MEDICAL TUESDAY . NET

NEWSLETTER

Community For Better Health Care

Vol VIII, No 11, Oct 13, 2009

 

In This Issue:


1.                  Featured Article: Turbocharging the Brain

2.                  In the News: How the Waste was Won

3.                  International Medicine: Incompetency Starts at the Top

4.                  Medicare: Our $2 Trillion Bridge to Nowhere

5.                  Medical Gluttony: Hospitalists are only one step in usurping health care control.

6.                  Medical Myths: Universal coverage will achieve access and reduce costs.

7.                  Overheard in the Medical Staff Lounge: Congress Approval Ratings Slip to 21 percent

8.                  Voices of Medicine: America needs "Moore" Democracy

9.                  The Bookshelf: Taking Back Healthcare

10.              Hippocrates & His Kin: Are Health Care Costs Really Soaring?

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

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

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The Annual World Health Care Congress, a market of ideas, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. The third year it was about half, indicating open forums such as these are critically important. The 4th Annual World Health Congress was held April 22-24, 2007, in Washington, D.C. That year many of the world leaders in healthcare concluded that top down reforming of health care, whether by government or insurance carrier, is not and will not work. We have to get the physicians out of the trenches because reform will require physician involvement. The 5th Annual World Health Care Congress was held April 21-23, 2008, in Washington, D.C. Physicians were present on almost all the platforms and panels. However, it was the industry leaders that gave the most innovated mechanisms to bring health care spending under control. The 6th Annual World Health Care Congress was held April 14-16, 2009, in Washington, D.C. The solution to our health care problems is emerging at this ambitious Congress. The 5th Annual World Health Care Congress – Europe 2009, met in Brussels, May 23-15, 2009. The 7th Annual World Health Care Congress will be held April 12-14, 2010 in Washington D.C. For more information, visit www.worldcongress.com. The future is occurring NOW. 

To read our reports of the 2008 Congress, please go to the archives at www.medicaltuesday.net/archives.asp and click on June 10, 2008 and July 15, 2008 Newsletters.

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1.      Featured Article: Cognition Enhancing Drugs – Improving Memory, Attention, and Planning

Turbocharging the Brain; October 2009; Scientific American Magazine; by Gary Stix

The symbol H+ is the code sign used by some futurists to denote an enhanced version of humanity. The plus version of the human race would deploy a mix of advanced technologies, including stem cells, robotics, cognition enhancing drugs, and the like, to overcome basic mental and physical limitations.

The notion of enhancing mental functions by gulping down a pill that improves attention, memory and planning - the very foundations of cognition - is no longer just a fantasy shared by futurists. The 1990s, proclaimed the decade of the brain by President George H. W. Bush, has been followed by what might be labeled "the decade of the better brain."

Obsession with cognitive enhancers is evidenced in news articles hailing the arrival of what are variously called smart drugs, neuroenhancers, nootropics or even "Viagra for the brain." From this perspective, an era of enhancement has already arrived. College students routinely borrow a few pills from a friend's Ritalin prescription to pull an all-nighter. Software programmers on deadline or executives trying to maintain a mental edge gobble down modafinil, a newer generation of pick-me-ups. Devotees swear that the drugs do more than induce the wakefulness of a caramel macchiato, providing instead the laserlike focus needed to absorb the nuances of organic chemistry or explain the esoterica of collateralized debt obligations.

An era of enhancement may also be advanced by scientists and drugmakers laboring to translate research on the molecular basis of cognition into pharmaceuticals meant specifically to improve mental performance - mainly for people suffering from dementias. But a drug that works for Alzheimer's or Parkinson's patients might inevitably be prescribed by physicians far more broadly in an aging population with milder impairments. Widely publicized debates over the ethics of enhancement have reinforced the sense that pills able to improve cognition will one day be available to us all.

Academic and news articles have asked whether cognitive enhancers already give some students an unfair advantage when taking college entrance exams or whether employers would step over the line if they required ingestion of these chemicals to meet a company's production deadlines. . .

Ethical Dissonance

Arguments about safety, fairness and coercion aside, demand is indeed high for cognitive enhancers that are otherwise prescribed for conditions such as ADHD. Based on government data gathered in 2007, more than 1.6 million people in the U.S. had used prescription stimulants nonmedically during the previous 12 months. Legal medicines in this category include methylphenidate (Ritalin), the amphetamine Adderall, and modafinil (Provigil). On some campuses, one quarter of students have reported using the drugs. And an informal on line reader survey by Nature last year showed 20 percent of 1,427 respondents from 60 countries polled about their own use said they had used either methylphenidate, modafinil or beta blockers (the last for stage fright). Overall, a need for improved concentration was the reason cited most frequently. People often manage to acquire the drugs on the Internet or from doctors, who can prescribe medicines approved for one purpose to treat something else (drugmakers, however, cannot legally promote such "off label" uses). . .

The recent push for ethical guidelines, of course, presumes that these drugs are better than placebos and do in fact improve some aspect of cognition, be it attention, memory or "executive function" (planning and abstract reasoning, for instance). Given that assumption, many argue, it behooves ethicists to consider the ramifications of the popularity of these drugs. Such logic led in 2002 to a new academic discipline, neuroethics, meant in part to address the moral and social questions raised by cognition-enhancing drugs and devices (brain implants and the like).

Taking a highly provocative stand, a group of ethicists and neuroscientists published a commentary in Nature last year raising the prospect of a shift away from the notion of drugs as a treatment primarily for illness. The article suggested the possibility of making psychostimulants widely available to the able-minded to improve performance in the classroom or the boardroom, provided the drugs are judged to be safe and effective enough for healthy people. Citing research demonstrating the benefits of these drugs on memory and various forms of mental processing, the investigators equated pharmaceutical enhancement with "education, good health habits, and information technology - ways that our uniquely innovative species tries to improve itself.". . .

These musings have not gone unchallenged. Other researchers and ethicists have questioned whether drugs that modulate mental processes will ever have a safety profile that will justify their being dispensed in the same fashion as a nonprescription painkiller or coffee or tea.

"People say that cognitive enhancement is just like improving vision by wearing glasses," says James Swanson, a researcher at the University of California, Irvine, who was involved with clinical trials for both Adderall and modafinil for ADHD. "I don't think people understand the risks that occur when you have a large number of people accessing these drugs. Some small percentage will likely become addicted, and some people may actually see mental performance decline.  That's the reason I'm opposed to their general use." Along these lines, the British Home Office, the interior ministry, is awaiting a report from an advisory panel on whether the potential harm from nonmedical use of enhancers requires new regulations. . .

A Checkered History

The notion that existing drugs might enhance cognition in the healthy dates back for the better part of a century and has produced ambiguous results. Chemist Gordon Alles introduced am phet amine for medical use in 1929, a synthetic drug chemically similar to the Chinese herb ephedrine.  (Alles also devised the drug Ecstasy, another amphetamine.) Various forms were dispensed on both sides during World War II to keep soldiers awake and alert and to bolster courage. The Germans and Japanese ingested methamphetamine, while the British and Americans used Benzedrine, a similar drug to Adderall.

Scientists soon wanted to know whether the perceived benefit in performance was genuine.  Psychological assessments by both British and Americans during the 1940s found that users self-rated their performance highly on tests that measured reading speed, multiplication and other factors. But their test scores, in most tasks, were no better than those earned by subjects who ingested caffeine. Performance, in fact, could decline on more complex tasks. "Because of their mood-elevating effects, amphetamines tend to make us feel we are performing especially well, when in fact we are not," says Nicolas Rasmussen, a historian of science at University of New South Wales in Sydney and author of the book On Speed (New York University Press, 2008). "In simplistic lab tests assessing performance on boring tasks, they boost scores by increasing diligence, but that's not the same as taking a law school exam or flying in combat."

Methylphenidate, a close chemical relative of the amphetamines, emerged in 1956 as a supposedly milder and gentler form of stimulant ("the happy medium in psychomotor stimulation," in the words of the drugmaker), but both its biochemical and psychological effects are similar when adjusted for dose. The halcyon era for amphetamines occurred nearly 40 years ago. U.S. consumption reached as much as 10 billion pills in the late 1960s before the Food and Drug Administration clamped down and labeled them as controlled substances that required a special prescription. Neuroscientist Michael S. Gazzaniga of the University of California, Santa Barbara, one of the authors of the Nature commentary, remembers his father sending him Benzedrine for studying when he was in college in the early 1960s.

In the mid-1990s the growing use of methylphenidate for treatment of ADHD prompted researchers to deploy novel brain-imaging techniques and sophisticated neuropsychological tests to examine effects of the drug in healthy subjects, supplying a baseline for comparison with patients with ADHD and other neuropsychiatric disorders. A 1997 paper in Psychopharmacology by Barbara Sahakian, Trevor Robbins and their colleagues at the University of Cambridge showed that methylphenidate improved cognitive performance on several measures (spatial working memory and planning, in particular) in a group of rested, healthy young males but not on others, including attention and verbal fluency. As testing progressed, the volunteers seemed to make more errors in their responses, perhaps because of impulsivity induced by effects of the drug.

The same researchers found little cognitive benefit in healthy elderly males. And in 2005 a group at the University of Florida Medical School at Gainesville could not turn up any cognitive boost from the drug among 20 sleep-deprived medical students. Another impediment to methylphenidate ever being placed alongside NoDoz and other caffeine pills is its potential for causing cardiac arrhythmias and for abuse as a recreational drug. Addiction is rare with normal dosing. But in the 1970s methylphenidate users routinely became addicted after inhaling or injecting the drug that they called "West Coast."

The Always-On Drug

The checkered legacy of amphetamines prompted neuroscientists and physicians to hail the arrival of modafinil as a wakefulness-promoting agent with a seemingly more favorable side effect and abuse profile than the amphetamines. The ability of modafinil (introduced in the U.S. in 1998) to allow people to work long stretches without the need for breaks has turned it into a lifestyle drug for the jet-lagged who attempt to live in four time zones at once.

Jamais Cascio, an associate of the Institute for the Future in Palo Alto, Calif., obtained a prescription for modafinil from his physician after hearing about it from friends who traveled a lot. On trips overseas, he noticed that it made him feel not only more awake but also sharper. "The perceived increased cognitive focus and clarity was very much of a surprise, but it was a very pleasant surprise," says Cascio, who has mentioned the drug in some articles he has written. "My experience was not that I'd become a superbrain. It was more an experience of more easily slipping into a state of cognitive flow, a state of being able to work without distraction."

Testing has confirmed some of Cascio's impressions. In 2003 Sahakian and Robbins found that 60 rested, healthy male volunteers did better on a few neuropsychological measures, such as recall of numerical sequences, but results were unchanged on others. Investigators elsewhere have also found benefits for the drug, although, as Cascio noted, it will not make a dunce into a genius. None of these studies, moreover, has tested effects on cognition over extended periods.

Unregulated availability of either modafinil or methylphenidate also remains unlikely because the drugs tend to affect individuals in different ways. Users with lower IQs appear to derive a large performance boost from modafinil, whereas those with more innate ability show little or no benefit. With methylphenidate, those having poor working memory improved when tested; those having a naturally higher memory capacity showed much smaller benefits. . .

Repackaging old attention-boosting drugs as cognitive enhancers for students, executives and software programmers may produce only marginal benefits over consuming a double espresso. The question of what exactly is an enhancer has prompted the convening of a group within the American College of Neuropsychopharmacology to discuss the standards that any drug should meet to be classified as a cognitive booster. Ultimately, enhancement drugs may come from another sphere of research. Insights into how we translate a baby's image or a friend's name into lasting memories has laid the groundwork for new drugs specifically designed to achieve better functioning in people with Alzheimer's or other dementias.

Optimism about a new generation of pharmaceuticals derives in part from advances in basic research into the biochemical processes underlying memory formation. More than 30 types of gene-altered mice have demonstrated the ability to both acquire information and store it in long-term memory better than the average mouse. "This is the first time in the history of neuroscience that we have the backbone of the molecular and cellular biology of memory," says Alcino J. Silva, a neurobiologist at the University of California, Los Angeles. "What this means for society is that for the first time we can use it to start changing how we learn and remember."

But truly effective memory drugs are probably a long way off, in part because of the scientific challenges. Most of the 200 gene mutations introduced into mice by researchers worldwide caused deficits. Silva remembers one mouse in his laboratory that illustrated the possible tradeoffs that researchers will confront during development of a cognitive enhancer. The animals learned faster than normal, unaltered mice but were unable to complete an elaborate puzzle administered by the investigators. "If you taught them something simple, they acquired it fast, but for anything more complicated, they couldn't acquire it," Silva says. He estimates that it may take decades before drugs from this research are routinely used. . .

Tully, 55, adds that he does not foresee his creations ever becoming the next Viagra or Prozac. "What the media loves to totally ignore is the side-effect potential and jump right to the wild speculation of this as a lifestyle drug," Tully says. "And I think it's just missing the mark. The reality is that if you've got a debilitating form of memory impairment these drugs may be helpful, but they're probably going to be too dangerous for anyone else.". . .

Lessons learned from drugs developed for dementia could lead to agents that ease the milder cognitive problems associated with normal aging, assuming these compounds do not arrive burdened with intolerable side effects. If sufficiently benign, these pills could find their way into college dorms or executive suites. "Within the pharmaceutical field, people recognize that a successful cognitive enhancer could be the best-selling pharmaceutical of all time," says Peter B. Reiner, a professor of neuroethics at the University of British Columbia.

Near to Market

As scientifically satisfying as it would be for researchers to discover cognition-enhancing drugs through detailing the molecular processes that underlie cognition, the first new agents to reach the market for dementia and other cognitive disorders may not spring from deep insight into neural functioning. They may come from the serendipitous discovery that some compound approved for another purpose has effects on cognition. For instance, one drug candidate that recently entered late-stage trials for the cognitive dysfunctions of Alzheimer's was developed in Russia as an antihistamine for hay fever and was later found to have antidementia properties. The potentially huge market has led some companies to take unorthodox routes to market, revisiting a failed drug or one that did not complete clinical trials and selling it as a dietary supplement or as a less stringently regulated "medical food."

Similarly, new medicines may arrive because regulatory agencies approve a broadening of allowed uses for a drug already known to influence cognition. Cephalon, maker of modafinil, took this route, obtaining FDA permission to market the substance for shift workers, who compose a much larger group than the narcoleptics (who suffer from uncontrolled sleep episodes) for whom it was originally approved. (Cephalon also paid nearly $444 million to two states and the federal government for promoting three drugs, including modafinil, for unapproved uses.) The impulse to improve cognition - whether to intensify mental focus or to help recall a friend's phone number - may prove so compelling to both drug makers and consumers that it may overshadow the inevitable risks of toying with the neural circuitry that imbues us with our basic sense of self.

Gary Stix is a writer at Scientific American.

www.sciamdigital.com/index.cfm?fa=Products.ViewIssuePreview&ARTICLEID_CHAR=C85AABF1-237D-9F22-E8CF0D982166AEF4

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2.      In the News:  Sweden to Host the World's first high-level Nuclear Waste Storage Facility

How the Waste was Won By Sam Knight, FT, 9-19-09

Civic competition is a deep and ancient force. Ever since towns were towns, they have found ways to assert their superiority over one another, through commerce, war and other, more sporting encounters. The thrill of outdoing a neighbour, the fear of losing to the rivals from along the shore, are apparently universal human urges and the world crackles with all kinds of local contests, from the town lantern competitions of the Philippines to America's "Best Tennis Town" and the tidy villages of Ireland.

A few of these competitions are born of a culture so specific they can be hard to understand. In the Thai town of Phuket, temples founded by Chinese immigrants compete to produce extraordinary displays of human self-harm and mutilation, known as mah song. In Sweden, meanwhile, two municipalities, Östhammar and Oskarshamn, have spent the past seven years competing for the right to host the world's first high-level nuclear waste storage facility.

Although it comes in many varieties, nuclear waste is short on what most people consider winning qualities. It is the downsides that catch our eye, and, of these, high-level nuclear waste has a peculiarly rich array. This kind of waste is normally "spent fuel", long rods of uranium that have been burnt in a nuclear reactor. No longer capable of supplying the steady chain reaction that a power station demands, the bundles of radioactive metal emerge at the end of their useful lives to become a terrifying hazard.

They are hot, for a start. Fuel rods come out of a reactor at around 400°C and take 30 or 40 years to become safe enough to handle, a century to cool completely. As a result, they are often placed under water, which also cloaks their radioactivity. Because although only around 5 per cent of the uranium in fuel rods decomposes in a nuclear reactor, that is enough to spawn hundreds of exotic elements and isotopes, most of which fizz with harmful ionizing radiation. Few people have ever been exposed to nuclear fuel in this state and none has lived to describe what it feels like. In 2003, a Canadian report calculated that if you stood one metre away from unshielded spent fuel, fresh from the reactor, you would receive 10 Sieverts (Sv) of radiation in 36 seconds. That is enough to kill you several times over and in any number of ways, but you would probably burn to death.

Radiation, of course, diminishes with time. The problem with high-level nuclear waste is that there is so much danger to lose. If you returned after 10 years to the same spent fuel that killed you when it came out of the reactor, it would kill you again, but you would have stand next to it for about 50 hours this time. After 100 years, high-level nuclear waste is merely poisonous in a more conventional sense and would only do you real harm if you inhaled or ingested some of its longer-lived radioactive contents, such as caesium, strontium or plutonium. Inside the body, these gravitate to the blood and bones, weakening the immune system and causing cancer. One of the earliest known radioactive ailments was "necrotic jaw", suffered by the painters of luminous watch dials in the 1920s, who licked their radium-tipped paintbrushes to make a nice sharp point and then had their mouths fall apart. Scientists agree that high-level nuclear waste should be kept out of reach of humans for a minimum of 100,000 years. . .

But as things stand, there is not a single, permanent storage facility for civilian high-level nuclear waste anywhere in the world. Instead, hundreds of thousands of tonnes of spent fuel (35,000 tonnes in the EU; 100,000 in the US) sit in cooling ponds with no final destination. And with the world's nuclear generating capacity forecast to rise by one-third in the next 20 years, these ponds will not be big enough forever. There will come a point when we all have to start digging. . .

Read the entire article . . .

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3.      International Medicine: Incompetency Starts at the Top

The British Disease By THEODORE DALRYMPLE

Whenever I am in Amsterdam, I stay in a small, elegant and well-run hotel. The excellent and obliging staff are all Dutch.

Whenever I am in London, I stay at a small, elegant and well-run hotel. The excellent and obliging staff are all foreign - which is just as well, for if they were English the hotel would not be well-run for long. When the English try to run a good hotel, they combine pomposity with slovenliness.

Perhaps this would not be so serious a matter if the British economy were not a so-called service economy. It has been such ever since Margaret Thatcher solved our chronic industrial relations problem by the simple expedient of getting rid of industry. This certainly worked, and perhaps was inevitable in the circumstances, but it was necessary to find some other way of making our way in the world. This we have not done.

Incompetence and incapacity are everywhere. Despite ever-rising local taxes, town and city councils are either unable or unwilling to clear the streets of litter, with the result that Britain is by far the dirtiest country in Europe.

Although we spend four times as much on education per head as in 1950, the illiteracy rate has not gone down. I used to try to plumb the depths (or shallows) of youthful British ignorance by asking my patients a few simple questions. Fifty percent responded to the question "What is arithmetic?" by answering "What is arithmetic?" It is not that they were good at doing something that they could not name: When I asked one young man, not mentally deficient, to multiply three by four, he replied "We didn't get that far."

This is the result of 11 years of state-funded compulsory education, or rather attendance at school, at a cost of between $100,000 and $200,000. The government's response has been to raise the school-leaving age to 18, thus making total ignorance even more expensive.

This is at the bottom rung of society, but incompetence starts at the very top. It is doubtful whether any major country has had a more incompetent leader than Gordon Brown for many years. The product of a pleasure-hating Scottish Presbyterian tradition, he behaves as if taxation were a moral good in itself, regardless of the uses to which it is put; he is widely believed to have taken lessons in how to smile, though he has not been an apt pupil, for he now makes disconcertingly odd grimaces at inappropriate moments. He is the only leader known to me who combines dourness with frivolity. . .

After 12 years of ceaseless Brownian motion, British public finances have gone from being comparatively healthy to being catastrophically bad. In order to expand vastly the public sector in which he is a true believer, Mr. Brown has raised taxes by stealth, undertaken government obligations that appear nowhere in the accounts and that will weigh on future generations, and eased credit to encourage asset inflation and give people the illusion of prosperity. For the duration of his time in government, Britain has been like a consumptive patient, with an excess of bogus well-being shortly before expiry. If the world is an opera stage, Britain has been playing Violetta or Mimi in the last act. . .

No words of mine can adequately convey the contempt in which the Conservatives are now, rightly, held by almost everyone. I do not recall meeting anyone who thinks that David Cameron, their leader, is anything other than a careerist in the mold of Tony Blair. The most that anyone allows himself to hope is that, beneath the thin veneer of opportunism, there beats a heart of oak.

But the auguries are not good: Not only was Mr. Cameron's only pre-political job in public relations, hardly a school for intellectual and moral probity, but he has subscribed to every fashionable policy nostrum from environmentalism to large, indeed profligate, government expenditure. Not truth, but the latest poll, has guided him - at a time when only truth will serve. However, he will be truly representative as prime minister. Like his country, he is quite without substance.

 - Theodore Dalrymple is the pen name of Anthony Daniels, a British physician. Printed in The Wall Street Journal, Sept 26, 2009, page A15

http://online.wsj.com/article/SB20001424052970203917304574414924180862140.html#mod=todays_us_opinion

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Government should limit itself to the External Departments of Defense and State--and the
Internal Departments of Treasury, Justice, Public Health and Interior.

This won't eliminate incompetency, but should reduce it by about 90 percent.

It will also follow the Constitution that all other aspects of government should be left to the states.

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4.      Medicare: Our $2 Trillion Bridge to Nowhere

Americans believe Washington squanders half of every tax dollar.

By STEPHEN MOORE

If you want to know why Americans are so fearful of a government takeover of the health-care system, take a look at the results of a new Gallup poll on government waste released Sept. 15. One question posed was: "Of every tax dollar that goes to Washington, D.C., how many cents of each dollar would you say is wasted?" Gallup found that the mean response was 50 cents. With Uncle Sam spending just shy of $4 trillion this year, that means the public believes that $2 trillion is wasted.

In a separate poll released on Monday, Gallup found that nearly twice as many Americans believe that there is "too much government regulation of business and industry" as believe there is "too little" (45% to 24%).

Perhaps most significantly, in both of these polls Gallup found that skepticism about government's effectiveness is the highest it's been in decades. "Perceptions of federal waste were significantly lower 30 years ago than today," say the Gallup researchers. Even when Ronald Reagan was elected president in 1980 with the help of the antigovernment revolt of that era, Americans believed only 40 cents of every dollar was wasted, according to Gallup.

These results are in some ways surprising because voters just elected a president who promised expensive government expansion almost across the board - from health care to foreign aid to housing to energy policy. Mr. Obama was the first president elected since Lyndon Johnson who didn't even pretend to want to cut the size of government.

Now there's a powerful voter backlash against the Bush-Obama agenda of bailouts, stimulus plans and trillion dollar-plus deficits. The rage began with the bank bailouts last fall. It grew with the $787 billion stimulus bill, which was little more than a refill of the budgets of every left-wing program Democrats have wanted to throw money at for 40 years. The nearly $100 billion bailout of General Motors and Chrysler - some $300,000 for every auto job saved - was a bridge too far for debt-weary voters. When Mr. Obama then released his 10-year budget plan - which even he admitted would double the national debt with $9 trillion of new borrowing over the next decade - he was lighting a match in a munitions factory.

There are several political lessons we can learn from the Gallup results. One is that Republicans' strategy of creating a unified bloc of "no" votes to Obama spending initiatives like government-run health care and the cap-and trade-energy bill is in line with where voters are. The Washington establishment is dead wrong: Americans don't want bipartisan cooperation in supersizing the government right now. Pollster Frank Luntz tells me that Republicans can kill ObamaCare by relentlessly hammering home one message: This is a government takeover of health care. "Americans hate that idea," he says.

But the polling suggests something even bigger: Americans are in the mood for a radical shrinking of government in order to reduce debt and waste. Republicans and Blue Dog Democrats should be talking nonstop about how to achieve this goal.

First, they should push for a 15% cut in every federal agency budget before the debt cap is raised later this year. Given that most agencies saw their budgets expand by more than 50% in the past year, according to the House Budget Committee, this is hardly going to throw programs into the poor house.

They should also propose an immediate freeze on federal pay and benefits until the budget is balanced - even furloughs of federal workers to save money. A new report from the Cato Institute shows that federal pay packages are nearly twice as generous as those in the private sector for jobs that require similar skill levels. They should call for the elimination of hundreds of useless and obsolete agencies like the Legal Services Corporation. Finally, they should demand that every penny of TARP money repaid by banks should go into a fund to reduce the debt - rather than allow the Obama administration to create a new slush fund for pet projects.

Over the last decade, the federal government has become bloated and inefficient. Voters are on to the scam. Mr. Obama keeps calling federal spending an "investment," but Americans apparently feel this is the worst investment they've ever made. They've come to regard Washington as a $2 trillion Bridge to Nowhere. They are right.

Mr. Moore is senior economics writer for The Wall Street Journal editorial page.

Printed in The Wall Street Journal, September 23, 2009, page 23. http://online.wsj.com/article/SB10001424052970204488304574424750482799212.html#mod=todays_us_opinion

Congress' propaganda that much of health care is over utilization may be true. But Congress squanders far more than doctors overutilize; and Congress has nothing productive to show for it. If gun purchasers require a one-week holding time for completing a purchase, if Taft Hartley requires a 30-day cooling off period before a labor strike, maybe Congress should have a three-month cooling off period before they strike Americans.

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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: Hospitalists are only one step in usurping health care control.

Over the past several decades, the practice of medicine has dramatically changed. Most physicians managed their own patients in their offices and when they were hospitalized, they continued to manage their care as inpatients. This was very efficient since the physician had a longitudinal perspective of his patients, which promoted a cost-effective management. Even with what were considered to be identical problems, there were large variations in the cost of individual physician's management of patients. In our own community hospital staff meetings, we were shown graphs illustrating the cost of each physician. Then managed care came on the horizon and claimed they could modify this large variation in care by eliminating those that fell out of the norm. That would save more money than their cost of management.

Well it didn't work. The sharp and articulate internist could get the managed care company to authorize a CT of the brain to evaluate a headache. Meanwhile, the less aggressive doctor couldn't get a brain CT on his stroke patient. He simply told the patient's family that the CT was denied and personally felt there was not much to do for a stroke; therefore, he made no significant efforts to challenge the money-laundering scheme. The managed care company did not reduce the high cost of those that over utilized, but did reduce the cost of those below the average. Thus the disparity increased and non-physicians came between the doctor and his patient for the first time.

As physicians became disenfranchised from the patient, the managed care companies hired physicians to take care of hospitalized patients under the pretense that this would be more efficient. They also could more easily control a small group of physicians in the high-cost center, otherwise known as hospitals. This was entirely voluntary for the first decade or so. I always opted out since I felt I was more cost effective in managing my own patient than someone who stepped in and had to learn anew all the details of my patient.

And then it happened. At a large managed care meeting several years ago, as the Hospitalist Program was being explained and justified, the CFO of the managed care company came over to my table and asked me if I was going to continue to be a non-participant. With a hundred eyes on me, I acquiesced and stated I would no longer resist. They assured us that we would maintain our hospital privileges.

Two years later on the renewal of our hospital privileges, a section of the Hospital Staff Bylaws was highlighted that read since we had no admissions for two years, we would no longer be eligible for active staff privileges. Thus a large number of Senior Medical Staff physicians became Affiliate members, similar to the allergists and dermatologists on Hospital Row that didn't admit patients. 

I pacified myself that after thirty years of practice, it was getting harder to get up in the middle of the night and make a run for the hospital to admit a patient from the Emergency Room. So I convinced myself that the loss of my hospital income would allow me to live longer without a coronary.

Shortly after this program started, one of my pulmonary patients with an old calcified tubercular granuloma was admitted. She had been fully evaluated and the diagnosis was firmly established. When I read the reports of the hospital summary when she came back to my office, I was amazed at what had transpired. She had received a "pulmonary nodule" evaluation costing thousands of unnecessary dollars. If they had called me or requested my records, the answer would have saved the time and money involved. Or better yet, if they had taken an extra 30 seconds to ask the patient about the nodule, she would have told them that it had been their since 1957 and "not to worry." When hospitalists work as university residents admitting a large number of unfamiliar patients, these things are bound to happen. For residents-in-training, such experiences are informative and educational. For practicing physicians, such errors are inexcusable.

There is nothing in Obama's health care reform that would diminish such expensive errors. They would be expected to increase, as patients become commodities to be managed economically without regard to their health and perhaps more dependent on their age and useful life remaining. The laws before Congress at the present time were written by a large number of attorneys and staffers who have not had the required eight to twelve years of post graduate physician training, no clinical experience, and thus no understanding of the clinical interface. Furthermore, with each section written by a different team, there is no continuity to the health care reform being presented. Practice guidelines only work with patients with a single disease entity. Our patients generally have several or even a dozen diseases all interfacing with each other. Clinical guidelines in such situations can be dangerous or even life threatening.

Thus, the reasons for usurping control were all invalid. It did not improve care. It was not more efficient. It was not cost saving. It interfered with personalized patient care. It caused duplication of care with the personal physician still responsible for the transition of care without even being able to examine the patient between the hospital, rehab facility, convalescent hospital and home care and thus a large number of hours of unremunerative time spent.

It's amazing that in this stage of our civilization, we could have come so far removed from reality. Obama is meeting with the Department of Defense at length so as not to make any mistakes by moving too quickly in a war zone.

Meanwhile, there is such urgency in changing the health care structure that it must be rushed through Congress before politicians deliberate too long. What a reversal of logic. In medicine and surgery, there is never any urgency that doesn't allow careful planning even in emergencies. Being inside the wrong part of the body at surgery can be catastrophic.

With no health care emergency, with Medicare covering everyone over 65, thus leaving none of our aged uncovered; with Medicaid covering everyone of any age that's poor and some not so poor (15 million people in this category with health insurance are covered immediately if they are sick and thus should not be counted in the 45 million allegedly without insurance); with Medicare Disability covering every one that's disabled from birth to grave; with the VA covering our war disabled and all military retirees, we have no urgency whatsoever. In fact we have essentially everyone covered. We can't help that the 15 million making over $50,000 have other priorities when many making $25,000 are able to buy simple health care policies. If there were 47 million uninsured, we would have a problem. However, that is a blatant lie perpetrated by those who are interested in expanding government control and are not particularly interested in health care. Another 15 million or so are aliens and not our responsibility. We already have the best health care net in the world. The maximum that don't have coverage is 4.5 million or 1.5 percent. This pales to the countries with 20 percent on their waiting list. The Canadian Supreme court had to rule that Canada does NOT have universal coverage. They only have access to a waiting list. The 20 percent waiting are in effect not covered.

It would be a tragedy that we may have to repeat the last two centuries of development since my Great Grandfather left Bismarck's Socialized Medicine in the mid nineteenth century Germany for freedom. How could any rational person with any understanding of history and medicine, look to Europe as the ideal goal to strive for?

Feedback . . .

Medical Gluttony thrives in Government and Managed Care Programs.

It Disappears with Appropriate Deductibles and Co-payments on Every Service in a Free Society.

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6.      Medical Myths: Universal coverage will achieve access and reduce costs.

Myth 7. Universal coverage, enforced through an individual mandate, as in Massachusetts, will achieve universal access and reduce costs. August 10, 2009, AAPS, KAS

According to the implicit hypothesis underlying the rush to "health care reform," the main barrier to ideal care for all at an affordable cost is the absence of universal "coverage" - payment and supervision - by an appropriate (governmental or government-credentialed) third party.

Without such a mechanism, some patients will avoid needed care or needlessly jam emergency rooms. Some clinicians and facilities will not get paid, or not provide care, or shift costs, or perform unnecessary but well-remunerated services. Insurers will avoid the sick.

The hypothesis is summarized by Linda J. Blumberg and John Holohan: "Some of the most prominent shortcomings of the U.S. health insurance market are rooted in the fact that the system is a voluntary one" (N Engl J Med 7/2/09). The market "segments" health risks, and avoids the sick rather than "managing" their care.

Massachusetts is the grand bipartisan experiment to test this hypothesis. The individual mandate - requiring purchase of insurance by law - brings in funds from "free riders" who use care without paying for it, or low-risk persons who decline to pay their "fair share" to subsidize coverage for higher-risk persons. (The latter phenomenon is called adverse selection - low-risk persons drop coverage rather than pay the high premiums resulting from community rating or guaranteed issue.)

To compensate for the perceived unfairness of forcing people to buy an unaffordable product, the Commonwealth subsidizes persons too well off to qualify for Medicaid but judged too poor to afford premiums. This expense is supposed to be offset by decreasing ("redirecting") payments for uncompensated care.

The "Connector" is supposed to help people choose suitable coverage that meets all its requirements.

The results of the experiment, which took full effect on July 1, 2007:

·              Premiums are approximately double those in many other states. Premiums in those states will double if Congress passes universal coverage with guaranteed issue and modified community rating (Council for Affordable Health Insurance).

·              Premiums in Massachusetts are increasing twice as fast as the national average (Eagle Forum 7/3/09).

·              Only 18,000 people have used the Connector to buy insurance during the past 3 years (ibid.).

·              The number of uninsured decreased, almost entirely because of subsidies rather than the mandate, but 200,000 remain uninsured (Michael Tanner, Cato Briefing Papers No. 112, 6/9/09).

·              The number of people receiving uncompensated care declined only 36% (ibid.).

·              State spending on all health programs has increased 42% since 2006. There are huge deficits despite tax increases. Eligibility reviews have already removed 25,000 people from the subsidy program (ibid.).

·              Substantial adverse selection is taking place; the combination of subsidies and mandates may actually be making the insurance pool older and sicker (ibid.).

·              Instead of unifying and rationalizing two dysfunctional regulatory schemes, the Connector has become an aggressive new regulatory body, adding more mandates plus a 4% increase in administrative costs (ibid.).

·              Insurers were ordered to cut payments to providers by 3% to 5%, and a cap on total spending (global budget) is under consideration.

·              Utilization has increased; supply of services has not. People are having more difficulty finding a physician and must wait longer for an appointment (Merritt Hawkins, 2009).

Already called the New Big Dig in May 2008, "the Massachusetts nonmiracle should be a warning to Washington." The Obama plan, however, is "Massachusetts on steroids" (Wall St J 5/21/08).

Additional information:

·              "Magical Thinking," AAPS News, May 2006.

·              "Massachusetts Resorts to Group Visits with Doctor," AAPS News of the Day 12/3/08.

Article originally appeared on TakeBackMedicine (www.takebackmedicine.com/).

See website for complete article licensing information.

Feedback . . .

Medical Myths originate when someone else pays the medical bills.

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

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7.      Overheard in the Medical Staff Lounge: Congress Approval Ratings Slip to 21 percent.

Dr. Dave: I see where Obama has been slipping even further in the polls. He now has 5 percent more disapprovals than approvals: 41 percent approve and 46 percent disapprove of what he's doing.

Dr. Yancy: That's at least 20 percent worse that Bush at the same time in his second term of presidency.

Dr. Milton: But did you see that nearly five times as many people have lost faith in Congress than still support it? I believe they have slipped from about 30 percent to 21 percent this week.

Dr. Edwards: I don't see why they feel they have any standing to reform health care. Why should we have someone so untrustworthy destroy our health care?

Dr. Milton: They don't believe the polls. It could be 99 to 1 against them and they would still feel they got elected and thus have a mandate. They don't see the polls as the will of the people.

Dr. Edwards: I see we have a new Doctor in our midst. I think I read Dr. Gayle on the lapel. What field are you in?

Dr. Gayle: I'm in neurology, both pediatric and adult. I started in July and admit my patients here. I'm developing a good consultative practice and do EEGs and EMGs in my office

Dr. Edwards: Well, do you have opinions on the current national subterfuge?

Dr. Gayle: Very much so. Public opinion polls also keep showing slippage for government-run healthcare.  I think it's very important that we slow this thing down. The more ground we gain the best are our chances.

Dr. Milton: So you're not discouraged?

Dr. Gayle: Not at all. BO is now promising a vote by Dec. 31 (when people are busy with holiday activities and aren't paying attention - he thinks). But people are watching. If an increasing majority of voters show that they don't want it, the tax and spend party (T & S) will be signing their own death warrant if they vote for it. 

Dr. Edwards: So you think we may have a backlash at the midterm elections in 2010?

Dr. Gayle: I'm convinced. If the T & S radicals stop being in denial about polls, they may be reluctant to stage a vote before 12/31 and may look for plausible reasons to delay the vote. And if a vote can be delayed until after New Year's, that's all the better.

Dr. Milton: Do you really think it will be a fiasco like the Hillary ordeal 16 years ago?

Dr. Gayle: I'm fairly optimistic that it might. I'm keeping my fingers crossed.

Dr. Paul: I don't think that Congress perceives it as destroying health care. I firmly believe they think they have to save us from our selves. Maybe they will.

Dr. Rosen: Not a chance. History is on our side. When Bismarck from Germany visited Napoleon in France, he understood why Napoleon had such loyalty from the French. Most French received a government pension. He had them by the purse. And he did Napoleon one better - he gave them government health care. As the world deteriorated to this travesty, no country has fully turned this around.

Dr. Milton: Naturally, they would be scared to death to give up the umbilical cord.

Dr. Rosen: Even though the hospitals in the UK are dirty, their mortality is high, their cancer statistics are far worse than ours, the rank and file after 55 years can't remember freedom and good health care.

Dr. Edwards: And they have such a good propaganda program on how their health care compares favorably to the USA, that the rank and file don't believe it ever was better than what they see and experience.

Dr. Rosen: I really enjoy talking to European physicians at our international meetings. They are so accepting of having the government tell them how to practice. And most of these physicians are polite to the bureaucrats and privately refer to them as medical illiterates - just something we have to work around.

Dr. Milton: And they think American physicians are too kind to their patients. They think we have to be or they won't come back. In their country, a patient only has about two cracks at getting a doctor that he or she likes. So they don't have to be considerate because the patient has no choice.

Dr. Rosen: I think that's a key point we have to keep pointing out to our patients. They will be the biggest losers in a government takeover of health care. We have many options to make a living. They will have no other options in getting their health care. They best preserve what they now have. It's the best on earth.

Feedback . . .

The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8.      Voices of Medicine: What Doctors are Thinking and Writing About

America needs "Moore" Democracy

Why a surprising number of Conservatives agree with Michael Moore

By James J. Murtagh, M.D.

Michael Moore has a knack for juxtaposing key moments in history. His new film starts with the fall of Rome, intercut with the collapse of American industry. Could Rome have acted differently when they knew their end was coming? Moore suggests, return to democracy! Moore shows societies are not sustainable with a widening gulf between "those who have everything, and those that have nothing." The oligarchs of Rome were poisoned by more than lead in their wine: selfishness and decadence, and disdain for common folk plebeians led to self-destruct.

Moore sounds an alarm, as once did Winston Churchill, "The era of procrastination, is coming to a close. We are entering a period of consequences." Our heads must come out of the sand, or our children will amazedly wonder why America slept as the coming storm darkened the sky. Unbridled, unregulated, swindling, corrupted, anarchy capitalism has strangled itself. Only a return to real democracy and a commitment to moral values and advancement of the middle class can save it.

Now for a shocker. Many conservatives (of whom I sometimes am a fellow traveler), privately agree. If the business of Ameria is business, regulation is essential. America needs markets, including customers from a vibrant middle class, to avoid a death spiral for American business. Greed is not good- unless carefully regulated to protect the average man, to make competition fair, and to safeguard democracy. In truth, the fundamental core of Republicans belief is very much rooted in the core values of this film.  Moore quotes rock-solid conservatives, including Thomas Jefferson, Benjamin Franklin and Jesus. All were against usury, speculation, and distrusted banks.

John McCain stressed real conservatives, are "Teddy Roosevelt Republicans." TR's vision was a government big enough to play "honest umpire," and to swing a big stick both at home and abroad, and a Big government able to protect Big Business from itself. But since Reagan, the death of regulation decimated the middle class, and in turn, decimated our industry. True TR conservatives want a stable business environment, not the roller coaster. Regulation of our economy is necessary to protect conservative values.

The other Roosevelt remarked that saving capitalism, was like saving a drowning man with a top hat. The drowning capitalist refused to thank FDR, but instead complained that he had lost the top hat!

So it is today. Herodotus showed the rich pursuing more wealth and in the process, destroyed the very societies that created wealth. Sophocles may have heard it long ago on the Aegean. . . the turbid ebb and flow of tragedy. Mathew Arnold may have seen the sea of Capitalism once ringed our globe, but like any other faith, may be replaced, as ignorant armies clash by night.

Lee Iacocca bluntly states, "our once-great companies are getting slaughtered by health care costs."  Iacocca asks: "Where the hell is our outrage? We should be screaming bloody murder. This is America, not the damned Titanic." Lee, like Moore, faces up to inconvenient truths.  Something is deeply rank, and our body politic needs stiff medicine.

Moore, like Roosevelt prescribes principles to restore honesty amid our society, a kind of "remoralization": "The measure of the restoration lies in the extent to which we apply social values more noble than mere monetary profit," FDR said.

Conservatives don't like Moore's style, appearance, or theatrics, but moral and true conservative ideas are at the heart of his movie. Sure, his citizen arrests of CEOs may be off-putting to some. But hey, it is a movie, and Moore needed to sell tickets. No capitalist could criticize Moore for needing to make a buck…

To read James Murtagh's entire OpEd, please go to www.HealthCareCom.net.

Feedback . . .

VOM Is Where Doctors' Thinking is Crystallized.

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9.      Book Review: Taking Back Healthcare

A CALL TO ACTION –Taking Back Healthcare for Future Generations, by Hank McKinnell, McGraw-Hill, New York, Chicago, San Francisco © 2005, ISBN: 0-07-144808-X, 218 pp, $27.95.

Hank McKinnel, Chairman & CEO, Pfizer, opens the preface with the question, "Is our healthcare system really in crisis?" He finds the question difficulty to answer because it makes a presumption he doesn't accept. The phrase with which he has trouble is "healthcare system." He agrees there's a crisis, but it isn't in "healthcare"- it's in "sick-care."

He quotes Mohandas Gandhi who had similar difficulty in 1932. He had led a campaign of non-violent disobedience to help colonial India win independence from Britain. After being named Time magazine's "Man of the Year," Gandhi visited London for the first time. The entire world was curious, the press swarmed wherever he went, when one reporter's hastily called-out question became a defining moment, both for him and for the nation, he was trying to set free.

"What do you think of Western civilization?" yelled the reporter.

"I think it would be a good idea," replied Gandhi.

That's what McKinnell thinks about our healthcare system: It would be a good idea.

He maintains we've never had a healthcare system in America. As far as he can tell, neither has any other nation. What we've had - and continue to have - is a system focused on sickness and its diagnosis, treatment, and management. It's a system that is good at delivering procedures and interventions. It's also a system focused on containing costs, avoiding costs, and, failing all else, shifting costs to someone, anyone else. In fact, discussions about better health now take a back seat to arguments about costs. In the United States, a nation already spending nearly $2,000,000,000,000 a year on sick care, tens of millions of people do not have adequate access to the system. In other developed nations, rationing and price controls undermine the patient-physician relationship, degrade the quality of care, and add to the anxiety of individuals struggling with health issues. An aging population around the world clamors for relief from chronic diseases and the cumulative effects of heredity and lifestyle behaviors. Some of these we cannot as yet prevent. Others, such as smoking, we can.

Today, in healthcare, we have it entirely backwards. We're like a community that builds the best fire-fighting capability in the world but stops inspecting buildings or teaching kids abut fire prevention. Fighting fires is sometimes necessary, and we must be prepared to do that with the most modern technology available. But firefighters around the world will tell you that they'd rather prevent fires than fight them.

To put it simply, McKinnell feels that our fixation on the costs of healthcare - instead of the costs of disease - has been a catastrophe for both the health and wealth of nations. By defining the problem strictly as the cost of healthcare, we limit the palette of solutions to those old stand-bys - rationing and cost controls. What if we reframe the debate and consider healthcare not as a cost, but rather an investment at the very heart of a process focused on health? Then other solutions suddenly appear out of the fog.

That's why this book was titled A Call to Action. It represents McKinnell's conviction that the debate on the world's healthcare systems is on the wrong track. Unless we correct our course, we will not be able to make the same promises to our children and grandchildren that our parents and grandparents delivered to us: that you will receive from us a better world than we received from our forebears. He feels that the basic bio-medical research conducted by his company is doing just that. But he's concerned that his and other research-based pharmaceutical companies might lose the capacity to advance the science that can change the lives of our children and grandchildren for the better, just as polio vaccines and cardiovascular medicines and other therapies changed out lives.

McKinnell doesn't believe in surprise endings. Although he loves a good mystery, this book was not meant to be one. The first phase of his book sets up its basic theme - that when our most cherished support systems are at risk, we are called to rethink our most well-accepted assumptions. Everywhere in the developed world, people are dissatisfied with the healthcare their families are receiving. The near universal experience is that healthcare is increasingly unaffordable, fragmented, and impersonal. Thus, the first third of the book details the proposition that the current system is profoundly misfocused in three ways. It is preoccupied with the cost of healthcare, it defines the provider as the center of the system, and it regards acute interventions as its primary reason for existence.

In chapter one, he gives his "Personal Take, a Personal Stake" which outlines his qualifications to write the book. In chapter two, he addresses the almost trivial question of "What is Health?" which he finds very resistive to answers. In chapter three, on "Reluctant Healthcare Providers," he considers how employers are instrumental in the healthcare of their employees.

After establishing these basic theses, the second third of the book speaks of the pharmaceutical industry that McKinnell helps lead. It is a source of considerable pain to him that this life-saving industry that he represents is viewed with suspicion, cynicism and anger. In this section, McKinnell answers some of the most pointed questions that patients are asking.

In chapter four, "Why Are Prescription Medicines so Expensive?," he deals directly with questions and objections that customers and patients send him. In chapter 5, he discusses a common question "Why Does the Industry Do So Much Marketing?," which they feel  should lower pharmaceutical costs. In chapter six, he answers the question, "Why Do Americans Pay More Than Canadians for Drugs?" The answers are interesting.

In chapter seven, he "Welcomes Competition in Healthcare," which currently is between the wrong players and over the wrong objectives. He favors value added competition that focuses on increasing healthcare value instead of dividing it. In chapter eight, he describes his conviction that investments in health pay off in great wealth: "Health Creates Wealth: No One Left Behind." Uninsured people in poor health cannot be said to have equal opportunities in a market economy. In chapter nine, he discusses "Consumer-Driven Healthcare: Balancing Choice, Responsibility, and Accountability," a model based on the notion that the demand for healthcare service is limitless, especially when someone else is seen as paying the bill. Giving the correct financial incentives to patients will reduce use of services of marginal value. It will also give patients an incentive to seek out lower-cost providers of care. 

In chapter ten, "The Research Imperative: The Search for Cures," he feels that the real task of innovation is to make the new discovers and ideas into widespread use. In chapter eleven, "Information Intensive: Reaping the Benefits of Technology," he addresses the difficult problem of incorporating patient-friendly information technology into a healthcare system that resists accountability demanded by information systems. Information technology is not the problem, and it's not a solution. But we cannot get a handle on costs, reduce medical errors, and put individuals in control of their healthcare without embedding information systems deeply into healthcare at every level.

In the last part of the book, McKinnell delivers on the implicit promise made by the title of the book and sets forth a number of calls to action that seem to him most critical if the healthcare system is to be transformed. If taken seriously, he believes these actions can save millions of lives and billions of dollars over the next generation.

In chapter twelve, "Change is Possible: Infectious Disease and the Struggle for Hope," he describes social investments and projects. . In chapter thirteen, "Next Steps: A Call to Action Starts Here," he connects the dots with his prescriptions for change that include action items at the individual, corporate, regional or national level. Chapter 14 "The Deadline for Complaints Was Yesterday," describes his hopes that transformation is not only possible, but it is inevitable. Our children are depending on us. He is confident we will not let them down.

A Call to Action distills more than three decades of experience - both joyous and painful - that has brought McKinnell to this special vantage point. He offered these thoughts, plans, and calls to action to give our descendents all the benefits of healthcare that we have enjoyed. But we cannot do so under the liabilities and constraints that today weighs down the world's healthcare systems. These systems promise healthcare but actually swindle people out of both their health and wealth. He concludes that you and I, our children - indeed, our entire human family - most certainly deserve better.

The three decades of thought and experience shows throughout the entire treatise. There is little to disagree with. Every physician, nurse, administrator and healthcare executive should read this volume and keep it as a handy and useful reference - someplace within reach, preferably on your desk. This refocus is crucial to our understanding and to healthcare reform.

Reviewed by Del Meyer, MD

Feedback . . .

This book review is found at . . .    

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10.  Hippocrates & His Kin: Are Health Care Costs Really Soaring?

Cliff Asness on Health Care: Myth - Health Care Costs Are Soaring

No, they are not. The amount we spend on health care has indeed risen, in absolute terms, after inflation, and as a percentage of our incomes and GDP. That does not mean costs are soaring.

You cannot judge the "cost" of something simply by what you spend. You must also judge what you get. I'm reasonably certain the cost of 1950s level health care has dropped in real terms over the last 60 years (and you can probably have a barber from the year 1500 bleed you for almost nothing nowadays). Of course, with 1950s health care, lots of things will kill you that 2009 health care would prevent. Also, your quality of life, in many instances, would be far worse, but you will have a little bit more change in your pocket as the price will be lower. Want to take the deal? In fact, nobody in the US really wants 1950s health care (or even 1990s health care). They just want to pay 1950 prices for 2009 health care. They want the latest pills, techniques, therapies, general genius discoveries, and highly skilled labor that would make today's health care seem like science fiction a few years ago. But alas, successful science fiction is expensive.

Health care today is a combination of stuff that has existed for a while and a set of entirely new things that look like (and really are) miracles from the lens of even a few years ago. We spend more on health care because it's better. Say it with me again, slowly - this is a good thing, not a bad thing.

In summary, if one more person cites soaring health care costs as an indictment of the free market, when it is in fact a staggering achievement of the free market, I'm going to rupture their appendix and send them to a queue in the U.K. to get it fixed. Last we'll see of them.

Hedge-fund manager Clifford Asness, writing at Stumblingontruth.com on The WSJ


Dr. Obama's Tonsillectomy

Those greedy doctors. "You come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats," President Obama explained at Wednesday's press conference. "The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid's tonsils out.'"

If that's what he really thinks is wrong with U.S. health care - and with the medical profession - then ObamaCare is going to be even worse than we thought. The point Mr. Obama oversimplified is that the way the U.S. pays for medical services can encourage some physicians to prescribe unnecessary tests or treatments, especially in Medicare. But his implication is that doctors aren't acting in the best interests of their patients in order, basically, to rob them.

Actually it is President Obama and Congress who are not acting in the best interest of our patients and basically are robbing them.

Incentives matter, yet maybe the truth is that medicine is a highly complex science in which the evidence changes rapidly and constantly. That's one reason tonsillectomies are so much rarer now than they were in the 1970s and 1980s - but still better for some patients over others. As the American Academy of Otolaryngology put it in a press release responding to Mr. Obama's commentary, clinical guidelines suggest that "In many cases, tonsillectomy may be a more effective treatment, and less costly, than prolonged or repeated treatments for an infected throat."

OK, WSJ, let's not talk above the heads of President Obama and Congress. Let's get it to the second grade level.

Mr. Obama seems to think that such judgments are easy. "If there's a blue pill and a red pill and the blue pill is half the price of the red pill and works just as well," he asked, "why not pay half price for the thing that's going to make you well?" But usually the red and blue treatments are available - as well as the green, yellow, etc. - because of the variability of disease, human biology and patient preference. And the really hard cases, especially when government is paying for health care, are those for which there's only a red pill and it happens to be very expensive.

But Mr. Obama and Congress will only pay for the yellow pill. That it may not help is irrelevant.

Under the system Democrats are trying to ram through Congress, these case-by-case choices, currently made between patients and care-givers, will gradually be replaced by rigid government schemes. "Part of what we want to do is to make sure that those decisions are being made by doctors and medical experts based on evidence, based on what works - because that's not how it's working right now," Mr. Obama said. We await the President's evidence that the nation's pediatricians are striking it rich with unnecessary tonsillectomies.

Wait a minute. When did Pediatricians rather than surgeons do Tonsillectomies?

Printed in The Wall Street Journal, Editorial page A14

This is a recurring naďveté for Obama and Congress. They seem to think that the person that makes the decision to do an expensive surgery rather than a medical treatment is the same doctor. With such a magnitude of misunderstanding and ignorance, we should bar Obama and Congress from being involved in any health care revision. Such stupidity can only worsen the world's best health care. -Editor

To read more HHK, go to www.healthcarecom.net/hhkintro.htm.

To read more HMC, go to www.delmeyer.net/HMC.htm.

Feedback . . .

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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. This month, read Nancy Pelosi admitting that Democrats may have to impose a huge new tax on the middle class to fund their spending ambitions. . .

                      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. Be sure to read Mr. Graham's evaluation of Governor Jindals Grab Bag of ten "ideas" which collapse into incoherence . . .

                      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. This month, read the Policies that Produced the Financial Crisis of 2008 . . .

                      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. This month, you might focus on Why the Rush on Health Care. . .

                      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?. This month, be sure to read about Obama's health plan: Rationing, Higher Taxes, and Lower Quality 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: Why the Government fails on maintaining anything. . .

                      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. Read about HealthCare Innovations . . .

                      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. This month, read an analysis of Paul Ehrlich and Deconstructing The Population Bomb.

                      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. Read their public policy review . . .

                      The Heritage Foundation, 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. -- 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, they have lost site of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions.

                      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 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 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, 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.]

                      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.

                      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 17th 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, read Walter Williams on the Future Prospects of Economic Liberty at www.hillsdale.edu/news/imprimis.asp. The last ten years of Imprimis are archived.

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Words of Wisdom - by Will Rogers

"We all joke about Congress, but we can't improve on them. Have you noticed that no matter who we elect, he is just as bad as the one he replaces?"

"When Congress makes a joke it's a law, and when they make a law, it's a joke."

"Never blame a legislative body for not doing something. When they do nothing, they don't hurt anybody. When they do something is when they become dangerous."

"About all I can say for the United States Senate is that it opens with a prayer and closes with an investigation."

"There is something about a Republican that you can only stand him just so long; and on the other hand, there is something about a Democrat that you can't stand him quite that long."

Some Recent Postings

www.healthplanusa.net/archives/October09.htm

www.healthplanusa.net/archives/July09.htm

www.healthplanusa.net/archives/April09.htm

www.healthplanusa.net/archives/January09.htm

In Memoriam

Irving Kristol, father of neoconservatism, died on September 18th, aged 89

From The Economist print edition Sep 24th 2009

www.economist.com/obituary/displaystory.cfm?story_id=14492286

REGRETS were very few in Irving Kristol's long, happy and disputatious life. He had none at all for his youthful flirtation with Trotskyism, over coffees and egg sandwiches, in gloomy Alcove 1 at City College in New York; Trotskyism had taught him to think and theorise, and as a bonus it had drawn him to meet, and fall in love with, the slim and brilliant Gertrude Himmelfarb. No regrets, either, for the fact that when he edited Encounter magazine with Stephen Spender in the 1950s it was subsidised by the CIA; secret subventions to intellectual endeavour were probably rather a good way to counter anti-Americanism in Europe. No lingering sadness for that novel he put in the incinerator; he knew his forte was as a journalist and a formidable essayist, not a book-writer. And none at all for the lean circulation of his magazines, from Encounter to the Public Interest to National Affairs, because "with a circulation of a few hundred, you could change the world." And he did. . .

The unrepentant bourgeois

Mr Kristol's scepticism came from his roots on the left. He belonged essentially in the Democratic Party of Roosevelt and the New Deal, the natural place for the son of a struggling Brooklyn clothes-dealer. By 1968 he was still a short, sharp Hubert Humphrey Democrat, faute de mieux. But he had become steadily disenchanted with Lyndon Johnson's vast social programmes and the view of human nature they assumed. The poor were without hope or gumption, living on handouts from the government; above them loomed a "New Class" of educationalists, criminologists, lawyers and planners, who made up an anti-capitalist establishment he proposed to take apart.

Mr Kristol couched his attack in their language, that of social science. There was no social action, he wrote, that was not subject to the law of unintended consequences. If the poor were given handouts, it encouraged dependency. If they were helped with preferential programmes, they ceased to strive. Suddenly, the voice of rigorous scientific methodology was coming from the right, not the left.

The start of Mr Kristol's rightward drift was assigned various dates, from his (unregretted) argument in 1952 that communists had no claim to civil liberties, to the founding of the Public Interest in 1965. The convulsions in America's universities from 1968 to 1971 probably shook him most, revealing not only the nihilistic horrors of the counter-culture but also how deeply he himself believed in traditional bourgeois values. To defend these, as much as anything, he soon found himself inside that "alien entity", the Republican Party.

Yet neoconservatism, for him, was never an ideology. To be ideological was "to preconceive reality", which he refused to do. He preferred to call it an "impulse" that had simply made conservatism better. First, it had made it intellectual. Second, it had given it a moral and philosophical dimension (expressed, in the early 1980s, in an alarming Faustian alliance with evangelicals), for conservatism without religion was "thin gruel". And third, it had cheered the right up. For Mr Kristol, nostalgia in politics was pernicious. He looked resolutely forward, delighting in the fact that his son and daughter, as well as the dozens of interns who had weathered his bright-eyed brashness at the Public Interest, had all become good conservatives "without adjectival modification".

On This Date in History - October 13

On this date in 1792, George Washington laid the cornerstone of the President's Mansion.

On this date in 1775, the first U. S. Naval Fleet was authorized.

After Leonard and Thelma Spinrad


MOVIE EXPLAINING SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE's SiCKO

Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements is the former publisher of "American Venture" magazine who made news in 2005 for a property rights project against eminent domain called the "Lost Liberty Hotel."
For more information visit www.sickandsickermovie.com or email
logan@freestarmovie.com.