MEDICAL TUESDAY . NET
Community For Better Health Care
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
* * * * *
Tulane University President Scott Cowen was at the tail end of a respected career when Katrina hit. The hurricane almost destroyed his institution--and gave him the chance to reinvent it. . .
It's a cloudy, foggy day in New Orleans, but at least it's not raining. That wouldn't bode so well for freshman move-in day at Tulane University. After all, the last time these students arrived, on August 27, 2005, they were here only a few hours before Scott Cowen, Tulane's president, told them to get the hell out of town. The rain that Hurricane Katrina brought--and the terrible wind, and the broken levees, and the chaos, and the devastation--not only shuttered Tulane for a semester but also spawned the largest diaspora from a natural disaster ever to befall an American city. . .
Most crises that affect an organization affect only one part. A computer virus might cripple a company's intranet but not its phone lines. A train derailment might delay one component of a product, but there should be alternative sources. Katrina was an assault on all fronts at once. Tulane had no functioning IT infrastructure, no way to communicate with its 12,500 students and 6,000 employees, no news on federal funding, no way even to assess the damage. Some of the staff had no homes, clothes, or news of relatives. But Cowen and his team plunged in, fueled by little more than adrenaline. "Why wait for the government?" he says. "If we did, we'd be out of business.". . . (Emphasis ours.)
Cowen put in place a triage system centered on a daily 9 a.m. meeting. "Scott would say, 'We have 1 million things on our plate, but what are the top-five things that need to get done today?' " says Luann Dozier, VP for development, who lost her home. "You go and come back with the recommendations and move on. So you could see progress every day." The first order of business was to retrieve the school's IT files from the 14th floor of a downtown New Orleans building with massive flooding, no working elevators, and chaotic surroundings. A posse of Tulane employees, escorted in SUVs by police officers, spent hours lugging the disks down the darkened stairways. They needed the records to find students as well as to figure out how to pay staffers and faculty, many of whom had been displaced and presumably needed the money right away. "If we didn't make payroll, everyone would have thought we were gone," says Cowen.
Yet some 15% of the employees were not on direct deposit, and there was still no central Web site for students seeking information about whether and when the school would reopen. Cowen reached out to alumnus David Filo, cofounder of Yahoo, for help. Filo donated some manpower and Web-hosting resources, and soon a makeshift Web site came to life, along with a relentlessly cheery blog from Cowen. Privately, however, he had doubts. Why would freshmen, about to be dispersed to hundreds of different colleges, feel loyalty to a school they'd attended for just a few hours? Who would want to come back to a campus with absent professors, few services, limited pizza joints, and, possibly, no Mardi Gras? To make it easier to come back (actually, harder to leave), national university organizations asked other schools to accept students affected by Katrina, but only for one semester. The school also took out a $150 million loan to hire a disaster-relief firm to fix the damaged campus. . .
"As I was going to say before Katrina interrupted me…, " begins Cowen, looking resplendent in his president's robes. "We are absolutely delighted that you are here with us finally… No major research university, or for that matter, any organization, has ever been confronted with the challenges we've faced. Yet we have recovered, we have survived, and we have charted a path to the future."
With equal parts grit, creativity, and optimism, Cowen has resuscitated Tulane--formerly the largest private employer in New Orleans and, since Katrina, the largest altogether--even as the rest of the city remains mired in the literal and figurative muck. But Cowen has also decided to do something more than merely rebuild his institution as it once was. Using the powers granted him as a result of the school's financial emergency, he has enacted a bold, controversial, and wrenching "renewal plan," with which he hopes to remake Tulane from a very competitive school into a truly elite one. "I wouldn't wish this on anybody," he says. "But out of every [disaster] comes an opportunity. We might as well take the opportunity to reinvent ourselves." . . .
The dozens of meetings--which went on throughout October and into November--were long and painful, but seven years of experience and a lot of the analysis Cowen had already done in prior years led the group to some obvious cost savings. It quickly became clear that the medical school, which had moved to Baylor University for the year, was in the most trouble, primarily because of the lack of patients. The group ended its emphasis on clinical work and reduced the school's faculty and staff by a full 30%. "That was really difficult," says Dr. Paul Whelton, SVP for health sciences and dean of the medical school, "to tell people who had been loyal to this university for 20 years that unfortunately you are not critical to the mission." . . .
Given the scope of the crisis, Cowen's plan met with little initial resistance. It didn't hurt that he required Tulane's board to approve or reject the plan as a whole; it passed unanimously. But now, perhaps because Tulane is perceived to be on the mend, the critical rumblings are getting louder. In January, the American Association of University Professors wrote Cowen asking for a full accounting of exactly how he eliminated 166 full-time faculty positions (including 61 with tenure)--believed to be the largest number of mass terminations ever at an American university. Groups have sprung up to fight the changes with petitions and protests. And chalked in front of the engineering building was a lament: "We survived Katrina, but not the administration." . . .
Cowen denies having any sort of master plan to alter the course of the university, but he was prepared to move aggressively in part because he had launched a financial analysis of every Tulane department in 2001, giving him data to rely upon once the hurricane hit. While no one would ever wish the horror of a Katrina on anyone, it gave Cowen the clout to move faster than any university administrator in memory. Other university presidents respect that decisiveness. "The first thing that popped into my mind was the quote from Plunkett, the Tammany Hall guy," says Madeleine Wing Adler, president of West Chester University of Pennsylvania. " 'I seen my opportunities and I took 'em.' "
Jennifer Reingold (firstname.lastname@example.org) is a Fast Company senior writer.
To read the entire article, please go to www.fastcompany.com/magazine/104/tulane_Printer_Friendly.html.
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2. In the News: Some Convenient Truths, Comment by Gregg Easterbrook, The Atlantic Monthly
If there is now a scientific consensus
that global warming must be taken seriously, there is also a related political
consensus: that the issue is
Here's a different way of thinking about the greenhouse effect: that action to prevent runaway global warming may prove cheap, practical, effective, and totally consistent with economic growth. Which makes a body wonder: Why is such environmental optimism absent from American political debate?
Greenhouse gases are an air-pollution problem - and all previous air-pollution problems have been reduced faster and more cheaply than predicted, without economic harm. Some of these problems once seemed scary and intractable, just as greenhouse gases seem today. About forty years ago urban smog was increasing so fast that President Lyndon Johnson warned, "Either we stop poisoning our air or we become a nation [in] gas masks groping our way through dying cities." During Ronald Reagan's presidency, emissions of chlorofluorocarbons, or CFCs, threatened to deplete the stratospheric ozone layer. As recently as George H. W. Bush's administration, acid rain was said to threaten a "new silent spring" of dead Appalachian forests.
But in each case, strong regulations were enacted, and what happened? Since 1970, smog-forming air pollution has declined by a third to a half. Emissions of CFCs have been nearly eliminated, and studies suggest that ozone-layer replenishment is beginning. Acid rain, meanwhile, has declined by a third since 1990, while Appalachian forest health has improved sharply.
Most progress against air pollution has been cheaper than expected. Smog controls on automobiles, for example, were predicted to cost thousands of dollars for each vehicle. Today's new cars emit less than 2 percent as much smog-forming pollution as the cars of 1970, and the cars are still as affordable today as they were then. Acid-rain control has cost about 10 percent of what was predicted in 1990, when Congress enacted new rules. At that time, opponents said the regulations would cause a "clean-air recession"; instead, the economy boomed. . . .
One reason the global-warming problem seems so daunting is that the success of previous antipollution efforts remains something of a secret. Polls show that Americans think the air is getting dirtier, not cleaner, perhaps because media coverage of the environment rarely if ever mentions improvements. For instance, did you know that smog and acid rain have continued to diminish throughout George W. Bush's presidency? . . .
Does it matter that so many in politics
seem so pessimistic about the prospect of addressing global warming? Absolutely. Making the problem appear unsolvable encourages
a sort of listless fatalism, blunting the drive to take first steps toward a
solution. Historically, first steps against air pollution have often led to
pleasant surprises. When Congress, in 1970, mandated major reductions in smog
caused by automobiles, even many supporters of the rule feared it would be
hugely expensive. But the catalytic converter was not practical then; soon it
was perfected, and suddenly, major reductions in smog became affordable. Even a
small step by the
And to those who worry that any greenhouse-gas
reductions in the
Americans love challenges, and preventing artificial climate change is just the sort of technological and economic challenge at which this nation excels. It only remains for the right politician to recast the challenge in practical, optimistic tones. Gore seldom has, and Bush seems to have no interest in trying. But cheap and fast improvement is not a pipe dream; it is the pattern of previous efforts against air pollution. The only reason runaway global warming seems unstoppable is that we have not yet tried to stop it.
Gregg Easterbrook is a contributing editor of The Atlantic, a visiting fellow at the Brookings Institution, and the author of The Progress Paradox.
The URL for this page is www.theatlantic.com/doc/200609/global-warming.
* * * * *
European Health Care, By HELEN DISNEY, The Wall Street Journal -
Reform of health services in Europe is as controversial a topic as you can find, stoked by headlines like "American firm hired to do all National Health Service shopping" in one British newspaper. As the private sector is called on to play a new health-care role, though, should Europeans really be alarmed?
The news that a
Critics claim these developments are the beginning of the end of the welfare state -- a drive toward the "Americanization" of health care -- and the antithesis of equity, solidarity and everything else good that European systems are meant to represent. They also note, legitimately, that reforms should be about driving up the quality of service, not just cutting costs.
The strength of European feelings against liberalization was made quite clear in February, when the EU Parliament amended the services directive. In the process, lawmakers threw out the directive's public health and social services element, which would have created a more competitive internal market in health care.
Though introducing market mechanisms may seem radical
now, it likely won't in a decade's time. A combination of demographic changes,
increased consumer demand, rising medical costs and the resulting bankrupt
welfare systems makes further market-oriented reform of European health systems
highly likely. In fact, as in the
Many countries are introducing what would have been
seen as heretical moves a few years ago. Some, like "left wing"
For the most part, the reforms have turned out to be good for both health-service users and staff. Why? First, they make systems more responsive to individual needs. Second, they introduce more investment in the system. Third, and perhaps most important, they lead to more sustainable health systems for the long term without sacrificing access for all.
To the north, in
Yet this development would never have come about
without the so-called
Last but not least, the
Despite the scare mongering, many of these efforts
have little to do with copying the
Ms. Disney is director of the Stockholm Network, a pan-European think tank.
Read the entire article at http://online.wsj.com/article_print/SB115507043277230264.html (subscription required).
The NHS does not give timely access to health care; it only gives access to a waiting list.
Kaiser Permanente, the world's leading totally integrated health-care system, is known for giving immediate, same-day access to a physician or nurse practitioner and improving quality.
What a logical and sensible way to eliminate waiting lists that extend over years.
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4. Medicare: Saving Health Insurance from the Minimum Wage by John C. Goodman and Richard B. McKenzie
Political support is growing in Congress for another increase in the federal minimum wage. A bill now under consideration would raise the minimum hourly wage from $5.15 to $7.25 over the next two years. According to the Economic Policy Institute, an estimated 6.6 million workers currently earn less than $7.25, and a total of 14.9 million workers would be affected by 2008.
What are the likely consequences? Economists have traditionally warned that a higher minimum wage causes more people to be unemployed. [See, for instance, David R. Henderson, "The Negative Effects of the Minimum Wage," NCPA Brief Analysis No. 550.] But a number of studies point to an even more serious consequence: fewer fringe benefits, including health insurance.
An unintended consequence of a minimum wage increase would likely be a rise in the number of Americans without health insurance. Congress can avoid adding to the ranks of the uninsured - in fact, it can make progress toward reducing their number - by giving employers and employees the option of using the amount of the minimum wage increase for health insurance in lieu of wages.
Wages versus Other Benefits. Workers tend to get paid a wage equal to the value of what they produce. So employees who produce $5.15 worth of goods and services per hour will tend to be paid $5.15. But what happens if the law makes employment illegal unless the wage is at least $7.25 per hour? No employer is going to pay $7.25 for $5.15 worth of productivity. So employers and employees will seek ways around the law - by reducing nonwage compensation:
Employers can also reduce labor costs by spending less on working conditions or employee training. Employers may also impose more rigorous work requirements, insisting that employees work faster or work harder.
The net effect of these adjustments is to largely neutralize the cost impact of the minimum wage hike. For example, when the minimum wage increases by $1, the cost of labor may, on balance, rise by only 5 cents. Workers who retain their jobs are unlikely to be any better off than before. They get more money, but they also get fewer benefits and have to work harder for their pay.
Of course, if employers can't reduce fringe benefits (say, because there are none) or are unable to make other adjustments (such as increased work demands), employees are in danger of losing their jobs.
Wages versus Health Insurance. One of the most important employer benefits that substitutes for money wages is employer-provided health insurance. But health insurance premiums are rising and some employers no longer offer this benefit. Low-wage workers are particularly affected:
A minimum wage increase will induce even more employers to drop or reduce health insurance benefits, resulting in a further increase in the number of uninsured.
Solution: Creating an Option for Employers. If there is an increase in the minimum wage, employers should be able to count their spending on health insurance for their employees - dollar for dollar - against the minimum wage increase. Specifically, all employers should be allowed to count up to $2.10 per hour per worker in health benefits toward meeting the minimum wage level. As a result, employers would not have to reduce health insurance benefits to meet the wage mandate.
This option would allow an employer to substitute a nontaxable benefit for taxable wages. For a person working 2,000 hours per year, a $2.10 increase in nonwage benefits would amount to $4,200, enough to purchase an individual health insurance policy in most places. A couple, both working at the minimum wage, would have $8,400, enough to purchase a family policy in most places.
Solution: Individually-Owned Insurance. In many states, individual and family insurance is less expensive than group insurance (usually because there are fewer cost-increasing regulations). However, employers currently cannot buy individually-owned insurance for their employees. If they were allowed to, employers could pay some or all of the premiums for insurance employees could take with them as they move from job to job.
Insuring the Uninsured. Market forces will largely neutralize the impact of a minimum wage increase, and the minimum-wage employee is unlikely to be much better off than before the increase. However, if the health insurance option is part of the legislation, it offers an opportunity to reduce rather than increase the number of Americans without health insurance.
To read the entire article, go to www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=10061.
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
Shore: Americans can't feed the world, but we can do much more to help the world feed itself. Some of the most effective antihunger and antipoverty programs in developing nations are small-scale projects run by local or regional social entrepreneurs innovating in ways governments can't. We saw this in Ethiopia with an organization called Action for Development, which was introducing new crops, innovative farming methods, and water projects into the community. Such local programs may be less glamorous than global antipoverty programs, but in the long run, they're more effective. But we'd be in a better position to advance such efforts if we closed the economic gap that exists in our own country, one that leaves too many families with children seeking emergency food assistance. Hunger in the United States is one issue that is eminently solvable.
Easterly: Whenever I hear that a tragic problem is "eminently solvable," I feel the urge to reach for my intellectual shotgun. If hunger in the U.S. is so solvable, why didn't decades of antipoverty campaigns already solve it? And what does this have to do with Ethiopians? I am sympathetic to your program to address the much more serious hunger problem in Ethiopia--it sounds like just the right kind of thing to do. Let the people who know the problem best--the poor people themselves--solve their own problems. However, I hope you are resisting the official-aid-agency syndrome:
Do lots of symbolic things that play well to the rich-country public but don't let yourself be held accountable for whether the intended beneficiaries are better off or not.
Shore: When I hear a catchall phrase like "decades of antipoverty campaigns," I reach for my protective vest. But fortunately, we're not debating antipoverty programs. The antihunger programs in the U.S., which I suspect you are lumping into that broader category, have actually done an amazing job of reducing hunger, which is why school lunch, school breakfast, food stamps, and the Women, Infants and Children supplemental feeding program (WIC) are among the few to enjoy so much bipartisan support. In the U.S., we are able to measure progress, hold ourselves accountable, and invite our stakeholders to judge us upon those results. I'm not sure how one would best do that globally. Are you?
Easterly: You have put your finger on the problem with foreign aid: Official aid agencies have virtually no feedback from, or accountability to, the voiceless poor of the world. I hope nongovernment organizations like yours can do better--such as subjecting yourselves to independent evaluation of the impact of a random sample of your projects by third parties. In short, if you want to know if you've helped the poor, try asking them.
Shore: You've put your finger on what seems like a dilemma. There are a lot of things NGOs can do that the government cannot: They can innovate, take risks, and be closer to the people they serve. But even the best NGO efforts probably won't reach all of those in need without broader public and government support. And that's when things get muddy. I have been encouraged by the eagerness of antihunger leaders in developing countries to access help. On my last trip to Ethiopia, a young man whose agricultural project we visited followed us back to our small plane. He said, "If you know anyone who could give us just two weeks of training in marketing and communications, it would be a great boost." Creating chances for people to share their strengths this way seems like a huge opportunity. . .
To read the rest of the debate, please go to www.fastcompany.com/magazine/105/open-debate.html.
Feed the world, but not by throwing money at the problem.
On that, Share Our Strength's Billy Shore and William Easterly of New York University agree.
* * * * *
Payment Delay Looming: Physicians should be aware Medicare will not pay any
claims for the last nine days of the federal fiscal year (
Held claims will be paid on October 2. No interest or late-payment penalty will be paid to physicians or other health care providers whose payments are delayed by this one-time hold. Physicians with large numbers of Medicare patients should prepare now for this cash flow interruption.
[When we have single-payer medicine, the government,
which is not adverse to delaying one-third of a
physician's monthly income, an involuntary short term loan without interest,
will have no trouble delaying a month's income and then one week out of each
month, and then "Only God Knows." When the State of
Come on Docs, Let's Get to the Federal Trough - There Aren’t Enough Husks For Everyone.
Tell Your Member of Congress to Stop the Payment Cut
and Give Physicians a 2.8% Increase.
Physicians, CMA needs you to turn up the heat on your members of Congress and motivate them to fix the Medicare payment problems before Congress adjourns in September. As you know, CMA has for years been fighting for a long-term fix to Medicare's flawed sustainable growth rate (SGR) formula.
If Congress fails to act before the end of the year, physician rates will be cut 5 percent on January 1 of next year, and rates will be cut by a total of 35 percent during the next six years. The cuts are an unintended consequence of a formula, established under laws passed in 1989 and 1997, that was supposed to establish a "sustainable growth rate" for spending on doctors' services. The formula allows Medicare spending on physician services to grow at the rate of the gross domestic product (GDP), but it actually penalizes physicians because the cost of physician services rises more rapidly than the GDP.
Reimbursement for all other Medicare providers is calculated using the Medicare Economic Index (MEI), which is a market index of actual medical practice costs. Health plans, hospitals, and nursing homes are all seeing payment increases, while physician payments are being slashed.
2007 Medicare Provider Payment Updates: Health Plans: + 7 percent; Hospitals: + 3.6 percent; Nursing Homes: + 3.5 percent; Physicians: - 5 percent
To read the entire CMA article, please go to www.calphys.org/html/alert083106.asp?anchorID#1.
[Looks like the government's actuaries are smarter than our actuaries and reducing physician payments while increasing all others are the real intended consequences of the laws. When will we learn to oppose all government shenanigans? And why are we the pigs at the trough asking for government largess? Why don't we let patients handle their problem? As doctors quit seeing Medicare patients, the Medicare patients have far greater clout with Congress than we will ever have. We have none - or rather a negative effect. Medicare patients have 37 million votes; we have less than one million. It's really a no-brainer.]
Should All Doctors Start Working For The Government?
The Cato Institute's Chris Edwards tracks government compensation, and he finds that in 1950 the average federal bureaucrat received $1.19 for every dollar that a private employee earned. By 1990 that ratio had risen to $1.51 and is now $2. In 2005 federal wages rose 5.8% compared to 3.3% in the private sector.
[Let's see. Did we say physicians working for the government's Medicare division were getting a 35 percent cut over the next six years? But are employed Federal physicians sharing in this rape of the public till? A fulltime physician told me last week he makes a salary of $60 an hour or $120,000 for a 2,000-hour work year. He thinks his administrative boss, who doesn't know in which organ system a seizure fits (is it neurological or musculoskeletal?), makes more than $180,000 a year and wishes he could put the disease in the category he chooses. No, Hippocrates, the government hates employed and Medicare contract physicians equally.
Single Payer, Like Medicare in the
* * * * *
How About Dropping Some Devices on
Dr Sam: The
Dr Michelle: I can't believe you said that, Sam. Look at all the innocent women and children you would kill. And it won't stop the terrorist.
Dr Sam: There
were a lot of women and children killed in
Dr Kaleb: Actually there are a couple of areas in
Dr Michelle: None
of this would have happened if we hadn't gone in and stirred up the pot in the
Dr Sam: How can you be so naïve, Michelle? Did you have any idea that such a major part of the globe is so uncivilized?
Dr Rosen: The mission to establish a beachhead of democracy in that uncivilized society was a noble idea. But the constitution with law and order should have come first. Democracy and elections should have come years later. It would take at least a generation to change the thinking that prevails in that part of the world. Arab textbooks have first graders recite when the teacher asks: Who are the Jews? CHILDREN: THEY ARE OUR ENEMY. What do we do with our enemies? CHILDREN: WE KILL THEM. To have this drilled into the heads of the children from preschool through secondary school cannot be changed in a few years. We would have to occupy the country for at least 12-14 years, one entire school cycle, to assure that the next generation does not grow up to hate and murder for no reason whatsoever except ethnicity.
Dr Sam: Can't
we learn from the Second World War? After
Dr Michelle: I think I'll go back to my office and see some patients before I lose my lunch.
* * * * *
the Hour, By ROBIN
COOK, The New York Times,
A PRIMARY care doctor I've known since we were residents 30 years ago recently described for me his typical day as foisted on him by current economic realities. He rises at to make a dent in his avalanche of paperwork before dashing off to make rounds at the hospital and arrive at his office before 8. For the next 10 to 11 hours, he races through a series of patients so long, he cannot talk to any one of them as much as he believes he should, and he constantly worries he'll miss something. Worst of all, he admitted, he no longer enjoys practicing medicine.
Ten-plus years ago primary care was lauded as the potential rescuer of a health care system in chaos. Primary care doctors, it was hoped, would fix what had become an expensive, fragmented specialty system geared toward treating emergencies and episodes of acute illness. Thanks to new technologies and treatments, medicine had become a team effort, but the teams needed captains who would keep patients' overall health in mind, and that role was to be filled by the primary care doctors: internists, family physicians, general practitioners and pediatricians. We would all know our doctors, and they would know us.
But unfortunately, primary care has not flourished, and the ranks of primary care doctors are thinning. As reported in a series of articles in The Annals of Internal Medicine in 2003, medical students are shunning residencies in primary care, and primary care doctors are migrating to other careers or retiring early. Many who have remained in primary care are, like my friend, dispirited, disgruntled and disillusioned.
What is the solution? We must make primary care a more manageable business by changing the way we pay for it. Primary care doctors should be paid by the hour.
As it is now, insurance companies - following Medicare's lead - pay primary care doctors according to the number of patients they see. Each patient visit is generally reimbursed at a flat rate of slightly more than $50. The payment is the same whether the patient is a healthy, young person with a runny nose or an elderly person whose multiple chronic illnesses require many tests, referrals to specialists and detailed explanations to both the patient and his or her family. . .
A typical primary care doctor spends slightly more than half of his or her day seeing patients; the other half is spent conferring with specialists, lab technicians and patients' families, or trying to persuade health insurance companies to cover some needed treatment. This other half of his work day must be considered pro bono. Factor in rising overhead costs (office space, employees and malpractice premiums), and the situation easily becomes untenable.
No wonder hundreds of primary care doctors have switched to concierge-style practices, in which patients are charged subscription fees in return for more personal service in markedly smaller practices. But this trend only adds to the problem of accessibility by reducing the pool of regular primary care doctors.
Ideally, the hourly rate would not be the same for all primary care physicians, but would be assessed on a sliding scale, predicated on a doctor's level of education. Internists and pediatricians - the primary care doctors who have had the most training - would receive a higher rate than general practitioners and family physicians would. . . .
But this expense can be balanced out by cutting the health care pie differently - as some large, multi-specialty medical groups already do. Recognizing that Medicare and health insurance companies pay disproportionately higher amounts for specialty procedures (angioplasties, for example, or colonoscopies or even freckle removal) than for consultations by primary care doctors, many practices redistribute their total income according to each doctor's contribution. Consequently, primary care doctors receive more than the amount the group is reimbursed for their services. . . .
In the long run, paying by the hour could save money. It would provide doctors the time they need to investigate symptoms themselves rather than reflexively refer patients to specialists. After all, every headache doesn't need to be evaluated by a neurologist; nor does every painful shoulder require an M.R.I.
It would also increase the pool of primary care doctors, so that more health problems could be handled in doctor's offices rather than in emergency rooms, where the cost of care is more expensive. And finally, better long-term doctor-patient relationships might reduce the number of malpractice lawsuits. Paying for primary care by the hour would be better for both doctors and patients, and it would return a measure of rationality to our health care system.
Robin Cook is a medical doctor and the author, most recently, of the novel "Crisis.''
[We always welcome the wisdom of physician authors and especially Robin Cook who has entertained us with his Medical Thrillers. Actually much of what Dr Cook describes has been tried. There was a massive revision of the Relative Value Scale to make it reflect the time that physicians spent with a difficult diagnostic problem. The short and intermediate office calls were subdivided into five levels. Unfortunately, the government did not trust doctors to use the correct level of service and proceeded to review a massive number of charts. In their estimation, what doctors recorded didn't measure up to what Medicare thought the level of complexity should be. They even sent doctors to jail for fraud when the doctors thought they were providing the complexity of service billed. If doctors charged by the hour, the government would have similar problems in trusting doctor’s charges for a twenty minute charge in one patient and a 40 minute charge in another. Furthermore, patients can use up an hour of time and think they've been there only 15 minutes. Until the co-payment is a percentage of the fee, there will be no patient incentive to monitor his or her own healthcare costs. So the answer is not an hourly rate, but patient-driven health care where the patient monitors each and every item of cost - including his/her own time with the physician.]
* * * * *
9. Book Review: THE AMERICAN WAY OF HEALTH - How Medicine is Changing and What it Means to You by Janice Castro, Back Bay Books, (Little, Brown, & Company), Boston, 1994, x & 282 pages, including glossary, notes, & index, $9.95, Paperback. Reviewed by Del Meyer, MD
Janice Castro, senior health-care correspondent at TIME who interviews professionals, patients, and others, opens with "Ask most people what they think about the state of American medicine, and they will tell you about their own doctors, or about something that happened to them during an illness. Chances are, if they see a need for health-care change, it will be very specific, based on personal experience. On the other hand, listen to American leaders discussing health-care reform. They speak of providers. Access. Alliances. Competition. Mandates... The concepts seem impossibly complicated and remote from the experience of one sick person needing help."
She continues, "This book will help the general reader understand how the American health system works, why it costs so much... Medicine is too important, too personal, to be left to economists and politicians... After all, the health-care debate is really about life and death. It is about those times when people need help and about whether it will be there, about one sick patient at a time and the doctor or nurse who provides care... It is fundamentally a moral problem. Viewed in that light, the challenge... begins to come more clearly into focus. It is not really that complicated. We know what we need to do. We need to take care of old people... Children should see doctors and dentists. A pregnant woman should be able to check in with a doctor as the baby grows. People should not be dying in the street... Families shouldn't lose their home over the cost of coping with medical disasters. Breadwinners should not quit good jobs in order to qualify for poor people's insurance... People should take responsibility for their own health and for their family's. Children should not be having children..."
And, "If we are going to ensure that every American has access to decent health care, while also controlling the burgeoning costs, all of us must curb our medical greed. All of us must stop pretending that someone else is paying the bills. 'What do you think most people would say if one of their parents called up and said they needed a hundred and twenty-five thousand dollars for an operation?' asks one economist. 'Do you think that son or daughter would think twice and wonder whether that operation was really necessary? Of course they would. But none of us think we pay for medical care. And of course we all do.' All of us must pay our share..."
Castro then takes us on a tour de force of health-care about our country. She starts at Kaiser Walnut Creek's two delivery rooms where 4,000 infants, mostly delivered by midwives, take their first breath each year. She interviews a midwife who feels that midwives can deliver most women in tents, a practice which is prevented by organized medicine. She then takes us inside the delivery room where the midwife has a complication with a stuck shoulder. Within seconds, an obstetrician and pediatrician come through the delivery room doors and deliver a healthy infant two minutes later. Castro feels it was fortunate this baby was not born in a tent and that the pediatric ICU is only twenty steps from the delivery room. . .
To read the entire review, please go to www.delmeyer.net/bkrev_AmericanWayOfHealth.htm.
To browse the Doctor/Patient Bookshelf, please go www.delmeyer.net/PhysicianPatientBookshelf.htm.
To review in topical fashion, please go to www.healthcarecom.net/bookrevs.htm.
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Teacher: There's a morbid disease that can grow until it consumes the body that gave it life! Who in the class can tell me what it is? Yes, Johnny?
Johnny: The Government
The Slovak parliament adopted new health laws at the end of 2004, including the introduction of user charges. . . Reformers also instigated a major public consultation . . . in order to determine what should be covered by mandatory health insurance. . . Health insurers and providers were given for-profit status to spur competition, rather than leaving patients to rely on a single state provider. These changes have already led to a sharp reduction in the annual health-system deficit by cutting costs . . . In all likelihood, they will go on to allow patients more and better choices, as the new providers begin to compete on quality and thereby drive up standards.
What a crazy world. The misguided in our country want
to install government single payer health care to improve quality and decrease
In our recent review of the last issue of Sonoma County Physician, there were excellent articles on sexual dysfunction, sexual discrepancies, and the health hazards of closets. The photography and multicolored cover are of the high caliber we've come to expect from Steve Osborn, the managing editor. To end on a more personal note, the humor in several of those articles caused me to reflect on my late uncle who was widowed in his mid 60s. He became serious about a woman he met at a senior citizens' gathering whom he eventually married. Because she smoked an occasional cigarette after meals, which he detested, he asked her if she ever smoked after sex? "Well, Otto," she answered, "I'm not sure. I don't think I've ever looked."
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• 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 be sure to read Reveal Health Care Costs at www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=11383.
• 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. Be sure to review the book: What States Can Do to Reform Health Care - A Free-Market Primer at www.pacificresearch.org/pub/sab/health/2006/What_States_Can_Do/index.html.
• 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. If you're in the market to purchase or change health insurance, be sure to review the exceptionally large data base at www.nahu.org/consumer/healthcare/index.cfm. 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 columns, enter my name in the search box.
• 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 Grace-Marie's report this months "Ownership of Insurance" at www.galen.org/ownins.asp?docID=918. With many employers priced out of the health insurance market and with an increasingly mobile workforce, it is vital that policy changes be made to give people more options. Our prescription: Tax credits and deductions to allow individuals and families to buy their own health insurance that they can take with them from job to job, and giving them new options to purchase policies that are not burdened by mandates and regulations that drive the price of premiums sky high.
• 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 real facts on medical bankruptcy which is only 6 percent of unsecured debt, not a primary cause, at www.chcchoices.org/publications/CPR%20--%2044.pdf or read the original reference at www.aei.org/publications/filter.all,pubID.24680/pub_detail.asp.
• The Heartland Institute, www.heartland.org, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care? At www.heartland.org/Article.cfm?artId=10333. You may sign up for their health care email newsletter at www.heartland.org/Article.cfm?artId=10478. To read a report on a bill pending in Congress which would create a framework for a national interoperable network for storage and transmission of individual health care records, please go to www.heartland.org/Article.cfm?artId=19596.
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. Does freedom extend to smokers? To read a news report on Alexander Schoppmann’s Airline for Smokers to Begin Germany-Japan
Service, please go to www.fee.org/in_brief/default.asp?id=751. He couldn't do this in the
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
• The Health Policy Fact Checkers is a great resource to check the facts for accuracy in reporting and can be accessed from the preceding CAHI site or directly at www.factcheckers.org/. This week read the Fact File: Cost of Health Insurance at www.factcheckers.org/showArticleSection.php?section=factInsurance&archive=.
Independence Institute, www.i2i.org, is a free-market think-tank in Golden,
• 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 THE RATIONAL ARGUMENTATOR: PROFIT IS MORAL by Gennady Stolyarov II. All too often today, we hear condemnations of the profit motive as destructive and uncaring. But is it really? Or is the profit motive one of the noblest forces that can impel a man to act? If human flourishing is moral than so is the pursuit of profit. To read the entire article, go to www.quebecoislibre.org/06/060813-2.htm.
• The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. 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 month, note the new Hospital Report Card at www.hospitalreportcards.ca/.
• 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. This month, review the Values-Driven Health Care at http://policy.heritageblogs.org/2006/08/valuesdriven_health_care_on_pa.html.
• 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 month read the real reason behind the Minimum Wage at www.mises.org/story/2266. 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. To read his current column on police should serve, not help politicians, go to www.lewrockwell.com/akers/akers46.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
• 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. To peruse the Center for Education Reform, go to www.edreform.com/index.cfm?fuseAction=section&pSectionID=5&CFID=4505275&CFTOKEN=74575788.
• 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.]
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Today we say thank you and
bid farewell to our MedicalTuesday Secretary, Jessica Falkenstein, for her work
the past two years in responding to all of your emails, address changes,
enrollment and removal requests. She has also formatted the newsletter,
inserted all the links and posted it to Constant Contact for automatic send on
the second and fourth Tuesdays of each month. She maintained the website visit
log (which now has reached 30,000 a month). (Our other electronic journals, www.HealthCareCom.net and www.DelMeyer.net have an additional 20,000
visits per month). We wish Jessica well as she heads off to the
Please note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff. Sections 1-6, 8-9 are entirely attributable quotes in the interest of the health-care debate.
Editorial comments are in brackets.
ALSO NOTE: MedicalTuesday receives no government, foundation or private funds. The entire cost of the website URLs, website posting, distribution, managing editor, email editor, and the research and writing is solely paid for and donated by the Founding Editor, while continuing his Pulmonary Practice, as a service to his patients, his profession, and in the public interest for his country.
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Del Meyer, MD, Editor & Founder
Words of Wisdom
"Whatever may be conceded to the influence of refined education on minds of peculiar structure, reason and experience both forbid us to expect that National morality can prevail in exclusion of religious principle." -George Washington
"The only difference between a tax man and a taxidermist is that the taxidermist leaves the skin." -Mark Twain
Some Recent Postings
Physician Profile: Michael Goodman, MD at www.healthcarecom.net/MG_Profile.htm
July HPUSA Issue: www.healthplanusa.net/July06.htm
April HPUSA Issue: www.healthplanusa.net/April06.htm
January HPUSA Issue: www.healthplanusa.net/January06.htm
NOT only Africa has a heart of darkness. South America has one too, squeezed in the tight embrace of Argentina, Bolivia and Brazil. Two great rivers, the Paraguay and the Parana, flow through Paraguay and past it, but travellers have little reason to come to this empty, landlocked place. The dry western chaco has no gold or oil, though wars were fought on the supposition it did; the east is more fertile, but still poor. The people are mostly Indian farmers, the army dangerously unpredictable. It is good ground for dictators.
For 35 years, from 1954 to 1989, Alfredo Stroessner ruled there. Under him, although he brought electrification, asphalt roads and friendship with America, the place became yet more isolated and benighted. The economy was based on contraband: whisky, cigarettes, passports, coffee, cocaine, luxury cars, rare bird skins, anything, until the unofficial value of Paraguay's exports was said to be three times the official figure. The style of government was a spoils system, underpinned by terror of a vicious network of spies and secret police. Foreign policy was a buddies' brigade with other dictators - Videla of Argentina, Pinochet of Chile - to co-ordinate counter-terrorism and assassinations. And the most famous tourist was Josef Mengele, the fugitive doctor of Auschwitz, riding into a village in the Paraguayan wilderness to be welcomed and protected. . .
As healthcare is in a power struggle with the government against our sick, suffering and dying patients with no concept of family bereavement, with costs their only consideration and euthanasia beoming an acceptable approach to end lives not worth living or spending money on, we may be able to learn from how the ruthless have maintain their power structures. To read the rest of the obituary, go to www.economist.com/obituary/displaystory.cfm?story_id=7826946
On This Date in History - September 12
On This Date in 1866, the premiere of a
show called The Black Crook in
On This Date in 1953, Nikita Khrushchev
became the first Secretary of the Communist Party of the
Speaker's Lifetime Library, © 1979, Leonard and Thelma Spinard