MEDICAL TUESDAY . NET
Community For Better Health Care
Vol VII, No 12, September 23, 2008
In This Issue:
MOVIE EXPLAINING SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE's SiCKO
a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the
truth about socialized medicine. Clements is the former publisher of
"American Venture" magazine who made news in 2005 for a property
rights project against eminent domain called the "Lost Liberty
For more information visit www.sickandsickermovie.com or email firstname.lastname@example.org.
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Why Do Some People Sleepwalk?—Carlos Navarro, via e-mail
Neurologist Antonio Oliviero of the National Hospital for Paraplegics in Toledo, Spain, explains:
Sleep disorders such as sleepwalking arise when normal physiological systems are active at inappropriate times. We do not yet understand why the brain issues commands to the muscles during certain phases of sleep, but we do know that these commands are usually suppressed by other neurological mechanisms. At times this suppression can be incomplete—because of genetic or environmental factors or physical immaturity—and actions that normally occur during wakefulness emerge in sleep.
People can perform a variety of activities while asleep, from simply sitting up in bed to more complex behavior such as housecleaning or driving a car. Individuals in this trancelike state are difficult to rouse, and if awoken they are often confused and unaware of the events that have taken place. Sleepwalking most often occurs during childhood, perhaps because children spend more time in the "deep sleep" phase of slumber. Physical activity only happens during the non–rapid eye movement (NREM) cycle of deep sleep, which precedes the dreaming state of REM sleep.
Recently my team proposed a possible physiological mechanism underlying sleepwalking. During normal sleep the chemical messenger gamma-aminobutyric acid (GABA) acts as an inhibitor that stifles the activity of the brain's motor system. In children the neurons that release this neurotransmitter are still developing and have not yet fully established a network of connections to keep motor activity under control. As a result, many kids have insufficient amounts of GABA, leaving their motor neurons capable of commanding the body to move even during sleep. In some, this inhibitory system may remain underdeveloped—or be rendered less effective by environmental factors—and sleepwalking can persist into adulthood.
Sleepwalking runs in families, indicating that there is a genetic component. The identical twin of a person who sleepwalks often, for example, typically shares this nocturnal habit. Studies have also shown that frequent sleepwalking is associated with sleep deprivation, fever, stress and intake of drugs, especially sedatives, hypnotics, antipsychotics, stimulants and antihistamines. . .
Why do we get "brain freeze"
when we eat something cold?
-Christina Zuniga, via e-mail
Mark A. W. Andrews, professor of physiology and director of the Independent Study Pathway at the Lake Erie College of Osteopathic Medicine, replies:
This commonly experienced pain, also known as an ice cream headache, results from quickly eating or drinking very cold substances. Officially termed sphenopalatine ganglioneuralgia (talk about a painful mouthful!), it is the direct result of the rapid cooling and rewarming of the blood vessels in the palate, or the roof of the mouth. A similar but painless blood vessel response causes the face to appear "flushed" after being outside on a cold day. In both instances, the cold temperature causes blood vessels to constrict and then experience extreme rebound dilation as they warm up again.
In the palate, this dilation is sensed by nearby pain receptors, which then send signals back to the brain via the trigeminal nerve, one of the major nerves of the facial area. This nerve also senses facial pain, so as the signals are conducted the brain interprets the pain as coming from the forehead—the same "referred pain" phenomenon seen in heart attacks. Brain-freeze pain may last from a few seconds to a few minutes, which is blissfully short as compared with the duration of its cousin, the migraine headache. Research suggests that the same vascular mechanism and nerve implicated in brain freeze cause the aura (sensory disturbance) and pulsatile (throbbing pain) phases of migraines. Interestingly, it is impossible to give yourself an ice cream headache in cold weather—only in a warm ambient temperature will it hurt to wolf down a banana split.
Fortunately, abstaining from ice cream is not necessary. Placing the tongue hard against the palate may help, as will eating cold foods more slowly or warming food in the front of your mouth before swallowing.
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The Virginia Supreme Court declared the state's anti-spam law unconstitutional Friday and reversed the conviction of a man once considered one of the world's most prolific spammers.
The court unanimously agreed with Jeremy Jaynes' argument that the law violates the free-speech protections of the First Amendment because it does not just restrict commercial e-mails — it restricts other unsolicited messages as well. Most other states also have anti-spam laws, and there is a federal CAN-SPAM Act as well, but those laws apply only to commercial e-mail pitches.
The Virginia law "is unconstitutionally overbroad on its face because it prohibits the anonymous transmission of all unsolicited bulk e-mails, including those containing political, religious or other speech protected by the First Amendment to the U.S. Constitution," Justice G. Steven Agee wrote.
Agee wrote that "were the Federalist Papers just being published today via e-mail, that transmission by Publius would violate the statute." Publius was the pseudonym used by Alexander Hamilton, James Madison and John Jay in essays urging ratification of the Constitution.
"In my view, the case was never about Jeremy Jaynes — it was about the First Amendment," said Jaynes' attorney, Thomas M. Wolf. "The argument was never that there's a constitutional right to send commercial spam. It was that the government cannot criminalize the sending of noncommercial e-mail for political and religious purposes, and that is what this statute did."
Lawyers for the state had argued that the First Amendment doesn't apply because the Virginia law bars trespassing on privately owned e-mail servers through phony e-mail routing and transmission information. The court rejected that characterization of the law. . .
The Virginia Supreme Court last February affirmed Jaynes' conviction on several grounds but later agreed, without explanation, to reconsider the First Amendment issue. Jaynes was allowed to argue that the law unconstitutionally infringed on political and religious speech even though all his spam was commercial.
Wolf said sending commercial spam is still illegal in Virginia under the federal CAN-SPAM Act. However, he said the federal law does not apply to Jaynes because it was adopted after he sent the e-mails that were the basis for the state charges. To read the entire article, please go to http://license.icopyright.net/user/viewFreeUse.act?fuid=MTUzMDIyOQ%3D%3D.
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Is the law bleeding the NHS to death? By Richard Girling From The Sunday Times, August 3, 2008
For Dr Spencer at his Norfolk surgery, the whoops-a-daisy moment came when he dosed a woman with bismuth. Startled by her dyspeptic response, and eager to reassure her increasingly agitated husband, he swallowed a spoonful of the stuff himself. "See? Perfectly safe!"
Two things then happened: Dr Spencer vomited, fell down and lay writhing on the floor. His patient died.
The explanation was simple. As the doctor explained to the coroner, bismuth and strychnine look remarkably similar in the bottle and, well, mistakes do happen. At the subsequent trial for manslaughter, Mr Justice Willes agreed. A simple blunder, he said, was not in itself a criminal act. To secure a conviction, the crown would have to prove that the doctor's medicines were in such chaotic disorder that it was impossible for him to know which was which. Not guilty, said the jury.
That was in 1867. Legal actions against clinical killers then were exceedingly rare, and would remain so. By 1989 only six more doctors had been fingered for manslaughter – an average of one every 20 years. Then something changed. In the 1990s, 17 were prosecuted, and since 2000 there have been 11 more. One or two of them, like the Spencer case, were tales of startling improbability. A woman under anaesthetic was connected to an oxygen cylinder instead of to a ventilator and inflated like a balloon (the anaesthetist got six months' jail, suspended for 18 months). Mostly, however, they were mundane tragedies of misread notes, wrong drugs or lethal doses administered by exhausted, inexperienced or occasionally negligent practitioners who failed in the most basic of their responsibilities.
This relatively small number of headline cases, however, was only the tiny tip of a legal iceberg. It wasn't just the police and Crown Prosecution Service who were taking a more critical look at wards and clinics – it was the patients themselves. In England between 1990 and 1998, the rate of civil negligence claims against hospitals doubled, reaching a peak in 1998-9 of 6,168. If we didn't know them to be true, the numbers would strain credibility. The cost to the NHS of claims settled in 2006-7 was £579.3m. In the same year it was hit by 5,426 new cases. The NHS Litigation Authority (NHSLA) estimates that the combined cost of settling all outstanding claims, including incidents so far unreported, will be £9.09 billion.
Paralysing tentacles of fear are now putting the squeeze on medical practice, and changing the way we are treated. Type the words "clinical negligence" or "no win, no fee" into Google and you'll see why – a clamorous pack of legal agencies and law firms who trade on the idea that every accident must be someone's fault. Some websites even provide interactive body maps showing the value of everything from an injured finger (£1,000 to £75,000) to serious brain damage (millions). The come-on to patients is the promise of "no win, no fee". If the lawyer wins your case for you, he collects his fee in costs from the other side and you walk away with your damages in full. If he loses, he charges nothing. So, come on! What are you waiting for? Sue the doc! . . .
As so often with the NHS, vice is the bastard child of virtue. "No win, no fee" deals, known in law as conditional-fee arrangements, were introduced by an amendment to the Courts and Legal Services Act in 1995. It was meant to be a double benefit. The courts would be opened up to those in the income trap who were ineligible for legal aid but unable to afford lawyers. The government itself would save money by effectively privatising legal aid. On the surface it looked like the long-overdue democratisation of civil justice.
But law firms are not charities. Working for nothing – pro bono – is not unknown, but it hardly stands as an ideal business model. If lawyers were to drop their fees when they lost, then they would need a bonus when they won. Recognising this, the law allows a "success fee" of up to double the normal scale. In clinical- negligence cases, when judgment favours the patient, this must be paid by the NHS, otherwise known as the taxpayer. . .
Once upon a time, family doctors were revered members of communities that knew how to respect their betters. They tended to tweediness and avuncularity, and knew each patient from the moment of conception. Their status was impregnable. Like magistrates (which they also often were), they dwelt upon a high moral plateau where errors and injustices were as rare as club-footed Martians with syphilis. They cut your umbilical cord, signed your passport photograph and came to your funeral. You would no more think of suing them than you would of denying God or insulting the king. Doctors for their part were sworn by Hippocrates to guard the sick against harm and injustice. From this grew the modern ideal of "preventive medicine" – the inoculations, health checks, dietary advice and so forth that cure illnesses before they happen.
All this now is changing. Vulture culture, compensation culture, blame culture. Call it what you will, the effect is the same. As the British Medical Journal pointed out, the rise in prosecutions in the late 20th century was not likely to have been caused by a sudden epidemic of clinical malpractice. An entire profession does not go rotten overnight. "More plausible explanations," it suggested, were "a greater readiness to call the police or to prosecute, perhaps because the Crown Prosecution Service perceives that juries are readier to convict nowadays."
The old notion of a lifelong relationship between patient and practitioner was also under assault. Large group practices and the increasing influence of professional managers made the NHS seem more remote and bureaucratic.
Suing it seemed less like attacking a friend than asserting your rights against an impersonal monolith that knew you only as a computer file. Instead of grumbling about our grievances, we went to law, and doctors went on the defensive. Out went the bedside manner; in came proceedings that, in the words of the government's chief medical officer, Sir Liam Donaldson, "frequently progress in an atmosphere of confrontation, acrimony, misunderstanding and bitterness".
This is the real cost of the compensation culture. Preventive medicine (protecting the patient) is being superseded by defensive medicine (protecting the doctor from litigation). What it means is that GPs behave more like trampolines than physicians, bouncing their patients on to consultants rather than taking responsibility themselves. It means a plethora of clinically unnecessary, just-in-case blood tests, x-rays, endoscopic examinations, CT and MRI scans, avoidance of tricky procedures, shunning of awkward patients and reluctance to try new treatments. As birth defects account for the majority of new claims each year, it results in a huge increase in the number of caesareans. . .
Because of rapacious lawyers, he says, GPs now prescribe more freely, refer patients to consultants and order laboratory tests much earlier than they would have done in the past. "It's dumbing down what we do. It requires experience and judgment to do nothing. If there was a diagnostic test for everything, then why would you need a doctor? Now I can spend a whole surgery writing out test request forms. It's a hell of a long way from preventive medicine." Because GPs, like consultants in private practice, are self-employed, they are not covered by the NHSLA's Clinical Negligence Scheme for Trusts – effectively a government-run insurance scheme into which local NHS trusts pay annual premiums of up to £5m each. GPs and private practitioners instead have to use specialist insurance companies whose payouts are not included by the NHS but still siphon money away from medicine and into law. The Medical Defence Union, which indemnifies just over half the UK's GPs and private consultants, primly declines to reveal the figures. . .
The other thing that bacteria love is filth, and the ideal place to look for it is in an NHS hospital. The result is that there are now law firms claiming to specialise in hospital "superbug" cases, and the number of claims is multiplying like bacteria on a Petri dish. One of the most notorious cases involved the three hospitals administered by the Maidstone and Tunbridge Wells NHS Trust where, between April 2004 and September 2006, more than 1,170 patients were infected with Clostridium difficile. According to the Healthcare Commission's official report, about 90 people "definitely or probably died as a result of the infection". The commission's inspectors found that the hospitals were epidemics waiting to happen. Supposedly clean bedpans were contaminated with excrement. Nurses were not washing their hands, emptying commodes, cleaning mattresses and equipment, or wearing aprons and gloves. If there was a parlour game called "pass the bacteria", this is how you'd play it. The health secretary, Alan Johnson, described the episode as "scandalous", and Kent police are still weighing the possibility of prosecution. . .
The nurses might not be washing their hands, but the lawyers sure as hell are rubbing theirs.
To read the entire lengthy article, go to http://business.timesonline.co.uk/tol/business/law/article4428686.ece.
The NHS does not give timely access to health care, but it may give access to legal compensation.
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Medicare Is Bad for Your Health By Philip R. Alper, MD
Hoover fellow Philip R. Alper explains how Medicare's convoluted regulations put the nation's health care system at risk. Hoover Digest, 1998. (As relevant today as ten years ago.)
Last summer Columbia/HCA teetered on the brink of disaster after the Health Care Financing Administration (HCFA), which administers Medicare, accused the company of massive fraud. On the other side of that continuing fight, HCFA head Bruce Vladek recently resigned, saying he was exhausted by trying to control fraud in the $300 billion Medicare and Medicaid programs.
This battle is really over differing answers to the question "How many CPAs can dance on the head of a syringe?" What's lost in all the bureaucratic and legal mumbo jumbo is a fact that's far more damaging to our nation's health care system: It's too difficult for doctors to do their jobs well while at the same time coping with a proliferating web of fraud-fighting regulations.
The predicament is a lonely one. My patients don't know that new laws subject physicians to criminal fraud prosecution whenever they disagree with Medicare about when to order a lab test or how to characterize a diagnosis. As an internist specializing in geriatrics, I can't ignore the increasing risk to my own well-being and my family's simply from remaining in practice. But Washington doesn't care that doctors like me do our best to play by the rules and have never had any regulatory problems.
This is surely hard to believe. So here's a test question: If a doctor orders a stool specimen to test for occult blood--which might indicate early colon cancer--is he engaging in good medical practice or criminal behavior?
Answer: It all depends. If the patient doesn't have symptoms and the bill is sent to Medicare, it's a criminal offense because these "preventive services" aren't covered benefits. Thus, billing them to Medicare is considered fraud. The absence of intent to cheat Medicare doesn't matter. Fines of up to $10,000 per "incident" of such "fraud" may be levied on the physician who simply orders the test from a lab at no personal profit.
In contrast, tests are legal when they are used to confirm a suspected diagnosis. But many cases are borderline. And there's a difference between the screening tests that Medicare covers and what's recommended by medical authorities. Sometimes the authorities don't even agree among themselves. For instance, the American Association of Clinical Endocrinologists strongly recommends thyroid screening for elderly patients, but the American College of Physicians doesn't endorse it. That's why the personal physician treating George Bush--who's had access to first-rate health care his entire life--failed to check his thyroid and why Mr. Bush's heart complications were the first clue that something was awry.
I've tried explaining Medicare's rules to patients. Most are bewildered. One patient left me when I asked that she pay for some screening tests herself. Since mammograms, Pap smears, and flu shots are covered and since her friends hadn't been asked to pay for any tests, she figured I must have been up to something funny.
Other doctors concur that ordering a lab test for Medicare patients can be as complicated as obtaining an informed consent for surgery. That's just crazy. In this Alice-in-Wonderland system, patients and doctors are both in trouble. Nobody knows what to do and everyone is afraid to ask.
One regulatory time bomb is now ticking loudly: The HCFA advises labs that don't get a "correct" diagnosis code from the ordering physician to bill either the patient or the doctor for the test--or just do it free. Instead of a bill, patients receive three-page, single-spaced letters advising them of Medicare's action in terms that would take a team of lawyers to decipher. That leaves doctors, patients, and hospitals to fight it out among themselves. And if anything goes wrong, patients may be liable for bills for lab tests and some diagnostic procedures at up to ten times what Medicare will pay.
Given its concern over rising costs, it's extremely odd that Medicare has never attempted to educate doctors on how to order lab tests in cost-effective ways. Instead, in its accelerated anti-fraud mode, HCFA is now instructing labs to "voluntarily" set up their own programs to spy on physicians and to report "suspicious" test-ordering patterns. Labs that cooperate with this spying are told they can expect the HCFA to go easier on them when it is their turn to be audited. A Russian friend told me this reminds him of the Soviet Union.
Even in the best of worlds, medical care is a complex business. But the HCFA is poisoning doctor-patient relationships. When an elderly patient of mine demanded unnecessary home health visits because her neighbor got them, I followed the rules and refused. The patient soon found someone else who was less concerned with the rules--and with the criminal penalties for breaking them. Since I became a doctor in order to care for patients, such cases are hard to forget.
Controlling Medicare fraud requires cooperation between doctors and the HCFA. Over the years, I've kept many patients out of the hospital, avoided unnecessary operations, and reassured people who incorrectly thought they needed expensive tests. I don't expect a commendation for saving a bundle of money for Medicare because that's part of my job. But I must say that when I see problems and solutions that Medicare ought to know more about than it apparently does, I feel more like a character in a Kafka novel than a partner in the program.
Philip R. Alper, M.D., is a clinical professor of medicine at the University of California, San Francisco, and the Robert Wesson Fellow in Scientific Philosophy and Public Policy at the Hoover Institution.
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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Mrs. Platnick, a five-foot 300-pound rotund female with severe COPD had some low chest discomfort. Her boyfriend insisted on having her brought to the emergency room for evaluation. He was concerned about a coronary; she felt it more like her ulcer acting up.
In the emergency room when her friend mentioned chest pain, the antennas went up and she received the full cardiac press. After the first round of tests, she tried to tell an RN and the MD that she felt she was having severe heartburn and could she have some antacids. She was told it was much more serious than that. Instead, they rolled her out to the imaging department for another series of tests. She asked the technician if he had some antacids in his pocket or available in the department. He told her he didn't have any and there was none in the department, which had tons of white chalky material to be infused into stomachs and rectums for diagnostic purposes but not for treatment.
When she returned to the emergency department an hour or two later, she asked the nurse for some antacids and she gave her an ounce. Within minutes, she not only felt better, but also felt quite well and wanted to go home. After some wrangling, she was allowed to go home, where she immediately took a few swallows of antacids and an acid reducing pill and slept well for the remainder of the night. Her boyfriend felt better, even though he had to wait in the ER for about five hours. He felt it was worth the inconvenience of waiting to put his mind at ease. There was no cost - they were MediCal patients.
This is a frequent occurrence in the practice of medicine. The patient frequently knows what's wrong with her but the friends and relatives are having an acute anxiety attack over emotionally sensitive terms such as "chest pain." If she would have just said, George, could you get my antacids and acid reducers (she was too heavy to walk to the bathroom or the medicine cabinet on her own steam), she would have gotten well in the same few minutes, like after the five-hour ER ordeal when she finally got the antacids.
Unfortunately, much of health care cost is determined by well meaning relatives and friends when the patients have lost control.
The health care costs of treating anxieties in the Emergency Rooms are out of control.
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6. Medical Myths: Is Mandatory Health Insurance Really a Good Idea?
Imposing a federal mandate is a hot issue on the campaign trail. It's also a burning issue in Congress, where Democratic Sen. Ron Wyden and Republican Sen. Bob Bennett are pushing the Healthy Americans Act, which would require everyone not in Medicaid or another government program to buy health insurance.
But is mandatory health insurance really a good idea? Requiring catastrophic coverage (our parents called it major medical) probably is smart. This would ensure that a person who is hurt in a car accident or diagnosed with a costly illness can pay his own medical bills, instead of being a burden on society.
But catastrophic coverage is not what the mandate advocates want. They would require that everyone have comprehensive health insurance, covering preventive and routine care.
The rationale for this mandate is not personal responsibility but "shared responsibility," a polite way of saying shared costs. Requiring comprehensive coverage, the argument goes, will make it affordable for the sick, by pulling the young and the healthy -- neither of whom use these health services very much -- into the insurance pool. Advocates also argue that requiring this type of coverage will cure overcrowded emergency rooms and help tame skyrocketing health costs.
These arguments are based on myths, not facts.
The first myth is that it's fair to make everyone pay the same price for health insurance. It is not: For young people who rarely use health services, this is a rip-off. If people in their 20s paid attention to politics and voted, politicians wouldn't dare try this.
According to the latest Census data, 56% of the uninsured are adults aged 18-34. True enough, forcing them to be a part of a same-price-for-everyone insurance pool will likely bring down premiums. These young people generally need minimal health care ($1,500 a year, on average, according to a Commonwealth Fund study).
In most states, (but not New York and Vermont), young adults who buy health insurance are charged premiums that reflect their low medical needs. A 25-year-old man can buy a $1,000 deductible policy for a quarter to a third of what a 55-year-old man has to pay. (In Manchester, N.H., a 25-year-old man pays $156 per month, while a 55-year-old pays $542 for the same policy, according to ehealthinsurance.com).
Both the Clinton proposal and the bipartisan congressional proposal prohibit insurers from giving such price breaks to the young. Their mandates would force the young to subsidize the heath tab for the middle-aged generation. This subsidy would come on top of the payroll tax younger people already pay to support today's Medicare recipients. This is contrary to a fundamental American principle. This nation has always believed in making life better for its children, not exploiting them. . .
The second myth behind federal mandate proposals is this: Lack of insurance forces people into the emergency room for routine health care. "It's a hidden tax, the high cost of emergency room visits that could have been prevented by a much less expensive doctor's appointment," Mrs. Clinton said recently. The truth is that the uninsured do not use emergency rooms more than other people.
Federal data (the Medical Expenditure Panel Survey provided by the Agency for Healthcare Research and Quality) show that the elderly are most inclined to go to the emergency room, though they are universally covered by Medicare.
Other repeat users, according to an Institute of Medicine study, are the "frequent flyers" who are in the ER repeatedly because of mental illness or substance abuse. Enacting a mandate isn't going to eradicate the behavioral problems that land them in the ER.
The third myth, in the words of Mr. Edwards, is that a "system that leaves 47 million Americans without health care is a moral disgrace." The remedy he has in mind is a mandate.
The rise in the number of uninsured people (up from 42 million in 2002) is not due to a sudden moral failure of the country or a broken health system. Instead, a major cause is immigration and cultural differences that make recent arrivals especially likely to be uninsured.
Immigration over the past seven years has been the largest for any seven-year period in American history. Over 10 million immigrants entered the country, more than half of them illegally, according to a report by the Center for Immigration Studies in Washington, D.C. Nearly 75% of the increase in the number of uninsured people since 1990 consists of newcomers and their U.S. born children, according to the study.
In the most recent Census report, the lion's share of the increase in the uninsured occurred in five border states: Arizona, California, Florida, New Mexico and Texas. In San Francisco, public health authorities estimate that 61% of the city's uninsured are not citizens. . .
Not only are newcomers from Central and South America uninsured when they enter the U.S., but a cultural unfamiliarity with health insurance means that many continue to go without coverage even when they can afford to buy it. One third of all people who identify themselves as Hispanic on the 2006 Census are uninsured, including Hispanics with high incomes.
These facts should point the presidential candidates and Congress toward a sounder policy on health insurance.
According to the Census Bureau, of the 47 million uninsured, nearly 10 million have household incomes of at least $75,000. They probably can afford coverage but have chosen not to buy it. Another 14 million of the uninsured are already eligible for government programs such as Medicaid (for low income adults) and the State Children's Health Insurance Program (for children) and simply need to sign up.
That leaves about 23.7 million people -- some citizens, others newcomers -- who cannot afford coverage. It's up to the nation to decide what to do about that. One thing is clear: Mandating that everyone, including young adults, buy insurance, and then hiding a hefty, cost sharing tax inside their premium, is an unfair solution.
Ms. McCaughey, a former lieutenant governor of New York, is an adjunct senior fellow at the Hudson Institute.
To read the entire article, go to http://online.wsj.com/article/SB119941501118966929.html.
[Some have said that the 10 million Americans making $75,000 a year are effectively self-insured and shouldn't be counted.]
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[Editor's note: In 2007, of the 200 million Americans overweight, 100 million are considered obese. Of the ones obese, 15 million are considered morbidly obese. Of the 20 percent complication risk, it is estimated that up to 40,000 complications arose. With a one percent death risk, it is estimated that about 2,000 deaths occurred.]
Dr. Edwards: Wasn't that a great lecture on treatment of Mobid Obesity by our liability insurance carrier at Grand Rounds last month?
Dr. Yancy: He was trying to scare all you internists in order to prevent referrals for Bariatric Surgery.
Dr. Michelle: I think he did that.
Dr. Yancy: You mean you're no longer going to refer your morbidly obese patients to me?
Dr. Michelle: I will. But it will take longer to get them to you. I'll give them the complication list to get them motivated to lose weight by eating less.
Dr. Rosen: Every obese patient I know does not believe that eating causes obesity. They say it's glandular.
Dr. Michelle: I recorded the complication list into my PDA: Infections, Bleeding, Incisional and internal hernias, Bowel obstruction, Stricture, Erosions, Ulcers, Adhesions, Fascial dehiscence, Gallbladder disease, Re-hospitalization and additional surgeries.
Dr. Rosen: That's quite a list. That should put the Fear of God in them.
Dr. Michelle: That gets the patient in tuned to try medical weight loss first.
Dr. Edwards: For medical weight loss, I give them the information that it takes 3500 calories above their maintenance to gain a pound. An extra cookie or a coke with 100 calories equals 35,000 per year or 10 pounds of weight gain per year.
Dr. Rosen: Well, does it work?
Dr. Edwards: Then I translate their weight into calories eaten.
Dr. Ruth: Is that so they can count calories? Two dieticians can't agree on what my patients eat.
Dr. Edwards: That's the point. We want the patient to understand just how many calories he or she eats. If the patient went to Weight Watchers, they multiply the patient's weight by 10.
Dr. Michelle: So a 150-pound person eats 1500 calories.
Dr. Edwards: Precisely. So if the person takes 100 calories off his plate a day, such as a cookie or drink, then he or she will lose 10 pounds over a year.
Dr. Ruth: Does that compute for the average patient? If I told a 150-pound woman that she eats 1500 calories a day, she wouldn't believe me.
Dr. Rosen: But that's a discussion you can't enter. When a 300-pound lady tells you she doesn't eat more than a bowl of peaches a day, just say, "Start eating a half bowl," and continue the next discussion. Otherwise, you won't make it home at night.
Dr. Edwards: Weight watchers use an average. It is more accurate to use 8-10 calories per pound for women and 10-12 calories per pound for men. So I use 9 as an average for women and 11 as an average for men to calculate their current caloric intake.
Dr. Ruth: Isn't that making it more complicated?
Dr. Edwards: It's not the math I leave. It's the quantity visualization that I leave with the patient. So, if I have a man, I multiply his weight by 11 and tell him that's what he's eating. We're just trying to quantify his portions. So, if a 250-pound man is eating 2750 calories per day, then we can talk about taking one-fifth of his food off the plate.
Dr. Michelle: I see now where you're going. So, by taking 500 calories off his plate a day, he's removing 3500 calories per week, which is one pound per week.
Dr. Edwards: Precisely. Then he should lose 8 pounds in two months, 16 pounds in four months and 24 pounds in six months?
Dr. Ruth: Have you ever seen anyone do that?
Dr. Rosen: Yes, I have experienced it. When my doctor told me I had to lose 30 pounds if I want to live, since my mother had diabetes, I removed what I thought was one-fourth my plate or 500 calories. I must have taken off about 625 calories since in two months I lost 10 pounds, in four months I lost 20 pounds, and in six months I lost the entire 30 pounds.
Dr. Edwards: Have you had any success in getting patients to see the light?
Dr. Rosen: After the Grand Rounds presentation, I've made a renewed effort because of the patients that are suing after Bariatric surgery. They are not only suing the surgeons, they're suing their personal physician, surgical assistants and anybody whose name they can read on the records they acquire.
Dr. Yancy: You guys are making me upset. I spent and lot of time and money learning laparoscopic Bariatric surgery.
Dr. Michelle: I'll still refer, but there will certainly be less because I think I will have more success with the medical treatment of obesity. Many of my patients with Bariatric surgery may lose 150 pounds, but they all seem to regain 50-75 pounds and get back to their old eating habits.
Dr. Rosen: Maybe less patients, Yancy, but they will be much better prepared and knowledgeable and thus lawsuits will be less likely.
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PRESIDENT'S MESSAGE Above and Beyond the Call of Duty by KATE MCCAFFREY, D.O.
I made a trip last week to Humboldt and Del Norte Counties to recruit preceptors for medical students. What struck me most were the increase in work load and the decrease in morale of the physicians and the offices I visited.
Depending on their specialty field, some physicians are seeing up to 45 patients per day on top of doing procedures. Practices are absorbing patients from physicians who are leaving the area or retiring and closing their practices.
The average age of primary care and specialty physicians in Humboldt and Del Norte Counties is over fifty. The area's recruitment efforts so far have been enough to stem the dam of physicians leaving but not enough to re-build the area's surplus of physicians for the future.
For instance, in Del Norte County they will be losing their only otolaryngologist this year and there likely will not be a replacement. That will mean that the primary care physicians in Del Norte will have to refer elsewhere such as Southern Oregon, Humboldt County and the Bay Area.
We all know the barriers to physician recruitment and retention in Humboldt. Developing a teaching program and eventually a residency in our counties is part of the solution. Introducing medical students to the area will expose them to rural medicine which is a different set of skills than practicing medicine in the bigger cities. Rural physicians are usually well rounded in their skills and resourceful. We know when to treat and when to transport. We also see more progressed pathology in our patients than our counter arts in the cities due to a unique rural set of barriers to health care access.
The other thing that struck me on my trip and in talking to dozens of physicians was the recognition that as physicians in a small community, we are all interconnected. When someone leaves or retires, we all feel the effects and have to shift our practices to compensate. Fortuna has a delicate balance but they are stable. Arcata is going through changes in several specialties. Eureka is ever growing and expanding but the doctors are looking at retirement in the next ten years. Del Norte County is on empty and things are getting worse if that is possible. If we can get volunteers to house the Touro medical students, we will be able to place them in practices in Del Norte County.
I recently received an award from the students at Touro University entitled, "Above and Beyond the Call of Duty". I would like to pass this award on to my colleagues in Humboldt and Del Norte Counties for hanging in there during these difficult times in medicine and also for practicing in a rural county. I am proud to call you colleagues as well as friends.
What Dr. McCaffrey failed to mention is that, physician recruitment is only necessary because physicians are paid less than Market Value by the current bureaucratic system. If physicians were paid what they are worth, they would flock to the best deal in the state and there would be no underserved areas.
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THE AMA ESSENTIAL GUIDE TO . . . ASTHMA; HYPERTENSION; DEPRESSION; MENOPAUSE. Pocket Books, New York, 1998, $14 each
Pocket Books sent these four "Guides" subtitled "Clear, authoritative health information for your family" for my review. The editorial staff at the AMA, with Angela Perry, MD, as the overall Medical Editor produces these books, each with its own science writer and medical advisor. This system has produced a number of excellent patient reference books. The previous Pocket Guides, which are about 250 pages, include Emergency First Aid, Sports First Aid, and Back Pain. Large coffee table compendiums have included the AMA Family Medical Guide, AMA Encyclopedia of Medicine, and AMA's Seven Weeks to Better Sex. While attending an AMA Science Reporters Conference in San Francisco, I was given the 750 page AMA Complete Guide to WOMEN'S HEALTH, which Dr Eleanor Rodgerson of our editorial board reviewed in September 1997. She felt it was the most comprehensive of the numerous volumes available.
Christopher Winslow, MD, is the pulmonologist who edited the AMA Essential Guide to Asthma. This is a well written, easily readable, patient friendly book that gives numerous examples of asthma patients, their environment and infectious triggers for an attack, what may and should be done in order to facilitate a prompt understanding of the medical chain of events, and how best to handle the struggle for breath. Today asthma affects more than 5% of our population--14 million people in the US, up from 10 million in 1990, with one-third under age 18. This useful self-help includes a list of commonly asked questions about asthma, a glossary of terms, and a list of asthma organizations that can give further help and support. . . To read the rest of the review, please go to www.delmeyer.net/bkrv1a99.htm.
To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.
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Private patients, frequently from the business/professional world, who pay me $125 for an office visit, never call me between office visits. If they have an intervening problem, they try to handle it to the best of their ability or make an appointment and face me directly to discuss the problem.
However, most of my HMO patients pay a $10 co-payment to see me, and their HMO pays me an additional $65 about which the patient is uninformed. These folks have no problem calling at any time about any subject and try to get three or four office calls for their one $10 co-payment. Their HMO does not reimburse for office calls, like attorneys do.
Third party medicine totally distorts the Doctor-Patient relationship.
The Cost of Creating Jobs
The social cost of collecting $1.00 in taxes is $1.24, notes Linda Gorman of The Independence Institute. For every four jobs created by spending, about five jobs or their equivalent will be lost because of taxes.
If you rob Peter to pay Paul, you can always be assured of Paul's vote to help you rob more Peters.
The Cost of Bail Outs
The federal government bailed out the American Insurance Group, Inc. for $85 billion. That's stealing about $500 from every couple in the United States. It seems the rational for this grand theft could also apply to the auto industry, which seems to be in severe straights. I think the newspaper industry is nearly there also. The surgeons tell me they are already there.
Will the Feds feel they are justified in stealing all of our money and say it's in the public interest?
I don't think the public's interest is the same as the interest of Congress trying to get re-elected.
We don't argue with people
with whom we disagree. We just shoot them.
An Iranian patient came in last week having visited his country where a large number of his family still live. Although he enjoyed seeing them, he stated the leaders are lunatics. They have so much oil money, that individuals who don't serve their purpose have no value to them and are totally dispensable. There is no two-way discussion with them. While he was there, he said there was one group of 99 people that were summarily shot.
We have a presidential candidate who wants to go over to Iran and have a two-way discussion to reason with them in an effort to produce world peace. Reminds me of a miner who said they would send a canary into a mine and if the bird came back alive, it was safe to proceed.
A Republican suggested we send the Democratic candidate into Iran before the elections to test this. He said this would hi-light two problems and solve one. I wonder what the other problem was.
To read more HHK, go to www.healthcarecom.net/hhk2001.htm.
To read more HMC, go to www.delmeyer.net/hmc2005.htm.
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• John and Alieta Eck, MDs, promote first-century solutions to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. The Zarephath Health Center is located on the scenic campus of Zarephath, in Somerset, NJ, also home of Star 99.1, Zarephath Christian Church, and Somerset Christian College. We began in September 2003 with a specific mission--to help the churches meet the health care needs of the poor, uninsured and under-insured. We take our model from that of the Good Samaritan. In the Bible, Jesus tells the story of a man who was beaten and left to die on the side of the road. A minister and a religious teacher came by and walked around him, feeling that they did not have the time or means to help. Then a Samaritan, a religious outcast, stopped, cared for his immediate needs, and took him to a place where he could recover. He paid the bills as well, promising to return and pay more if other expenses were incurred. Jesus finished this story, telling those around him to "Go and do likewise." To read the rest of the story, go to www.zhcenter.org and check out their history, mission statement, newsletter, and a host of other information. For their article, "Are you really insured?" go to www.healthplanusa.net/AE-AreYouReallyInsured.htm.
• PATMOS EmergiClinic - is where Robert Berry, MD, an emergency physician and internist practices. At PATMOS EmergiClinic, we provide prompt care for many of the injuries and illnesses treated in Emergency Rooms at a tiny fraction of their cost. We also take care of chronic problems such as diabetes and hypertension. PATMOS EmergiClinic does not accept any third party payment and makes no apologies for this. In order to keep costs down for the uninsured and the increasing number of patients who have high co-pays and deductibles, we choose not to assume the massive overhead involved in billing third party payers. This has the added benefit of eliminating bureaucratic hassles and intrusions into the doctor-patient relationship, ensuring strict confidentiality of patient information, and keeping our typical charges usually between the cost of an oil change and a brake job. To read his story and the background for naming his clinic PATMOS EmergiClinic - the island where John was exiled and an acronym for "payment at time of service," go to www.emergiclinic.com. To read more on Dr Berry, please click on the various topics at his website. Dr. Berry practices in Greeneville, Tennessee.
• PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. http://home.earthlink.net/~doctorlrhuntoon/. Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. I also believe in an honest day's pay for an honest day's work. Please Note that PAYMENT IS EXPECTED AT THE TIME OF SERVICE. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law. Dr. Huntoon practices Neurology in Derby, New York.
• FIRM: Freedom and Individual Rights in Medicine, Lin Zinser, JD, Founder, www.westandfirm.org, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance. America was founded on the principles of freedom and individual rights. Applied to medicine, the law must respect the individual rights of doctors and other providers, allowing them the freedom to practice medicine. This includes the right to choose their patients, to determine the best treatment for their patients, and to bill their patients accordingly. In the same manner, the law must respect the individual rights of patients, allowing them the freedom to seek out the best doctors and treatment they can afford.
• Michael J. Harris, MD - www.northernurology.com - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis" at www.northernurology.com/articles/healthcarereform/administrativectomy.html..
• Dr Vern Cherewatenko concerning success in restoring private-based medical practice which has grown internationally through the SimpleCare model network. Dr Vern calls his practice PIFATOS – Pay In Full At Time Of Service, the "Cash-Based Revolution." The patient pays in full before leaving. Because doctor charges are anywhere from 25-50 percent inflated due to administrative costs caused by the health insurance industry, you'll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year! To read the rest of the story, go to www.simplecare.com.
• Dr David MacDonald started Liberty Health Group which is a leader in Consumer Directed Health Care. Professionals with practical experience who are need-focused and solution-driven! To compare the traditional health insurance model with the Liberty high-deductible model, go to www.libertyhealthgroup.com/Liberty_Solutions.htm. There is extensive data available for your study. Dr Dave is available to speak to your group on a consultative basis.
• Madeleine Pelner Cosman, JD, PhD, Esq, (1937-2006) has made important efforts in restoring accountability in health care. She will be remembered for her important work, Who Owns Your Body, which is reviewed at www.delmeyer.net/bkrev_WhoOwnsYourBody.htm. Please go to www.healthplanusa.net/MPCosman.htm to view some of her articles that highlight the government's efforts in criminalizing medicine. For other OpEd articles that are important to the practice of medicine and health care in general, click on her name at www.healthcarecom.net/OpEd.htm.
• David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.
• Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, who would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at www.peerreview.org.
• Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848 no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the California Medical Board response, see www.delmeyer.net/HMCPeerRev.htm. Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD.
To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, please go to www.semmelweissociety.net.
• Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP), is making efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and Responsibilities of Patients and Health Care Professionals. For more information, go to www.sepp.net. There are a number of sub-sites that can be accessed from the home page including a popular Life Site.
• Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, write an informative Medicine Men column at NewsMax. Please log on to review the last five weeks' topics or you may prefer to peruse the archives.
• The Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians. They just completed their 65th annual meeting in Phoenix last week with an international faculty speaking on successes of privatizing medicine in many bastions of socialized medicine. Stay tuned for important reports on the meeting, giving new hope for all physicians and their patients everywhere. Be sure to read News of the Day in Perspective: Sex-selective abortions punished in India; coming to America. Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. This month, be sure to read ABOUT THE MONEY. Browse the archives of their official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents of the current issue. Don't miss the excellent Number of Timely Articles or the extensive book review section that covers four great books this month.
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Del Meyer, MD, Editor & Founder
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Words of Wisdom
What this country needs are more unemployed politicians. -Edward Langley, Artist 1928-1995
The ideas of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist." -John Maynard Keynes
The most important events in every age never reach the history books. -C. S. Lewis
Even posthumous fame depends largely on accident. -C. S. Lewis
Some Recent Postings
Diets Don't Work by Bob Schwartz, PhD, 1996
Diets Still Don't Work by Bob Schwartz, PhD, 1990
Yuri Ivanovich Nosenko, a Soviet defector, died on August 23rd, aged 80
THERE were many reasons why Yuri Nosenko found himself, in June 1962, sitting in an overstuffed armchair in a fussily furnished CIA flat in Geneva, with a glass of American whiskey in one hand and an American cigarette in the other, offering to sell "two pieces of information". He suggested several of them himself. A prostitute had robbed him of his $250 spending allowance as a member of the Soviet disarmament delegation, and he desperately needed cash. He had spent too many nights on the town, and lost the money that way. Or it was not a matter of money at all; he simply wanted to get in touch with Americans, because the urge to defect to the West "was slowly growing in me since my studentship". To
But Mr Nosenko was no ordinary Russian. He was a member of the KGB, chief of the First Section of the Seventh Department of the Second Directorate, whose job was "work against tourists". At that first meeting he declared himself not yet "psychologically ready" to defect. So for the next two years, with $25,000 deposited for him in a Western back account, he stayed in the KGB and passed on information. He had agreed that, on visits to the West, he would meet his contacts at 7.45pm outside the first cinema listed in the local telephone book two days after sending a telegram signed "George". And so in February 1964 there he was, with his combed-back hair and broad, soulful face, loitering outside the ABC in Geneva as if waiting for a girl; but in fact eager, now, to jump.
Over the previous two years, he had told his CIA contacts in detail how their chief informant, Popov, had been exposed; how bugs had been planted in the American embassy in Moscow; how the KGB had tried to recruit Americans and had laid honeytraps for others; and, most useful of all, how he had reviewed the entire KGB file on Lee Harvey Oswald, President Kennedy's killer, and knew for a fact that the KGB had never used him because he was "unstable". This was riveting stuff. Perhaps, thought the high-ups in counter-intelligence in Langley, it was too good. . .
To read the entire obit, go to http://www.economist.com/obituary/displaystory.cfm?story_id=12051491.
On This Date in History – September 23
On this date in 1779, John Paul Jones was in a naval battle commanding the Bonhomme Richard against the British fighting vessel Serapis. The Bonhomme Richard was in a bad way and the British ship captain asked John Paul Jones to surrender. Jones' answer was the one we all know, "I have not yet begun to fight." Jones then went on to capture the Serapis.
On this date in 1642, the first college commencement in America took place at Harvard. It was neither the same month nor the same kind of college commencement that we are partial to these days, but for the students at Harvard College, it was a great event.
After Leonard and Thelma Spinrad