Community For Better Health Care

Vol IX, No 24, March 22, 2011


In This Issue:

1.                  Featured Article: Duty Hours: Where Do We Go From Here?

2.                  In the News: Is Your Job an Endangered Species?

3.                  International Medicine: British Med Assn proposes the first walkout by doctors since 1975

4.                  Medicare: Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy

5.                  Medical Gluttony: Gouging on the Hospital Laboratory Bill

6.                  Medical Myths: ObamaCare with Increased Taxes will solve our Healthcare Problems

7.                  Overheard in the Medical Staff Lounge: ObamaCare Sooners

8.                  Voices of Medicine: Medicaid Is Worse Than No Coverage at All

9.                  The Bookshelf: Legal Academia and an Overlawyered America

10.              Hippocrates & His Kin: Subsidizing Students, Housing, and Healthcare are the same

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

Words of Wisdom, Recent Postings, In Memoriam . . .

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Remember: Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people's welfare.

Thus we must also remember that ObamaCare has nothing to do with appropriate healthcare; it was similarly projected to gain loyalty by making American citizens dependent on the government and eliminating their choice and chance in improving their welfare or quality of healthcare. Socialists know that once people are enslaved, freedom seems too risky to pursue.

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1.      Featured Article: Duty Hours: Where Do We Go From Here?

Paul H. Rockey, MD, MPH, Author Affiliations, Division of Graduate Medical Education, American Medical Association, Chicago, IL

In this issue of Mayo Clinic Proceedings, [two] articles explore the effects that limiting resident physician duty hours have had on the learning environment and patient care.1,2 These articles will prompt discussion among resident physicians and their faculty and evoke memories for those of us who completed residency training in an earlier era. In this regard, I am no exception.  

As a “rotating” intern at Harborview Medical Center in Seattle, WA, 40 years ago, I endured 4 months on the surgery service of “2 nights on, 2 nights off.” Starting rounds at 6 am on Monday and coming home at 6 pm on Wednesday meant a 60-hour shift. Admissions and emergency surgeries at all hours left little time for food, showers, or naps. Thursday was just a 12-hour day with no admissions, but the cycle resumed early Friday morning. My [four] months on the internal medicine service were more humane: I was on call just every other night. Once, after I had finished a marathon shift, my wife took a picture of me asleep in a recliner with my infant daughter in my arms.

Although these schedules were arduous, I never felt alone or abandoned. A seasoned resident was always on service with me, and my learning curve was steep. I have no regrets and still revere the experience. This crucible, shared by many in my generation, taught me that a good and effective learning environment has many aspects—and that hours worked is only one. (But that is enough personal nostalgia; there is no way we will return to such schedules.)

Journalist Sidney Zion brought the issue of resident duty hours to public attention after the death of his 18-year-old daughter, Libby, at a New York hospital in 1984. Although the root cause of her death was really lack of supervision, not excessive duty hours, New York instituted duty hour regulations for residents in 1989, limiting weekly service to 80 hours and shift lengths to 24 hours. At that time, I was an associate dean and medical director of a large community teaching hospital in Massachusetts. Our faculty physicians began to emulate New York duty hour limits for our residents, anticipating that similar laws could be enacted in the Commonwealth.

Despite a tenuous link to the quality of patient care, resident hours have become the all-too convenient explanation for a variety of systemic ills and inefficiencies in health care. Outside agencies have pressured the Accreditation Council for Graduate Medical Education (ACGME) to limit duty hours as a way to improve patient care, even though the number of hours that residents work is only one aspect of their clinical learning environment. Furthermore, frequent changes to the duty hour requirements have made the evaluation of the actual effect of past changes almost impossible. . .

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2.      In the News: Is Your Job an Endangered Species?

Technology is eating jobs—and not just obvious ones like toll takers and phone operators. Lawyers and doctors are at risk as well.

So where the heck are all the jobs? Eight-hundred billion in stimulus and $2 trillion in dollar-printing and all we got were a lousy 36,000 jobs last month. That's not even enough to absorb population growth.

You can't blame the fact that 26 million Americans are unemployed or underemployed on lost housing jobs or globalization—those excuses are played out. To understand what's going on, you have to look behind the headlines. That 36,000 is a net number. The Bureau of Labor Statistics shows that in December some 4,184,000 workers (seasonally adjusted) were hired, and 4,162,000 were "separated" (i.e., laid off or quit). This turnover tells the story of our economy—especially if you focus on jobs lost as a clue to future job growth.

With a heavy regulatory burden, payroll taxes and health-care costs, employing people is very expensive. In January, the Golden Gate Bridge announced that it will have zero toll takers next year: They've been replaced by wireless FastTrak payments and license-plate snapshots.

Technology is eating jobs—and not just toll takers.  

Tellers, phone operators, stock brokers, stock traders: These jobs are nearly extinct. Since 2007, the New York Stock Exchange has eliminated 1,000 jobs. And when was the last time you spoke to a travel agent? Nearly all of them have been displaced by technology and the Web. Librarians can't find 36,000 results in 0.14 seconds, as Google can. And a snappily dressed postal worker can't instantly deliver a 140-character tweet from a plane at 36,000 feet.

So which jobs will be destroyed next? Figure that out and you'll solve the puzzle of where new jobs will appear.

Forget blue-collar and white- collar. There are two types of workers in our economy: creators and servers. Creators are the ones driving productivity—writing code, designing chips, creating drugs, running search engines. Servers, on the other hand, service these creators (and other servers) by building homes, providing food, offering legal advice, and working at the Department of Motor Vehicles. Many servers will be replaced by machines, by computers and by changes in how business operates. It's no coincidence that Google announced it plans to hire 6,000 workers in 2011.

But even the label "servers" is too vague. So I've broken down the service economy further, as a guide to figure out the next set of unproductive jobs that will disappear. (Don't blame me if your job is listed here; technology spares no one, not even writers.) . . .

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3.      International Medicine: British Medical Assn considers the first walkout by doctors since 1975

Doctors call for industrial action over 'devastating' NHS reforms

More than 50 hospital units could be forced to close down under “devastating” reforms to the National Health Service, it has been claimed, as doctors’ leaders took the first step towards possible strike action.

| 23 Mar 2011

Dr Mark Porter said the “brutal” cuts being made to the NHS would lead to the rationing of treatment and hospitals becoming “financially unviable” as they are undermined by private competitors.

He also accused the Government of breaking its promises not to meddle in the health service, and said ministers’ “stubborn” refusal to listen to expert critics suggested they were motivated by “ideology”.

His claims came as consultants in the British Medical Association, which last week called on the controversial health bill to be withdrawn but agreed to continue negotiations, took the first steps towards a ballot for industrial action over their pay and pensions.  

It could lead to the first walkout by doctors since 1975, as opposition grows towards the plan to abolish two tiers of management and allow private firms to treat more patients at the same time as the NHS is under orders to save £20billion over three years.

In his speech to the annual BMA consultants conference on Wednesday, Dr Porter said reminded delegates that the Coalition had promised to give GPs and patients more power as well as ending top-down reorganisations of the health service. . .

“That truth is that this Bill aims to transform the NHS by making the development of a market in health care the most important priority in the NHS.” . . .

“It seems that on the most conservative commissioning assumptions about reducing low-priority services, 58 hospital trusts will be unable to cover the costs of entire service departments. . .

“This government’s stubborn and obdurate refusal to listen is starting to look as if the purpose in this Bill is more the exercise of ideology and authority, than a desire to engage doctors in improving healthcare.” . . .
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Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

The National Health Service is equally bad and their doctors appear to be at war!

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4.      Medicare: Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy

I had to train myself not to get too interested in their problems, and not to get sidetracked trying to be a semi-therapist.”
DR. DONALD LEVIN, a psychiatrist whose practice no longer includes talk therapy.

New York Times, March 5, 2011

DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”  

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional. . .

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.” . . .

On a recent day, a 50-year-old man visited Dr. Levin to get his prescriptions renewed, an encounter that took about 12 minutes.

Two years ago, the man developed rheumatoid arthritis and became severely depressed. His family doctor prescribed an antidepressant, to no effect. He went on medical leave from his job at an insurance company, withdrew to his basement and rarely ventured out.

“I became like a bear hibernating,” he said.

He looked for a psychiatrist who would provide talk therapy, write prescriptions if needed and accept his insurance. He found none. He settled on Dr. Levin, who persuaded him to get talk therapy from a psychologist and spent months adjusting a mix of medications that now includes different antidepressants and an antipsychotic. The man eventually returned to work and now goes out to movies and friends’ houses.

The man’s recovery has been gratifying for Dr. Levin, but the brevity of his appointments — like those of all of his patients — leaves him unfulfilled. . . .

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. . .

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 Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5.      Medical Gluttony: Gouging on the Hospital Laboratory Bill

Mrs. Trudy came in two weeks ago stating that she went to the hospital the evening before our office visit. Her asthma wasn’t much worse than the previous days but her daughter, who was living approximately 50 miles away, felt that she should go to the hospital emergency room and get checked out. Otherwise she would worry about her all night and she wouldn’t get any rest. Not breathing normally, she maintained, was really a bona fide emergency if anything ever was. She was sure her mother’s insurance covered emergencies.

The patient was breathing rather well when seen by the ER physician who simply ordered an extra nebulized treatment, which she had already administered twice that day. After four hours, the RN told the doctor that all the laboratory work was normal, the patient was doing well and he advised her to be discharged.

Although the minimal treatment spoke volumes that this was not an emergency, what caught my eye were the outpatient laboratory charges she had in her hand.

The charges listed are as follows.                    Medicare payment for similar services in the office.

Emergency Dept visit               $1,515             $64

Electrocardiogram                        $465                        $18

Chest x-ray                                  $755                        $36

Complete blood count                 $240                        $28

Urinalysis                                    $101                        $ 3

Obtaining the samples                  $   9             $ 0

Metabolic blood panel                  $915                       $ not done in offices, sent out for about $65

Total Claim                              $4,000                        $140

Medicare paid the provider for this claim $244          

The patient pointed out to me that, in addition to these costs, her ambulance ride to the hospital was $1500.

Conversely, the automobile mileage to our office at 35¢ per mile for three miles = $1.05

Much of the public’s frustrations with health care are the exorbitant charges that bear no relationship to either cost, value, or expected payment, unless you’re without insurance. The person without insurance will be sent to collections for failure to pay. The largest defense to keep from going broke from health care is to have any insurance to provide a shield against the hospital and practitioners who send patients to collections. No one without insurance can traverse the health care charges where price and value are in a total disconnect. If there was patency in health care charges, someone without insurance could traverse the health care market place rather well. This may prove to be the biggest drive to socialized medicine since patients and their doctors feel so helpless.

Patency would become instantly apparent if the patient had to pay a co-payment on every hospital charge. When the patient registers, the charges would have to be patent or visible so the ten percent or any appropriate percentage would be seen by the patient on admission. The patient would instantly police his or her own costs. In our research, by asking the patient as in the illustration above if she had known that the ER co-payment would be 20 percent of the average ER charge of $1500, or a minimal charge of $300, she more than likely would have made a better assessment of her illness, realizing that she was really no worse than the previous day, and a co-payment of 20 percent on a $150 office call is only $30, a lot less than the $300 ER visit. Our research has also shown that if Welfare or Medicaid patients had one-tenth of the private patient’s co-payment, or $30 for the ER visit and $3 for the office visit, they would have come to the same conclusion—the office is the best deal in medicine.

In either case, there would have been a 90 percent savings in health care cost. Health care inflation, or medical gluttony, or rising insurance premiums would have been stopped in their tracts.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6.      Myths: ObamaCare with Increased Taxes will solve our Healthcare Problems


Reagan's Legacy and the Current Malaise

Lower taxes and a strong dollar could spur growth once again.


Today, the Ronald Reagan Presidential Foundation, the Manhattan Institute and The Wall Street Journal will host a morning seminar concerning the economic legacy of Ronald Reagan. The get-together couldn't be timelier.

Reagan came into the White House facing an economy as troubled as ours—one that had even higher unemployment, catastrophic interest rates (18% for mortgages) and a stock market that in real terms had fallen 60% from its mid-1960s levels. When he left office eight years later, the U.S. had become an economic miracle: 18 million new jobs had been created; Silicon Valley had blossomed, becoming a global symbol for innovation; and the stock market was experiencing a bull run that, despite dramatic ups and downs, didn't end until the turn of the 21st century, after the Dow had expanded 15-fold. The expansion of the U.S. economy exceeded the entire size of West Germany's economy, then the world's third-largest.  

How did this happen? You could make the case that Reagan's economic miracle had its origins at a Washington, D.C., restaurant in 1974. That December night, 34-year-old University of Chicago professor, Art Laffer, scribbled a single—and now legendary—curve on a cocktail napkin to illustrate to a group of President Ford's advisers why a proposed plan to raise taxes would not increase government revenues. Mr. Laffer posited that deep cuts in existing tax rates would stimulate the economy and ultimately lead to far higher government revenues. Conversely, increase the tax burden and government receipts would fall below expectations because of a weaker economy.

Mr. Laffer's curve headed off the tax boost, but the Ford people did not accept the conclusion that big reductions in tax rates were just what the anemic U.S. economy needed. However, when Reagan met with Mr. Laffer and other like-minded thinkers several years later, he quickly grasped the Laffer Curve's fundamental message.

The concept that a free market unencumbered by barriers, government regulation and taxation will create the most growth-friendly economic environment was simple but radical. After taking the oath of office, Reagan went to work to convince the American people of the benefits of supply-side economics: lower taxes, less regulation, and less government spending, as well as a monetary policy focused on ridding us of the seemingly incurable disease of ever-rising inflation.

Reagan's program was a resounding success. Its centerpiece was the Economic Recovery Tax Act of 1981, which dramatically cut income tax rates for everyone. He managed to pass the bill during his first eight months in office, with bipartisan support in a divided Congress.

Critics howled that Reagan was being financially irresponsible, but the president pressed on. Once his cuts were fully phased-in and the hard fight against inflation was won, the economy took off like a rocket. Reagan's achievements set up a great, long boom in the U.S. and the world that didn't end until the economic crash in 2007. (Yes, there were periods of slower growth rates before that year, but none can be compared to the crash of 2007.)

At the same time, Reagan's British counterpart, Prime Minister Margaret Thatcher, was accomplishing similar feats by taking an axe to Britain's draconian tax system. Almost overnight, Britain went from being Europe's economic weak link to being the continent's most vibrant large economy. . .

Mr. Forbes, chairman and editor in chief of Forbes Media, is co-author of "How Capitalism Will Save Us: Why Free People and Free Markets Are the Best Answer in Today's Economy" (Crown Business, 2009). He is also a trustee of the Ronald Reagan Presidential Foundation.

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Medical Myths Originate When Someone Else Pays The Medical Bills.

ObamaCare will originate more Myths.

Myths Disappear When Patients Pay Appropriate Deductibles and Co-Payments on Every Service.

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7.      Overheard in the Medical Staff Lounge: ObamaCare Sooners and they’re not from Oklahoma

Dr. Rosen: States are taking the lead and implementing ObamaCare piece by piece and swelling the ranks of Medicaid. This is making health care less rather than more available to the poor and downtrodden. The increasing numbers are adding to the waiting lists and not receiving improved care.

Dr. Edwards: I’ve noticed that I’m having increasing difficulties getting my Medicaid patients to surgeons and other specialties.

Dr. Milton: We’re seeing a number of Medicaid patients that are now part of a managed care IPA. Surgeons who formerly took the managed care patients are not taking the Medicaid/Managed Care patient. So the integration of the poor into regular society is not working.  

Dr. Kaleb: I think two-tiered healthcare has always been more efficient. It is absolutely necessary in the developing countries. There is no way that all the poor could be integrated into regular care. These countries are leading the way with superior medical centers equal to any in the world; but their prices are sometimes one-fourth or less than in the advanced societies.

Dr. Michelle: Medical tourism is really taking off. In some cases, the cost of the trip to India or Bangkok plus the cost of a hip replacement or even coronary bypass surgery is less than the cost of the surgery in our country.

Dr. Kaleb: Of course none of these countries have the overwhelming regulations that you see in America, which I would think in and of them selves would at least double our health care costs.


Dr. Paul: So doesn’t that make health care more available for the poor in Bombay and Bangkok?

Dr. Kaleb: You have to remember that your poor are rich in comparison to our poor. Our poor can’t even dream of cars or televisions like your poor have.

Dr. Paul: Are you sure? Have you been back recently?

Dr. Kaleb: Just this past year. Many of our poor still don’t have waterproof houses over their heads like your poor.

Dr. Paul: Don’t you keep up with our homeless?

Dr. Kaleb: I saw a homeless in my office last week. He has a red Honda bike with accessories you would never have in India and the Middle East. And my patient last week also has a wealthy family who travels two months a year. He has access to his parents' home to shower, pack a lunch, and even stay for a month each time they are gone. Our poor in the Middle East don’t have wealthy families. Our wealthy families wouldn’t tolerate having one of their own live in the streets.

Dr. Rosen: So, our so-called poor who are now in Medicaid have available health care in the Medicaid group. These ranks are swelling two years before implementation because of state action before ObamaCare kicks in during 2014. So, can you imagine what our waiting lists will be like in 2014? Much like the rest of the world, including Canada, the UK, Bangladesh and other developing countries that are happy to see volunteers from the United States to provide care.

Dr. Kaleb: So we have the best available care by comparison with any other country. So why aren’t our local societies, state societies and the AMA fighting for our patients and pointing this out?

Dr. Rosen: They have a different agenda. They publish the CPT codes, the codes that are the bane of our lives in charting. If Medicare requires codes, they should be available to all physicians. The codes should not remain proprietary to the AMA, which makes more money from them than all the membership dues. That’s why only about a third to a quarter of physicians belongs to the AMA. They change the codes every year, which is like changing the dictionary every year. Who can keep up with thousands of new definitions each year? In 2012, there will be essentially a doubling of the number of codes—equivalent to two Webster’s Collegiate Dictionaries.

Dr. Edwards: That seems more like harassment rather than progress or our professional organization supporting doctors. In fact, they supported ObamaCare, which will destroy private practice.

Dr. Milton: I understand they see this future realignment as an even greater need to represent us in Medicare, Medicaid and government.

Dr. Kaleb: Dream on, AMA.

Dr. Edwards: Oh, to have Dr. Edward Annis back again as our president.

Dr. Rosen: Dr. Annis was in some respect like President Reagan. The socialists couldn’t wait for him to get out of office so they could reverse his tax reductions which increased revenue. That is certainly beyond the socialist’s mental capacity. They can’t comprehend how reducing taxes increased the economy so greatly that the lower taxes bring in much greater revenue than the exorbitantly high taxes did. Isn’t that the Socialist’s dream—more tax money?

Dr. Milton: Dreams and logic are not socialistic bedfellows.

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The Staff Lounge Is Where Unfiltered Medical Opinions Are Heard.

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8.      Voices of Medicine: A Review of Articles by Physicians

Medicaid Is Worse Than No Coverage at All

New research shows that patients on this government plan fare poorly. So why does the president want to shove one in four Americans into it?


Across the country, cash-strapped states are leveling blanket cuts on Medicaid providers that are turning the health program into an increasingly hollow benefit. Governors that made politically expedient promises to expand coverage during flush times are being forced to renege given their imperiled budgets. In some states, they've cut the reimbursement to providers so low that beneficiaries can't find doctors willing to accept Medicaid.  

Washington contributes to this mess by leaving states no option other than across-the-board cuts. Patients would be better off if states were able to tailor the benefits that Medicaid covers—targeting resources to sicker people and giving healthy adults cheaper, basic coverage. But federal rules say that everyone has to get the same package of benefits, regardless of health status, needs or personal desires.

These rules reflect the ambition of liberal lawmakers who cling to the dogma that Medicaid should be a "comprehensive" benefit. In their view, any tailoring is an affront to egalitarianism. Because states are forced to offer everyone everything, the actual payment rates are driven so low that beneficiaries often end up with nothing in practice.

Dozens of recent medical studies show that Medicaid patients suffer for it. In some cases, they'd do just as well without health insurance. Here's a sampling of that research: . . .

• Major surgical procedures: A 2010 study of 893,658 major surgical operations performed between 2003 to 2007, published in the Annals of Surgery, found that being on Medicaid was associated with the longest length of stay, the most total hospital costs, and the highest risk of death. Medicaid patients were almost twice as likely to die in the hospital than those with private insurance. By comparison, uninsured patients were about 25% less likely than those with Medicaid to have an "in-hospital death." Another recent study found similar outcomes for Medicaid patients undergoing trauma surgery.

• Poor outcomes after heart procedures: A 2011 study of 13,573 patients, published in the American Journal of Cardiology, found that people with Medicaid who underwent coronary angioplasty (a procedure to open clogged heart arteries) were 59% more likely to have "major adverse cardiac events," such as strokes and heart attacks, compared with privately insured patients. Medicaid patients were also more than twice as likely to have a major, subsequent heart attack after angioplasty as were patients who didn't have any health insurance at all. . .

So why do Medicaid patients fare so badly? Payment to providers has been reduced to literally pennies on each dollar of customary charges because of sequential rounds of indiscriminate rate cuts, like those now being pursued in states like New York and Illinois. As a result, doctors often cap how many Medicaid patients they'll see in their practices. Meanwhile, patients can't get timely access to routine and specialized medical care.

The liberal solution to these woes has been to expand Medicaid. Advocacy groups like Families USA imagine that once Medicaid becomes a middle-class entitlement, political pressure from middle-class workers will force politicians to address these problems by funneling more taxpayer dollars into this flawed program.

President Barack Obama's health plan follows this logic. Half of those gaining health insurance under ObamaCare will get it through Medicaid; by 2006, one in four Americans will be covered by the program. A joint analysis from the Republican members of the Senate Finance and House Energy and Commerce Committees estimates that this will force an additional $118 billion in Medicaid costs onto the states.

We need an alternative model. One option is to run Medicaid like a health program—rather than an exercise in political morals—and let states tailor benefits to the individual needs of patients, even if that means abandoning the unworkable myth of "comprehensive" coverage.

Democratic and Republican governors are pleading with the president for flexibility to do just this. At least so far, this has been a nonstarter with an Obama health team so romanced by Medicaid's cozy fictions that it neglects the health coverage that Medicaid really offers, and the indecencies it visits on the poor.

Dr. Gottlieb is a clinical assistant professor at the New York University School of Medicine and a resident fellow at the American Enterprise Institute.

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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about.

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9.      Book Review: Schools for Misrule - Legal Academia and an Overlawyered America
 by Walter Olson

BOOKSHELF  | John O. McGinnis | WSJ | MARCH 21, 2011

The Law Is a Class

Law schools wield more social influence than any other part of the American university.
To what effect?

The British economist John Maynard Keynes famously observed, 75 years ago, that statesmen who think that they are pursuing policies of their own devise are really showing themselves to be "the slaves of some defunct economist." In America today statesmen are more likely to be the slaves of some defunct legal theorist. Our litigation-prone culture and complex legal structure—not least the matrix of overlapping state and federal powers—regularly translate questions of policy into questions of law. As a result, American law schools wield more social influence than any other part of the American university.  

In "Schools for Misrule," Walter Olson offers a fine dissection of these strangely powerful institutions. One of his themes is that law professors serve the interests of the legal profession above all else; they seek to enlarge the scope of the law, creating more work for lawyers even as the changes themselves impose more costs on society. By keeping legal rules in a state of endless churning, lawyers undermine a stable rule of law and make legal outcomes less predictable; the result is more litigation and, not incidentally, more billable hours for lawyers, who must now be consulted about the most routine matters of business practice and social life.

Mr. Olson reminds us that the mere presence of law schools on college campuses was deeply controversial at the turn of the last century. Thorstein Veblen said that law schools belonged in the academy no more than schools of dancing or fencing, because their practical, vocational training detracted from the enterprise of intellectual discovery. Thus if law teachers wanted to become members of the professoriate, they had to do more than merely impart the content of legal doctrine. They had to find arguments implicit in academic trends and critique the law's very architecture. To meet the need for intellectual respectability, Mr. Olson implies, professors became engineers of reform.

Mr. Olson shows that the reforms that had the most baleful effects were those that coincided with the expansionist interests of lawyers. Legal theorists dismissed, for instance, concerns that a wider use of "equitable relief"—a doctrine that judges properly employed to enforce school desegregation—would dissolve the difference between politics and judging. But the concerns we were well placed: Courts ended up playing an important role in managing schools, prisons and welfare agencies. Law professors also helped to develop the class action into an extortionate threat: Companies now pay out million-dollar settlements rather than bet their very existence on a single trial that might well impose massive liability.

Mr. Olson superbly describes the rise of legal clinics, the law-school component ostensibly designed to give students hands-on training. He notes that the charitable foundations that first funded these clinics were more concerned with creating turbines of social change than with educating students. These days, many more clinics engage in public-interest litigation (defined by a rather predictable liberal agenda) than devote themselves to matters like the legal ordeals of small businesses, though thinking about a deli's contract dispute with a supplier would be more relevant to a law student's future working life. Some of these public-interest litigation shops have substantial funds. Mr. Olson observes that the budget of Brennan Center at New York University alone comes to roughly 80% of that of the Federalist Society, the national organization of legal conservatives that is routinely vilified by Democratic politicians for its inordinate—and, of course, pernicious—effect on our legal culture. . .

Mr. McGinnis is a professor at the Northwestern University School of Law.

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The Book Review Section Is an Insider’s View of What Doctors are Reading about.

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10.  Hippocrates & His Kin: Subsidizing Students, Housing, and Healthcare are the same problem

Are College Students Learning?

In their first two years of college, 45 percent of students made no significant improvement in skills related to critical thinking, complex reasoning and communication... After the full four years, 36 percent still had not substantially improved those skills.

Automatic class advancement and grade inflation is the corruption of education to qualify for aid.

Government money (loans) inflated tuition out of sight and decreased the quality of education.


Is the Middle Class disappearing?

The government decides to try to increase the middle class by subsidizing things that middle class people have: If middle-class people go to college and own homes, then surely if more people go to college and own homes, we’ll have more middle-class people. But homeownership and college aren’t causes of middle-class status, they’re markers for possessing the kinds of traits - self discipline, the ability to defer gratification, etc. - that let you enter, and stay, in the middle class. Subsidizing the markers doesn’t produce the traits; if anything, it undermines them.

Law professor Glenn Reynolds on his InstaPundit blog, Sept. 23, 2010

Obama Care is as popular as Prohibition once was

When the first OPEC oil shock hit the U.S. in 1973, President Nixon encouraged Americans as a voluntary gas-saving measure to drive 55 mph on the interstate. Not long after, the infamous "double nickel" became mandatory as Congress made states choose between adopting the lower speed limit and losing millions in federal aid. For two decades, most Americans voted with their gas pedals and flagrantly ignored the federal speed limit. It had become the least respected law since Prohibition by the time President Clinton repealed it in December 1995.

Now, as we learn more about ObamaCare, the odds are good that it will ultimately rank right down there with Prohibition and the double nickel in public esteem.

Voluntary encouragement to drive 55 mph was more effective than government mandating 55 mph.

Columnist Janet Daley writing in London's Telegraph, March 19:

But the history of this ignominious chapter in American foreign policy is already being re-written in Washington with an enthusiastic chorus of support from Obama fans here: on Friday, Labour backbenchers and the BBC were already suggesting that all this apparent floundering was actually part of a superbly clever strategy. America had deliberately refrained from taking the lead on Libya, thus allowing "space" for the Arab nations and the UN to "take their proper place" as the authors of any intervention policy. . . .

Even if we take this wildly charitable interpretation at face value, what does it say about the role that America is choosing to adopt on the global stage? That in the future, we can expect it to follow rather than lead? That it has abdicated its role as defender and standard bearer for the principle of freedom—the idea that all men are born with inalienable rights to "life, liberty and the pursuit of happiness," that the great founding documents of the United States declare to be universal and not simply the birthright of residents of one nation? If America is now to make its commitment to those values conditional—even when the oppressed populations of totalitarian countries are putting their lives at risk to embrace them—then we are living in a very different world from the one to which we have been accustomed.  WSJ March 21, 2011

How Sad . . .

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Hippocrates and His Kin / Hippocrates Modern Colleagues /
The Challenges of Yesteryear, Today & Tomorrow

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11.  Professionals 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 and check out their history, mission statement, newsletter, and a host of other information. For their article, "Are you really insured?," go to

                      Medi-Share Medi-Share is based on the biblical principles of caring for and sharing in one another's burdens (as outlined in Galatians 6:2). And as such, adhering to biblical principles of health and lifestyle are important requirements for membership in Medi-Share. This is not insurance.

                      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 To read more on Dr Berry, please click on the various topics at his website. To review How to Start a Third-Party Free Medical Practice . . .

                      PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. ( 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,, 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. Read Lin Zinser’s view on today’s health care problem:  In today’s proposals for sweeping changes in the field of medicine, the term “socialized medicine” is never used. Instead we hear demands for “universal,” “mandatory,” “singlepayer,” and/or “comprehensive” systems. These demands aim to force one healthcare plan (sometimes with options) onto all Americans; it is a plan under which all medical services are paid for, and thus controlled, by government agencies. Sometimes, proponents call this “nationalized financing” or “nationalized health insurance.” In a more honest day, it was called socialized medicine.

                      To read the rest of this section, please go to

                      Michael J. Harris, MD - - 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 

                      Dr David MacDonald started Liberty Health Group. To compare the traditional health insurance model with the Liberty high-deductible model, go to There is extensive data available for your study. Dr Dave is available to speak to your group on a consultative basis.

                      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 To read his "Lessons from the Past," go to For additional articles, such as the cost of Single Payer, go to; for Health Care Inflation, go to

                      ReflectiveMedical Information Systems (RMIS), delivering information that empowers patients, is a new venture by Dr. Gibson, one of our regular contributors, and his research group which will go far in making health care costs transparent. This site provides access to information related to medical costs as an informational and educational service to users of the website. This site contains general information regarding the historical, estimates, actual and Medicare range of amounts paid to providers and billed by providers to treat the procedures listed. These amounts were calculated based on actual claims paid. These amounts are not estimates of costs that may be incurred in the future. Although national or regional representations and estimates may be displayed, data from certain areas may not be included. You may want to follow this development at During your visit you may wish to enroll your own data to attract patients to your practice. This is truly innovative and has been needed for a long time. Congratulations to Dr. Gibson and staff for being at the cutting edge of healthcare reform with transparency. 

                      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

                      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 To see Attorney Sharon Kime's response, as well as the California Medical Board response, see 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

                      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

                      Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, who wrote an informative Medicine Men column at NewsMax, have now retired. Please log on to review the archives. He now has a new column with Richard Dolinar, MD, worth reading at

                      The Association of American Physicians & Surgeons (, 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:  Governors, You Can Say No to the Feds!  Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. 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 Table of Contents.

The AAPS California Chapter is an unincorporated association made up of members. The Goal of the AAPS California Chapter is to carry on the activities of the Association of American Physicians and Surgeons (AAPS) on a statewide basis. This is accomplished by having meetings and providing communications that support the medical professional needs and interests of independent physicians in private practice. To join the AAPS California Chapter, all you need to do is join national AAPS and be a physician licensed to practice in the State of California. There is no additional cost or fee to be a member of the AAPS California State Chapter.
Go to California Chapter Web Page . . .

Bottom line: "We are the best deal Physicians can get from a statewide physician based organization!"

 PA-AAPS is the Pennsylvania Chapter of the Association of American Physicians and Surgeons (AAPS), a non-partisan professional association of physicians in all types of practices and specialties across the country. Since 1943, AAPS has been dedicated to the highest ethical standards of the Oath of Hippocrates and to preserving the sanctity of the patient-physician relationship and the practice of private medicine. We welcome all physicians (M.D. and D.O.) as members. Podiatrists, dentists, chiropractors and other medical professionals are welcome to join as professional associate members. Staff members and the public are welcome as associate members. Medical students are welcome to join free of charge.

Our motto, "omnia pro aegroto" means "all for the patient."

Words of Wisdom

I fear we are developing a group of competent technicians, treating disease, but not treating the whole patient. All medicine is judgment. I can bring anybody in off the street and teach him how to cut and sew in three months. It is knowing when to operate and when not to operate that matters. Alton Ochsner

The twentieth century will be remembered chiefly, not as an age of political conflicts and technical inventions, but as an age in which human society dared to think of the health of the whole human race as a practical objective. Arnold Toynbee.

Euthanasia is a long, smooth-sounding word, and it conceals its danger as long, smooth words do, but the danger is there, nevertheless. –Pearl S. Buck

To save a man’s life against his will is the same as killing him. –Horace

Some Recent Postings

In The March 8 Issue:

1.          Featured Article: Taming the Wild

2.                  In the News: Artificial intelligence is developing much more rapidly than most of us realize.

3.                  International Medicine: Here’s the ugly truth about government-controlled health care

4.                  Medicare: Medicare Newsletters may be more important to read than Medical Journals

5.                  Medical Gluttony: ER visits are becoming a separate circular practice which is gluttonous

6.                  Medical Myths: The Practice of Medicine is a Myth to most attorneys

7.                  Overheard in the Medical Staff Lounge: Professional Organizations

8.                  Voices of Medicine: ObamaCare Is Already Damaging Health Care

9.                  The Bookshelf: Stammering George the Sixth

10.              Hippocrates & His Kin: Troopers Hunt for Wisconsin Senators

11.              Related Organizations: Restoring Accountability in HealthCare, Government and Society

Words of Wisdom, Recent Postings, In Memoriam . . .

In Memoriam

The Man Who Taught Us to See



It's not every day that the passing of an art historian becomes a media event. But then Leo Steinberg, whose death in New York on March 13 at age 90 was widely reported in the print media and blogosphere, was no ordinary art historian. Nominally he was a University of Pennsylvania professor whose specialty was Renaissance and Baroque art, the work of Michelangelo in particular. (He retired in 1991.) But he spoke to a far wider public through his writings, and in doing so changed the way an entire generation looked at and thought about art.  

During the 1950s and '60s the reigning orthodoxy, articulated by Clement Greenberg, the most influential art critic of the day, held that what mattered in a work of modern art were its formal qualities—color, form and their disposition across the flat canvas support. Subject matter and symbolism were considered of no account.

By contrast, Steinberg's own experience of art, and his academic training, had persuaded him that works of art are far more complex than such a reading allowed, a point that informed his lectures and published works.

An example was "The Philosophical Brothel," a two-part article on Picasso's "Les Demoiselles d'Avignon" (1907) that Steinberg published in ARTnews magazine in the fall of 1972. For decades "Les Demoiselles" had been referred to as the "first Cubist picture" because of the way its fragmented forms and crystalline spaces broke with 500 years of eye-fooling illusionism that began with the Renaissance. Its narrative content, a brothel scene, was mentioned only in passing.

Without discounting the stylistic revolution the painting heralded, Steinberg argued that the brothel subject was central to its form and meaning. The painting, he said, was about the sexual confrontation between the five prostitutes staring out from the painting and the viewer standing in front of it.

But it was in "Other Criteria: Confrontations With Twentieth-Century Art," published a few months later, that Steinberg's aesthetic outlook found its fullest expression. An anthology of 18 articles and essays, the book constituted a thoroughgoing alternative to the accepted way of seeing. It's hard to overstate the impact it had when it appeared. It was as if someone had opened a window in a dark, airless room, and brought works of art back to life again.

At its core were two pieces, the title essay and another, "The Eye Is a Part of the Mind," that offered the most sweeping argument against Greenbergian formalism. Drawing on examples from the Old Masters to modern art, he showed that the ways works of art are made and experienced are too sophisticated, too multilayered to be easily reduced to the two-dimensional schema Greenberg proposed. Today the length of these pieces—some 20,000 words between them—might seem like overkill. Yet it is a measure of how firmly the formalist aesthetic was entrenched that such an all-out assault was required.

But Steinberg was more than a polemicist; he led by example. The remaining pieces in "Other Criteria" are on artists or artworks—among them Picasso, Rodin, Jasper Johns, Monet's water-lily paintings. Undergirding his examinations was the question, "What is the artist trying to tell us?" In his quest for answers Steinberg didn't limit himself to the history of art, but looked at popular and material culture as well. He would even adopt the posture of a depicted figure, the better to understand it.

He seemed to transform every work of art he wrote about; you never looked at one the same way after reading what Steinberg wrote about it. The three essays on Picasso were ahead of their time in seeing the artist's career as a unity of motifs, themes and obsessions spread across eight decades, rather than, as had long been the practice, in narrowly stylistic terms—"Cubism-and-everything-else." His essay on Rodin remains the best introduction to the artist yet published.

Besides possessing a keen eye, wide-ranging intellect and stubborn resistance to received wisdom, Steinberg was a born writer—and English was his third language. (He spoke Russian and German first.) In place of the desiccated, impersonal drone of most academic writing, we get a voice—a flesh-and-blood personality—and a fluid, impassioned and nuanced prose stylist. He didn't just illuminate a work of art; he captured the experience. The 186 figures on Rodin's "Gates of Hell," he wrote, "drift and writhe like leashed flying kites." . . . 

Mr. Gibson is the Journal's Leisure & Arts features editor.

Read the entire obituary/feature on the WSJ (Subscription required) . . .

On This Date in History - March 22

On this date in 1882, Edwards Law outlawed polygamy in the U.S. It was aimed at dissident Mormons who were clinging to that sect’s earlier belief in the idea of multiple wives. It was a time when nice people did not talk about sex, women didn’t have many rights and the opponents of polygamy were convinced that they were striking a mighty blow for morality. The solution adopted in our own times has been a different version of multiple wives—or husbands. To phrase it in electrical terms, it is now done in series instead of in parallel.

On this date in 1621, Governor John Carver of Plymouth and Chief Massasoit of the Indians made the first non-aggression agreement in America. As such agreements go, it was a pretty good one. It lasted half a century.

After Leonard and Thelma Spinrad

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The Annual World Health Care Congress

Advancing solutions for business and health care CEOs to implement new models for health care affordability, coverage and quality.

In partnership with, the 7th Annual World Health Care Congress was the most prestigious meeting of chief and senior executives from all sectors of health care. The 2010 conference convened 2,000 CEOs, senior executives and government officials from the nation's largest employers, hospitals, health systems, health plans, pharmaceutical and biotech companies, and leading government HCC LOGOagencies. Please watch this section for further reports in the future as well as








The 8th Annual World Health Care Congress will be held April 4-6, 2011
Washington, DC
Toll Free: 800-767-9499