MEDICAL TUESDAY . NET
Community For Better Health Care
Vol VI, No 11, Sept 11, 2007
In This Issue:
The Annual World Health Care Congress, 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. Last year it was 50 percent, 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. This 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 World Health Care Congress - Middle East will be held in Dubai, United Arab Emirates, on November 12-14, 2007. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2008. The 4th Annual World Health Care Congress - Europe 2008 will meet in Barcelona on March 3-5, 2008. The 5th Annual World Health Care Congress will be held April 21-23, 2008 in Washington, D.C. For more information, visit www.worldcongress.com.
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1. Featured Article: A New "Designer" Treatment for Multiple Sclerosis, Scientific American, By Nikhil Swaminathan August 28, 2007
Research shows that estrogen can be used to counteract nerve cell degeneration caused by MS without increased risks of breast and uterine cancers
Researchers have proposed a new treatment for multiple sclerosis (MS) that utilizes the hormone estrogen to stave off and even reverse some of the mysterious disease's debilitating symptoms without the dangerous side effects of some other hormone therapies.
MS is largely believed to be an autoimmune
disease in which the immune system turns on healthy tissue - in this case in
the brain and nervous system. Current treatments include medicines designed to
suppress an overactive immune system and reduce inflammation, a first-line
response of the immune system. Whereas Copaxone and other such drugs often
improve some of the muscle weakness and movement issues associated with the
condition, they do little to combat the accompanying neurodegeneration.
To read more, please go to www.medicaltuesday.net/index.asp .
In recent years, researchers began focusing on the potential of estrogen in battling MS after observing that the disease went into remission during pregnancy. "Pregnant women had this beautiful effect their estrogen levels went skyrocketing," says Seema Tiwari-Woodruff, an assistant professor of neurology at the University of California, Los Angeles, and lead author of a study on estrogen as a potential MS treatment published in Proceedings of the National Academy of Sciences USA. "As soon as they had the baby, the MS came back, and more drastically."
In the body, estrogen binds to two types of receptor proteins in cells: estrogen receptor α and estrogen receptor β. The former - often referred to as estradiol - is known to play a role in mediating the effects of tumor-causing agents - and a major risk of estrogen treatments is the increased risk for breast and uterine cancer in women. Estrogen receptor β has no known connection to tumor cell proliferation and, thusly, the research team believed it may present a better treatment option.
The U.C.L.A. team was able to target specific receptor proteins in a mouse model of multiple sclerosis by attaching receptor-specific compounds to estrogen. Young adult female mice (five to six weeks old) were given a compound that induced encephalomyelitis, an autoimmune condition similar to MS. Some of the infected animals immediately received estrogen targeted to the α receptor, whereas others received the β receptor-specific hormone.
The α group did not develop any MS symptoms; the animals did not display any movement effects or damage to nerves or to the myelin (protective sheath) on the cells' axons, which transmit information - in the form of electrical impulses - away from neurons. Tiwari-Woodruff notes that despite the heartening result, researchers are not sure exactly why it works. "We don't know if it was stopping inflammation," she says, "or directly stopping the degeneration of neurons and axons."
The mice that received estrogen targeted
to the β receptor initially developed signs of MS, including difficulty
maintaining balance and a generally slower gait. The scientists say there was
inflammation throughout these animals' central nervous systems. But some 20
days later, these mice began to show improvements in motor control, eventually
regaining the ability to walk normally - and despite inflammation there was no
neurodegeneration, which typically occurs at this stage of the disease.
"This is the first time," she says, "a hormone treatment has
been described [that works] without touching the inflammation part" of the
equation. . . To read the entire article,
go to (Subscription required)
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In the News: This Won't Hurt a Bit, Forbes,
No company benefits more than WellPoint from the current health care mess. New chief executive Angela Braly is trying to put a kind face on this controversial business.
Two months into her job as chief executive of health insurance giant WellPoint, Angela Braly, number 16 on FORBES' list of the World's Most Powerful Women, is on a listening tour in New Haven, Conn. She makes a halfhour stop in the office of Marna Borgstrom, the head of the Yale-New Haven Hospital. Yale offers a WellPoint plan to its 20,000 hospital employees, who each get full coverage - unlike many of the patients who use the hospital. Borgstrom is worried about the cost of caring for uninsured folks and deadbeats. She favors some kind of government intervention.
Braly makes the case that the American system could be
worse, the if-it-ain't-broke argument. "In China they roll you out of the
hospital if you run out of cash," Braly tells Borgstrom. She's skeptical
that government can come to the rescue and predicts that Medicare will run out
of money in 2014, five years sooner than forecasted: "I think partnering
[among insurers, health providers and employers] on cost and quality is the
only solution." Braly plugs WellPoint's incentive policy - paying hospitals
more when patients have fewer complications. She also describes a new bonus
system that pays WellPoint workers more if the overall health of its 34 million
members goes up. As the meeting ends, the two women wish each other luck, their
views apparently unchanged.
To read more,
please go to www.medicaltuesday.net/news.asp .
At the youthful age of 46, with only a few years of operational business experience, Angela Braly has become the most powerful woman in health care. Her company provides coverage to one in nine Americans, more than better-known UnitedHealthcare, Cigna or Aetna. The 42,000-employee behemoth runs Blue Cross and Blue Shield plans in 14 states. It's the biggest corporation in the world with a woman on top, its sales of $56 billion bigger than those of Pepsi, Archer Daniels Midland, Kraft or Xerox.
But in today's heated debate over reforming health care, Braly might wish at times she ran a less visible company. Well- Point's strength has made it a fat target for people who think that for-profit health insurers are callous and evil. Earlier this year the company settled lawsuits with ten patients who claimed that their policies were canceled after an injury or diagnosis. (WellPoint had argued that they had concealed preexisting conditions.) Doctors in several states have filed class actions claiming WellPoint plans withhold payments. It's the only health insurer in California actively opposing Governor Arnold Schwarzenegger's plan to provide everyone with health insurance.
In her slow Texas drawl, Braly, who was WellPoint's general counsel before getting the top job, understands her challenge: "A Senator told me recently: It's going to be a bumpy road, and you will be the shock absorber.'"
Underneath the friendly veneer is a hardheaded negotiator who grew up professionally in the health-care-industrial complex and is not about to roll over for the likes of Michael Moore. While she talks about health care reform, she insists it must be done by the private sector, and in measured steps. Her success as a chief executive and public figure will depend on whether she can smooth out bumps in the health care system while fending off government intrusion - and keep Well- Point a money machine.
Earnings (including acquisitions) have risen 55% a year on average since 2000, to $3 billion, while revenues have grown 37% a year. It does big acquisitions without losing members, a fate rivals regularly experience. Its health plans have 30% to 60% market share and offer the widest networks of doctors and hospitals. Warren Buffett just quadrupled Berkshire Hathaway's stake in the company to 4 million shares, even though the growth in what WellPoint can charge is starting to slow (See charts at the URL)
WellPoint's history goes back to the 1980s, when for-profit insurers started winning business away from nonprofit Blue Cross-Blue Shield companies. In response, many Blues combined and started writing policies using data on medical histories rather than offering the same deal to everyone in a given community regardless of risk. The pushiest Blues converted to for-profit, investor-owned companies. The final result was WellPoint, now worth $48 billion, formed after Indianapolis insurer Anthem, led by Larry C. Glasscock, bought the larger Well- Point in 2003 and took its name. Of the 100 million Blues customers, a third are part of WellPoint . . .
Two years later WellPoint, which had started as Blue Cross of California, bought RightChoice for $1.3 billion. In August 2003 Braly finally got her chance to run the Missouri business, but her time in an operating position was cut short by another promotion a year and a half later, this time to general counsel of the national holding company in Indianapolis.
There she clicked with WellPoint chief Glasscock and rode shotgun to finance chief David Colby on the $6.5 billion purchase of New York's Empire Blue's plans in 2005. Then came the shocker. In February Glasscock, who is only 58, announced he was retiring to tend to a family matter.
How Braly, a dark-horse candidate, was selected to replace Glasscock is a matter of some office intrigue. In WellPoint's last proxy statement she was not even considered a top-level executive. . .
Ultimately the board gave her the job because she has "no ego," is a good listener and was skilled at public policy, says William Ryan, a board member and chairman of TD Banknorth in Portland, Me. The conference call announcing it was awkward. Stock analysts pounced on why Colby or Watts had not been chosen. "You can't get annoyed that easily or take it personally," shrugs Braly, whose new contract includes $2.4 million in salary and bonuses, plus 410,000 options. . .
Braly officially wants WellPoint to remake the health care system by turning individuals into health consumers. It trumpets Tonik, a $77 per month health plan for young people who go without coverage because they freelance or work in retail. It covers a few visits a year and then goes to a high deductible. WellPoint has expanded it to seven states. But despite the hype, after two years WellPoint has sold only 70,000 policies. "Tonik has gotten more press coverage than members," says David Olson, a senior vice president at rival California HMO Health Net.
And for all the talk of individual directed plans, the company is still reliant on traditional full-coverage corporate accounts. Sales chief Watts recently landed Bank of America and Kroger as national clients. Is there a plan to move big accounts such as these to consumer directed plans, which are cheaper for employers and fit into WellPoint's vision? Nope, says Watts, because such a move would hurt profit margins. Rather, he says, consumer plans like Tonik will be used only to reach new customers. . .
Then there's California, where Well- Point's image has taken the worst beating. WellPoint plan California Blue Cross has been savaged in newspaper articles and at the Capitol for retroactively canceling plans of sick members who it says falsified their applications. One woman who withheld information about a yeast infection and later got her policy canceled ended up blasting the company in Michael Moore's Sicko. (WellPoint says privacy laws and lawsuit settlements prevent it from explaining what really happened.)
WellPoint is spending $2 million to attack Schwarzenegger's health plan; one ad compares it to the electricity deregulation that led to blackouts in California. Braly argues that Schwarzenegger's plan, which requires that insurance companies open the door to all applicants, will fail because healthy people will not buy insurance until they get sick, sending the market into a "death spiral." She says that in states where insurers must offer coverage to everyone regardless of their health, premiums are three times as high. "You need to protect the individual market. Right now it's very affordable," she says. Braly claims that the Massachusetts universal coverage plan, which is based on similar principles, is falling apart for the reasons she cites, though insurance companies there deny that is the case.
Braly's stance annoys not just the governor's office but also WellPoint's rivals. "We have spent a lot of time trying to talk them into a more progressive position," says George Halvorson, head of Kaiser Permanente, the second-biggest health plan in California after WellPoint's Blue Cross subsidiary.
Expect a standoff, for which Braly is ready. "People will say, Why don't you line up behind the governor?'" she says. "That's not who we are." She recounts some good advice she once received: "You have to know who you are because people will always tell you who you should be."
To read the entire article, go to http://members.forbes.com/forbes/2007/0917/116.html?partner=alerts.
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3. International Medicine: Whistleblower: Surgeon breaks cover over NHS beds crisis, The Independent On Sunday, Exclusive report by Andrew Johnson and Marie Woolf, 29 July 2007
One of Britain's leading trauma surgeons has broken cover to expose the scandal of a national shortage of emergency trauma beds which is leading to thousands of serious injury victims suffering in agony.
In an unprecedented intervention by a senior practitioner in the NHS, Martin Bircher, a consultant at St George's hospital in London, one of Europe's leading centres in the treatment of major accident victims, has revealed a system paralysed [sic] by red tape and disputes over funding, which is putting thousands of patients waiting for treatment in specialist wards at risk.
His revelations have prompted calls for a review of funding for A&E services and a shake-up in the management of Britain's leading trauma centres [sic].
Mr Bircher says the problem is worsened by the
bureaucracy of the internal market. He has become so frustrated that he has
broken free of NHS strictures against speaking to the press and agreed to talk
to The Independent on Sunday about the suffering patients are put through.
To read more, please go to www.medicaltuesday.net/intlnews.asp .
Every one of Britain's specialist trauma beds is full, which means some patients can wait up to three weeks after their accident before badly broken bones can be repaired. The delay, says Mr Bircher, can jeopardise recovery. With nothing but praise for frontline staff, he says patients who have been critically injured in road or other accidents have to wait an average of 12 days - often in agonising pain - before they can receive the vital specialist treatment.
This is because only a limited number of hospitals have the expertise to repair smashed bones, and those hospitals have a shortage of intensive care beds. With the average cost of keeping a trauma patient at around £500 a day and up to £2,000 a day in intensive care, this is also a false economy. . .
Squabbles over funding
Mr Bircher, who risks censure from the NHS for speaking out, said primary care trust and bed managers are involved in making the final decision as to whether a patient can be moved. If they have to move them there is often a conflict or reluctance because the new area does not want an extra cost. So after initial admission to a general hospital's emergency wards, where lives are saved, patients can find themselves waiting up to three weeks before their real recovery process can begin. . .
Delays in treatment
He said: "The delays are caused at various levels. If doctors, nurses, physiotherapists, the treating teams, were left to communicate between themselves without bureaucracy, things would happen much more quickly. In the good old days somebody would ring me up about a patient, I'd say send them across, make one call to sister on the ward and it would happen.
"Now I'm loath to accept a patient unless I'm sure their injury requires surgery. If I'm unsure I ask them to send X-rays. Even in this technological age this can take two or three days. It's not unusual for them to be delayed or get lost . . .
"You can argue whether a patient needs a hip replacement at hospital x or y," he added. "As long as it's done in a reasonable time by a good team it doesn't matter. You can't have these petty squabbles. There just isn't time with trauma."
Patients in pain
His argument is illustrated by Lucy Lynn-Evans, a 21-year-old student from London who was severely injured in a road accident last month. She was riding her scooter to Brighton when she was run over by a 10-tonne lorry which came to rest on her hip. She is alive only because a laptop in her backpack took the full force when the lorry ran over her spine. Her life was saved a second time by the staff at Redhill hospital, where she was initially taken with a smashed pelvis, smashed knee and leg broken in two places. They gave her a blood transfusion - she had lost five pints - and wrapped her hip, described by doctors as a "bag of crisps", in a sheet which was then pulled tight to keep the fragmented bones together.
This is the correct procedure. But Redhill hospital did not have the expertise to repair Ms Lynn-Evans's bones. That would require specialist surgeons and equipment that can be found only in certain hospitals around the country. All they could do in Redhill was put her on morphine and wait for a bed which at one point she was told could take up to three weeks. . .
Lack of beds
Ms Lynn-Evans's problem was that she was stable and not going to die; when a bed became available it would go to another more pressing case. At one point a bed became available at the John Radcliffe hospital in Oxford, but before she could be moved John Radcliffe's fund manager had to agree. The fund manager did not arrive at work until 9.30am. By the time Ms Lynn-Evans's case came to the top of the administrator's pile and permission was granted, the bed had gone. . .
"The delays not only cause distress to families and patient, but other serious medical issues - thrombosis, bed sores, chest infections and urine and wound infections," said Mr Bircher. "The longer the bone fragments are left displaced, the more the clot begins to form new bone, thus the harder it is to replace the fragment to the correct position.
"The first step to dealing with the problem is an acceptance and realisation that the system isn't working with trauma and other emergency services in medicine. Sending each other forms and bills is not a good way of doing it. I'm acutely aware that resources are an issue. But basic emergency services should be of the highest quality. If we consider ourselves a leading nation we should have a first-class emergency healthcare system. We do not, and the situation is worsening.
"It's pot luck where you go. There's not a defined system. We have to fight every day to get patients in. We have to break through the bureaucracy and develop a new system. There is a lack of intensive care beds in London and around the country which further magnifies the problem. . .
Further reading: 'NHS plc: The Privatisation of Our Health Care' by Allyson M Pollock (Verso)
The NHS does not give timely access to healthcare, it only gives access to a waiting list.
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Two years ago, Blue Shield and the California Public Employees' Retirement System booted 13 Sutter hospitals out of its health maintenance organization network, saying they cost too much.
Now, the health plan and giant benefits group are taking a similar -- and controversial -- approach to individual physician groups. In January, local Mercy doctors will be excluded from a new, lower-cost Blue Shield plan available to CalPERS members in 17 counties, including most of Greater Sacramento.
State Physicians Medical Group Inc, also will be shut out of the new plan. The
only doctors available in the new "high-performance network" will be
those with UC Davis Health System and local doctors affiliated with San
Ramon-based Hill Physicians Medical Group Inc
. . . To
read more, please go to www.medicaltuesday.net/medicare.asp .
Medical groups were judged on clinical data and patient satisfaction surveys used in the pay-for-performance program run by the Integrate Healthcare Association: and from a separate assessment of grievances, appeals, and complaints. . .
Blue Cross of California next year will for the first time offer to CalPERS members a preferred provider organization network with a narrow doctor panel. The narrower PPO will be available in 54 counties, including Sacramento, El Dorado and Yolo. It also was narrowed based on cost and quality and is cheaper than its counterpart, PERS Choice. But far fewer CalPERS members are signing up for with PPO Plans.
The plan, approved by the CalPERS board in June when it adopted new premiums for 2008, finally makes a business case for groups that support high-quality medicine, said Steve McDermott, CEO of Hill Physicians. Doctors who provide quality care at a reasonable price stand to reap more business, while the rest could lose patients.
It also stands to make Blue Shield competitive in price with Kaiser Permanente in the CalPERS program, possibly prompting Kaiser members to switch plans, McDermott said. This could bring a significant bump in enollment for the selected groups overall. . . To read the entire article, go to (subscription required) www.bizjournals.com/sacramento/stories/2007/08/27/story1.html?ana.
[Ever feel like doctors and patients can be traded like commodities or ball players?]
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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Mr. Moore had shortness of breath, a cough with some phlegm. His family insisted on taking him to the emergency room of the local hospital. A simple course of antibiotics should have been sufficient.
Instead he had extensive x-rays, an ECG, CT exams,
numerous laboratory tests and was told he had an infection. However, he was
discharged. When the doctor reviewed his work later the next day, he noted that
he had failed to treat his infection and the patient was called in to get an
intravenous infusion of antibiotics.
To read more,
please go to www.medicaltuesday.net/gluttony.asp .
On his return, the ER couldn't find his records and so proceeded to obtain additional x-rays, an ECG and laboratory tests to confirm the logged in diagnosis and proceed with the antibiotic infusion. He had no chills or fever.
Before the infusion was completed, the old records were found and he was given a prescription for additional oral antibiotics.
When he came in today for the standard one-week later ER follow up, he brought in both ER records which proved to be nearly identical. Now he was worried if this infection that was discovered could be life-threatening and questioned whether he should be on more antibiotics or possibly be admitted to the hospital for intensive treatment. The examination failed to reveal any evidence of infection. It took considerable time to allay his anxieties produced by the excessive testing and comments in the ER.
If his family had allowed it, the estimated cost of coming to the office would have been for an office call and a prescription, or a total cost of about $150. The estimated costs of an ER visit, if he only saw the doctor and obtained a prescription, is on the order of five to ten times the identical office evaluation. However, as our last newsletter pointed out, ER physicians don't have a longitudinal history of a patient and those standards are entirely different, which explains the five- and ten-fold costs over the patient's personal physician. To then duplicate those costs and pay the hospital charge for two ER visits, the extensive x-rays, ECGs, CTs laboratory tests, and antibiotic infusion is why ER visits can be as high as 50- to 100-fold more expensive as we have enumerated in these pages over the years. No system can sustain costs of such exorbitant magnitude.
Then how can such gluttonous behavior be stopped? Medicare and Medicaid have not been effective in controlling costs, even with all the restrictions and controls the government has implemented. Standard first-class health insurance has not been able to control costs even as the fixed-dollar co-payments have increased. Health maintenance organizations (For profit HMOs) have not controlled costs, even with the $billions spent on policing and controls on doctors and hospitals.
Patient-directed health care (PDHC) plans, where patients are responsible for some percentage of every charge levied against their health plan, is the only mechanism that can control costs. If every day in the hospital costs the patient a certain percentage of that day's charge, if every visit to the ER costs the patient a certain percentage of every test done in the ER, or if every visit to the doctor or lab or x-ray costs the patient a certain percentage of the charge on the office visit or test, then this gluttonous behavior will be stopped in its tracks.
Unfortunately, the players are against such logical behavior. Hospitals, insurance companies, physician organizations, unions, employers and the government would not dare implement such a plan even though actuarial estimates that such a plan would save 30 to 50 percent of health care costs. This innovation will have to come from the private sector. It would take someone on the order of Bill Gates, Sergey Brin, Larry Page, Andrew Grove, Gordon Moore or William Buffet to implement such an innovation. This would place their accomplishment into the Annals of the Greatest Health Care Event of the twenty-first century on the order of our Constitution, which changed the world order in the eighteenth century. It would easily merit the first double Nobel Prize in Medicine and Economics.
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6. Medical Myths: Universal Care Myths, by Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
I expected the Buffalo News, a very liberal
newspaper, to have a litany of praises for Michael Moore's movie Sicko
and a story on how wonderful universal care is for Canadians. I was shocked to
read the headline story on July 29 about a man who almost certainly would be
dead now had he waited to receive "universal care" for his brain
tumor. He had an MRI done in Buffalo rather than waiting 4 months in Ontario.
Armed with a study that showed a possibly malignant tumor, Lindsay McCreith
headed home to Canada. The next available appointment with a neurosurgeon was
in 3 months.
To read more, please go to www.medicaltuesday.net/myths.asp .
Back to Buffalo he went for a biopsy that showed low- grade astrocytoma, which was immediately removed. Reimbursement was refused because he failed to get pre-approval which also takes months. McCreith is now suing the government for violating his right to life, liberty, and security, the same approach taken by Dr. Jacques Chaoulli in Quebec. Each province has it own ban on private insurance. If successful in Ontario, this would be a big win for freedom in medicine in Canada. The trial is scheduled soon. www.aapsonline.org/newsletters/sept07.php
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Dr. Edwards: Our office building was sold and to bring the heating, air, plumbing, electricity, elevators and restrooms all up to code, they increased our rent 80 percent.
Dr. Milton: I understand three-fourths of the building moved out.
Dr. Edwards: We got out within 30 days of the notice and moved into more reasonable quarters at half the rent.
Dr. Michelle: That should be the easy part. We moved twice in two years. But changing addresses proved to be the biggest hassle.
Dr. Edwards: We're just finding that out. When we gave our notice to the Landlord in May that we'd be out in 30 days, we immediately began notifying all the patients, our business contacts and our insurance carriers. We thought it would require just a simple change of address form.
Dr. Michelle: Welcome to the bureaucratic world of medicine.
Dr. Edwards: I
don't think you can blame medicine. The bureaucratic hassles were all
To read more, please go to www.medicaltuesday.net/lounge.asp .
Dr. Michelle: Well, just Medicare and Medicaid which were somewhat more involved. It took about a month longer to square them away. That was about two years ago. Have things changed?
Dr. Edwards: Our simple change-of-address notices were received with a note that we had to access their websites, print out a change of address form and complete the application process. So we did.
Dr. Michelle: And so was everything fine as soon as they received it?
Dr. Edwards: Maybe that was two years ago. But on July 15, we received a rejection notice stamped "Received June 15, 2007" stating that the forms were incomplete and were returned. When reviewing the new forms, they were essentially identical to the old forms - both the seven-page initial form and the 17-page detailed version. We completed them again, paying attention to their comments, and two weeks later, they were again returned for additional information. So now at three months, what we thought a simple change of address within the same city and zip code, we still have not yet heard if the third completion was accepted. We have not received any payment for the work done these past four months.
Dr. Dave: We've had a very similar experience, only our Medicaid harassment was even worse. It took more than four months, then we had to serve a 12-month probation, which we didn't have to do when we first started some twenty years ago. We were treated like a new employee.
Dr. Rosen: We shouldn't forget the now third great government bureaucracy, the National Provider Identifier Number (NPI). This has now been expanded to include health plans and a large bureaucracy. The National Plan and Provider Enumeration System (NPPES) has been developed. Remember when the Medicare and Medicaid sites said it just takes 20 minutes to apply for the NPI number?
Dr. Milton: When this was implemented last year, that's about how long it took me.
Dr. Rosen: With our recent move, we had to go through a lengthy reapplication with two rejections, just like Medicare, and it took about two months. This number is also required before Medicare and Medicaid will make payments.
Dr. Michelle: Well, I must say it was very simple to work with Blue Cross, Blue Shield, HealthNet and others.
Dr. Bob: Let me toss out another caveat. I retired the end of August. I started notifying insurance companies in June that my patients would be seeking other physicians. I made the huge mistake of notifying Medicare and Medicaid. Since June, we have not been reimbursed by Medicare or Medicaid for any work we billed since that date, which included some of our May work.
Dr. Michelle: You've got to be kidding.
Dr. Bob: No I'm not. For two months, we've been trying to figure out how to break into this bureaucracy and get paid and have been totally unsuccessful. So, when you retire, don't tell the government for at least six months after your last patient and until all your accounts receivable have been worked over to as close to zero as you can get them. Don't ever trust the government, especially when they say, may we help you.
Dr. Rosen: Wait till patients have to wrestle with such a condescending bureaucracy to obtain health care when the only provider is the government, whether Medicare, Medicaid, Schip Program or A Single-Payer HealthCare program. The mortality from the wait period will exceed the dangers of the flu pandemic, whether bird or swine variety. Only then it will be too late. And there won't be any treatment or antidote.
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From San Francisco Medicine: A Symposium on Medicine and Religion, May 2007
Editorial: Religion and Healing Mike Denney, MD, PhD
to Harold G. Koenig, MD, director of the Center for the Study of Religion, Spirituality,
and Health at Duke University Medical Center and author of many books, including Spirituality in Patient Care: Why,
How, When, and What, "There have been more than 1,200 studies on
religion and healing. Two-thirds to
three-fourths of them find a link between religious practices and physical and
emotional well-being. For example, religious patients are less likely to be
depressed or anxious than others, and they're more likely to be in better
physical health, with better-functioning immune systems and lower blood
To read more, please go to www.medicaltuesday.net/voicesofmedicine.asp .
On the other hand, scrutiny of scientific studies of religious effects upon healing has exposed serious flaws. Lynda Powell, PhD, epidemiologist at Rush University Medical Center, reviewed nearly 150 studies on religion and healing and, noting scientific weaknesses, concluded that although subjective faith has its place in relieving suffering, it cannot be said to influence objective physical outcomes of disease. Reporting in The Lancet, Richard Sloan, MD, Professor of Medicine at Columbia University, cites weak data and erroneous logic. After evaluating the literature, Sloan says, "Doctors should feel free to refer patients to hospital chaplains, but that's as far as the religious conversation should go."
Religious leaders have also criticized scientific study of spiritual beliefs, noting that to reduce God to biomedical statistics may be an arrogant affront to the divine. Raymond J. Lawrence, an Episcopal priest and director of pastoral care at New York-Presbyterian Hospital of Columbia University, states flatly, "Scientists who undertake the work of theologians are as reckless as theologians who pretend to be scientists."
Viewed from a mythological and historical perspective, these opposing arguments may seem superfluous. Religion has always been closely associated with sickness, health, and healing. The Encyclopedia of Religion (Macmillan) notes, "Healing occupies a singular and prominent place in religious experience throughout the world. Often the most important figure or symbol in any given religious tradition is the source of healing." In their book Future Science, John White and Stanley Krippner offer names for spiritual healing energy from ninety-seven different cultures . . .
Yet our objective science seems inadequate when it comes to measuring those religious aspects of healing that seem to be inborn. Many psychologists and philosophers, including Freud, Jung, Hume, and Kant, have described an innate natural propensity in humans to seek the divine. William James, the father of American pragmatic psychology, speaking of religious experiences, put it this way, "Treating these as purely subjective phenomena, without regard to the question of their truth,' we are obliged, on account of their extraordinary influence upon action and endurance, to class them amongst the most important biological functions of mankind." At the very least, we accept the fundamental subjective reality that there seems to be something rather than nothing - and we can become awestruck when contemplating whence that "something" came. And when we become sick, our awe may turn to deep concern about our own place in the cosmos.
And so it is that as in this issue of San Francisco Medicine we contemplate the place of religion in medicine, we quite naturally accept the reality that sick patients experience a relationship with the mystery of life and death. With articles on the many facets of the relationship of medicine and religion, we find a salutary union of objective science and subjective faith working together to heal both body and soul. In the words of the great theologian Paul Tillich in the book The Meaning of Health, "Only a medicine which denies the nonbiological dimensions of life in their significance for the biological dimension can come into conflict with theology. An understanding of the differences as well as the mutual within-each-otherness of the dimensions can remove the conflict and create an intensive collaboration of helpers in all dimensions of health and healing."
To read the entire article, go to
To review the entire symposium, go to www.sfms.org/AM/Template.cfm?Section=SF_Medicine_Magazine&Template=/CM/HTMLDisplay.cfm&ContentID=2316.
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9. Book Review: Current Books, from Sonoma Medicine: Nice Car By Brien A. Seeley, MD
Questions of Value, by Patrick Grim, "Great Courses" lecture series, The Teaching Company, $35 and up, www.thegreatcourses.com.
The state of happiness comes down to engaging in
activities just beyond our skill level.
At about age 5, my daughter liked to play the game of "What would you rather have?" She would ask questions like, "What would you rather have, a nice car or a swimming pool? No arms and no legs or be blind?" Such conscious explorations of values are important to children. They learn early on that every act involves a choice, and that, in order to choose well, one needs to prioritize values.
Prioritizing values is what philosophers do, and they do it as a science, by rationally testing their theories against the history of human culture and individual behavior. Philosophers argue that some things are far more valuable than a nice car. Indeed, philosophers examine the deeper questions in life that are the fundamental drivers of how we choose to live. Their teachings about the hierarchy of values have perhaps never been more relevant to physicians than in today's medical system.
SUNY philosophy professor Patrick Grim, in a series of 24 half-hour lectures entitled "Questions of Value," laments the fact that people so often lead unexamined lives, growing up and starting a family and career without ever deliberately prioritizing their values. They go through life as mere spectators, spending the only life they have by passively accepting value systems imposed by others, falling victim to peer pressure and advertising buzz. To remedy such passivity, Grim says that we should each write down our own Big List of Values, and then carefully prioritize them. Only then, he claims, are we able to commit to an examined life with a direction and purpose clearly aimed at what we value most. Only then do we live our lives to the fullest.
To read more, please go to www.medicaltuesday.net/bookreviews.asp .
To aid that effort, Grim presents a starter list of "good things," including accomplishment, freedom, recreation, intelligence, fame, honesty, love, a good education, fun and adventure, money, romance, safety, respect, meaningful work, a fulfilling sex life, generosity, a big house, and a nice car. He points out that some of these "good things" have intrinsic value (e.g. freedom), while others have merely instrumental value (e.g. money). He lumps together things that are good to do, good to be, and good to have. The Big List also includes more than just ethical and moral values. Grim's lectures deal with axiology, the study of values in general, and as such also cover spiritual, aesthetic, communal, character, material, relationship, and knowledge-seeking values. As we begin prioritizing the Big List, we must ask, "Is there a single highest good, and how does one choose it?"
invites the listener to explore these questions from every angle by supplying a
comprehensive, elegantly interwoven critique of classic and modern
philosophies. His lectures encompass a wide range of topics, from religion and
business ethics to hedonism versus self-sacrifice; from immortality,
conscience, the greater good, and capital punishment to the value of a life,
Darwinism, game theory, and free will. This philosophic tour de force amounts
to a tool kit to help listeners compose and manage their Big List of Values and
The lectures lead off by cautioning listeners to be on guard against arguments that use so-called "is-ought" syllogisms to define values. In 1739, David Hume famously pointed out the flaw in such derivations, which array several "is" statements of fact toward a final, non-factual "ought" statement that sneaks in a value judgment unsupported by the facts. A medical example would be as follows: Fee-for-service health care "is" expensive. The premium for fee-for-service "is" negotiable. It "is" a fact that premiums can be reduced by corporations or governments that unionize patients into large groups. It "is" a fact that such large groups can demand that physicians work for less money. A physician "is" forbidden from unionizing to resist such demands. Reducing premiums "is" a way to make health care affordable for more people. Therefore, unionizing patients to force doctors to work for less "ought" to be done.
The utilitarian value judgment in the final sentence disregards the rights of individual physicians. Note also that the emotionality or affect of the syllogism is flat until the final "ought" value judgment is stated. Professor Grim warns that history is filled with hindsight about the unintended consequences of such syllogisms. To read Dr. Seeley's entire book review, please go www.scma.org/magazine/scp/sm07/seeley.html.
Dr. Seeley, a Santa Rosa ophthalmologist, serves on the SCMA Editorial Board.
* * * * *
At the Medical Grand Rounds last week, the visiting professor gave his differential diagnosis of the patient presented to him as an unknown, working through additions and deletions in his well-formatted Power Point presentation. After discussing all the esoteric possibilities in the case, he said it's a good practice at one point to Google the symptoms and findings before making the final determination of the most likely diagnosis. He said one should put in 5 or 6 of the findings in the case and let Google sort out the diseases with those findings. He stated that Google was very good at classic diagnosis of unusual diseases.
Any idea of what might be next?
Doctor: Noting that his receptionist was crying, asks, "Is something's wrong?"
Receptionist: My mother died.
Doctor: Why don't you take the day off? We'll be able to manage.
Receptionist: No, I'll be alright. I'd rather work.
Doctor: Later sees that the receptionist is crying again, and asks "Is there something else?"
Receptionist: I just got a call from my sister, her mother also died.
Doctor: Please take some time off.
Receptionist: I'll be alright. I'll keep on working.
Doctor is quite concerned now and calls his attorney and asks if a third sister calls in and tells his receptionist that her mother also died, can he insist on at least a nine-month bereavement leave?
Competency shows itself in
the most unusual circumstances.
To read more
vignettes, please go to www.medicaltuesday.net/hhk.asp .
Is Congress Really In The Toilet?
Just 20 percent of California voters approve of Congress' performance, while 66 percent disapprove. That's worse than the 23 percent approval rating state voters gave the Republican-led Congress in May 2006 before the GOP lost its decade-long control in the November elections. It's the lowest rating for Congress since the Field Poll started asking the question in 1996.
Congress hasn't change course for 10 years since 1996 aiming for the sewer. If they ever control health care, our health would really be in the cesspool. There are really deadly germs down there.
Legalized Stealing from Taxpayers by Congress
Top congressional lawmakers still rake in dough in earmarks. While spending on earmarks may be trimmed and more closely scrutinized this year, top Democrats like House Speaker Nancy Pelosi aren't exactly suffering. The San Francisco Democrat raked in almost $100 million in earmarks in the spending bills passed this year, according to an analysis by Taxpayers for Common Sense, which tracks congressional spending. That means Pelosi is getting more than 1 percent of all earmarks doled out to the House's 435 members.
If any of us subverted $100,000,000 of taxpayer's funds, we'd be prosecuted, tried, and probably end up in Jail. Why can't we put Congress in Jail?
In a new political satire, Boomsday by Christopher Buckley, baby boomers born between 1946 and 1964 are to be offered tremendous incentives to "voluntarily transition" (commit suicide) by age 75. If only 25% do so, Social Security and Medicare will supposedly become solvent.
My, what a way to keep stealing from our children and grandchildren to balance our gluttony.
* * * * *
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 week, be sure to read the report on Health Care and Taxes.
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 subscribe at www.pacificresearch.org/pub/hpp/index.html or access their health page at www.pacificresearch.org/centers/hcs/index.html. This week, we have been favored by a report by John R. Graham on Messing Up Health Insurance in California.
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. Read the current paper on Medical Malpractice Reform.
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. www.nahu.org/publications/hiu/index.htm . 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. Be sure
to review the current articles listed on their table of contents at hiu.nahu.org/paper.asp?paper=1 . To see my recent column, go
to http://hiu.nahu.org/article.asp?article=1328&paper=0&cat=137 . To read what a single payer
system really means for consumers, please go to www.nahu.org/media/tools.cfm . To read the
rest of this column, please go to www.medicaltuesday.net/org.asp . 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 . Be sure to read the current article on Toward Free-Market Health Care . Greg Scandlen , an expert in Health Savings Accounts (HSAs) has
embarked on a new mission: Consumers for Health Care Choices (CHCC). To read
the initial series of his newsletter, Consumers Power Reports, go to www.chcchoices.org/publications.html . To join, go to www.chcchoices.org/join.html . Be sure to read the current newsletter at www.chcchoices.org/publications/CPR%20--%2093.pdf . The Heartland Institute, www.heartland.org , publishes the Health Care News. Read the late
Conrad F Meier on What is
Free-Market Health Care? . You may
sign up for their health care email newsletter at www.heartland.org/Article.cfm?artId=10478 . The Foundation for Economic Education , www.fee.org , has been publishing The Freeman
- Ideas On Liberty , Freedom's Magazine, for over 50 years, with Richard M
Ebeling, PhD, 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. This month, try to understand
Why Medical Managed Care is Not Free Enterprise Medicine from a classic on Managed Trade Is Not Free Trade . 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
careand may even make things worse." This week, be sure to read Dr. Merrill Matthews , "This paper, authored by some of the
country's top health care actuaries, should be a wake-up call to a Congress
that is asleep at the Medicare wheel." 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 www.i2i.org/healthcarecenter.aspx. This week, read David
Hogberg on The Myths of Single-Payer Health Care . 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
week, read ONE L IBERTARIAN'S J OURNEY T OWARDS M ARKET A NARCHY . 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 at www.fraserinstitute.ca/health/index.asp?snav=he . This week, gain some real insight by reading Wishful thinking to believe Canada's current health
care system is financially sustainable . 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. This
week, treat yourself to Health Care at the Crossroads: What Constitutes
Fair and Equal? . 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. This
week read an heroic story: Mises: The Last Knight of
Liberalism at www.mises.org/story/2696 You may
also log on to Lew's premier free-market site at www.lewrockwell.com to read some of his lectures
to medical groups. To learn how state medicine subsidizes illness, see www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone
would want to be an MD today, see 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 www.cato.org/people/cannon.html . Also read Cannon's current article on how to Fix Health Care by Making Americans Care About
Costs . 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. This week,
consider reading Regulate the Regulators . T he 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, war time allows the
federal government 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 war time 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 . Be sure to scroll down to
the book review section to read my review on Who Really Cares on the opening
page. Hillsdale College , the premier small liberal
arts college in southern Michigan with about 1,200 students, was founded in
1844 with the mission of "educating for liberty." It is proud of its
principled refusal to accept any federal funds, even in the form of student
grants and loans, and of its historic policy of non-discrimination and equal
opportunity. The price of freedom is never cheap. While schools throughout the
nation are bowing to an unconstitutional federal mandate that schools must
adopt a Constitution Day curriculum each September 17 th or lose
federal funds, Hillsdale students take a semester-long course on the
Constitution restoring civics education and developing a civics textbook, a
Constitution Reader . You may log on at www.hillsdale.edu to register for the annual
weeklong von Mises Seminars, held every February, or their famous Shavano
Institute. You may join them to explore the Roots of American Republicanism on
a British Isles cruise on July 10-21, 2006. 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. Be sure to read the current issue of Imprimis on Global Warming:
Man-Made or Natural? . T he last ten
years of Imprimis are archived at www.hillsdale.edu/imprimis/archives.htm .
* * * * *
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Del Meyer, MD, Editor & Founder
6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608
Words of Wisdom
We can let circumstances rule us, or we can take charge of our lives from within. -Earl Nightingale
People are where they area because that is exactly where they really want to be - whether they admit that or not. -Earl Nightingale
Our attitude towards others determines their attitude towards us. -Earl Nightingale
Some Recent Postings
AMERICA ALONE, The End of the World as we Know It, by Mark Steyn, Regnery Publishing, Inc, an Eagle Publishing Company, Washington, DC, xxx & 224 pages, $27.95; © 2006 by Mark Steyn. ISBN-13 978-0-89526-078-9. Understand what 9-11-01 was really all about at www.delmeyer.net/bkrev_AmericaAlone.htm.
WHO REALLY CARES - America's Charity Divide Who Gives, Who Doesn't, and Why It Matters by Arthur C. Brooks, Basic Books, New York, 250 pp, $26 © 2006, by Arthur Brooks, ISBN-13: 978-0-465-00821-6. Understand what America is all about at www.delmeyer.net/bkrev_WhoReallyCares.htm.
SEPTEMBER 11, 2001 VICTIMS
This site is dedicated to the victims of September 11, 2001 tragedy
Click on the Victim to read his memorial
On This Date in History - September 11
On this date, 19 Saudis from the Kingdom attacked America in a devastating suicide mission, which exceeded all suicide bombers after the first attack on the United States that started World War II, starting what some have termed the World War IV [identifying the Cold War as WWIII]. When will we learn who are our friends? (re-read Steyn above) If we can introduce freedom into the Mid East, it will truly be a wakeup call from which the free world can profit and a major part of the globe can become freer and less hostile towards us. Let's not ask anyone to like us. But let's make them respect us.