. This is where the additional costs should be - with the company involved - and not by establishing legislation that imposes unintended costs on all other companies.

B of A would obviously make major efforts to satisfy customers as any company would do. Otherwise they could lose 1.2 million customers immediately, and millions of other customers would become concerned and change banks also. Businesses can always correct their own problems more effectively and efficiently than the federal government.

If the government tried to regulate a part of information, it would seriously jeopardize freedom of all types of information. Also, when Congress passes restrictive laws, lobbyists from other companies and agencies immediately pressure lawmakers to give them access to information they allegedly need - without disclosure - in the same way as HIPAA (Health Insurance Portability and Accountability Act) has opened up private medical information to privileged agencies who now have access to private, personal and medical data without additional disclosure. Patients have no idea who might be reading their personal file.

3. Our Nursing Colleagues Look to Lawmakers to Solve Their Hospital Problems
The California Nurses Association, the professional organization of nurses that has devolved into a union, is protesting the decision by Governor Schwarzenegger to delay the implementation of part of a law signed by former Governor Gray Davis that requires many hospitals to employ more nurses. The union argues that increased nurse-to-patient ratios lead to better health care. No one can take issue with that statement. The short term effect may seem to be better patient care. But just look at the long term effect as seen in VA and other governmental hospitals, both here and abroad.

The nurse situation has many lessons for health care, including physicians. As professional doctors and nurses allow unions and legislatures to determine their professional status, we must understand that although we then lose our professional status, our patients will lose even more - their very lives may be at risk. My discussion with nurses has been discouraging. Many do not see an alternative to forcing their employer to behave in a certain way. The CNA spent large sums of money, energy and time to get Governor Davis and his legislature to pass the law in question. Another political administration reversed everything. How many years of one's life can be spent sucking up to lawmakers without getting your face soiled?

Nurses, like physicians, have many options to practice. Certainly the hospital is a major employer. But when a nurse feels she cannot deliver appropriate care in her current hospital, she does have other opportunities. At a medical society meeting, a physician remarked that the nurse on her obstetrics floor complained that it took her four hours daily to attend to other pressing duties before she even met all the patients she was responsible for that day. If I were that nurse, I would begin looking for other options. What if more nurses began practicing in physician’s offices, free standing clinics, administrative roles, industry and  schools and hospitals developed such a shortage that they had to close one-fourth or more of their beds, losing money on a major investment? They would be forced to solve the staffing or salary problem or whatever it took to get nurses interested in working at their hospital. As Stack says in section one above, it would be the business - or the profession in this case - solving their own problem without government intrusion. They return to the ranks of a profession rather than a labor organization.

4. Government Medicine - Follow the Rules - Don't Worry About the Patient Dying
It seems that every week there's a new government mandate to follow, which interferes with taking care of patients. The Health Insurance Portability and Accountability Act (HIPAA) has made it essentially impossible to obtain patient records in a timely fashion in order to have relevance to immediate patient care. Starting with no information when interviewing and examining a new patient could take thirty minutes to grasp the essential medical problems that may require immediate attention. One can glean significant information, within a matter of minutes, from a prior record that would facilitate adequate care of a sick or dying patient.

Today, I received a request from a regional mail-order pharmacy to justify a three times-a-day, rather than four-times-a-day, finger-stick glucose measurement that I had ordered for a type I diabetic patient on insulin. The note from the pharmacy indicated that the prescription for insulin, lancets, and glucometer measuring sticks would not be shipped until I verified that the patient's variations on my prescription was satisfactory. The verification form was three pages long. Since bureaucrats attach great importance to complying with law, even to the detriment of the patient's life, I quickly reviewed the chart and made a clinical decision, much the same as for an office call. Complying with the pharmacy request meant that my scheduled patients waited an extra 10 minutes to be seen.

In my discussion with those that write laws or regulations, it is clear that they believe they are doing more good than harm, when if fact the reverse is true. They do not see themselves as interfering with patients’ care or jeopardizing lives. They have no comprehension of a brittle diabetic waiting an extra week or two for his insulin while pharmacies and physicians comply with regulations. They have a total disconnect between what physicians do and their benefit to patients.

5. Medical Gluttony: The Value of Lab Work is Obtaining Them - Not the Results
When patients make demands for expensive tests because it is a benefit of their insurance program, they may not even be interested in the results. We recently received a lipid and chemistry panel on a patient in which the triglycerides were 900 (normal 150) and the cholesterol nearly 300 (desired level 175). The blood sugar was over 400 (normal 65-99) indicating uncontrolled diabetes. We gave him an urgent call to inform him of the seriousness of these levels, that his diabetes needed immediate attention, and his lipids needed to be brought into line.

He said they have always been elevated, he was much too busy to come in to discuss the matter, and since he was moving in a month there was no need to get started on the problem. I couldn't convince him otherwise. When asked why he wanted the tests if he already knew they would be abnormal and he was not interested in treatment, he said he was just curious if his previous doctor was telling him the truth. He felt better that my report was identical to the previous report. He saw no relationship between the testing and treatment.

The insurance carrier will pick up these reports and will write letters of reprimand to the physician for not treating his lipidemia or diabetes. Like all bureaucrats, they feel patients are automatons that simply do what they are told, when, in fact, many patients may not even fill prescriptions or act on laboratory requests. Health insurance carriers should stick with writing health insurance to cover patient's health care costs and let doctors take care of the sick without interference.

6. Medical Myths - Health Insurance Improves Health Care
A patient came in last week after having changed insurance coverage. He had diabetes of 30-years duration and was on insulin, among other things. He was treating the diabetes with 22 units of Humulin Insulin before breakfast and 12 units before dinner.

When asked what his glucose monitoring values were in order to know when to adjust his insulin dosing, he replied that he had not measured his sugar in well over five years, perhaps even ten. He felt fine and saw no need to inconvenience himself with checking his blood sugar. He also was not interested in obtaining a blood sugar test at the laboratory.

What needs to be pointed out to those who feel that universal health insurance improves health care is that there are a number of people that have health insurance that allows the management of important diseases (such as diabetes, which can cause devastating injury to the eyes, nerves and kidneys if not treated) at minimal expense, but don't utilize the coverage.

7. Medicine at the Bedside - Dying is Such a Risky Business - Challenge is the Family
This past month, we've helped a couple of patients who've been with us for more than thirty years say goodbye. What the family sees and what the patient does are frequently poles apart. Every doctor learns in his first decade of practice that although many patients eschew having their spouse or family around during medical discussions, as time goes on it becomes important to have members of the family, whether spouse or offspring, present with the patient to listen to the doctor's discussion after the medical examination.

One of my memorable patients in his 9th decade of life had been having multiple-organ failure for the past several years. With a life time of asthma, which was well compensated until the past several years, he had severe vascular disease over the past 30 years that slowly involved his arteries from his legs to his heart to his brain, with two multi-vessel coronary artery bypass grafts 25 and 15 years ago. His cardiac catheterization a year or so ago revealed he had one patent coronary left with a floating clot that was successfully inactivated with a stent.

During the past year, his heart failure became intractable. His legs filled with fluid to the mid thigh and the water level began filling his lung cavities with heart-failure fluid. He was on an extensive diuretic program and it took constant reminders to prevent well meaning family members from forcing fluids into his water-logged body. His kidney failure had been progressing for several years. His urea level for the past two years was in the 50s and 60s (normal 15-25). It started climbing about six months ago into the 80s and 90s and his family was pushing for kidney dialysis.

For about the first twenty-five years, he generally made all his own medical decisions - where to go, whether the Veterans hospital, the military hospital or his HMO, and which specialists to see. I tried to fill in the gaps between wide variations in care and coverage because he never understood how one doctor's treatment of one organ might affect another doctor's treatment of a different organ. He never asked for advice.

About six months ago, when his cardiologist suggested a renal consult and possible dialysis, he asked me what I would do. Since this was a totally different discussion than any we had before, I figured he was asking me to help him say goodbye to his family and friends. Since his family would want everything possible to be done, I was careful to couch my discussion in terms of what I would do and not what he should do. Otherwise, if the family disagreed, I might get caught in the crossfire.

He did see the nephrologist and then asked me if he should go on dialysis. Looking at his bruised, non-healing arms and legs, from which every available blood vessel had been harvested for his coronary bypasses, I told him it might be difficult to find access to his vascular system for the dialysis. And then the words, "What would you do if you were me?"

Dangerous question. I told him if I had all those health challenges and enumerated them to him again, I would go home to the three women in my life, my wife and two daughters, help them write my obituary and spend some time with them. If I'd live one week with them, one month, or a year, I would consider it time well spent. But I would no longer put my body through more destruction or torture.

He then thanked me, went home to his wife and family and shortly thereafter met his Maker. The family thanked me for my thirty years on behalf of their husband and father. When I write these anecdotes for my final memoirs, my reflection may be entirely different. But such is the life of a family lung doctor.

8. MedicalTuesday Recommends the Following Organizations for Their Efforts in Restoring Accountability in HealthCare, Government and Society:

• The National Center for Policy Analysis, John C Goodman, PhD, President, who, along with Devon Herrick, wrote Twenty Myths about Single-Payer Health Insurance which we reviewed in this newsletter the first twenty months, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log onto http://www.ncpa.org and register to receive one or more of these reports. Please read a review of their new book, Lives at Risk, http://www.healthcarecom.net/JGLivesAtRisk.htm, the definitive work on Single-Payer National Health Insurance Around the World. It shows that the United States has the best health care system in the world. The book can be ordered at http://www.ncpa.org/pub/lives_risk.htm.

• The Mercatus Center at George Mason University (http://www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center’s Government Accountability Project. Last month, Dr. Jerry Ellig examines the effects economic regulation has had on telecommunications and broadband Internet service in the United States. “Our estimates find that federal telecommunications and broadband regulations cost consumers up to $105 billion annually in higher prices and forgone services,” writes Ellig. “The most costly of all federal telecommunication regulations is spectrum management, costing consumers at least $77 billion in higher prices and foregone wireless services.” To read the entire report, go to http://www.mercatus.org/regulatorystudies/article.php/1074.html.

• The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging onto their website at www.galen.org. Grace-Marie Turner points out in the current newsletter that Social Security isn’t Health Care. To read the three reasons why Social Security Reform isn't the same as Health Care Reform, go to http://www.galen.org/hcbasics.asp?docID=772.

• Greg Scandlen, Director of the “Center for Consumer-Driven Health Care” at the Galen Institute, has a Weekly Health News Letter: Consumer Choice Matters. You may subscribe to this informative and well-outlined newsletter that is distributed every Tuesday by logging onto http://www.galen.org and clicking on Consumer Choice Matters. Archives are now located at http://www.galen.org/ccm_archives.asp. Read last week’s newsletter in which Greg discusses the Profound Changes that are Underway in Health Care at http://www.galen.org/ccbdocs.asp?docID=771.

• The Heartland Institute, http://www.heartland.org, publishes the Health Care News, Conrad Meier, Managing Editor Emeritus. Corporate greed has nothing on Senatorial and Representative greed in their quest for taxpayer-funded Golden Parachutes. To read how 38 former Senators and Representative are fairing, with Senator Daschle heading the pack with a $5 million pension, go to http://www.heartland.org/Article.cfm?artId=16544.

• The Foundation for Economic Education, http://www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom’s Magazine, for over 50 years, has Richard M Ebeling, PhD, President, and Sheldon Richman as editor.  Gail Russell Chaddock, Staff writer of The Christian Science Monitor, reports on Medicaid: the "Monster in the Road" with the federal government funding a program that is expanding beyond healthcare for the poor. Click on "Battle over Medicaid Is in the Offing" on the home page or go directly to http://www.csmonitor.com/2005/0303/p01s01-uspo.html.

• The Council for Affordable Health Insurance, http://www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. “The belief that more medical care means better medical care is deeply entrenched. To read the current first in a series on The Health Care Safety Net We Want and Need go to http://www.cahi.org/cahi_contents/resources/pdf/n128safetynet.pdf.

• The Health Policy Fact Checkers is a great resource to check the facts for accuracy in reporting and can be accessed from the preceding CAHI site or at http://www.factcheckers.org/. This week read the Daily Medical Follies: “Woeful Tales from the World of Nationalized Health Care” Die in Britain, survive in America, where James Bartholomew makes the case that although the American Health Care may be a patchwork, it is just that British state-run healthcare is so amazingly, achingly, miserably and mortally incompetent. See http://www.factcheckers.org/showArticle.php?id=520.

• The Independence Institute, http://www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter at http://www.i2i.org/healthcarecenter.aspx. Get your Spending bumper sticker, It’s not the Taxpayers’ Bill of Rights that will cause the budget shortfall. It's the spending stupid!

• The National Association of Health Underwriters, http://www.NAHU.org, The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page, including HSAs.

• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Québécois Libre. Please log on at http://www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, for a change in pace and humor, read what would have happened if Noah had lived in the United States today and God had commanded him to build an ark at http://www.quebecoislibre.org/05/050215-9.htm.

• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well-being of all Canadians. Be sure to read Brett Skinners report on how Government Interference in Pharmaceutical Markets Costs Canadians $2 billion to $5 billion Annually at http://www.fraserinstitute.ca/shared/readmore.asp?sNav=nr&id=644.

• The Heritage Foundation, http://www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. Be sure to read David C. John's How Today's Social Security Works at http://www.heritage.org/Research/SocialSecurity/bg1827.cfm.

• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we’ve seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at http://www.mises.org to obtain the foundation’s daily reports. Be sure to read last weeks article by George Reisman on why we need to Kill the Prescription Drug Benefit at http://www.mises.org/fullstory.aspx?Id=1752.  To learn how state medicine subsidizes illness, see http://www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone would want to be an MD today, see http://www.lewrockwell.com/klassen/klassen46.html.

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

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

• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of “educating for liberty.” It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. You may log onto http://www.hillsdale.edu to register for the annual week-long von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for it's national rankings in the USNews College rankings. Last year, changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Read President Arnn's comments at http://www.hillsdale.edu/arnn/usnews.asp. Also read his comments on Ronald Reagan, RIP, at http://www.hillsdale.edu/newimprimis/default.htm. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read Robert J. Herbold on K-12 Establishment is Putting America’s Industrial Leadership at Risk at http://www.hillsdale.edu/newimprimis/default.htm. The last ten years of Imprimis are archived at http://www.hillsdale.edu/imprimis/archives.htm.

Stay Tuned to the MedicalTuesday.Network and Have Your Friends Do the Same
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Carey Perloff, Artistic Director, American Conservatory Theater, San Francisco, on the current production of "Well." We spend an enormous time in American culture obsessing about health, while at the same time behaving in all kinds of ways guaranteed to promote sickness. In particular, we love to talk about "stress" (a word I don't remember hearing uttered as a child). We seem convinced that if we could just eliminate stress, we would give birth to the happy, healthy culture we imagine we have it in ourselves to create–but probably wouldn't recognize if we found ourselves a part of it.

Robert J Dole, former US Senator: When political action committees give money, they expect something in return other than good government.

Edward Langley, Artist 1928-1995: What this country needs are more unemployed politicians.

Dr Muhammad Yunus, Global Health Care A moving story of patient-directed health care in Bangladesh. Please read Dr Yunus speech given at the World Health Care Congress last month at http://healthplanusa.net/GrameenBank.htm.

David Gibson, MD, Fundamental Health Care Reform. A consensus is forming. California cannot begin to solve its structural budget deficit problem without first addressing the fundamental issues of health care’s structure and cost. Read the entire OpEd article at http://healthplanusa.net/DGFundamentalHealthCareReform.htm.

Oliver Wendell Holmes, Jr, was born in 1841. Supreme Court Justice Oliver Wendell Holmes was already famous on this date. He was the son of the doctor and author who was one of the great literary figures of New England's golden age. He resigned from the Court when he was past 90, after 30 years of service.

Arnold Schuster, the law-abiding citizen who recognized and reported the legendary bank robber Willie Sutton, was shot and killed on this date in 1952. The murder was never solved. Sutton's Law, invoked by every professor of Medicine in my memory to point out the obvious in any diagnostic syndrome, was named after the bank robber when asked why he always kept robbing banks, "Isn't that where the money is?"