2.
In
the News: How
The Man, Not the Plan by Michael R.
Auslin, WSJ,
Junichiro Koizumi has pulled off the
unthinkable: A smashing electoral victory that would be the equivalent of
carrying 49 states and 525 electoral votes in an American presidential
election, were his. The Japanese prime minister humiliated not only the main
opposition, but also the "rebels" from his own Liberal Democratic
Party, whose resistance to his sweeping postal reform bill provided the impetus
for the election. He gave the LDP 296 of 480 seats in the lower house, a
two-thirds majority when combined with coalition partners. He is claiming a
mandate to reintroduce his bold plan to privatize the postal system, along with
its approximately $3 trillion in assets. He has, it seems, firmly steered the
Japanese ship of state into the strong current of administrative and economic
reform he's been promising since taking the premiership in 2001.
Sober reflection on the election's
outcome, however, raises questions about the true strength of the victory and
the message voters were really sending. Far from a powerful affirmation of Mr.
Koizumi's policies on the merits, the results reflect the lack of a viable
opposition, as well as the citizenry's willingness to indulge bold schemes -- the
details of which few really grasp, and which are so far in the future that they
seem painless ways to endorse the idea of reform. Ironically, it is
Despite what many observers claim, the
election was always more about personality than policy. Leading up to the votes
on postal reform, Mr. Koizumi cunningly portrayed himself as David versus the
Goliath of old machine-style LDP politics. His oft-repeated claim that he would
"destroy" the party if it didn't pass his reform package grabbed the
attention of an electorate starved for dramatic, meaningful politics.
And theatrical it was. The lower house, in
a vote covered live on TV, passed the postal reform measure by a mere three
votes, making the upper house vote crucial, since it was clear Mr. Koizumi did
not have the votes in the lower house necessary to override the senior chamber.
He lost the (again, televised) vote in that chamber decisively, thanks to the
resistance of 20 LDP holdouts. He immediately dissolved the lower house, called
a snap election and sacked a minister who refused to sign the dissolution
decree.
Like many successful politicians, Mr.
Koizumi is blessed with weak opponents. The LDP rebels symbolized the worst of
the old system, coming off as backroom dealers beholden to special interests
and championing the status quo. As for the opposition, Katsuya Okada, the head
of the Democratic Party of Japan (DPJ), seemed unable to convince even himself
that his party would triumph. He subsequently resigned to take responsibility
for the debacle on Sunday. By contrast, Mr. Koizumi played the charismatic
leader, a part he's perfected over the last four years. The battle was over
before it was joined.
Mr. Koizumi's masterstroke was to make the
election a referendum on the future of the LDP. This not only highlighted his
progressive leadership against the forces of stagnation, it sucked the oxygen
out of the DPJ's campaign. No one was listening to a party that seemed
sidelined by the main event. Despite recent electoral successes, this election
showed that the DPJ never established legitimacy as a true opposition party,
especially since its founders had all come from the LDP. The DPJ dropped to 113
seats from 175, and was crushed by the LDP in the urban areas where it
supposedly drew its strength: The LDP took 23 seats in
Likewise, the generally good economic
indicators and the visual evidence provided by bustling city centers make the
gamble of distant administrative reform seem palatable. Take away such
conditions and it is questionable whether the traditionally conservative
Japanese electorate would be willing to put up with Mr. Koizumi's quixotic
trajectory. For his political opponents, then, there is always hope -- but
their victory would come at a high price for
Mr. Auslin teaches Japanese history at
Yale. To read the
entire article, please go to (subscription required) http://online.wsj.com/article_print/0,,SB112657866783238964,00.html.
[This Gives Hope
for the Healthcare Bureaucracy Throughout the World.]
* * * * *
By Andrew Alderson and Tony Freinberg,
(Filed:
Patients are being
made to pay more than £250 a year to guarantee an appointment with their family
doctors. Surgeries across the country are encouraging National Health Service
patients to switch to a private service if they want to ensure that they can
see a doctor within 24 hours or have home visits.
Critics of the
growing trend call it is "extremely alarming" and say it in effect
guarantees a "two-track" health system. Many fear that it is only a
matter of time before a significant number of general practitioners go the same
way as dentists and offer only a private service.
Some have already
quit the NHS, such as Dr Richard Willis, who set up his Salisbury Independent
Medical Practice as a reaction to "intolerable political
interference".
The revelation comes
just days after official figures disclosed that millions of people are unable
to get urgent appointments with their GPs. A survey from the Healthcare
Commission, the Government watchdog, showed that almost five million patients
have to wait longer than the 48-hour target set by ministers.
One practice in west
The site lists its
charges which include £255 a year for an adult, £395 for a couple and £575 for
a family. There is an extra charge of £100 for a weekend or night home visit
and £55 for a day home visit
At the Mayfair
Medical Clinic, also in
Other surgeries, from
The findings were
condemned last night by Michael Summers, the chairman of the Patients'
Association pressure group. "The existence of a two-track health system is
extremely alarming. Patients have already paid for their healthcare on the NHS
and they continue to pay for it - and they shouldn't have to pay further fees
in order to get an appointment," he said.
"It all seems a
little strange - if you're a doctor, either you have availability or you don't.
Frankly, allowing patients to pay for a private booking may be legal but it
doesn't seem appropriate."
To read the entire
article, that points out the doctors organization is in the government camp of
socialized medicine and against private practice, please go to www.telegraph.co.uk/news/main.jhtml?xml=/news/2005/09/11/ndoc11.xml.
When bureaucratic government
healthcare becomes entrenched, competition becomes anathema.
* * * * *
4.
Medicare:
The NCPA Suggests Allowing Seniors to Choose Rather than Reform
As currently structured, Medicare pays the
many small bills that the elderly could easily afford and does not pay the
catastrophic expenses that could devastate them financially. Medicare is in
need of serious reform.
The
To estimate the
effects of the Medicare MSA proposal, this study made the following
assumptions:
*Forty percent of
Medicare spending is reserved for the 5.2 percent of high-risk enrollees; they
would continue in the current program.
*Sixty percent of
spending is redirected to a combination Medical Savings Account-catastrophic
insurance program for the remaining 94.8 percent of enrollees.
*Private plans that
accept Medicare enrollees would receive a risk-adjusted premium reflecting
expected health care costs.
*The 33 million
enrollees would effectively face a doubling of copayments — most of the
increase paid out of MSAs funded by the difference between the costs of the
catastrophic policy and the amount paid to beneficiaries.
*Because copayments
would be effectively doubled, the
* By the year 2005,
Medicare spending would be 18 percent lower than currently projected spending,
and total
* Hospital and home
care costs — heavily subsidized by Medicare — would decrease by 16.3 percent.
* Spending on drugs
and devices — not heavily subsidized by Medicare — would increase by 7.6
percent.
* An increase in the
production of other goods and services would outweigh the resulting reduction
in medical services.
* By the year 2005,
annual GDP would be $55 billion (or 0.4 percent) higher than otherwise.
* Although spending
on health care would decrease by $186 billion, the output of other goods and
services would increase by $241 billion.
* There would be
367,000 more jobs than otherwise, and labor income would have increased by
almost one-half trillion dollars between 1997 and 2005.
* Despite improved
economic conditions, the stock of
Government is not the solution to our problems, government is the
problem.
Ronald Reagan
* * * * *
5.
Legislative
Gluttony: Have Funds Will Travel
California State Sen.
Kevin Murray has jetted to
Sen. Jim Battin has taken his family on
two weeklong
Assemblyman Ron Calderon has spent nearly
$30,000 on trips to the gambling mecca of
Voters who contribute to their favorite
politicians have no assurance the money will be used for get-out-
the-vote drives
rather than round-trip airline tickets. Fifty-two of 95 incumbent legislators
serving in 2003 and 2004 tapped into campaign funds for out-of-state travel
during that period, according to records filed with the secretary of state.
The lawmakers
collectively spent nearly $300,000 - perhaps much more because of limited
reporting requirements - on trips that ranged from personal excursions to
special-interest conferences to political-party events or state-sanctioned
visitations.
Assemblyman Ed Chavez, D-La Puente, used
campaign coffers to pick up the tab not only for himself but also for
legislative employees during a
By leaving the Capitol, lawmakers say,
they can see firsthand how other states or nations have handled problems - such
as electricity production - or they can push for increased trade or other
benefits. But abuse or extravagance in travel can be hard to spot because of
the state's limited disclosure requirements. Legislators must disclose the
total of any payments made, but not with whom they met or what public purpose
was served.
The result is that
records will show $700 paid to United Airlines with no destination listed, for
example, or $4,000 to a
"Politicians
depend on the inability of the public, including the press, to really get to the
bottom of their politicking," said Doug Heller of the Foundation for
Taxpayer and Consumer Rights, a nonprofit consumer advocacy group. "They
depend on the lack of transparency to hide their self-indulgence."
When Sen. Edward
Vincent visited his hometown of
Campaign funds are
private donations, not public funds, but they were solicited to benefit public
elections, and state law requires them to be spent for a political, legislative
or governmental purpose.
Trips bankrolled by campaign dollars are
given little scrutiny, however. Only one of every four legislative races is
randomly audited - by the Franchise Tax Board - after statewide elections. Few
abuses are found, records show.
Assemblyman Joe
Canciamilla, D-Pittsburg, said he believes that most trips are legitimate. “You're electing people to make decisions over
your life," he said. "If you can't trust their judgment on buying a
plane ticket to
Legislators largely
decide for themselves what limits to set on job-related travel. Some decline to
use campaign funds even for state or national conventions of their political
party. Assemblywoman Lois Wolk, D-Davis,
said she would expect to pay her own tab. "It's hard for people to give me
money in my district. It's not easy to raise it," Wolk said. "And I
try to take good care of it and use it for what it was intended, which is to
run my race."
Bob Stern, president
of the Center for Governmental Studies in
Stern said traveling
money typically is no object because few legislative races are hotly contested.
"It shouldn't necessarily be called campaign money any more, because they
don't always need it for campaigns," he said. . . .
"They say the
best way to lobby legislators is to be on a private jet with them," Stern
said. "Even if they want to leave, they can't. ... Like they say in the
MasterCard ad: Priceless."
To read the entire
article, please go to www.sacbee.com/content/politics/v-print/story/13584500p-14425344c.html.
MedicalTuesday has always supported transparency in hospital charges. We should also demand transparency in politicians’ income and expense accounts.
* * * * *
6.
Medical
Myths: Single-Payer Health Care Would Provide More Care to Everyone
The NCPA reports that
Because of these
factors, virtually all countries with a single-payer system of national health
insurance experience chronic equipment shortages and long waiting lines for
treatment (not to mention higher taxes). Waiting lists exist simply because
there aren't enough specialists, treatment beds and operating facilities to
accommodate patients needing care. Thus, care is given to those patients most
likely to benefit - at the least cost. For instance, in
* * * * *
7.
Overheard
in the Medical Staff Lounge: How Do You Deal with Senility in the Senate?
Dr Edwards: Judge Robert’s hearings made you realize that the time for term
limits for Senators has arrived. Two members of the Senate Judiciary committee
couldn’t remember their questions after they had completed them. Since Senators
with Senile Dementia don’t have the courtesy to resign from the Cesspool, as
one editorial put it, Senators should be limited to two or at most three
six-year terms. And while we’re writing constitutional amendments, let’s limit
Representatives to three four-year terms with half staggered each two years.
And let’s get rid of this “One man-one vote” Supreme Court ruling. Since
Senators represent a geographic area, or one state, with some states
representing up to 30 times as many votes as others, each representative should
represent a county or two counties at most with the larger counties having a
second or third representative to eliminate gerrymandering where many votes
don’t count at all.
Dr Michaels: Looks like WalMart was better mobilized and provided
greater assistance to the
* * * * *
8.
Voices
of Medicine: Review of the
Various Local and Regional Medical Journals
and the Press
Disinformation
Technology
Luther F Cobb, MD,
president of the Humboldt-Del Norte County Medical Society, wonders whether IT
has been mislabeled and really should be DT (Disinformation Technology). He
observes that a keystroke menu can insert a large amount of data into the EMR
[Electronic Medical Record] on the disease the patient has but otherwise has no
relevance to the patient consultation. He notes:
"As we all know,
there is great interest, both within and outside the medical profession, for
converting to electronic medical records. Many are the benefits alleged to be
derived from a massive conversion of medical information to an interchangeable,
portable, and easily retrievable set of medical data. Many of us wonder why the
medical profession has been slower to take advantage of the apparent advantages
inherent in the easy exchange of information, which has been fundamental to
other, seemingly similar, professional areas. Certainly, pundits outside the
profession are asking this question of us. Recently, I saw an interview with
Newt Gingrich on The Daily Show, which I regard as probably the best
source of commentary and criticism of the political scene today. It turns out
that Mr. Gingrich, one of the principal
authors of the Republican Revolution of the 1990’s, has now turned his
considerable political talents to, believe it or not, health-care reform. In
this effort, he has enlisted a most unlikely ally: Hillary Clinton. The
erstwhile Speaker of the House of Representatives, now a fellow at the Hoover
Institution at Stanford, believes that he can offer us backward physicians
needed guidance. In his interview with Jon Stewart, he offered the opinion that
electronic medical records, in and of themselves, could 'save 40,000 lives a
year.'
"This is an
interesting conflation of the
"What is truly
fascinating about this is that, now that this is accepted truth, it has been
seized upon as a mandate for institution of electronic medical records, which
purportedly would obviate all of these errors. That is a truly breathtaking
leap of (il)logic. Yet, with the power of Newt and Hillary, and probably other
heavyweight politicians behind it, perhaps this will become accepted wisdom as
well. Can this be true?
"I write this
having not converted to electronic medical records in my solo practice office.
Although I find electronic information very useful, and in fact I am dictating
this column using Dragon voice-recognition technology on the personal computer
in my office, I have found, so far, that the electronic medical records I have
seen in practice in other settings have been somewhat disappointing.
"Part of the
problem is that there is no accepted standard or interchangeability among the
various systems, but perhaps more importantly, much of the information
contained in the office notes from the systems isn’t useful. A large measure of
the blame for this rests on the Medicare E&M Coding regulations from 1997,
which specify a specific amount of information that has to be contained in the
documentation of an office visit in order to receive Medicare (and by
extension, other third party payers) reimbursement. A lot of this information
is simply not relevant to the particular of an office visit, yet it is included
in order to justify a higher code for the specific patient encounter. For
instance, I recently saw a patient in consultation for gallbladder disease, and
was considering whether or not to perform laparoscopic cholecystectomy. In
reviewing the information sent in the print-out from the patient’s referring
clinic, there was an extensive section on risk factors for hepatitis C. Reading
this, I was amazed that this patient had so many positive risk factors for
hepatitis, and was somewhat concerned, especially since I was considering doing
a cholecystectomy, and concomitant liver disease might be a very significant
problem in the risk of that operation. However, when I got down to the end of
this long list, it stated that the patient had refused to answer the questions
regarding hepatitis C; in other words, all this information in that long
printout was absolutely irrelevant to the consultation. Reading it had been a
total waste of time.
"In the past,
when it was only possible to include information if it was written down by
hand, a physician tended to include only the information it was important and
relevant to that specific office visit. Provided his or her handwriting was
legible (which I admit is not an insignificant problem), one was able to figure
out, fairly easily, what the referring or consulting physician had in mind as
the important issues. Now, however, there is so much chaff in the information
that the kernels of important information are hard to pick out. With some
electronic systems, it’s very easy to include sentences and whole paragraphs
with a single keystroke or entry from a menu, which satisfies the coding
requirements but clutters up the record significantly.
"Of course, when
such menu entries are inserted, it also calls into question the very cognitive
input that such “bullet points” are supposed to document as having occurred.
The professional technique of the clinical interview or taking the history,
when done well, is a subtle and beautiful skill that I think is being eroded by
this “disinformation technology.” . . .
To read the entire President's
Message, go to www.humboldt1.com/~medsoc/images/bulletins/July 2005.pdf.
[It would be best if
healthcare, including the
From the
'I was sick of going through hoops dreamt up
in
"Why should GPs
have to do everything according to central dictates, when the chances are that
we and our patients know what's really needed?" says Richard Willis, a
Salisbury GP. "I was sick of jumping through hoops dreamt up by civil
servants in
Four other GPs have
joined the practice, which is able to offer patients 15 to 30-minute
consultations, with no patient waiting more than two days to see the GP of
their choice. Patients can access hospital care within the NHS, under
contractual arrangements already in place between the local primary care trust,
South Wiltshire, and local hospitals.
He is a little coy
about his list size, but says it is less than that of an average NHS GP
(usually about 1,800). "If I had that many patients to look after I
probably wouldn't be able to offer as much time in consultations," he
says. "I probably earn a little less than the average GP. I would like to
earn more, but as doctors are always saying, there are issues about job
satisfaction."
As a member of the Independent
Doctors Forum, Dr Willis is required to go through re-accreditation checks for
fitness to practice. These, he says, are stricter than those required for NHS
doctors. His patients say the practice's services are good value for money. . .
. To read the whole report, please go to
www.telegraph.co.uk/news/main.jhtml?xml=/news/2005/09/11/ndoc111.xml.
Sidestepping Risk -
Extensions of Your Practice Come with Extended Risks
Russell A Jackson
reporting in Southern California Physician on the nine malpractice risks
notes:
"The liability
landscape for physicians is changing rapidly, as new technology and new
restrictions on medical expenditures drive doctors into often unexplored areas
of practice. But knowing what’s looming can help you steer clear of risk
management pitfalls. Here’s a look at nine particularly troubling areas of
liability you face.
Medical Procedure
Liability Still Dominates
If you’re a surgeon,
your biggest trouble area is and always will be situations where a technical
problem or surgical error occurred,” says Waldene Drake, RN, MBA, vice
president for risk management and patient safety at Cooperative of American
Physicians Inc., a malpractice carrier based in
In addition, the
age-old problem of reimbursement restrictions takes on a new twist as it drives
doctors to undertake less familiar procedures. “We see primary care doctors -
the family practitioners and the internists - doing more and more of the care
themselves, because in an HMO or when the patient has limited or no insurance,
it’s harder to refer to a specialist.”
SPA Procedure
Liability Looms
Be aware that
extensions of your practice come with extended risks. “Many doctors looking for
a way to make a little more money are moving into hair removal, dermabrasion,
Botox and new products that make fuller lips and cheeks,” Drake says. “We see
less-trained people doing that even though by law, only a nurse or physician’s
assistant can do so under the direction of an MD.” The remaining risks are as
follows:
Communication and
documentation breakdowns persists
Business problems
Technology issues
Elective surgeries
such as cosmetic or knee replacement in the elderly
The increasing
risks of more prescriptions with three areas of liability
Patient
non-compliance
And obesity
patients represent a growing threat
To read the entire
report and the discussion of the nine risks, go to www.socalphys.com/jun05/medical_world.pdf.
* * * * *
FALSE HOPES -
Why America's Quest for Perfect Health Is a Recipe for Failure by Daniel
Callahan, Simon & Schuster, New York, 1998. 330 pp, $24, ISBN 0-684-81109-X
Daniel Callahan,
cofounder of the Hastings Center and the Director of its International
Programs, takes on the entire medical establishment--doctors, nurses, hospital
administrators, medical researchers, and pharmaceutical and medical technology
companies--all of whom he believes are united in a relentless pursuit of
unlimited medical progress, stopping at nothing short of the conquest of all
disease and the indefinite extension of life spans (see last month's review of
Schwartz' Life Without Disease - The Pursuit of Medical Utopia).
The
Initially, the
reason he takes this stance is not clear. However, he soon points out that the
universal, if poorly financed and often corrupt, healthcare systems in
Callahan
realizes that if everyone is having a problem, and all are looking for answers,
there must be an underlying basic issue. Almost all healthcare reform efforts
assume that the solution lies in better organization and financing. Callahan
then observes that no matter how much money is spent and no matter what the
health gains may be, they never seem to be enough. Conventional solutions do
not address the real problem. No matter how much progress, they always seem
insufficient to meet the "needs" of the day.
The most cherished
and celebrated aims, commitments, and values of modern medicine are beginning
to give us trouble. But challenging these ideas, Callahan reflects, is not new.
Rene Dubois in his 1954 book Mirage of Health questioned the then
imminently anticipated total conquest of disease and stated this would not
happen, not soon, not ever. In the 1970s, theologian Ivan Illich, British
physician John Powles, American physician Rick Carlson, and British professor
of social medicine, Thomas McKeown, each showed in a systematic way that there
is no clear correlation between population health and medical care.
Callahan emphasizes that "A serious transformation will require
taking money away from the acute-care sector, including research into the cure
of many lethal diseases, and using it instead on prevention research and
massive educational efforts designed to change health-related behavior."
Callahan asserts that sustainable medicine will do the following: give priority
to preventing and treating diseases that afflict the many rather than finding
cures for diseases that effect the few, improve the quality of life for the
elderly rather than extend life indefinitely, and focus on primary care and
public health measures that benefit society as a whole rather than satisfying
the health needs of individuals.
Callahan as an
ethicist explores topics and issues on which to base future dialogue as well as
change the direction of the debate. But he doesn't give us the final answer. He
does point out that many Americans are bypassing traditional physicians and
hospitals and are going to alternative medicine practitioners whom they pay
from their own pockets. According to some estimates, these visits exceed those
to traditional practitioners. This demonstrates that patients will pay for what
they perceive as valuable.
However,
Callahan's prejudices outlined in the preface, may prevent an objective
extension of the excellent groundwork he has developed. He might also have
mentioned that the current debates in
To read some of the
other book reviews, please go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
* * * * *
A Desperate Call in the Middle of the
Night. Lisa Nichols,
co-author of “Chicken Soup for the African American Soul,” had delivered a
motivational speech to a group of 400 teenage girls. She received the call for
help and heard the following. “I am class president, on the honor roll, a
student peer counselor, and I have been accepted to six universities, but I
don’t plan to attend any of them because I am looking at my suicide letter right
now.” After Nichols talked her out of it and helped her obtain further
counseling, she hired her as the first teen facilitator to work for her
company, Motivating the Teen Spirit, an empowerment skills program designed to
address the challenging issue of the teen experience.
Dr Michael, a local
proponent of “Health Care for Everyone,” commented that Medicare should
consider covering all providers such as Ms Nichols who certainly provided a
valuable service before the class president interfaced with the medical
establishment. When asked, “If Medicare should pay book authors for their
services to people who become patients, why shouldn’t Medicare pay every person
who provides CPR, or gives First Aid, or anyone who gives valuable medical
advice (which may be better at times than that given by some physicians or
nurses) and even the clerk in the drug or grocery store that helps shoppers
obtain the correct over-the-counter medications?” Dr Michael commented,
“Perhaps, it’s an idea whose time has come.”
Has Nirvana really
arrived? Let’s see now: If everyone gets paid by the U.S. Treasury, and fewer
and fewer pay into it, won’t it run out of money? Dr Michael said, “The U.S.
Treasury could never run out of money. They would just tax the Medicare
payments like they already tax Social Security to pay for benefits.” When
asked, “Wouldn’t the taxes have to rise to 100 percent to keep the country
afloat?” He said, “Not at all, the U.S. Treasury is a master at deficit
spending. And there just isn’t any limit to that benefit. And besides, who
knows how many hidden assets the government has off shore?”
The
How many bank accounts does General Motors
have? Recent news
releases report that the health care costs allocated to each new automobile now
exceeds the cost of the steel to manufacture it; that retirement benefits have
to be cut or the company will cease to exist; that health and pension benefits
for retires have to be cut or eliminated, and yet the unions are clambering for
more wages and benefits. Businesses also have one bank account out of which it
has to pay salaries and wages, taxes, health care, pension benefits, as well as
all production and marketing overhead. If income remains stable, then any
change in one item must produce a corresponding opposite change in the other
items. They can’t all increase. Witness huge airlines that last week, after
four years of deficit spending, had to declare bankruptcy. Remember Khadafy in
A difficult concept for students with
modern math: Outflow can’t exceed Inflow.
The Wall Street Journal asks about the
great, unreported fiscal story of 2005: The shrinking federal deficit.
It's down by at least $100 billion because federal tax receipts have
skyrocketed this year by 14.6% (or $204 billion) through June. http://online.wsj.com/article/0,,SB112113079506182976,00.html?mod=todays_us_opinion
Now we know why
Congress doesn’t understand that by reducing the tax rate, the economy
increases to such an extent that the lower tax RATE produces MORE tax revenue –
It’s because of the increasing number of senators that are suffering from
dementia. (See “Overheard . . . ”
section 7 above.
To review some of the
other Hippocrates Columns, please go to www.healthcarecom.net/hhkintro.htm.
Couldn’t we at least pass out some
Risperdal on the Senate floor to stabilize the decline?
* * * * *
11. Restoring Accountability in Medical
Practice and Society