Community For Better Health Care

Vol IX, No 1, April 13, 2010


In This Issue:

1.                  Featured Article: fMRI can predict Broken Promises

2.                  In the News: The Rise of Instant Wireless Networks

3.                  International Medicine: End the NHS' 'secretive' attitude so patients can decide

4.                  Medicare: ObamaCare: Repeal, Replace or What?

5.                  Medical Gluttony: How long does it take to read a 243-page Electronic Medical Record?

6.                  Medical Myths: With all this oversight, ObamaCare can't help but be successful!

7.                  Overheard in the Medical Staff Lounge: Has the Debate Ended or Just Begun?

8.                  Voices of Medicine: The Electronic Medical Record: Garbage In, Garbage Out

9.                  The Bookshelf: Single Payer, Many Faults

10.              Hippocrates & His Kin: How to reduce the deficit by 45 percent.

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

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

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The Annual World Health Care Congress, a market of ideas, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 7th Annual World Health Care Congress was held April 12-14, 2010 in Washington D.C. For more information, visit The future is occurring NOW. You should become involved.

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

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1.      Featured Article: Broken Promises  By Allison Bond, Scientific American, April 2010

Brain scans reveal when a vow will not be honored

What goes on in the brain of the groom who says "I do," then has an affair? Or the friend who pledges to repay a loan but never does? Breaking a promise is a complex neurobiological event, a new study shows—and a brain scan may be able to predict those who are making false promises before they break their word.

Using functional MRI, scientists at the University of Zurich in Switzerland scanned the brains of subjects playing an investment game. Subjects assigned to be "investors" had to decide whether to pledge to share their money with other players who were "trustees." This arrangement boosted the amount of money in the pot, but it also could result in a loss to the investor if the trustee chose not to share. Nearly all the subjects said they would give to the trustee—but in the end, not everyone kept this promise.

Based on the fMRI scans, the researchers were able to predict whether the players would break their promise before they actually had the chance to do so in the game. Promise breakers had more activity in certain brain regions, including the prefrontal cortex, an indication that planning and self-control were involved in suppressing an honest response, and the amygdala, perhaps a sign of conflicting and aversive emotions such as guilt and fear.

If the predictive ability of these scans is borne out in future studies, someday the technique could be of use to the justice system. "Brain imaging might be able to help psychologists or psychiatrists decide whether a criminal offender can be released or whether the risk of relapse is too high," says lead author Thomas Baumgartner, who emphasizes that such scans would supplement assessments by health professionals, not replace them.

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Further Reading
Sounds Make Memories Stick During Sleep
Can the Peace Drug Help Clean Up the War Mess?

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2.      In the News: The Rise of Instant Wireless Networks; Scientific American Magazine, April 2010; by Michelle Effros; Andrea Goldsmith; Muriel Médard;

Key Concepts

         Ad-hoc wireless networks require no fixed infrastructure. Instead they pass information from device to device, forming a web of connections.

          These networks can be used in places where building traditional mobile network infrastructure would prove too unwieldy or expensive—for example, in remote areas and combat zones.

          Because any ad-hoc network is constantly in flux, innovative strategies must be employed to avoid data loss and mitigate interference.

In this era of Facebook, Twitter and the iPhone, it is easy to take for granted our ability to connect to the world. Yet communication is most critical precisely at those times when the communications infrastructure is lost. In Haiti, for example, satellite phones provided by aid agencies were the primary method of communication for days following the tragic earthquake earlier this year. But even ordinary events such as a power outage could cripple the cell phone infrastructure, turning our primary emergency contact devices into glowing paperweights.

In situations such as these, an increasingly attractive option is to create an "ad-hoc" network. Such networks form on their own wherever specially programmed mobile phones or other communications devices are in range of one another. Each device in the network acts as both transmitter and receiver and, crucially, as a relay point for all the other devices nearby. Devices that are out of range can communicate if those between them are willing to help—passing messages from one to the next like water in a bucket brigade. In other words, each node in the network functions as both a communicator for its own messages and infrastructure for the messages of others.

Disaster relief is but one potential application for ad-hoc networks. They can serve anywhere building a fixed infrastructure would be too slow, difficult or expensive. The military has in­vested a large amount of money in designing these systems for battlefield communications. Ad-hoc networks in your home would allow de­vices to find one another and begin communication automatically, freeing you from the tan­gle of wires in your living room and office. Re­mote villages and lower-income neighborhoods that lack a broadband infrastructure could con­nect via ad-hoc networks to the Internet. Scien­tists interested in studying microenvironments in the treetops or hydrothermal vents on the ocean floor could scatter sensors in their intend­ed environment without worrying about which sensors will hear one another or how informa­tion will travel from the jungle to the research­ers' laptops.

These networks have been in development for more than three decades, but only in the past few years have advances in network theory giv­en rise to the first large-scale practical exam­ples. In San Francisco, the start-up Meraki Net­works connects 400,000 San Francisco resi­dents to the Internet through their Free the Net project, which relies on ad-hoc networking technology. Bluetooth components in cell phones, computer gaming systems and laptops use ad-hoc networking techniques to enable de­vices to communicate without wiring or explicit configuration. And ad-hoc networks have been deployed in a variety of remote or inhospitable environments to gather scientific data from low-power wireless sensors. A number of break­throughs must still be achieved before these net­works can become commonplace, but progress is being made on several fronts. . .

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3.      International Medicine: Tories would force hospitals to supply unprecedented levels of care data Denis Campbell ,, April 2010

A Conservative government would end the NHS's 'secretive' attitude so patients can decide where to go for treatment, says shadow health secretary Andrew Lansley

Hospitals will be forced to give NHS patients unprecedented details about whether they provide good or bad healthcare so people can decide where to go for treatment, the Conservatives have pledged.

The move would end the NHS's "secretive" and "highly paternalistic" attitude to giving patients information and drive up the quality of care by using data to expose hospitals that provide inadequate service, shadow health secretary Andrew Lansley told SocietyGuardian.

He detailed how a Conservative government would ensure that patients were routinely told:

• How successful different types of surgery at a particular hospital had been, judged by how soon patients were able to return to work, whether or not they were left pain-free and how many had to undergo further treatment

• Ward-by-ward infection rates for all superbugs, not just MRSA and Cdifficile

• How many new mothers were left alone in labour and found it scary

• How many of the hospital's staff would be happy to be treated there

• Its rate of patient readmission - a key indicator of quality of care

• How much single-sex accommodation it had and numbers of single rooms

• How many patients died during or soon after treatment

• The number of complaints it had been receiving.

Lansley also promised that he would institute regular surveys of large numbers of patients which ask searching questions about how they felt about their experience in hospital, for instance if they were happy with the staff's response when they pressed their call button.

The NHS is "a vast information-gathering machine" but is poor at giving patients useful information in a clear, accessible way, said Lansley. "Clearly [the NHS] is too secretive ... and it's a secrecy that is both unnecessary and unhealthy. There's a culture inside the NHS which is highly paternalistic. You know, 'We give them the service and they are grateful,' and we have to move to shared decision-making. Our interaction as patients with the NHS should be on the basis that there's a presumption that all information is shared with us," he added.

But the British Medical Association, the doctors' trade union, raised concerns about Lansley's plan. "We welcome patients having more information, which is good and relevant information, because that's what doctors do," said Keith Brent, deputy chair of the BMA's consultants committee. "But crude, uninterpreted data could frighten people unnecessarily and demoralise staff. I would have particular concerns about simply publishing crudely the outcomes of surgery, because those very much depend on how the patient was before they went into surgery. The quality of hospital care isn't the only factor. If crude figures could then come out with some very bizarre results [and] would frighten patients away from units that actually provide very good care."

Brent also warned that surgical units could respond by refusing to operate on sicker patients whose outcomes might then make its performance look bad. . .

"Like all hospitals we collect a great deal of data and we believe it's important to share the information with patients in a useful form. It's important to ask patients for their input as well, so we have developed our own patient questionnaires which go beyond the questions asked in the national NHS inpatient survey," said Karen Castille, chief nurse and operating officer at Cambridge University hospitals NHS foundation trust. . . .

Hospital leaders welcomed Lansley's plans. "The general principle of sharing much more information with patients is absolutely right," said Nigel Edwards, policy director of the NHS Confederation. "The evidence internationally is that this information isn't greatly used by patients but has a profound effect and the providers, who take big notice of it and use it to target improvements."

Making much more information readily and quickly available would also flag up problems very soon after they emerge, and prevent hospitals covering up the way that, for example, Stafford hospital disguised weaknesses that official inquiries have since found contributed to the deaths of hundreds of patients. "Things like a ward where people are getting pressure sores, or may be suffering from deep vein thrombosis, there should be no hiding place for that," said Lansley.

The Royal College of Surgeons of England said it backed all information being available to patients, as long as it was adjusted for risk. Surgeons were already developing public audits that record the outcomes of treatment, and such audits had already improved standards in heart surgery, a spokesman said.

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The NHS does not give timely access to quality healthcare.

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4.      Medicare: ObamaCare: Repeal, Replace or What? WSJ, March 26, 2010

Editor's Note: We asked five opponents of government-directed health care for their thoughts on our new health-care entitlement. Specifically: Now that ObamaCare is law, how should Republicans respond? Should they work to repeal some or all of it, and do they need to offer an alternative health reform proposal of their own?

Massachusetts Is Our Future, By Timothy P. Cahill

White House Senior Adviser David Axelrod hailed the Massachusetts health-care program as "the template" for the national health-care reform legislation the president signed into law earlier this week. That should be cause for serious concern about this law's ability to improve our health-care system at an affordable cost.

As state treasurer, I can speak with authority about the Massachusetts pilot program. It has been a fiscal train wreck.

The universal insurance coverage we adopted in 2006 was projected to cost taxpayers $88 million a year. However, since this program was adopted in 2006, our health-care costs have in total exceeded $4 billion. The cost of Massachusetts' plan has blown a hole in the Commonwealth's budget. Just last Thursday, Gov. Deval Patrick's office announced a $294 million shortfall related to health-care costs. . .

Mr. Cahill is the state treasurer of Massachusetts. He is currently running as an independent for governor.

We Good Europeans, By Mitch Daniels

As if governors these days don't have enough on their plates. Now that ObamaCare has become law, there's a whole new to-do list for my state:

1)   Plan for the termination of our Healthy Indiana Plan. This is the program that's currently providing health insurance to 50,000 low-income Hoosiers. With its health savings account-style personal accounts, it has been enormously popular among its participants. I hope those folks will do all right when they are pitched into Medicaid.

2)   Start preparing voters for a state tax increase. The axe won't fall until someone else is governor. But when we are forced to expand Medicaid to one in every four citizens, the cost will add several hundred million dollars to the budget.

3)   Check to see if Indiana should drop its health insurance plans and dump its government workers into the exchanges. . . .

4)   Ramp up our job retraining programs to handle those who will be fired by our medical device companies, student loan providers, and small businesses as they wrestle with new taxes, penalties, or in the student loan case, outright nationalization of their business.

5)   Call the state's attorney general to see if we can join one of the lawsuits to overturn ObamaCare. Yes, it's a long shot. But why not try?

6)   Investigate an offset to all this extra cost. We may no longer need the Department of Insurance since insurers will now be operating as regulated utilities under the thumb of the federal government.

It's discouraging that all of this could have been avoided. Congress could have done what Republicans should suggest now: Shift to a system that allows individuals—not businesses—to buy health insurance tax free. They could also create tax credits for buying health insurance based on income and health status to guarantee everyone coverage and encourage medical care and insurance competition. Republicans should push to lower barriers for buying insurance across state lines, create incentives for states to repeal mandates, and limit frivolous lawsuits that increase the price of insurance.

But for the moment, our federal overlords have ruled. We better start adjusting to our new status as good Europeans.

Mr. Daniels, a Republican, is governor of Indiana.

Resistance Is Not Futile By Phil Gramm

For every dollar's worth of health care that Americans received last year, they paid a dime and somebody else paid 90 cents. If you bought food the way you buy health care—where 90% of everything you put in your basket was paid for by your grocery insurance policy—you would eat differently and so would your dog. We have the best health-care system in the world, but as rich as America is we can't afford it. . . .

Even though the Obama bill became far more unpopular than the Clinton bill ever was, the daunting size and rigid commitment of the Democratic majority to a government-run system was such that they could override public opinion. Now the Democrats are out to make Americans like their plan—or at least get them to acquiesce to it. But as Gandhi once explained, 40,000 British troops cannot force 300 million Indians to do what they will not do.

Republicans have a job to do. They must make it clear to the American people that this is only the beginning of the debate. There will be two congressional elections and a presidential election before the government takeover is implemented in 2014. . .

If Republicans don't want America to follow Britain and Canada down the road to socialized medicine, they must change the system so that families have more power to control their own health-care costs. This will entail real changes like tax deductions for health insurance, not for prepaid medicine; refundable tax credits for families to buy their own insurance; freedom to negotiate with insurance companies; rewarding healthy lifestyles; tort reform; and reforming Medicare and Medicaid so every consumer has deductibles and copayments based on their income. This system will require Americans to make choices in health care—just as they do in every other area of their lives. . .

Mr. Gramm, a Republican, was a senator from Texas from 1985 to 2002 and served as chairman of the Health subcommittee of the Senate Committee on Finance.

Persistence Is the Key By Bobby Jindal

After forcing through a massive health-care overhaul that the public does not want, the president and Democratic leaders in Congress are threatening us with yet another PR campaign to make us like it. Good luck with that.

Meanwhile, some level of handwringing has broken out among GOP strategists. Should we push for repeal? Will it work? Is there some danger in that strategy?

Well, let's see. We just spent 13 months arguing against the Democrats' top-down approach to health care, contending that it must be stopped for the good of our country, the health of our citizens, and the future of our nation's economy. So, should we try to repeal it? Only in Washington is this a hard question.

The arguments against repeal and the response is the following: Let's take them one at a time.

1)   It's impossible. Wrong. There is a first time for everything. It's similarly "impossible" for the son of Indian immigrants to get elected in the deep South. It's impossible for an African-American to get elected president. You get the picture.

2)   President Obama would veto a repeal bill. Yes, he sure would. Do it anyway. And do it again after he is gone. (By the way, President Clinton vetoed welfare reform twice before he signed it into law.)

3)   It will be hard to take things away. Probably so. But the reality is that growth of federal entitlements is strangling the economic engine of our country. Someone has to draw the line somewhere. Do we want to go the way of Western Europe? If not, we better get moving in the other direction immediately.

4)   There are parts of the bill the public will like. No doubt about it. There are parts I like—though I have yet to read the fine print—such as allowing parents to keep kids on their policies until they are 26-years-old. And there's bound to be more good policy in there: 2,409 pages can't be all bad. But the overall direction of the bill is to empower government, not patients.

5)   We don't want to be labeled the party of "no." As it pertains to this bill, how about "hell no"? Newt Gingrich is saying we should "repeal and replace." That works.

Mr. Jindal, a Republican, is the governor of Louisiana.

Printed in The Wall Street Journal, March 26, 2010,  page A19

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 Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5.      Medical Gluttony: Electronic Medical Records: How long does it take to read 243 pages?

To try to make sense of the political climate of the EMR might be blasphemous. In our pulmonary office we have what I consider digital records for about twenty years. By the late 1980s, my associates and I had seen about 29,000 pulmonary consultations. We had a numeric filing system in which the first number would tell us whether the consult originated in the hospital, our office or was referred in. After twenty years, the volume had become unmanageable unless an extensive card catalog or computer was close at hand that would identify the patient's number, which would lead us to the correct chart. When the chart had served its current purpose it could be re-filed because of terminal digit filing. We simplified the system by filing alphabetically. Although our advisers said we only need the first two digits of the last name on the chart, we decided to put the first three digits highlighted since we had twenty Johnsons, 15 Browns, and 10 Rodriguez'. We also decided that all medical histories and physical examinations, along with the pulmonary function tests, arterial blood gases, electrocardiograms and chest x-rays we took in our office would be typed up and filed electronically.

This is not the EMR that the late Senator Kennedy, President Bush, or the current White House resident desired, but it served our purpose. Easy access and retrievability, short five- to eight-page complete medical record, easy to review quickly, to duplicate to a consulting physician, and easy to update yearly. Since the California Medical Board only allows refills for a maximum of one year without an examination, and since most of our pulmonary patients, whether emphysema, asthma, bronchitis, silicosis, asbestosis, sarcoidosis, inactive tuberculosis, histoplasmosis, and others should be evaluated in some detail at least yearly, we saw all patients for an annual exam, even though they may have had office visits during the course of the year. This also allowed us to have a continuing digital record simply by copying and pasting the previous year's record and revising it with the patient in front of us. We would then end up with another current five- to eight-page record plus the current CXR, PFT, ABG, ECG, which would then be placed on top of the patient's file. All the previous pages would be kept in the paper file, but the yearly exams would always be on the computer. This has been important in a number of instances when a patient moves out of town or goes to another medical facility for 10 or 15 years and then returns. The cost of storage of our records reached $22,000 for the first twenty, at which time we began shredding records after four years of inactivity. We could always print out the previous annual exams to start a new record a decade or two later.

Recently, we have received EMRs from patients that have been elsewhere. These records in several instances reach 195 pages and in one case 243 pages. These are the type of records that Congress and the President desire everyone should have to improve healthcare and reduce costs by making medical care more efficient. However, we have found that it is much more time consuming to wade through several hundred pages of electronic records with endless duplications, variations from one physician to the next, outright differences in the exam of the same patient, and duplication of errors as one doctor copies the previous record of another physician into his own records, even though there are blatant errors. It has also become apparent that one physician has not reexamined much of what is recorded as being done by him. Also, these are written records and our compact eight to 12 pages a year is completely overwhelmed by these outside EMRs of hundreds of pages. In fact, at times it is difficult to find our succinct but complete records in the midst of all this paper.

If electronic medical records could be transferred electronically, would this have been easier? In our experience, we are now getting CDs of EMRs that can be loaded into our computer. We have the capability to download these hundreds of pages right into our digital records. Administrators are very proud to facilitate this. They tell us this should make it much easier to review the 195 or the 243 pages of digital records.

However, we have not found this to be the case. Each of us found that we could review 243 pages using our ten fingers to hold places and make much more out of the review than in running pages on our computer screen that fast, which limits the ability to absorb any details, take notes, and then retype a summation for our consult that would make sense to the next consultant.

I wonder what would happen if we started meddling with attorney's client records like the bureaucratic attorneys are meddling in medical histories?

Has anyone tried to tell attorneys how they should record their legal records?

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Medical Gluttony thrives in Government and Health Insurance Programs.

It Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6.      Medical Myths: With all this oversight, ObamaCare can't help but be successful!

It's not just a healthcare coverage law. It's alllllll that goes with it. Layers and layers and layers and layers of government bureaucracy, employees paid out of our taxes, including their benefits, retirement plans and on and on and on......
With older physicians retiring rather than face all the bureaucracy, red tape and reduced fees paid, and younger ones going underground or leaving the profession altogether, we won't have enough doctors

New Boards and Commissions created in the NEW OBAMA HEALTH CARE

Take a good look at the face of statism.

1. Grant program for consumer assistance offices (Section 1002, p. 37)
2. Grant program for states to monitor premium increases (Section 1003, p. 42)
3. Committee to review administrative simplification standards (Section 1104, p. 71)
4. Demonstration program for state wellness programs (Section 1201, p. 93)
5. Grant program to establish state Exchanges (Section 1311(a), p. 130)
6. State American Health Benefit Exchanges (Section 1311(b), p. 131)
7. Exchange grants to establish consumer navigator programs (Section 1311(i), p. 150)
8. Grant program for state cooperatives (Section 1322, p. 169)
9. Advisory board for state cooperatives (Section 1322(b)(3), p. 173)
10. Private purchasing council for state cooperatives (Section 1322(d), p. 177)
11. State basic health plan programs (Section 1331, p. 201)
12. State-based reinsurance program (Section 1341, p. 226)
13. Program of risk corridors for individual and small group markets (Section 1342, p. 233)
14. Program to determine eligibility for Exchange participation (Section 1411, p. 267)
15. Program for advance determination of tax credit eligibility (Section 1412, p. 288)
16. Grant program to implement health IT enrollment standards (Section 1561, p. 370)
17 Federal Coordinated Health Care Office for dual eligible beneficiaries (Section 2602, p. 512)
18. Medicaid quality measurement program (Section 2701, p. 518)
19. Medicaid health home program for people with chronic conditions, and grants for planning same (Section 2703, p. 524)
20 Medicaid demonstration project to evaluate bundled payments (Section 2704, p. 532)
21. Medicaid demonstration project for global payment system (Section  2705, p. 536)
22. Medicaid demonstration project for accountable care organizations (Section 2706, p. 538)
23. Medicaid demonstration project for emergency psychiatric care (Section 2707, p. 540)
24. Grant program for delivery of services to individuals with  postpartum depression (Section 2952(b), p. 591)
25. State allotments for grants to promote personal responsibility education programs (Section 2953, p. 596)
26. Medicare value-based purchasing program (Section 3001(a), p. 613)
27. Medicare value-based purchasing demonstration program for critical  access hospitals (Section 3001(b), p. 637)
28. Medicare value-based purchasing program for skilled nursing  facilities (Section 3006(a), p. 666)
29. Medicare value-based purchasing program for home health agencies (Section 3006(b), p. 668)
30. Interagency Working Group on Health Care Quality (Section 3012, p.  688)
31. Grant program to develop health care quality measures (Section  3013, p. 693)
32. Center for Medicare and Medicaid Innovation (Section 3021, p. 712)
33. Medicare shared savings program (Section 3022, p. 728)
34. Medicare pilot program on payment bundling (Section 3023, p. 739)
35. Independence at home medical practice demonstration program  (Section 3024, p. 752)
36. Program for use of patient safety organizations to reduce hospital  readmission rates (Section 3025(b), p. 775)
37. Community-based care transitions program (Section 3026, p. 776)
38. Demonstration project for payment of complex diagnostic laboratory  tests (Section 3113, p. 800)
39. Medicare hospice concurrent care demonstration project (Section  3140, p. 850)
40. Independent Payment Advisory Board (Section 3403, p. 982)
41. Consumer Advisory Council for Independent Payment Advisory Board (Section 3403, p. 1027)
42. Grant program for technical assistance to providers implementing  health quality practices (Section 3501, p. 1043)
43. Grant program to establish interdisciplinary health teams (Section  3502, p. 1048)
44. Grant program to implement medication therapy management (Section  3503, p. 1055)
45. Grant program to support emergency care pilot programs (Section  3504, p. 1061)
46. Grant program to promote universal access to trauma services (Section 3505(b), p. 1081)
47. Grant program to develop and promote shared decision-making aids (Section 3506, p. 1088)
48. Grant program to support implementation of shared decision-making (Section 3506, p. 1091)
49. Grant program to integrate quality improvement in clinical  education (Section 3508, p. 1095)
50. Health and Human Services Coordinating Committee on Women's Health (Section 3509(a), p. 1098)
51. Centers for Disease Control Office of Women's Health (Section 3509(b), p. 1102)
52. Agency for Healthcare Research and Quality Office of Women's Health (Section 3509(e), p. 1105)
53. Health Resources and Services Administration Office of Women's Health (Section 3509(f), p. 1106)
54. Food and Drug Administration Office of Women's Health (Section 3509(g), p. 1109)
55. National Prevention, Health Promotion, and Public Health Council (Section 4001, p. 1114)
56. Advisory Group on Prevention, Health Promotion, and Integrative and Public Health (Section 4001(f), p. 1117)
57. Prevention and Public Health Fund (Section 4002, p. 1121)
58. Community Preventive Services Task Force (Section 4003(b), p. 1126)
59. Grant program to support school-based health centers (Section  4101, p. 1135)
60. Grant program to promote research-based dental caries disease  management (Section 4102, p. 1147)
61. Grant program for States to prevent chronic disease in Medicaid  beneficiaries (Section 4108, p. 1174)
62 Community transformation grants (Section 4201, p. 1182)
63. Grant program to provide public health interventions (Section  4202, p 1188)
64. Demonstration program of grants to improve child immunization  rates (Section 4204(b), p. 1200)
65. Pilot program for risk-factor assessments provided through  community health centers (Section 4206, p. 1215)
66. Grant program to increase epidemiology and laboratory capacity (Section 4304, p. 1233)
67. Interagency Pain Research Coordinating Committee (Section 4305, p. 1238)
68. National Health Care Workforce Commission (Section 5101, p. 1256)
69. Grant program to plan health care workforce development activities (Section 5102(c), p. 1275)
70. Grant program to implement health care workforce development  activities (Section 5102(d), p. 1279)
71. Pediatric specialty loan repayment program (Section 5203, p. 1295)
72. Public Health Workforce Loan Repayment Program (Section 5204, p. 1300)
73. Allied Health Loan Forgiveness Program (Section 5205, p. 1305)
74. Grant program to provide mid-career training for health professionals (Section 5206, p. 1307)
75. Grant program to fund nurse-managed health clinics (Section 5208, p. 1310)
76 Grant program to support primary care training programs (Section  5301, p. 1315)
77. Grant program to fund training for direct care workers (Section  5302, p. 1322)
78. Grant program to develop dental training programs (Section 5303, p. 1325)
79. Demonstration program to increase access to dental health care in  underserved communities (Section 5304, p. 1331)
80. Grant program to promote geriatric education centers (Section  5305, p. 1334)
81. Grant program to promote health professionals entering geriatrics  (Section 5305, p. 1339)
82. Grant program to promote training in mental and behavioral health (Section 5306, p. 1344)
83. Grant program to promote nurse retention programs (Section 5309,  p. 1354)
84. Student loan forgiveness for nursing school faculty (Section  5311(b), p. 1360)
85. Grant program to promote positive health behaviors and outcomes (Section 5313, p. 1364)
86. Public Health Sciences Track for medical students (Section 5315,  p. 1372)
87. Primary Care Extension Program to educate providers (Section 5405,  p. 1404)
88. Grant program for demonstration projects to address health  workforce shortage needs (Section 5507, p. 1442)
89. Grant program for demonstration projects to develop training  programs for home health aides (Section 5507, p. 1447)
90 Grant program to establish new primary care residency programs (Section 5508(a), p. 1458)
91. Program of payments to teaching health centers that sponsor medical residency training (Section 5508(c), p. 1462)
92. Graduate nurse education demonstration program (Section 5509, p. 1472)
93. Grant program to establish demonstration projects for community- based mental health settings (Section 5604, p. 1486)
94. Commission on Key National Indicators (Section 5605, p. 1489)
95. Quality assurance and performance improvement program for skilled  nursing facilities (Section 6102, p. 1554)
96. Special focus facility program for skilled nursing facilities (Section 6103(a)(3), p. 1561)
97. Special focus facility program for nursing facilities (Section  6103(b)(3), p. 1568)
98. National independent monitor pilot program for skilled nursing facilities and nursing facilities (Section 6112, p. 1589)
99. Demonstration projects for nursing facilities involved in the culture change movement (Section 6114, p. 1597)
100. Patient-Centered Outcomes Research Institute (Section 6301, p. 1619)
101. Standing methodology committee for Patient-Centered Outcomes Research Institute (Section 6301, p. 1629)
102. Board of Governors for Patient-Centered Outcomes Research Institute (Section 6301, p. 1638)
103. Patient-Centered Outcomes Research Trust Fund (Section 6301(e),  p. 1656)
104. Elder Justice Coordinating Council (Section 6703, p. 1773)
105. Advisory Board on Elder Abuse, Neglect, and Exploitation (Section 6703, p. 1776)
106. Grant program to create elder abuse forensic centers (Section  6703, p. 1783)
107. Grant program to promote continuing education for long-term care staffers (Section 6703, p. 1787)
108. Grant program to improve management practices and training (Section 6703, p. 1788)
109. Grant program to subsidize costs of electronic health records (Section 6703, p. 1791)
110. Grant program to promote adult protective services (Section 6703, p. 1796)
111. Grant program to conduct elder abuse detection and prevention (Section 6703, p. 1798)
112. Grant program to support long-term care ombudsmen (Section 6703, p. 1800)
113. National Training Institute for long-term care surveyors (Section 6703, p. 1806)
114 Grant program to fund State surveys of long-term care residences (Section 6703, p. 1809)
115. CLASS Independence Fund (Section 8002, p. 1926)
116. CLASS Independence Fund Board of Trustees (Section 8002, p. 1927)
117. CLASS Independence Advisory Council (Section 8002, p. 1931)
118. Personal Care Attendants Workforce Advisory Panel (Section  8002(c), p. 1938)
119 Multi-state health plans offered by Office of Personnel  Management (Section 10104(p), p. 2086)
120. Advisory board for multi-state health plans (Section 10104(p), p. 2094)
121. Pregnancy Assistance Fund (Section 10212, p. 2164)
122. Value-based purchasing program for ambulatory surgical centers (Section 10301, p. 2176)
123. Demonstration project for payment adjustments to home health services (Section 10315, p. 2200)
124. Pilot program for care of individuals in environmental emergency declaration areas (Section 10323, p. 2223)
125. Grant program to screen at-risk individuals for environmental health conditions (Section 10323(b), p. 2231)
126. Pilot programs to implement value-based purchasing (Section 10326, p. 2242)
127. Grant program to support community-based collaborative care networks (Section 10333, p. 2265)
128. Centers for Disease Control Office of Minority Health (Section 10334, p. 2272)
129. Health Resources and Services Administration Office of Minority Health (Section 10334, p. 2272)
130. Substance Abuse and Mental Health Services Administration Office of Minority Health (Section 10334, p. 2272)
131. Agency for Healthcare Research and Quality Office of Minority Health (Section 10334, p. 2272)
132. Food and Drug Administration Office of Minority Health (Section 10334, p. 2272)
133. Centers for Medicare and Medicaid Services Office of Minority Health (Section 10334, p. 2272)
134. Grant program to promote small business wellness programs (Section 10408, p 2285)
135. Cures Acceleration Network (Section 10409, p. 2289)
136. Cures Acceleration Network Review Board (Section 10409, p. 2291)
137. Grant program for Cures Acceleration Network (Section 10409, p. 2297)
138. Grant program to promote centers of excellence for depression (Section 10410, p. 2304)
139. Advisory committee for young women's breast health awareness education campaign (Section 10413, p. 2322)
140. Grant program to provide assistance to provide information to young women with breast cancer (Section 10413, p 2326)
141. Interagency Access to Health Care in Alaska Task Force (Section 10501, p. 2329)
142. Grant program to train nurse practitioners as primary care  providers (Section 10501(e), p. 2332)
143. Grant program for community-based diabetes prevention (Section 10501(g), p. 2337)
144. Grant program for providers who treat a high percentage of medically underserved populations (Section 10501(k), p. 2343)
145. Grant program to recruit students to practice in underserved communities (Section 10501(l), p. 2344)
146. Community Health Center Fund (Section 10503, p. 2355)
147. Demonstration project to provide access to health care for the uninsured at reduced fees (Section 10504, p. 2357)
148. Demonstration program to explore alternatives to tort litigation (Section 10607, p. 2369)
149. Indian Health demonstration program for chronic shortages of  health professionals (S. 1790, Section 112, p. 24)*
150. Office of Indian Men's Health (S. 1790, Section 136, p. 71)*
151. Indian Country modular component facilities demonstration program (S. 1790, Section 146, p. 108)*
152. Indian mobile health stations demonstration program (S. 1790, Section 147, p. 111)*
153. Office of Direct Service Tribes (S. 1790, Section 172, p. 151)*
154. Indian Health Service mental health technician training program (S. 1790, Section 181, p. 173)*
155. Indian Health Service program for treatment of child sexual abuse  victims (S. 1790, Section 181, p. 192)*
156. Indian Health Service program for treatment of domestic violence  and sexual abuse (S. 1790, Section 181, p. 194)*
157. Indian youth telemental health demonstration project (S. 1790, Section 181, p. 204)*
158. Indian youth life skills demonstration project (S. 1790, Section 181, p. 220)*
159. Indian Health Service Director of HIV/AIDS Prevention and Treatment (S 1790, Section 199B, p. 258)*


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With all this oversight and bureaucracy, it should be catastrophic.

* * * * *

7.      Overheard in the Medical Staff Lounge: Has the Debate Ended or Just Begun?

Dr. Sam: Since we spoke last month, the Health Care Bill has passed.

Dr. Dave: Yes, by political maneuvering which makes most of us ashamed of how low they stooped.

Dr. Yancy: I no longer accept Medicare. If I'm forced into ObamaCare, I will close my practice.

Dr. Milton: There is a Dermatologist in Phoenix who put up a sign in his waiting room. If you voted for Obama, you should be aware that if ObamaCare is not repealed or thrown out by the Supreme Court by 2014 when it would be fully implemented, THIS OFFICE IS CLOSED.

Dr. Yancy: I would second that.

Dr. Milton: This Dermatologist said the worst part of ObamaCare was the increase in the fine for medical errors that went from $5,000 to $50,000.

Dr. Sam: That would close me down in a hurry. That's equivalent to three years of office rent.

Dr. Paul: What makes you think that if the government can force people to purchase insurance against their will, they couldn't force you to practice medicine against your will?

Dr. Dave: What a scary thought. That would be a more powerful government than a dictator. I don't think Stalin, Hitler, Mao or Mussolini would be able to force their subjects to purchase insurance.

Dr. Paul: They just provided health care from the general coffers.

Dr. Dave: And what quality of health care did they provide?

Dr. Paul: But they provided coverage.

Dr. Dave: Coverage is a meaningless term if you still can't get quality care.

Dr. Paul: The next thing you'll say is that Castro didn't provide quality care.

Dr. Dave: That's obvious. He barely provided any even decent care.

Dr. Paul: Didn't Michael Moore say that even heart surgery was better in Cuba?

Dr. Dave: When Michael Moore needs heart surgery and has it in Cuba, that will solve the Michael Moore problem for good.

Dr. Yancy: Boy, would I love to fix his hernia problem. It would never recur.

Dr. Paul: If you fixed his hernia, gangrene would probably do him in.

Dr. Yancy: As I said, it would never recur.

Dr. Rosen: Hey, fellows, let's get back on track. We were just getting to coverage and how that didn't mean getting access to care.

Dr. Paul: But that's all the government has to provide, coverage. The system must then provide it.

Dr. Rosen: Provide it when? In Canada they sometimes die in the interim.

Dr. Milton: Now that's a way to save money.

Dr. Rosen: That's the way America is also going. With 18 to 20 million more people being dumped into Medicaid, that will decrease access.

Dr. Milton: When Pew did their studies on 47 million people who don't have insurance, they subsequently found out that most people on Medicaid said they didn't have coverage. With an extra 30 million Medicaid patients saying they don't have "insurance," one can get to 40 million rather quickly.

Dr. Rosen: People on Medicaid have such a hard time finding a doctor who will see them, that they don't feel insured.

Dr. Milton: With 18 to 20 million more people in Medicaid, many will never find a doctor. I guess that will make Paul feel better.

Dr. Paul: We can solve that problem by forcing doctors to see them.

Dr. Milton: Now wouldn't that be forced conscription, rather like a military draft?

Dr. Dave: Or like the bank robber in a Western movie - holding a gun to the doctor as he took his appendix out.

Dr. Rosen: I've never understood that when I watched Westerns. If the doctor made a bad cut, and the bank bobber shot him, wouldn't the bank robber be in a bad way?

Dr. Paul: But the doctor would be in a worse way.

Dr. Sam: Doesn't it look like the real debate is just beginning?

Dr. Milton: The debate should have begun over a year ago.

Dr. Sam: Remember Pelosi didn't want a debate on the issues. She just wanted to force Socialized Medicine down our throat. Just like Medicare, once the public gets to like it, it will never disappear.

Dr. Rosen: Well, you see when we all lose our freedom; our civilization will be in a real bad way.

Dr. Sam: And health care will scrape the bottom of the barrel. Just like in Cuba.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8.      Voices of Medicine: A Review of Local and Regional Medical Journals

Peering over the Ether Screen - THE CSA BULLETIN - Winter, 2010

The Electronic Medical Record: Garbage In, Garbage Out By Karen S. Sibert, MD, Associate Editor

My first patient of the day was a congenial man in his 50s with a history of prostate cancer and radical prostatectomy, scheduled for replacement of a defective penile prosthesis. The history and physical in his chart was a pleasure to read because it was printed and legible, as opposed to the handwritten scrawls we often encounter. Imagine my surprise, however, at reaching the section about this patient's previous surgical history, and finding that he was supposed to have had none. I looked twice to make sure I was reading it correctly. No prior surgery. Impossible, of course—he had had both prostate surgery and the initial penile prosthesis placement. Then I realized the obvious truth: We were sabotaged once again by the fatal ease of data entry error in a computerized record.

Right now I'm not talking about computerized anesthesia records—I have a few things to say about that later, but for the moment I'm referring to the computerized documents that are starting to appear in my hospital's charts.  Early problems surfaced with the "Medication Reconciliation" form. It's good to know what medications your patients are taking, and when they were taken last. Unfortunately, our nurses in preop holding, on the wards, in the emergency department, and everywhere else, are deluged with paperwork and computer documentation requirements. They can't be faulted for the occasional typographic error, and there's no proofreading process. Yet, if the patient took his beta-blocker this morning, but the nurse types in yesterday's date by mistake, we will wrongly be "dinged" as noncompliant for perioperative betablocker administration.

Worse still is the potential propagation of errors in the patient's medication list.  The other day we had two patients in preop with the same, quite common, first and last names. Looking over the computer printout of my patient's medications and seeing Keppra listed, I asked him if he was doing well on Keppra and how long it had been since he had a seizure. He looked puzzled.  He didn't take Keppra, he said, and to his knowledge had never had a seizure.  We quickly figured out that the nurse had merged his med list with that of the other "John Smith." That was the easy part. The hard part was fixing the mistake. It turns out that once the nurse "closes out" and prints the record, apparently it takes an act of God to undo it. In the meantime, Keppra remains on the med list.

I think we can all agree that we expect more of some H & Ps than we do of others. If the gynecologist or the orthopedist has done the H & P, especially if it's a "short form" for outpatient surgery, I don't pay a lot of attention to the documentation of heart sounds. I'm a bit surprised if the existence of the heart is acknowledged at all. But when a consulting internist performs the preop H & P, especially if the patient is sick, we have every reason to hope for better.  Sadly, we may be disappointed.

With handwritten H & Ps, if parts of the exam were omitted, they would be left blank or "deferred." Now, what we're seeing is a lot of documentation that may or may not be true. Recently I've seen a normal cardiac auscultation documented in the case of a patient who actually had a loud, harsh, aortic stenosis murmur. If I can hear it, I assure you it wasn't subtle. The other night on call, I was evaluating a patient for a cadaver kidney transplant and was surprised to palpate a firm 3-cm. mass in the right side of her neck. The primary physician and renal consultant both recorded the neck exam as "supple, no masses or adenopathy." The surgeon had no choice but to cancel the transplant and send the kidney to another recipient. The neck mass needed proper diagnostic workup to rule out malignancy.

Such examples underscore the fact that the mere presence of legible documentation doesn't make it thorough or accurate. On a computer, it's perilously quick and easy to check off a list of negatives, especially if they're all mandatory fields. This has led me to develop the following guidelines for critical reading of the H & P:

1.         If a positive history or physical finding is described, it's probably true.

2.         If a negative history or normal finding is documented, one of the following is true:

a.         The question was never asked or the exam never done.

b.         It was done in a hurry.

c.         It was done by someone in training who gets most clinical information from Wikipedia.

d.         It was done properly and is really negative.

3.         A long list of negatives should be viewed with suspicion unless the patient is an athlete under the age of 30.

At the ASA annual meeting in October, I looked at the newest generations of automated anesthesia record-keeping systems. There's no doubt in my mind that handwritten anesthesia records should go the way of the quill pen. I don't want to chart vital signs when there are perfectly good machines to do it for me, more accurately. However, we will have to guard against the tendency to document trivia ad infinitum just because it's easy to do.  .  .

Back to my patient with the penile prosthesis: Once I had determined that everything in his H & P was going to require independent verification before it could be relied upon, I took a longer look at the internist's recommendations for perioperative care. I include them verbatim:

Pt is at low risk for surgery. Please avoid shifts in Blood Pressure and Volume. As is true with all surgery the anesthesiologist should mind the blood pressure as this will reduce any unknown cardiac risk the patient may have. A profound anemia would add further risk, which this patient has no evidence of. Should heavier than expected bleeding occur, please keep Hct over 30 for further cardiac risk reduction. 

Although I don't know for sure, I would bet money that this internist had a check-off list on his computer with someone's idea of appropriate advice for the anesthesiologist. How would I ever have managed the case without it? Is this really the quality of information we can expect from a completely paperless system? Computers, after all, don't generate content; they only store it and make it available for retrieval. At the end of the day, if you put garbage in, you'll get garbage out, and any time we thought we saved will be spent sorting through the trash.

Should we send this evaluation of the EMR to Obama? Or would it be futile to hit him with logic?

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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about.

* * * * *

9.      Book Review: Single Payer, Many Faults by Joseph Rago, WSJ, March 12, 2010

Health Care Turning Point, By Roger M. Battistella, (MIT, 165 pages, $21.95)

To hear President Obama tell it, the health-care entitlement that Democrats are on the verge of passing is the natural result of his pragmatic approach to government. Above the scrum of politics, technocrats have convened their commissions, weighed the evidence, and decided what works and what doesn't.

Yet these pragmatists—these putative servants of data and dispassionate analysis—have somehow persevered through more than a year of debate without ever acknowledging the core irrationality in American health care, something that economists have spent decades begging the political class to fix. Namely: "Because most consumers of health care are largely insulated from directly paying for the services they use, health care is generally perceived as an unlimited free good. . . . Wants and needs become insatiable when care is believed to be free."

That is how Roger Battistella, an emeritus professor at Cornell University, puts it in "Health Care Turning Point," his brief for a "health policy paradigm in which pragmatism counts for more than ideology." With admirable bluntness, Mr. Battistella dismantles a lot of health-policy conventional wisdom, showing how it has been made obsolete by new economic and social realities.

Mr. Battistella begins with the original sin of modern American health care: the government's World War II-era decision that gave businesses tax incentives to sponsor insurance for their workers but that did not extend the same dispensation to individuals. Since third parties were paying most of the bills—employers at first and eventually, with the creation of Medicare in 1965, the government as well— no one had any reason to be assiduous about controlling the cost of care. Patients always seemed to be spending someone else's money.

Mr. Battistella is acute on the distorting effects of such third-party arrangements. Health care, he writes, is one of the "most backward sectors of the economy." It ignores "managerial and corporate practices for attaining productivity and quality improvements."

Since no one is scrutinizing the relation between costs and marginal benefits, for instance, medical science has become ever more specialized and technologically intensive—leading to unnecessary and overly costly procedures, in Mr. Battistella's critique. And yet many of the doctors who dispense such sophisticated care—say, taking a three-dimensional image of your brain—still use handwritten paper records. Medical business models haven't capitalized on economies of scale either: Almost half of U.S. hospitals have fewer than 100 beds, while one-fourth of doctors practice solo. Nor have providers reorganized to manage chronic conditions, such as diabetes, which are better handled by integrated teams than today's fragmented and uncoordinated system. And because the income of doctors and the revenue of hospitals are rarely connected to the quality of the care they provide, preventable errors—like infections acquired in hospitals—may be the third leading cause of death in the U.S.

The solution, Mr. Battistella argues, is the "hidden pragmatism of market competition." In a competitive environment, he says, the "prosperity and survival" of caregivers would depend on "outperforming one's rivals." Meanwhile buyers—that is, patients—would be motivated to inform themselves and to "obtain the best service at the lowest price." It sounds elementary, except that in American health care it has never been tried. What would it look like? Mr. Battistella imagines individuals free to buy a wide variety of insurance coverage and choosing providers on the basis of transparent data about price, quality and value. There would be a transition, but it could be as smooth as the shift from defined-benefit pensions to 401(k)s.

Mr. Battistella concentrates his salvos on "single payer" health care, the state-run medicine that prevails in the rest of the Western world. Hospitals are owned by the government; doctors are public servants; and care is funded by taxes but rationed by limiting procedures that don't meet politically determined criteria. It is an approach particularly unsuited to medicine, given the biological variability of disease, the profusion of treatment options and the diverse needs of individual patients: What works and what doesn't simply cannot be the same for everyone. "The sheer complexity of real world conditions," Mr. Battistella writes, "surpasses the capacity of experts and their analytical models, regardless of how brilliant or sophisticated they are."

Decentralized market competition is the best option because, he says, "it depoliticizes responsibility for decision-making." He is confident that trends are moving in a market-based direction. That would be all well and good, as he patiently shows, but he is far too sanguine on the political front. Mr. Battistella considers it progress that few Democrats in recent years have openly advocated a European-style single-payer system for the U.S. . .

Mr. Battistella confesses that he finds it "hard to carry on a conversation with true believers," because their idea about health care is "too deeply rooted in ideology." They simply don't want to think about practical solutions, where markets do their best work. There's no convincing some people—especially the supposed pragmatists now pushing for de facto single payer in Washington.

Mr. Rago is a senior editorial page writer at the Journal.

Printed in The Wall Street Journal, March 12, 2010, page A17

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* * * * *

10.  Hippocrates & His Kin: Short & Sweet

Discharge Note in a chart
He was hit by a car on October 22, 2008 and in the Medical Center overnight for 19 hours. He had innumerable x-rays and CT scans and all were normal including the knees which was an area of trauma and his chest which was an area of concern concerning Lingual abnormalities. He received a bill for $58,000 for these 19 hours. MediCal paid nearly $4000 of it.

Maybe the other $54,000 was Manna from Heaven?

What Happens to Government Subsidies?
California's nursing homes have received $880 million in additional funding from a 2004 state law intended to help hire more caregivers and boost wages. But 232 homes did just the opposite. They either cut staff, paid lower wages or let caregiver levels slip below a state mandated minimum, a California Watch investigation has found. (Christina Jewett & Agustin Armendariz, SacBee)

Has anyone ever seen government money end up where the taxpayers thought it would?

How to reduce the deficit by 45 percent?


By eliminating premiums that state and local governments pay above the private sector.

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* * * * *

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

                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at and register to receive one or more of these reports. This month, read the informative An International Trend Toward Self-Directed Care . . .

                      Pacific Research Institute, ( Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. Just released: Let's Face It: Nobody Will Ever Fully Understand This Bill . . .

                      The Mercatus Center at George Mason University ( is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This month, treat yourself to Economics for Yesterday, Today and TomorrowEconomics for Yesterday, Today and Tomorrow . . .  

                      The National Association of Health Underwriters, The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

                      The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. This month, you might focus on Compulsory Insurance Has Consequences.

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

                      The Heartland Institute,, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?. This month, be sure to read House Chairman Cancels Hearings on Obamacare's Costs . . .

                      The Foundation for Economic Education,, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President,  and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. Be sure to read the current lesson on Economic Education at Healing America: The Free Market Instead of Government Health Care . . .

                      The Council for Affordable Health Insurance,, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

                      The Independence Institute,, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. Read the latest newsletter: On Sunday, March 21st, the US House of Representatives passed what we call "Obama-care." This is one of the darkest moments in American history. The federal government has taken a large step towards control of our healthcare, and with it control of our very bodies. The federal government is taking away our decisions over health insurance and, unprecedented in history, forcing citizens to purchase private products, ultimately under penalty of incarceration. Read more . . .

                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at 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 Healthcare Reform Passes: Following months of heated public debate and aggressive closed-door negotiations, Congress finally cast a historic vote on healthcare. It was truly a sad day on the House floor as we witnessed further dismantling of the Constitution.

                      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 for an overview of the extensive research articles that are available. You may want to go directly to their health research section. A free and prosperous world through choice, markets and responsibility.

                      The Heritage Foundation,, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site.—However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, they have lost site of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions.

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

                      CATO. The Cato Institute ( was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at

                      The Ethan Allen Institute,, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

                      The Free State Project, with a goal of Liberty in Our Lifetime,, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

                      The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read The Coming Constitutional Debate. The last ten years of Imprimis are archived.

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Del Meyer

Del Meyer, MD, Editor & Founder

6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608

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Words of Wisdom

"It was the best of times, it was the worst of times." - Charles Dickens.

"You get the best out of others when you get the best out of yourself." - Harvey Firestone: Tire executive.

Goals . . . They've driven all progress for man since the beginning of time. Without them, we would have shared the fate of the dinosaur.

Some Recent Postings

Health Care: A Two-Decade Blunder, by Tevi Troy . . .   

HIPAA Revisited: Your Medical Records Aren't Secure . . .  

In Memoriam

Wolfgang Wagner, custodian of the Bayreuth Festival, died on March 21st, aged 90
 From The Economist print edition | Mar 31st 2010

THE very moment he came into the world, breech-born, at Bayreuth, Wolfgang Wagner's life was mapped out for him. His aunts Eva and Daniela, leaning over his cradle, could discern already "the Master's" nose and chin, and imagine his baby lips babbling the prelude to "Die Meistersinger". Growing up in his grandfather's house (Wahnfried, or "peace from illusions"), his wrestling-ground was the Master's grave in the back garden, his dressing-up costume a Nibelung's cloak and horned helmet, and his playroom the prop-store at Richard Wagner's own Festspielhaus on the green hill, among the wooden models of gods awaiting their downfall.

But Wolfgang was the second son. This meant that responsibility for the treasure of Bayreuth, the shrine built especially for his grandfather's compositions and the annual festival devoted to them, was bound to devolve to his elder brother Wieland. Everyone applauded Wieland's "fabulous brilliance" at interpreting the works. Little brother Wolfgang, on the other hand, was straightforward, practical and plodding. He made a chicken run at Wahnfried, selling the eggs to his mother at market prices. He liked the technicalities of sawing and hammering, pounding his own anvil like the thieving dwarf Alberich of "Das Rheingold", and no job around the Festspielhaus was too humble for him to do.

Underneath that easygoing surface, though, with its thick Franconian inflections, ambition and resentment burned in Wolfgang's breast. He went to war in 1939, getting hurt in Poland, while Wieland was given a deferment for his genius. He was not included in Wieland's "fireside chats" about festival planning, "evidently thinking he could achieve better results by dispensing with my presence". And yet, from a stint at the Berlin Staatsoper, he knew about staging musical dramas. As American bombs began to pound Bayreuth in 1945, it was he who rescued the busts, pictures and autograph scores from Wahnfried, stuffing them into rucksacks on his bike and pedalling them to safety. And when the festival resumed in 1951, out of the ruins, his commercial flair found, from somewhere, sponsors and money.

So when, in 1966, Wieland died suddenly, there was no doubt in Wolfgang's mind that he should take over. Nor did he doubt that he should sit there, crouched over the Festspielhaus like the dragon Fafner over his hoard, until he died. No one else was remotely suitable. Certainly not his meddling sister Friedelind, who had turned her back on Germany and skipped off to America; not Wieland's pushy wife Gertrud, who had said "defamatory" things about Wolfgang on television; not Wieland's son, Wolf-Siegfried, who seemed to think he could drift into Bayreuth's top job without hard work or training; nor, as the years rolled by, his own children from his first marriage, the sniping Eva and that unspeakable leftist "crackpot", Gottfried.

Bedtime with Hitler

Controlling Bayreuth, in Wolfgang's terms, was not just a matter of organising directors, conductors, money and, in 1973 and 1986, legal instruments to ensure that the family, meaning him, kept its grip on the festival. He also had to keep the heritage pure. In fact he was not over-pious, refusing to see his grandfather's sets, even for the sacred "Parsifal", as holy relics; he ignored letters accusing him of betraying German culture when he allowed a communist salute during "Tannhäuser", or when a French "Ring" of 1976 put turbines on the Rhine and turned the Rhine-maidens into whores. He liked to think of Wagner's works as Greek tragedies, of fresh and universal human importance.

Nonetheless, because the Nazis had commandeered them, and because most of the family had been only too happy to go along, there was much purifying to be done. So Wolfgang hid away, in his motor-cycle sidecar in the garage, the film he had shot of Hitler, known as "Uncle Wolf" to him, happily strolling round Wahnfried in the 1930s. Presumably he buried deeper the memories of Hitler telling bedtime stories. His mother's devotion to "our blessed Adolf" remained acutely embarrassing; but Wolfgang, who had never joined the Nazi party, proclaimed that he himself had nothing to repent of. It was not his fault that Hitler had loved his family.

For himself, he loathed it. As long as his health allowed, he kept them all at bay—save Gudrun, his second wife, who died before him, and his daughter Kati, who now succeeds him. His life was not this squabbling brood, but the ten operas and music dramas his grandfather had left to the world. And though it could be argued that fiery Loge, foolish Wotan and impetuous Siegfried were not much improvement on the Wagners, Wolfgang at least controlled them. As the grasping antagonists sang on, gradually losing out to the tubas and bass trombones, he could make the set yawn open and shut like the giant circle from his 1970 "Ring" until, in the end, it swallowed them whole. The world ended then; silence descended; and the stocky second son, with his grandfather's profile, would stride onstage and take a bow.

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On This Date in History - April 13

On this date in 1983, Harold Washington was elected 1st black mayor of Chicago. Our concern is to heal. Our concern is to bring together. That fallacy flies in the face of studies that show, every day, in every way, things are getting a little worse for America's minorities relative to the progress made by those in the top percentiles of assets and income.

On this date in 1980, U.S. boycotts Summer Olympics in Moscow.

On this date in 1933, the 1st flight over Mount Everest

 was made by Lord Clydesdale. At 8,848 meters (29,029 feet), Mount Everest it the tallest mountain in the world. Since Sir Edmund Hillary's legendary ascent to the peak of Mount Everest in 1953, over 3,700 people have successfully made the difficult and dangerous climb. While both Chinese and the Nepalese people always claim that Mount Everest (and its peak) belongs to their respective countries, the world's tallest mountain actually straddles the border of China and Nepal.

On this date in 1929, my Brother, the Rev Dr. Eldor W. Meyer, was born. He lives in Girard, Kansas, with most of his extended family nearby. Happy 81st Birthday, Bro. May you have many more.

After Leonard and Thelma Spinrad


Don't forget that Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people's welfare.