1. Featured Article: Unrecoverable accounts receivables are more important than Medicare cuts

During our visit last week, we discussed the growing financial stress doctors in private practice are facing and the likely business trends that will result. In the past, the health care system has been able to cost shift from inadequate government health plan reimbursements onto the private market. The rising level of patient financial liability (see below) and the prohibition of balance billing under the assignment clause of managed care contracts (see below), the cost shifting issue is rapidly becoming moot. Thus, the inability to cost shift along with uncollectable aged accounts receivable represents a summative destabilizing reality for the health care system.

To illustrate the above, if you will click on the following link, you will see an article highlighted on the Drudge Report this morning concerning the declining fiscal health of doctors in private practice. Read more . . .

http://money.cnn.com/2012/01/05/smallbusiness/doctors_broke/index.htm?hpt=hp_t3&hpt=hp_c1

What I find most interesting here is the topics not covered. This article is an example of typical AMA political trope intended to influence Congress and prevent the impending 27.4% Medicare pay cut for doctors due early this year as dictated by the Balanced Budget Act of 1997. History indicates that such cuts are highly unlikely given the fact that Congress has blocked those cuts from happening 13 times over the past decade. Medicare & Medicaid reimbursement issues are serious problems for physicians. However, what is not discussed in this article represents a much more serious and destabilizing business issue for physicians.

This issue is the growing amount of unrecoverable accounts receivables from private insurance plan beneficiaries. In the past, physicians typically collected 84% of what they were due for services rendered under insurance company reimbursement contracts after claim adjudication. Now, with the rapid growth of high deductible insurance plans (HDHP) coupled with the “assignment clause” within all managed care provider panel contracts, the average physician in private practice has accumulated aged receivable balances approaching 12 month that total over $200,000 according to the Physician Coalition for Health Information Technology (PCHIT). Managed care assignment clauses forbid patient billing other than for co-payments until the service claim is adjudicated, thus the typical aging of a receivable beyond 6-months before any effort to collect from the patient is allowed.

The increasing market penetration for HDHP insurance products is demonstrated in the following graph from the just released Kaiser Employer Health Benefits 2011 Annual Survey:

Click to see graph of HMO decrease from 31 percent to 17 percent penetration in past 16 years
as well as other important changes in the health reimbursement arena.

The likely business strategy going forward for physicians will be to cancel their managed care contracts and begin dealing directly with their patients on the terms for reimbursement for services. Such a move would expose patients to the true cost of medical care and would serve as a much more effective medical cost inflationary trend moderator than managed care contracting has proven to be capable of in the past. A growing number of hospital based physicians (radiologists, anesthesiologists, pathologists & ER physician groups) have already adopted this strategy. Should such a strategy significantly penetrate provider panels, managed care contracted networks will implode and managed care products such as the non-staff based PPO and the HMO will no longer have a market presence.

I find it to be inexplicable that the AMA would concentrate on Washington politics and be demonstrably clueless as to the predominate business threat facing physicians in America today. This exploding accounts receivable issue is much more destabilizing for physicians in private practice than is the growing problem with increasingly inadequate reimbursement under Medicare and Medicaid.

David J. Gibson, M.D. Director

Reflective Medical Information Systems, Inc.

www.refelectivemedical.com

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2. In the News: Doctor’s Office Visit for the price of a cup of coffee for 57 years.

Illinois Doctor Offers $5 Office Visits

by Marti Attoun

Dr. Russell Dohner offers affordable and attentive health care in Rushville, Ill., seeing up to 120 patients a day.

Dr. Russell Dohner, 86, has been on call for 57 years in Rushville, Ill. (pop. 3,192), working seven days a week, seeing up to 120 patients a day and even making house calls.

To top it off, he charges patients only $5 a visit.

“When I first came here, every doctor in town charged $2,” Dohner says. “I didn’t think about changing the price for 30 years.” Read more . . .

When national publicity about his low fee brought the modest doctor unwanted attention in the 1980s, Dohner began charging $3 for a visit and then $5 about 15 years ago.

By 9 a.m. six days a week, his clinic on the town square begins to fill with 50 or more people, enough to keep his fee low, Dohner says. He accepts Medicare, but not private insurance.

Most patients, like Laura Fry, 41, and her daughter, Kayla, 19, know they’ll get their money’s worth from Dohner, who’s provided medical care to five generations of the Fry family.

“He’s so calm and so gentle,” Kayla says. “I’ve never been afraid to see the doctor.” . . .

Another country doctor inspired Dohner to enter the medical profession. “When I was a little boy, 5 or 6, I had tonsillitis bad and had seizures and my mother would call Dr. Hamilton,” he says. “I thought, ‘I’m going to be just like Dr. Hamilton.’”

After earning a medical degree in 1953 from Northwestern University Medical School in Chicago, Dohner opened his office. It looks much the same today with a homey mishmash of chairs, an examination room with knotty-pine walls, and a hallway papered with thank-you cards, letters and snapshots of patients. Dohner writes out medical records by hand on index cards, and receptionist Edith Moore, 84, answers an oft-ringing 1950s rotary dial telephone. She jots the day’s receipts in a tablet.

Most of all, Dohner’s devotion to his patients remains unchanged after more than a half-century of doctoring, says nurse Florence Bottorff, 88, who has worked alongside him since 1958.

“He doesn’t turn anyone away,” Bottorff says.

In case someone needs care, Dohner opens the office for an hour on Sunday mornings before attending services at First United Methodist Church, and he makes house calls as needed.

“People are at home and disabled and you need to look after them,” he says matter-of-factly.

Two calls that Dohner has responded to during the 1960s stand out among thousands of medical emergencies, ranging from ruptured appendixes to snake bites. After a ceiling collapsed in a nearby coal mine, he ventured underground and treated two survivors. He also came to the rescue of a boy who fell in a corn bin.

“All I could see was his head,” Dohner recalls. “I said, ‘the only thing you can do is tear down the bin so the corn will rush out.’ The little boy was fine.”

Though the bachelor doctor doesn’t have children, he has delivered more than 3,500 babies and has his hands full keeping them all in good health.

Rick Bartlett, 48, a pharmacist at Moreland & Devitt is a “Dohner baby,” as are his four children. He remains grateful for Dohner’s healing touch when he was a child.

“My older brother fed me a fishing lure with a treble hook that stuck in my cheek and tongue,” he says. “We didn’t go to the emergency room. We went to Dr. Dohner and he cut it out.”

“His patients are his family,” Bartlett adds. “That’s all Dr. Dohner thinks about—that someone might need him. He’s so unselfish.”

Read the entire article . . .

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3. International Medicine: Socialism & Socialized Healthcare have the same END GAME.

The Euro End Game

By John H. Makin, AEI

Europe has pursued repeated rounds of fiscal austerity and bank deleveraging in exchange for loans that were supposed to save the euro. The result has been a predictable recession with plummeting employment, incomes and prices, says John H. Makin, a resident scholar with the American Enterprise Institute.

The immediate result of this debt crisis is an increasingly radical political climate, pitting pro-euro politicians like Germany's Angela Merkel against anti-euro figures such as France's new president Francois Hollande and the current administration of Spain. Read more . . .

The backlash against euro-saving austerity measures isn't just political: it is manifesting itself in the economic policies of the heavily indebted countries.

· The Netherlands' conservative government has collapsed as austerity intensifies an already painful recession.

· The Spanish government has refused to impose the degree of fiscal austerity called for by the recent agreement to save the euro, recognizing that it cannot possibly reduce its deficits by the agreed amount.

Put simply, the primary measures that have been put into place to save the euro have intensified the pain of the recession, and have resulted in popular movements against the euro, manifesting in the elections of explicitly anti-euro politicians. . .

Source: John H. Makin, "The Euro End Game," American Enterprise Institute, May 2012.
For text: http://www.aei.org/files/2012/05/16/-the-euro-end-game_17001871275.pdf

ENDGAME by Samuel Beckett is currently playing at the American Conservatory Theater in San Francisco. The Endgame is not pretty, especially when played by Bill Irwin, founding member of Kraken Theatre Ensemble and San Francisco’s Pickle Family Circus.

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Socialized Medicine does not give timely access to healthcare, it only gives access to a waiting list.

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4. Medicare: Natural Rights Trump Obamacare, or Should

Only the natural law can explain the deep wrongs of the recent health-care bill.

By Hadley Arkes,

Past the politics of Obamacare—the tawdry buying of votes, the spectacle of representatives in a republic passing into law bills of two thousand-plus pages they had never been able to read—past all of that, there was an understanding, shared by both sides, that this was not merely a controversial measure, but a scheme that would change the regime itself. Whether it promised or threatened a change in the American regime would hinge on whether that change in regime was regarded as a good or bad thing. But no one denied the reach of its significance. Read more . . .

For the left, it gave the promise of matching the enlightenment of Europe and carrying the attack on inequality into its further reaches. For the right, it threatened the vast enlargement of the reach and powers of the state, bringing a sixth of the economy under the control of the government and reaching matters of life and death in a momentous new way. What was in prospect now was a scheme for the rationing of health care under the monopoly powers of the government. The generous provision of care to the poor would come along with controls that could deny to ordinary people the medical care they would regard as necessary to the preservation of their own lives, perhaps even when they were willing to pay for that care themselves.

The political storm set off by Obamacare may not subside, one way or another, until the public determines next November whether it will preserve in office the president who was determined to push it through with a Congress controlled by his party. Until then, the battle has already begun in the courts. Challenges to the Patient Protection and Affordable Care Act (PPACA) have been filed in federal courts in several parts of the country, with some judges sustaining the PPACA and others holding it unconstitutional.

The legal challenge has merged with the political challenge. For the most serious argument against Obamacare is that it threatens to change the American regime in a grave way: that it sweeps past the constitutional restraints intended to ensure a federal government “limited” in its ends, confined to certain “enumerated” powers, and respecting a domain of local responsibilities that it has no need or rationale for displacing.

And yet those limits have been so thoroughly exceeded over the years that they are now barely discernible. A federal government that can tear down and build housing in the cities, sponsor clinics on contraception, and impose unions on private companies, knows no distinct sense of boundaries. The formula for this expansion of the powers of the government has been settled now for nearly seventy-five years, since the New Deal. In creating Obamacare, the Democrats were simply drawing on a playbook long ago grown familiar.

The key to this expansion has been the Commerce Clause of the Constitution. Before 1937, that clause had offered a rough way of limiting the powers of Congress to transactions and activities that moved across state lines. The limitation did not always make sense, but it was a criterion sufficiently plain to ordinary folk, and good enough to limit federal power. But with the New Deal, the powers of Congress were extended to all activities that might somehow “affect” interstate commerce. In this way, and only in this way, could the Supreme Court sustain the government, in 1942, when it sought to bar Roscoe Filburn, a farmer in Ohio, from setting aside a portion of the wheat he was growing on his own farm for the use of his own family (Wickard v. Filburn). As the urbane Justice Robert Jackson explained, if every farmer claimed the right to do that, those many private acts, aggregated, could undermine a scheme that required the regulation of the national production of wheat.

The problem for conservatives is that even the jurists they most admire, such as Justice Scalia and the late Chief Justice Rehnquist, have shown their conservatism by their willingness to honor the precedents long settled by their liberal predecessors. And so, only a few years ago, Scalia was willing to invoke again this understanding—long settled among liberal judges—to explain why the federal regulation of controlled substances could not permit people in California to grow marijuana in their own gardens for their own private use.

Some of our most accomplished lawyers have sought to argue that Obamacare represents “a bridge too far”—that if the federal government can manage the access of individuals to their medical care, there is virtually no limit to what it can do, either in exercising every power now exercised by local governments or deeply invading the zone of personal freedom. But whether or not these lawyers notice it, they have come to argue within the same terms that judges have come to use and accept—and embed—in the law of the Commerce Clause. And as they do that, they may be deflecting themselves from the most powerful arguments against Obamacare, the arguments that run to the root of the law in “natural rights.”

We now find some of our best jural minds trying to concentrate their outrage on the moral problem at the center of this political takeover of medical care, and they reach the thunderous conclusion that with Obamacare we are—gasp—going to be compelled to buy something. Buy a product, buy a service, we have no interest in buying. The service is that of medical insurance offered by private companies.

The rationale of the act is to make sure that the medical care of every person is funded, and to cover the wave of costs that come about when hospitals are compelled to take in every person who shows up in an emergency room and insurance companies are barred from refusing to insure people who come with “pre-existing conditions.” The poor and the sick are mainly exempted from expense, and so the costs will be covered by compelling the purchase of a privately sold product by healthy, often young, people who have been unwilling to purchase the insurance. The scheme of legal compulsion is justified by the claim that it will serve, in the aggregate, the health of the public.

The counter-argument has been that many other products may plausibly serve the public health, and so people could be compelled, perhaps, to purchase broccoli or electric cars. These arguments have been made widely, but they have rarely been brought together as powerfully as they were by Judges Joel Dubina and Frank Hull of the United States Court of Appeals for the Eleventh Circuit this past August when they struck down this mandate to buy a privately sold service. “Few powers, if any, could be more attractive to Congress than compelling the purchase of certain products,” they wrote in Florida v. Health and Human Services, and yet even in the modern era Congress had not asserted this authority:

Even in the face of a Great Depression, a World War, a Cold War, recessions, oil shocks, inflation, and unemployment, Congress never sought to require the purchase of wheat or war bonds, force a higher savings rate or greater consumption of American goods, or require every American to purchase a more fuel efficient vehicle. . . . The government’s position amounts to an argument that the mere fact of an individual’s existence substantially affects interstate commerce, and therefore Congress may regulate them at every point of their life. This theory affords no limiting principles in which to confine Congress’s enumerated power.

For all we know, that argument may work. It may persuade five justices on the Supreme Court as it has persuaded some judges in some of the lower courts, and if it does, I for one will be grateful for the result. And yet . . . we need to remind ourselves that this same argument could have been made against the Civil Rights Act of 1964. The federal government had penetrated deeply into the ordering and regulation of the private sphere. It told people who were quite unwilling to have commerce with black people that they had to engage with those black people if they wished to stay in business. . .

Hadley Arkes, a member of First Things’ advisory council, is the Ney Professor in American Institutions at Amherst College.

Read the entire article at www.firstthings.com/article/2011/11/natural-rights-trump-obamacare-or-should

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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: The Medical Myth of providing improve access to care is gluttonous

Please see Medical Myths in the next section on how government directed health care has led to gluttonous behavior in many instances. The lack of understanding of medical costs has increased costs of care dramatically. This does not apply to all Medicaid patients but has been the experience of a large number of additions to our panel.

The Medicaid patient will spend considerable time repeatedly calling the office with the same question or problem. Approximately one-third will miss their initial one-hour appointment. They are unable to comprehend that missing an appointment of one hours’ duration is one hour of overhead they have cost the doctor who has to pay rent, staff and overhead during this income drop to zero. A Medicaid patient will generally take 50 percent longer or twice as long to interview and treat. Read more . . .

They are generally more expensive to treat being more demanding of lab tests, x-rays, and especially of MRIs. This may not be their fault. They have perceived themselves as so grossly deprived of healthcare that they are trying to compensate without knowing the norm.

Medicaid patients, even if camouflaged as HMO, generally request the newest drugs they’ve seen on TV not understanding that these are the newest and therefore the most expensive and not available to them; not understanding that many of them are not available to others in the same HMO. It will take at least twice as long to find a drug that will be paid by their minimal coverage plan as they think they are now first class patients. They have not had to deal with the limitations of the HMO patients which they have been led to believe is the highest rung of the healthcare ladder rather than the lowest rung.

What a rude awakening. It is unfortunate that this awakening couldn’t have occurred in the politicians’ office rather than the doctor’s office.

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Medical Gluttony thrives in Government and Health Insurance Programs.

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

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6. Medical Myths: Putting Medicaid patients into HMOs will improve their access to care.

A recent push to place all Medicaid patients into HMOs, presumably to give them better access to care has back fired. Doctor groups were asked to accept these welfare patients on the basis of being in an improved group of patient population and with this “premium” status would have better access to more physicians. The physicians were enticed to accept this on the basis of improved reimbursements to HMO rates from Medicaid rates. Read more . . .

After servicing several hundred of these transfers and not seeing any change in revenue, we asked our representative when this increase would occur. She told us it was already being paid at a 10 percent premium. And she was right; our follow up office visit had already increased from the usual $18 payment to $19.80. That dollar and eighty should really help doctors with all their financial struggles.

Most of these Medicaid or Welfare patients don’t have jobs. Yet they all have cell phones. To celebrate their new status they began calling their new personal physicians with the derogatory PCP. Don’t “private” patients have access 24 hours a day?

In the past, we would have two or three messages on our phone upon arrival in the mornings. It would take my office manager 10 or 15 minutes to process these several calls which might require calling the patient to make the requested appointment, to leave a message or other medical request. She could then get on with her daily work.

Immediately after four or five hundred patients were transferred into our panel, there were 45 or 50 phone messages on arrival in the office. Nonworking patients with cell phones were leaving voice mail all through the night. Many talked at length leaving rambling messages. My office manager would be busy for one to two hours just to take the messages. Thereafter, she had to spend three to five hours processing all these calls, not only to make appointments but explaining to medically unsophisticated patients that referrals to other specialties would first require a visit to our office. For instance, they thought that only neurologists could evaluate neurologic diseases or orthopedic surgeons could evaluate orthopedic problems. They didn’t understand that any doctor can do a complete neurologic or a complete orthopedic exam which is required to find a neurologic or orthopedic problem to document the need and then of such severity that a neurologist or orthopedist is required.

On trying to illustrate this to patients, we would talk out loud as we progress in our examination through the head, eyes, ears, nose, throat, neck, chest, heart, abdomen and extremity exam. We placed special emphasis when proceeding to the neurologic exam and mentioning out loud that your cranial nerves, motor, sensory, reflex, and coordination exams were all intact. And we would do the same with the orthopedic exam as we went through the range of motions of the spine, neck, peripheral and proximal joints and then explain that “your orthopedic exam” is quite normal. The patient may still reiterate that they would like to see an orthopedist for their back. We then have to re-explain that the back examination has the full 90 degrees of flexion, 30 degrees of extension, 30 degrees of lateral flexion and 45 degrees of rotation. The straight leg raising exam is normal and there was no tenderness over any joint or vertebrae. This effectively eliminates the possibility of having herniated protruding disc. “But you haven’t done an MRI yet and that’s what I want.”

It takes time to explained to the medical non-sophisticate that there has to be findings in any organ system before you can justify sending them to an organ system specialist. To begin to explain that 1) the subspecialist does not appreciate being sent non problems in their specialty; 2) to try to explain cost of care is never well received. You’re just not doing it because of my insurance. They can’t conceive that for every extra specialist involve in one’s care, healthcare and cost of insurance essentially doubles.

Many of these patients don’t understand why we can’t find on occasion a sub-specialist to see them. Recently we had a complicated skin condition that didn’t respond to the usual treatment. On checking with the HMO, there was not a single Dermatologist in Sacramento, a city with a million people in the greater area and it was suggested we send this patient to San Francisco, 120 miles away where there was a Dermatologist that would see an HMO-Medicaid combination.

Is this the care that Obama considers as being accessible? Or is he another medical illiterate who doesn’t understand healthcare? If someone were to explain it to him, would Obama understand? Or would he pass another law to force every doctor to accept any patient that presents himself to the doctor?

Socialized medicine has not improved access to care in socialized countries. Otherwise why would we continue to read about the three-, six- , 12- , or 18-months waiting list to obtain care with a specialist in countries of Europe which has the most sophisticated socialize medicine systems?

Government medicine has not and cannot improve health care in any of its aspects. Socialist cannot learn. Socialists cannot understand facts. Socialists cannot learn from facts. Socialists cannot learn from failure. Socialists cannot understand limits. Socialists cannot understand the wide variability in healthcare costs. It would be easier and more cost effective to give every American a car which has a price which generally will have less than a 10 percent variation from one dealership to another. The cost of health care has more than a ten-fold variation from one hospital to another with a different staff. It is the most illogical and unpredictable entitlement that can be imagined. With this huge variation, the government of necessity has to get intimately involved in our private lives, which now has included sexual activity to prevent procreation. When is enough, enough?

There is increasing evidence that privatizing health care with a deductible on every service will reduce health care costs in half without any loss of quality of care. This is continually being demonstrated by the practitioners that don’t accept insurance and essentially lower their office visits to about half their previous level. This cutting cost in half has improved access to care for private patients and has increase the physicians’ income by eliminating their business office and all billing which then eliminates all collection costs and reduces personnel. The High Deductible Medical Insurance Plans (HDHP) has shown even greater reductions in cost.

Why are our politicians and socialists blind to this reality? Maybe they aren’t blind. They just want to control healthcare which allows them to control people. It took 150 years to develop our system of freedom and democracy. It will take the socialists less than 75 years to enslave all of us again. We are in the final five years of that reversal of fortune unless we change the occupant in the White House this year.

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Putting Medicaid patients into HMOs has not improved their care or access to care.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

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7. Overheard in the Medical Staff Lounge: The next occupant for the White House

Dr. Rosen: Looks like we’re winding down the primaries for who is going to run against President Obama.

Dr. Milton: They are not coming out as we had hoped. Read more . . .

Dr. Edwards: We were hoping for a true conservative.

Dr. Ruth: Maybe that was too much to hope for.

Dr. Dave: I guess I’m mellowing also. I said I would never vote for Romney. But that is the choice we’re left with. I certainly can’t vote for the Anti-American Socialist that occupies the White House at this time.

Dr. Paul: I guess I’ll be the only one from our group that will vote for the current occupant in the White House.

Dr. Michelle: I think the primaries have turned out for the best. There was considerable disorder for many months. But I think the strongest candidate won.

Dr. Rosen: I have to agree with Michelle. The disorder is resolved. Again not to my liking. But, with all things being unequal, it’s as good as we’re doing to get. I still would like to see Mitt apologize for his Massachusetts mistake.

Dr. Paul: Massachusetts was not a mistake. And he won’t apologize for what he still deems a success.

Dr. Rosen: That he still feels Massachusetts was a success and the Obama Plan was patterned after his Massachusetts plan, makes me concerned that he could support the Obama Plan and hurt the American people even worse. But then I’m now convinced that Santorum could not have won in November.

Dr. Paul: Which is the reason I never spoke against him. With Romney we’ll have a battle to keep the current occupant in the White House another term.

Dr. Edwards: But I think we can win with Romney.

Dr. Rosen: We have to. We have no other choice.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8. Voices of Medicine: Inside Medicine – The Sacramento BEE

Inside Medicine: Doctors are often in the dark about costs

By Michael Wilkes, M.D.

Commercial Internet sites have some important lessons to offer for the practice of medicine.

When shopping online, each time you select an item for purchase – say from Amazon or Lands' End – you place the item in an electronic shopping cart. As you go along, you can monitor the total for your purchase. If the cost is too high, you can eliminate an item or two. You are informed of your cost as you shop.

Robert Brook, a scholar at RAND and one of the nation's great health policy thinkers, wrote recently that a major problem with American medicine is that there are no real attempts to reduce health care costs or even make doctors aware of costs. There is no "shopping cart total."

Brook points out that increasing numbers of doctors are using computers to write their notes, order lab tests and prescribe medications. Yet they are provided absolutely no information on the charge of the items. In fact, it is nearly impossible for doctors to find the charges for items we order every day. Read more . . .

Car makers, computer companies and construction firms use the power of computers to cut costs and improve value. Doctors do none of this.

In factory purchasing departments and in private homes, people regularly compare similar products by cost and quality across different websites. Why can't doctors look at antidepressants or pain relievers and compare the cost, the quality or the side effects in a side-by-side comparison?

We can look at what other people's experiences are with a hotel, a restaurant or even a doctor. Why can't we look at doctors' or patients' reviews of different drugs, lab tests or X-rays?

Would knowing the price or quality make a difference to doctors?

Based on some studies, it probably would. Brook points to one study where doctors merely were provided with documentation of their weekly costs of laboratory services. Over the 11-week study, lab orders decreased, saving tens of thousands of dollars. Providing costs to doctors would also allow us to compare ourselves with similar doctors to see how expensive our care is. Knowing costs, our computers could suggest other treatment or testing options that are effective but less costly.

As an example, doctors could get running totals (in their shopping cart) that would reveal how much it costs when they order a temperature or blood pressure every hour compared with every four hours.

Brook believes price awareness will make a difference to both doctors and patients.

Many private practitioners who accept only cash – what we often call docs in a box – already post prices for lab tests and procedures, thus allowing patients to decide how much they are willing to pay – a bit like the Web shopping cart.

Hospitals and clinics clearly know the costs of these tests, yet they shield doctors from this information. One can't help wondering why such information is not available in the electronic medical record.

Perhaps if doctors knew the prices, test ordering would decrease and hospital profits would also drop. Is there any other explanation?

www.sacbee.com/2012/05/10/4478277/doctors-are-often-in-the-dark.html#storylink=cpy

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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: Why We Get Fat: And What to Do About It, by Gary Taubes, 272 pages, Knopf

Questioning the Obesity Paradigm

Deborah Donlon, MD

Sonoma Medicine Volume 63, Number 2 - Spring 2012

As physicians, we think we know what causes obesity. Eating too much. Exercising too little. Sedentary jobs and leisure activities. Soda, chips, channel surfing and junk-food advertising. We counsel our patients to eat less and move more. I confess I am skeptical when an obese patient tells me she “eats tiny portions” and “exercises all the time.” Based on what I learned in medical school about calories consumed versus calories expended, this just can’t be true. Read more . . .

Or can it? In his book, Why We Get Fat: And What to Do About It, Gary Taubes argues against the prevailing wisdom about what causes people to gain weight. Over 10 years ago, bestselling author Taubes found that he continued to gain weight despite exercising regularly and restricting both caloric intake and fat consumption. As a self-identified carnivore, he started himself on an Atkins-like diet consisting of animal protein, healthy fats and vegetables--and lost 20 pounds in six weeks. He has maintained his weight loss by staying on the diet, and has spent the past decade researching the connection between specific foods we eat and their effect on our weight. (He is also the author of Good Calories, Bad Calories, a highly technical tome less accessible to the lay public than his current book.)

In Why We Get Fat, Taubes challenges widely held beliefs. For example, we tend to think that obesity is caused by affluence and abundance, or having “too much of a good thing.” We think that wealth, including the ability to buy machines to do work for us and transport us, is what is making us fat. Taubes turns this belief around by highlighting the historical connection between obesity and poverty. The Pima Indians became increasingly obese during a period of economic decline and famine. The poorest Americans during the Great Depression were those most likely to be obese. Today, people who live in poverty and are employed in physically demanding jobs have a high rate of obesity, as well as malnutrition. Under Taubes’ examination, the paradigm connecting obesity to too much food and too little activity begins to weaken.

Taubes follows his history lessons with two fairly discouraging chapters titled “The elusive benefits of undereating” and “The elusive benefits of exercise.” Prior to the 1970s, he observes, low-calorie diets were referred to as “semi-starvation diets,” the idea being that people would have great difficulty following such a regimen for a couple of months, let alone permanently. Well-controlled studies, according to Taubes, have failed to show a connection between calorie restriction and sustained weight loss. And vigorous exercise, while having numerous health benefits, leads to hunger and increased caloric intake. This fact limits the utility of exercise as a weight-loss strategy. Nonetheless, despite the lack of evidence for calorie restriction and exercise, the multibillion-dollar diet industry continues to promote these behavior changes for weight loss--and profits from our failures.

For Taubes, “why we get fat” turns out to be a complex interplay between genetics, diet and lipid metabolism. Those looking for a crash course in thermodynamics will be pleased to find one in his book. Basically, the more fat cells we have in our bodies, the more those fat cells drive us to eat and the more energy they rob from other cellular functions in the body. “What to do about it” requires identifying a villain that we should avoid in our diets. Taubes’ villain is the carbohydrate, which drives insulin secretion, which drives energy storage in fat cells. According to Taubes, the more carbohydrates we consume, the more we crave, and the fatter we become. The same carbohydrates zap our energy and leave us unmotivated to exercise. So, our fat cells from excess carbohydrate intake turn us into couch potatoes, rather than the other way around. The last chapter of Taubes’ book offers a nutritional program in which carbohydrates are essentially eliminated in favor of animal protein, vegetables and fats.

In the arena of weight-loss research, every argument has a counter-argument. One of those taking a contrary view to Taubes is local physician Dr. John McDougall, whose new book The Starch Solution will be published in May. According to McDougall, animal products are what should be limited in the American diet. He recommends a low-fat, vegan diet that includes liberal quantities of starches such as rice, beans and potatoes. . .

Dr. Donlon, a Santa Rosa family physician, chairs the SCMA Editorial Board.

Read the entire book review at Sonoma Medicine . . .

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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: Preventing Free Trade in HealthCare – is what enemies to do us in war

From "Protection or Free Trade" (1886) by Henry George:

Trade does not require force. Free trade consists simply in letting people buy and sell as they want to buy and sell. It is protection that requires force, for it consists in preventing people from doing what they want to do. Protective tariffs are as much applications of force as are blockading squadrons, and their object is the same—to prevent trade. The difference between the two is that blockading squadrons are a means whereby nations seek to prevent their enemies from trading; protective tariffs are a means whereby nations attempt to prevent their own people from trading. What protection teaches us, is to do to ourselves in time of peace what enemies seek to do to us in time of war. Read more . . .

A version of this article appeared April 7, 2012, on page A15 in some U.S. editions of The Wall Street Journal, with the headline: Notable & Quotable.

Osama’s strategy for Obama

Scholars at West Point as part of the large Osama bin Laden trove noted the late terrorist advocated the killing of Barack Obama so that Vice President Biden would assume the presidency . . . “which will lead the U. S. into a crisis.” —How did he know that Joe was so “utterly unprepared?”

Think Health-Care costs are out of control?

Try paying for a university degree. In the past 25 years, while healthcare costs have risen 250 percent, higher education costs have skyrocketed 450 percent, according to the National Center for Public Policy and Higher Education. Two professors, (Daphne Koller and Andrew Ng) who both teach computer science at Stanford, have launched Coursera, which will make course from tops-tier universities available online, at no charge to anyone. . . So far they’ve signed up volunteer professors from Stanford, Princeton, University of Michigan, and University of Pennsylvania. . . These aren’t just videotaped lectures; they’re full courses, with homework, assignments, examinations, and grades. . . “What we’re hoping to do is provide the technology to enable a university . . . to offer an education not just to hundreds or thousands of students, but to millions,” Koller said.

–Universities, did you hear that: Homework! Assignments! Examinations! And Grades!

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

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

• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports.

• Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog.

• The Mercatus Center at George Mason University (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. Join the Mercatus Center for Excellence in Government.

• To read the rest of this column, please go to www.medicaltuesday.net/org.asp.

• The National Association of Health Underwriters, 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. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

• 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 on at www.galen.org. A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels.

• Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

• The Heartland Institute, www.heartland.org, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?

• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. Be sure to read the current lesson on Economic Education.

• The Council for Affordable Health Insurance, 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 . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

• The Independence Institute, 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.

• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at 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.

• 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. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section.

• The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission was 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. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, and was used by some as a justification for the Obama plan, they have lost sight of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions. We would also caution that should Mitt Romney ever run for National office again, he would be dangerous in the cause of freedom in health care. The WSJ paints him as being to the left of Barrack Hussein Obama. We would also advise Steve Forbes to disassociate himself from this institution.

• 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 www.mises.org to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

• CATO. The Cato Institute (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 laid 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. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at www.cato.org/people/cannon.html.

• The Ethan Allen Institute, www.ethanallen.org/index2.html, 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.

• The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

• McLauren Institute MacLaurinCSF is a community of students, scholars, and thinkers working together to explore and understand the implications of the Christian faith for every field of study and every aspect of life.* Our Mission: MacLaurinCSF bridges church and university in the Twin Cities metropolitan area, bringing theological resources to the university and academic resources to the church. Our goal is to strengthen Christian intellectual life in this region by creating public space for leaders in the academy and church to address enduring human questions together. MacLaurinCSF is grounded in the Christian tradition as articulated in Scripture and summarized by the Apostles’ and Nicene creeds, and our conversations are open to all.

• The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.

• Chapman University: Chapman University, founded in 1861, is one of the oldest, most prestigious private universities in California. Chapman's picturesque campus is located in the heart of Orange County – one of the nation's most exciting centers of arts, business, science and technology – and draws outstanding students from across the United States and around the world. Known for its blend of liberal arts and professional programs, Chapman University encompasses seven schools and colleges: The university's mission is to provide personalized education of distinction that leads to inquiring, ethical and productive lives as global citizens.

• 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. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17^th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. 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. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month Choose recent issues. The last ten years of Imprimis are archived.

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Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

Words of Wisdom

A liberal is someone who feels a great debt to society, which he proposes to pay off with your money. –G. Gordon Liddy

We contend that for a nation to try to tax itself into prosperity is like a man standing in a bucket and trying to lift himself up by the handle. –Winston Churchill

A government which robs Peter to pay Paul can always depend on the support of Paul. –George Bernard Shaw

Recent Postings

In The Last Issue:

1. Featured Article: Politicized clinical medicine spins down to a zero sum budget reality.

2. In the News: How California's Colleges Indoctrinate Students

3. International Medicine: Why does politics always interfere with health care?

4. Medicare: Sutter Health estimates they will lose $2 billion in Medicare Reimbursements

5. Medical Gluttony: Cruel and Unusual Punishment

6. Medical Myths: The Myths of Solar Energy

7. Overheard in the Medical Lounge: Are we any further along in the November elections?

8. Voices of Medicine: Hard Truths About Life & Death Choices in My Own Family

9. The Bookshelf: The Righteous Mind – Why Good People are Divided by Politics and Religion

10. Hippocrates & His Kin: Inconvenient Truths

In Memoriam

Lyn Lusi, healer of Congo, died on March 17th, aged 62

The Economist |from the print edition | Mar 31st 2012

“DARKNESS” was a word Lyn Lusi was used to. Western journalists instinctively reached for it when they came to her hospital in Goma in the Democratic Republic of Congo, in Joseph Conrad’s “heart of darkness”. Goma itself was a black and grey place, a town built on volcanic basalt tough as broken glass through which green shoots struggled to grow. She knew; she gardened in it. But the real heart of darkness, Mrs. Lusi would say quietly, was man’s heart. Read more . . . .

The proof lay all about her. Congo was a rich country, but its minerals were swapped by local strongmen for weapons, or stripped away by corporations who left the people in poverty. It was ostensibly at peace, after years of warfare in which millions had died. But remnants of militias still haunted the forests, preying on the villages. So much evil. So much selfishness.

In this vast, damaged, neglected place her husband Jo, a Congolese and, like her, an ardent Baptist, was the only orthopaedic surgeon for 8m people. He alone had the skill to mend the crushed arms, the crooked feet. Irrepressible as he was, bubbling over with plans, he often used the image of a little bucket bailing out an ocean. She preferred the words of Isaiah 61:1: “The Lord hath sent me…to bind up the brokenhearted.”

Their hospital at Goma had been set up in 2000 to train young Congolese doctors. Two years later the building was destroyed by a volcano; they built it again, low brightly painted buildings behind battered metal gates, and called it HEAL Africa. By 2011 they had trained 30 doctors there, often with the help of students from American medical schools. Yet the hospital became most famous for something different. Hundreds of the patients were women with genital fistulas, or tears: some caused by childbirth, but a startling number the result of rape by militiamen.

This, too, was hidden in darkness. Mrs. Lusi was unaware of it until 2002, when a sobbing young woman came to her office. She realised then that horrific sexual violence was taking place in every village round Goma. Women working in the fields, or girls as young as five walking back from the market, would be abducted and raped repeatedly. Sticks and guns were forced into their vaginas. Sometimes the guns were fired. The brutalised victims, once home, would often be disowned by their families.

Over almost a decade HEAL Africa treated 4,800 such cases. The women would arrive in buses, traumatised after travelling for hours and stinking with the urine and faeces that leaked from their injuries. At the hospital, energetic local “Mamas” recruited by Mrs. Lusi would welcome them and wrap them in their arms. “Love in action”, she called it, and she too was “Mama Lyn” to everybody there. . .

Read the entire obituary in the Economist . . .

On This Date in History - April 10, 2012

On this date in 1790, the first US Patent law was approved. Inventions could now be protected against piracy. Nobody has a patent on honesty, but a property right to the results of human inventiveness and ingenuity is one of the things that has helped build this nation.

On this date in 1866, enlightened New Yorkers got a charter for a new organization called the American Society for Prevention of Cruelty to Animals. Despite the fact that humans have had a love affair with domestic animals is an old one, the fact is that mistreatment of animals, particularly cart horses and beasts of burden, and was so commonplace that it wasn’t even regarded as being particularly cruel.

On this date in 1945, Buchenwald’s Horror was discovered. Three quarters of a century after the birth of a movement to stop cruelty toward animals, the victorious Allies in World War II came upon the horror of the concentrations camps run by the Nazis at Buchenwald, Germany. In the concentration camps were found piles of corpses, as well as the living skeletons who survived, crematoria, gas chambers, paraphernalia which made the Middle Ages look like kindergarten. On this day, civilization discovered that barbarism was more barbaric than ever. And even today, we are discovering in the Middle East, as well as portions of Eastern Europe and Africa, that people are still barbaric?

After Leonard and Thelma Spinrad

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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, any single payer initiative, Social Security was born for the benefit of the state and of a contemptuous disregard for people’s welfare.

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.

MEDICAL TUESDAY . NET	NEWSLETTER
Community For Better Health Care	Vol XI, No 1, April 10, 2012