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

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In This Issue:
1. The Uninsured Go to India for Heart Surgery
2. The Relationship of Adverse Childhood Experiences to Adult Health
3. Fortis Healthcare Expanding its Network of Hospitals Across North India
4. Government Medicine: Health and Poverty
5. Medical Gluttony: If My Flu Shot Isn't Free, I Won't Get One
6. Medical Myths About Poverty
7. Overheard in the Medical Staff Lounge: Did You Hear The Debate Last Night?
8. The MedicalTuesday Recommendations for Restoring Accountability in HealthCare & Government
 

The Adverse Childhood Experiences Study (ACE Study http://www.acestudy.org/) is an outgrowth of observations made in the mid 1980s of an obesity program that had a high dropout rate. The first of many unexpected discoveries was that the majority of the dropouts actually were successfully losing weight. Accidentally, and to our surprise, we learned from detailed life interviews of 186 such individuals that childhood sexual abuse was remarkably common and, if present, always antedate the onset of their obesity. Some told of instances where they had brought up their history of abuse only to have the information rejected by a physician as being in the distant past and hence of no relevance to current problems.

The counterintuitive aspect was that, for many people, obesity was not their problem; it was their protective solution to problems that previously had never been acknowledged. An early insight was the remark of a woman who was raped at age twenty-three and gained 105 pounds in the subsequent year: "Overweight is overlooked and that's the way I need to be." The contrast was striking between this statement and her desire to lose weight. Many patients were driving with one foot on the brakes and one on the gas, wanting to lose weight but fearful of the change in social and sexual expectations that would be brought about by major weight loss.

The 26,000 consecutive adults coming through the Department were asked if they would be interested in helping understand how childhood events might affect adult health status. Seventy-one percent agreed. These volunteers were asked how many ACE events they were exposed to.

Adverse Childhood Experiences (ACEs) are defined as growing up (prior to age 18) in a household with:
    * Recurrent physical abuse.
    * Recurrent emotional abuse.
    * Sexual abuse.
    * An alcohol or drug abuser.
    * An incarcerated household member.
    * Someone who is chronically depressed, suicidal, institutionalized or mentally ill.
    * Mother being treated violently.
    * One or no biological parents.
    * Emotional or physical neglect.

An individual exposed to none of these categories had an ACE Score of 0; an individual exposed to any four had an ACE Score of 4, etc. The two most important findings are that these adverse childhood experiences:

    * are vastly more common than recognized or acknowledged and
    * have a powerful relation to adult health a half-century later.

One in four were exposed to two categories of adverse experiences; one in 16 were exposed to four categories. Given an exposure to one category, there is an 80 percent likelihood of exposure to another category.

Compared to a person with an ACE Score 0, one with an ACE Score of 4 is 260 percent more likely to have COPD, 240 percent more likely to have hepatitis; 250 percent more likely to contract a sexually transmitted disease. A male child with an ACE Score of 6 has a 4,600 percent increase in the likelihood of later becoming an IV drug user.

The same correlation also occurred with emotional disorders. Compared to individuals with an ACE Score of 0, those with an ACE Score of 4 or more were 460 percent more likely to be suffering from depression and 1,220 percent more likely to attempt suicide (increasing to 3,000-5,100 percent with higher ACE Scores).

The Kaiser study found that 22 percent of their members were sexually abused as children. How does that affect a person later in life? How does it show up in the doctor's office? What does it mean that sexual abuse is never spoke of?
Dr Felitti asks what is this hypertensive, diabetic old woman's diagnosis? He conceptualizes the problem this way:

Childhood sexual abuse
     Chronic depression
         Morbid obesity
               Diabetes Mellitus
               Hypertension
               Hyperlipidemia
                    Coronary artery disease
Macular degeneration
Psoriasis

Dr Felitti concluded: This is not a comfortable diagnostic formulation because it points out that our attention is typically focused on tertiary consequences, far down stream. It reveals that the primary issues are well protected by social convention and taboo. It points out that we physicians have limited ourselves to the small part of the problem. where we are comfortable as mere prescribers of medication. Which diagnostic choice shall we make? Who shall make it? And, if not now, when?

The full text of their initial report is at http://www.meddevel.com/site.mash?left=/library.exe&m1=4&m2=&right=/library.exe&action=search_form&search.mode=simple&site=AJPM&jcode=AMEPRE.

The implications for patient care are limitless. We have focused on the diagnosis farthest to the right, omitting the primary root causes that occur decades earlier. Except for staff models, HMOs such as Kaiser, managed care, government medicine, and insurance in general will afford little coverage or reasonable solution to the problem.

The company is focusing on increasing its capacity to 4,000 beds in 10 hospitals, up from the existing 600 beds in four hospitals. As part of this initiative, Fortis will be setting up a medi-city in the footsteps of John Hopkins Medical Centre at Gurgaon in Haryana. Called Fortis International Institute of Medical and Biosciences (FIIMBS), it will house a medical college, an attached hospital, other allied sciences institute and a referral centre among other facilities.

The hospital chain is also planning to get international patients to come here for treatment. "We are thinking of commencing discussions with the UK's National Health Service or any other body to send patients over to India. We have not yet initiated this or sewed up any deals," said Mr Harpal Singh, Chairman and Managing Director of the company.

To read the entire article about Fortis Healthcare moving into in the pharma industry, the healthcare services sector, the pathological labs business and the health insurance sector go to http://www.thehindubusinessline.com/2004/08/06/stories/2004080602380200.htm.

What always seems to be ignored is that there are more Americans with various problems in part because there are more Americans. True, the Census Bureau reported yesterday that, by its methodology (more on that in a moment), there was a record total of 45 million Americans without health insurance for part of 2003.

But the total number of people with insurance also rose by one million to 243.3 million. Or to put it yet another way, while there are three million more people uninsured in 2003 than in 1996, the percentage of uninsured Americans was exactly the same at 15.6 percent. That's lower than it was in 1997 and 1998 and within the same range it's been for the past decade.
Ready for more surprising news? The actual number of uninsured may be a third less than the Census figures claim, while another third of the uninsured appear to be wealthy enough to afford coverage.

How do we figure? Let's start with the fact that the Census Bureau counts individuals who are eligible for Medicaid and the State Children's Health Insurance Program (or S-CHIP) but not enrolled as uninsured. This way of counting doesn't make much sense since these individuals can enroll and have their expenses covered if and when they require health care.

In fact, John Kerry's health proposals single out this group for special attention, with his campaign literature noting, "Today, there are millions of uninsured children who are eligible for health care coverage under Medicaid or S-CHIP but are not enrolled." The hard truth is that making special efforts to enroll these people, as Mr. Kerry proposes, would make no actual difference in the number of people with access to health care.

And how many children and adult "eligibles" are there? Based on a review of the literature, Devon Herrick of the National Center for Policy Analysis estimates as many as 14 million. That figure seems quite possible given that the Census Bureau finds more than 15 million "uninsured" individuals eligible for assistance in households with less than $25,000 in income.

And what about the "wealthy" uninsured? The Census data for 2003 show almost 15 million uninsured people in households with incomes above $50,000 (7.6 million of them in households over $75,000). That's hardly rich, but it's enough to afford coverage in most states if individuals treat health care with the priority it deserves.

Finally, another 18.8 million of the uninsured are between the ages of 18 and 34, and many of them voluntarily (if unwisely) forgo coverage. Their gamble is actually encouraged by "guaranteed issue" laws in many states that reassure the irresponsible that they can avoid buying insurance until they get sick. This defeats the whole point of insurance, which is to pay into a pool when you're healthy so you can be covered when you do get sick. A young person who thinks he'll live forever is especially inclined to spend his marginal income on something other than health insurance if he knows he can buy it when he really needs it.

We don't deny that there are people having genuine difficulties in obtaining health insurance. But there are a lot fewer than 45 million of them. The Congressional Budget Office estimated earlier this year that the number of those actually uninsured for the entire year is between 21.1 and 31.1 million. Perhaps the best proxy for who's really in need are the 14.8 million uninsured who the Census lists in households between $25,000 and $49,000 in annual income.

States like New York could do a lot for this group  by merely getting rid of insurance regulations that make a basic policy roughly 10 times more expensive than in neighboring Connecticut. Better still, Congress could save poor New Yorkers from the tyranny of Albany by putting an end to our Balkanized and anachronistic 50-state insurance market and simply decreeing that there shall be nationwide commerce in health insurance. They could then buy policies issued in saner states or over the Internet. Equalizing the tax treatment for employer-purchased and individually-purchased health care, as President Bush proposes to do, is another good step.

Election-year opportunism aside, the Census numbers are actually better news than advertised. An honest review of the numbers shows no crisis of un-insurance in America, and certainly no need to dump more health-care costs and services onto businesses and taxpayers.

Source: Wall Street Journal, REVIEW & OUTLOOK, August 27, 2004; Page A12

Mr. Melloan writes that "only 12.1% of families were below the poverty line in 2002, compared to 22.2% in 1960." One might add that more than 30 percent were considered impoverished in 1940, something hard to visualize today. And many of the "poor" today have more goods and conveniences than the middle class had 50 years ago due to technology and social advances. The concept of poor is relative.

The official poverty rate has bottomed out and fluctuated around 12 percent to15 percent since 1970, due primarily to a steady inflow of poor immigrants and, perhaps more importantly, basing the official definition of poverty on income falling below a defined level at the time of sampling. Recent data show that 80 percent of those defined as experiencing poverty are there for no more than one year. Therefore, only about 2.5 percent can be considered long-term, core poverty cases; the large majority are simply temporarily out of work.

Playa del Rey, Calif, August 27, 2004; Page A13
 

Citizen:             What would we need jobs for?
                                                                                                                       (After Parker & Hart: 10-12-04)
 

• 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. The Mercatus Center has released The Millennium Challenge Account (MCA): Property Rights and Entrepreneurship as the Engine of Development which offers much promise for a new direction in international assistance to less developed countries. With a focus on results, the MCA promises to help those countries that have demonstrated a commitment to Economic Freedom, Ruling Justly, and Investing in People, along the path to prosperity. See http://www.mercatus.org/globalprosperity/subcategory.php/205.html?menuid=3.

• The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging onto their website at www.galen.org. We are hearing virtual panic among doctors worried that their patients won't be able to get a flu shot this year. Even some good free-market physicians have called for nationalization of the vaccine supply. She urges them to think again about the consequences of getting the government any more involved in the vaccine industry. To read the entire newsletters about the consequences, go to http://www.galen.org/pdrugs.asp?docID=700.

• Greg Scandlen, Director of the “Center for Consumer-Driven Health Care” at the Galen Institute, has a Weekly Health News Letter: Consumer Choice Matters. You may subscribe to this informative and well-outlined newsletter that is distributed every Tuesday by logging onto www.galen.org and clicking on Consumer Choice Matters. Archives are now located at http://www.galen.org/ccm_archives.asp. This is the flagship publication of Galen's new Center for Consumer-Driven Health Care and is written by its director, Greg Scandlen, an expert in Medical Savings Accounts (MSAs) which have became Health Savings Accounts (HSAs). This week read Greg’s discussion of the AHA critique of specialty hospitals at http://www.galen.org/ownins.asp?docID=695.

• The Heartland Institute, http://www.heartland.org, publishes the Health Care News, Conrad Meier, Managing Editor. The October issue of Health Care News carries an article by Sean Parnell titled: Specialty Surgical Hospitals Deliver Quality Care and Comfort. Known as specialty surgical hospitals, these facilities typically focus on a few areas of surgical practice, such as heart surgery or orthopedic surgery. They trace their roots to ambulatory surgical centers (ASCs), which started to appear roughly 30 years ago. An ASC is a facility whose patients are admitted, treated, and discharged within a single day. The ASCs developed slowly until 1982, when Medicare first approved them for reimbursement. From that point, growth has been rapid to the currently more than 3,500 ASCs in the U.S. From the ASCs developed modern specialty surgical hospitals. By focusing on a few surgical specialties, additional gains in efficiency and quality can be realized, this time in procedures that require an overnight stay or longer while the patient recovers. Medicare has placed an 18 month moratorium on these hospitals. The hospital associations want to make this ban permanent which Parnell says would be a terrible mistake. Read his entire article at http://www.heartland.org/Article.cfm?artId=15769.

• The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom’s Magazine, for over 50 years. Richard M Ebeling, PhD, is President, and Sheldon Richman is 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. This month we feature P. Gardner Goldsmith who describes a former urban-planner-turned-congresswoman who wants to subsidize Farmers Markets despite the fact that they are a thriving industry with an 80 percent growth rate. To read about another lawmaker leashing out to control an industry that is doing well on its own, go to http://www.fee.org/vnews.php?nid=6343.

• The Council for Affordable Health Insurance, http://www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. “The belief that more medical care means better medical care is deeply entrenched . . .  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.” This month read the Guide that Reveals How Elected Representatives Voted on Affordable Health Insurance at http://www.cahi.org/article.asp?id=431. Be sure to check on how your congressman and senator voted on key health-care issues.

• The Health Policy Fact Checkers is a great resource to check the facts for accuracy in reporting and can be accessed from the preceding CAHI site or at http://www.factcheckers.org/. This week look over the Rhetoric vs. Reality issues listed. After reading the Rhetoric, click on Reality to see the truth.

• 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 at http://www.i2i.org/healthcarecenter.aspx.  Read the latest OpEd articles for an alternate point of view of tobacco tax, renewable energy and other current issues at http://www.i2i.org/opeds.aspx.

• 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. This week, research the NAHU Voting Guide on issues of the candidates in your voting area by clicking on your state at http://www.nahu.org/government/Election_2004.htm.

• Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Québécois 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. This month, read the Flawed Doctrine of Nature's Intrinsic Value by Edward W. Younkins at http://www.quebecoislibre.org/04/041015-17.htm.

• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well-being of all Canadians. Log on at http://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 at http://www.fraserinstitute.ca/health/index.asp?snav=he. This week, read the  editorial: A Province Suffocated by Socialism. Saskatchewan is characterized by a larger government, higher tax rates, social ownership of capital (Crown Corporations) and heavier regulations. Next door is Alberta which has chosen to pursue a more market-oriented economy and is characterized by a smaller government and lower tax rates. Results for Albertans have been spectacular: higher incomes, more jobs, greater opportunities and a bright future. The results for Saskatchewanians, on the other hand, are dismal: The province continues to lose its young people and entrepreneurs to other provinces, chiefly Alberta; incomes are stagnating; and job creation is near non-existent. For Saskatchewan to turn the corner, it must undo 60 years of socialism and move aggressively towards a market-based economy. Read the whole editorial at  http://www.fraserinstitute.ca/shared/readmore1.asp?sNav=ed&id=306.

• The Heritage Foundation, http://www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. This week, be sure to read the analysis of the presidential candidates health plans: John Kerry at http://new.heritage.org/Research/HealthCare/bg1805.cfm and President Bush at http://new.heritage.org/Research/HealthCare/bg1804.cfm.

• The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we’ve seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation’s daily reports. Be sure to read Reducing Poverty by Reducing Government by George Reisman at http://www.mises.org/fullstory.aspx?Id=1647. To learn how state medicine subsidizes illness, see http://www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone would want to be an MD today, see http://www.lewrockwell.com/klassen/klassen46.html.

• CATO. The Cato Institute (www.cato.org) was founded in 1977 by Edward H. Crane with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens’ ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio at  http://www.cato.org/people/cannon.html. Read his current article Bush, Kerry Ignore What’s Ailing Health Care: Red Tape at  http://www.cato.org/research/articles/cannon-041018.html.

• The Ethan Allen Institute (http://www.ethanallen.org/index2.html) is one of some 41 similar but independent state organizations (click on "Links") associated with the State Policy Network (SPN) (http://www.spn.org/newsite/main/). 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.

• Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of “educating for liberty.” It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. You may log onto www.hillsdale.edu to register for the annual week-long von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, be sure to read the current issue of Imprimis by Victor Davis Hanson, Author, Between War and Peace: Lessons from Afghanistan to Iraq on "What Would Patton Say About the Present War?" http://www.hillsdale.edu/newimprimis/default.htm. The last ten years of Imprimis are archived at http://www.hillsdale.edu/imprimis/archives.htm.
 

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Del Meyer

Del Meyer, MD, CEO & Founder
DelMeyer@MedicalTuesday.net
www.MedicalTuesday.net
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Voltaire: The art of government consists of taking as much money as possible from one party of citizens to give to the other.

Placebo: Similar to a real drug and sometimes nearly as effective but it costs a lot less.

Michael Goodman, MD: Midlife Bible - A Woman’s Survival Guide - http://www.healthcarecom.net/bkrev_MidlifeBible.htm.

On this date in 1917, Lions International was founded in Dallas, Texas.