MEDICAL TUESDAY . NET
Community For Better HealthCare
Vol V, No 1,
In This Issue:
The 3rd Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most
prestigious meeting of chief and senior executives from all sectors of health
care. Renowned authorities and practitioners assemble to present recent results
and to develop innovative strategies that foster the creation of a
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Today, MedicalTuesday begins its fifth year of
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special thanks to
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1. Featured Article: Paternalism Costs Lives By HENRY I. MILLER, WSJ,
Decisions about drug safety and efficacy are far from easy. Tysabri, a multiple sclerosis (MS) drug that was voluntarily withdrawn from the market last year after the appearance of a previously unknown side effect, illustrates some of the conundrums.
In advance of the publication of three critical new studies on Tysabri in this week's issue of the New England Journal of Medicine, a major news organization recently asked me, as a physician and former FDA official, whether I knew of examples of prescription drugs that have "efficacy but [also] serious safety issues." That is, I responded, the rule rather than the exception.
Obvious examples include the antimetabolites used for traditional chemotherapy. Because these drugs are no more than poisons administered in a way intended to be more toxic to cancer cells than normal ones, it is not surprising that their side effects are often serious and even life-threatening. When I was a medical resident three decades ago, hospital gallows humor included referring to BCNU, an experimental cancer drug, as "Be seein' you." Approved in 1977, it is still widely used.
A more recent example is aldesleukin, a drug that has offered new hope to victims of kidney cancer and malignant melanoma. It is highly effective in a small proportion of patients but exhibits significant toxicity. The patient information booklet warns that those taking the drug "frequently experience serious, life-threatening or fatal adverse events," including dangerously low blood pressure and reduced organ perfusion, impaired function of infection-fighting white blood cells, disseminated infection and autoimmune disease.
Antibiotics are another class of wonder drugs that sometimes manifest significant toxicity. Chloramphenicol, a drug that is effective against a wide spectrum of bacterial infections, causes rare cases of fatal aplastic anemia, so it is used only sparingly. The potent antibiotic gentamicin is often lifesaving but can cause damage to the kidneys, nerves and ears. And significant numbers of patients are allergic to other important antibiotics, including the penicillins and cephalosporins.
But let us return to Tysabri, only the sixth medication approved -- and the first in several years -- for the treatment of MS, a common and debilitating autoimmune disease that affects the central nervous system. The impressive results of the drug's testing in clinical trials -- the frequency of clinical relapses reduced by more than half -- induced the FDA to grant accelerated approval in 2004. By the time that several thousand patients were being treated with Tysabri, however, three had contracted progressive multifocal leukoencephalopathy (PML), a rare neurological disorder caused by a virus. (Because the drug suppresses certain components of the immune response, regulators, clinicians and the product's developers had from the beginning been sensitive to the possibility of infections as a side effect.) Immediately -- some would say prematurely -- the manufacturers of the drug voluntarily halted production and distribution and withdrew Tysabri from the market. MS patients and many neurologists were bitterly disappointed.
The three clinical studies reported this week in the New England Journal of Medicine bolster our confidence about the safety and efficacy of Tysabri. In a study of almost a thousand patients that compared Tysabri to placebo, the drug cut the rate of clinical relapses by 68% (to 0.24 from 0.75), reduced by 83% the number of new or expanding brain lesions found on MRI, and slowed the clinical progression of disease. (The other currently used drugs for MS lower the occurrence of acute relapses by roughly one-third.) Similar results were obtained in a second trial which compared two-drug therapy with Tysabri plus interferon beta-1a to the interferon alone. . . .
The "safety" of a drug is a relative thing. Safety and efficacy, the two criteria required for marketing approval of a drug, are inextricably linked. The judgments of regulators (and practicing physicians) require a global and often difficult calculation of risk and benefit, including consideration of what alternative therapies are available. For a given drug, we are willing to tolerate greater uncertainty and more severe side effects for a potential cure for pancreatic cancer or AIDS, for example, than for a new drug that treats heartburn. When FDA grants marketing approval, the drug is deemed to be sufficiently safe and effective to be used for the conditions on the label.
In light of the just-published data -- to which the FDA should have had access months ago -- it is clear that this drug belongs back on the market, probably with new warnings about PML in the labeling.
The notion that the FDA should "err on the side of safety" sounds like a tautology but is an affront to patients with incurable or poorly treatable diseases: For them, there is no safety in the status quo, and we only damage them further with paternalistic public policy that prevents individuals from exercising their own judgment about risks and benefits. If the FDA must err, it should be on the side of patients' freedom to choose.
Mr. Miller, a physician and fellow at the Hoover Institution, headed the FDA's Office of Biotechnology from 1989 to 1993.
To read Dr Miller's entire article, please go to http://online.wsj.com/article_print/SB114125841380186971.html.
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2. In the News: In New Health Plan, Patients Pay Their Share -- Or Else By SARAH RUBENSTEIN
Health insurers are starting to look to patients' credit cards -- and paychecks -- to ensure hospitals and doctors don't get stiffed.
As health plans impose higher deductibles, co-pays and premiums, many patients are becoming slower to pay their portion of hospital and doctor bills, driving up providers' collection costs and bad-debt accounts. A major insurer, UnitedHealth Group Inc., is set to offer an automatic-payment program that would give providers a strong measure of assurance that patients will pay -- because if they don't, UnitedHealth will get the money, with interest, out of their paychecks.
The pilot program, which
UnitedHealth is set to launch in
UnitedHealth, based in
Tenet spokesman Harry Anderson says while collecting from the uninsured remains a bigger problem, slow payments from the insured are a growing concern. "The higher the amount owed by the patient, the worse the problem is," he says.
Under the new program, dubbed "OnePay," UnitedHealth will pay a patient's portion directly to a provider as soon as it processes an insurance claim. Then, it will collect from the patient, with payment due in 20 days. If patients can't pay 100% of their portion right away, UnitedHealth will act as a creditor, steadily receiving payments, plus interest, deducted from the patient's paychecks until the bill is paid in full.
UnitedHealth says it will charge interest at the prime rate -- currently 7.5% -- not the double-digit rates many credit cards apply. It says employees, and medical providers, enroll in the program on a voluntary basis.
What's in it for employees? Convenience is a major attraction for health-care consumers overwhelmed by the paperwork and the technicalities of health-care and hospital billing, the insurer says. In focus groups, lower-income consumers said availability of low interest rates and a structured payment plan was appealing, UnitedHealth says. Plus, UnitedHealth says enrolled patients would feel the discounts from participating providers.
Telecommunications company AT&T Inc. may be among the early
employers to sign up for OnePay. An AT&T spokesman says the company has
told UnitedHealth it has "an interest in looking at" the program.
Tenet, in addition to participating as a provider, says it will participate as
an employer, offering OnePay to its employees in
In 2002, UnitedHealth chartered its own bank, Exante, which will serve as lender for employers participating in OnePay, in effect extending lines of credit for employees to pay health-care expenses. UnitedHealth moved into the banking business as the Bush administration began promoting health-savings accounts, which banks have started offering as a way for people enrolled in high-deductible plans to save pretax dollars to cover future out-of-pocket medical expenses.
Many providers are taking
steps to collect from patients with high deductibles. Deductibles are "a
great sticker shock and cultural shock" for patients, says Nathan Beraha,
Gail Shearer, director of health-policy analysis at Consumers Union, says automatic-payment programs "can offer some convenience to consumers." But the programs can pose a problem, she adds, "if [patients] are concerned that because of their health status they may not be able to monitor the bills as carefully as they'd like."
To read the entire article, please go to http://online.wsj.com/article/SB114221304342196190.html?mod=todays_us_marketplace.
Write to Sarah Rubenstein at email@example.com
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3. International Medicine: Where in the World Is Ladrillera? By Herbert Brosbe, MD
am awake. Something awful is happening. I wait, trying to understand. The room
is pitch black. I can hear the gentle breathing of my
wife next to me. So what is wrong?
The pain begins again. I break into a sweat. Someone has stuffed a football into my stomach and is slowly turning it sideways. I check my watch. I will the pain not to return. No luck. I groan, biting my lip. The Peruvian highlands are not a good place to be sick.
I quietly roll out of bed and grab my flashlight. The heavy wooden door creaks as I leave our bedroom. The moon illuminates the cement stairs as I descend to the courtyard. My movement doesn't seem to make the pain worse. Good, not an acute abdomen.
I turn on the bathroom light, a single bulb hanging from a wire. The air is bitterly cold. It's July, the middle of winter down here. As usual, there is no running water and won't be until early morning. I try to make myself throw up as another spasm of pain hits. No luck. I'm really not good at this. I sit on the toilet, which has no toilet seat. A land of limited luxuries. Defeated, I retire to the kitchen next door. All the rooms here open onto the courtyard. I am in my heavy winter coat, with a watch cap on, rocking back and forth. I try to pretend the pain is just a dream. I have caught one of those ugly parasites.
During the next few days, I learn the lessons of dysentery. This version is much different from the "tourista" I have weathered in other countries. I learn that putting anything in your mouth will be met with horrible pain, followed shortly by violent emptying of whatever your bowels can produce: mucus, blood, bits of tissue, stool. I lose all desire to eat or drink. I need more than an hour to force a cup of tea down so I can take my Flagyl. I now know why children refuse to drink and dysentery kills so many worldwide. How did I get myself into this?
I have always nurtured the idea of practicing international medicine. In medical school, I spent a wonderful three months in the jungles of
Somehow that dream was compromised away during my subsequent career, but I recently decided to revive it. At first, I couldn't find a volunteer opportunity that didn't demand at least two months or high fees to participate. Then my daughter suggested visiting www.idealist.org where I found a posting for Mosoq Ayllu, an organization run by a husband-and-wife team of social workers, Patti and Juan Jose. They have adopted Ladrillera, a poor community on the outskirts of Huancayo, a city in the
was excited to begin my medical duties. At first, I worked in boys' orphanages
in Huancayo. They had an epidemic of mumps, a disease for which Peruvians do
not immunize. I also saw Hepatitis A and sundry common ailments. Then I was
brought to the community clinic in Ladrillera.
I don't think Patti and Juan Jose had any intention of shocking me. It's just a cultural thing. When I hear the word clinic I think, you know, clinic, as in a building equipped with medical personnel and supplies. The clinic at Ladrillera was an adobe brick room. Patti and Juan Jose were proud that it had a cement floor because the other homes and buildings in Ladrillera had dirt floors. It had a tarp for a roof and clear plastic taped over an opening for a window. No door. No electricity. No running water. A desk (doctors in
A long line was waiting outside when I arrived in the morning. Patti and Juan Jose had posted flyers saying that a doctor was coming. It was like a scene out of National Geographic. A line of people waiting for the American doctor to heal them. I was scared senseless. . . .
was so grateful when the patient was easy. Parasites. Pneumonia. But there were
few easy cases. One woman had waited 17 days for a doctor to take something out
of her eye. When I gently tried to open her eyelid, a pocket of pus poured out.
I was horrified. I could not identify any normal structures, just macerated
tissue and pus. I explained that my pills weren't able to cure her. She needed
to go to the hospital.
As I was later to learn, poor people in
Among the many memorable patients that first day were people with cataracts so thick their pupils were white glass. They asked for something to restore their sight. I explained that I had no medicine for cataracts. They would have to go to
young man comes in and wants pills for his arms. He has been building bricks
since he was eight. Both hands and forearms are swollen. There are barely any
creases left. He has blatant neuropathy and constant pain in his fingers,
wrists, and elbows. How do you explain repetitive-use injuries and prescribe
rest, physical therapy, and vocational rehab? I give him steroids and ibuprofen
and explain that his work causes the problem. He knows that. He must work. Period. He too is grateful for the medicine.
Within a short time, I have learned what to do. No one wants to wait hours in the cold for the doctor to tell them that nothing can be done. I am ashamed of myself. In some way I am practicing "poor quality" medicine, but these people are so grateful to have someone lay their hands on them, to give them anything to help them continue.
I dispense vitamins, Flagyl, ibuprofen, ranitidine. I begin telling patients to take una de gato, one of the local herbs used by native healers. I tell them how to massage and stretch. I ask them if they can afford to boil water and apply hot cloths to their aching necks, shoulders, and backs. They are all so grateful. They clasp my hands tightly and say thank you, over and over again.
At the end of the day, I am physically and emotionally exhausted. I ache from head to foot. I have not eaten for fear of picking up a parasite. I have drunk bottled water. The interpreter turns the last of the line away, saying come back tomorrow. The doctor will be here again tomorrow. There is no angry response. They will come back tomorrow.
After a few days, my shame mounts. But this time it is different. I am ashamed because I do not want to be here. I want a hot shower. I want hot food. I want heat in my home. I want my own comfortable bed. I want my life back. . . .
we return to
I wish every American could spend a day or two in Ladrillera. Perhaps it would strengthen our vision of how people should live. I will volunteer again. The next time I will go with a medical team and be part of a mobile clinic. I believe that kind of professional and emotional support will work for me. A younger doctor, one more resolved and more resilient, would be most welcome in Ladrillera.
Where in the world is Ladrillera? It is here, in
Dr. Brosbe, a
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1. The complexity and confusion of the Medicare Part D drug benefit, where the media focuses its attention, is actually a relatively insignificant part of the problem posed by the new entitlement, which accelerates a vicious circle of bad incentives for politicians, citizens, and providers.
Medicare drug benefit will make the
3. Americans are receiving mixed signals from the government: on the one hand, it gives us control of more of our health dollars while we are working and privately insured (through tools like Health Savings Accounts); but on the other hand it tells us that we are "entitled," out of the blue, to prescription drugs and other health goods and services almost for free when we retire and go on Medicare. This creates negative incentives for privately insured patients under 65 years old, increasing the likelihood that Health Savings Accounts (HSAs) will become simply retirement savings accounts for well off Americans.
4. Insurers do not have good incentives to spend the appropriate amount of money on prescription drugs. Instead, Medicare establishes a "silo" approach that forces insurers to consider only one area of health spending, to patients' detriment.
5. Drug makers are losing the incentive to offer their own discount programs to low-income seniors, now that the government has taken them over.
The "bidding" element of the drug benefit is its sole positive attribute, and it should be extended throughout Medicare as an interim reform. However, executing this will require extraordinary political will, which is extremely unlikely in the current climate of public opinion.
Serious Strategic Error
President Bush is doing an outstanding job developing patient-friendly solutions in the private health insurance market, by focusing on getting health care dollars out of the hands of the government and into the hands of the patients who need them, primarily via Health Savings Accounts (HSAs). If the Congress gets on board with the President's proposals to expand HSAs, 2006 will be the year that Americans will be able to engage these powerful tools to take control of their health care, as I discussed last month.1 Ironically, the legislation that introduced HSAs, commonly known as the Medicare Modernization Act of 2003 (MMA), also introduced a seriously flawed new entitlement into Medicare: the now infamous Part D drug benefit. . .
Despite the media flurry, and the pain of the affected patients, these are transitory, "frictional" challenges that will be sorted out sooner rather than later. The real problems with Medicare Part D will become apparent after it has reached equilibrium, with all interested parties relatively content. That's when the new entitlement's perverse incentives will really take hold, becoming deeply entrenched and extremely difficult for advocates of consumer-directed health care to dislodge.
It is important to remember the trajectory of this program: the politicians set up a brand new entitlement, which few seniors needed, outsourced it to the private sector, and then claimed to have injected "free market" incentives into Medicare, without compelling change in traditional Medicare
Describing the drug benefit as "free market" is like nationalizing interstate bus service, outsourcing the operations to Greyhound, and claiming that you are on the way to privatizing Amtrak!
To read John R.Graham's entire report, please go to www.pacificresearch.org/pub/hpp/2006/hpp_02-06.html.
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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A patient came to the window unannounced saying he wanted a new prescription in lieu of the one we gave him last week. With the new Medicare Drug Plan, he needed a 90-day supply and to have it filled elsewhere. This would save him 50 cents on each prescription. I believe he had four.
I looked him straight in the eye as I handed him the rewritten prescription, which I did outside of an office appointment making the next patient wait an extra five minutes, to see if there was any recognition or understanding of the costs involved. He said to my inquiring look, "A guy has to save fifty cents when he can."
It's on these days that makes a physician want to give up helping patients and rather just let the government take over - denying one form of health care today, delaying another operation tomorrow, postponing all necessary health care for six months due to budgetary reasons - as occurs in the National Health Service or Canadian Medicare. But we have to understand the self-centeredness of humankind and comply with our patient's requests, even if they don't understand our hesitation or we never get a thank you.
On the same day, a private patient who is a member of a large Integrative Health Plan came in for a complete pulmonary examination for his yearly second opinion. He handed my receptionist a signed, blank check made out to me. He told her to fill in the amount "when the doctor is done doing everything he thinks I need." After updating his medical and pulmonary information for the year, doing a chest x-ray and a pulmonary function test, my receptionist filled in the amount and gave him a copy of the check, the consultation and the PFT report for his personal physician.
After we thanked him, we mentioned the aforementioned incident. Being a retired businessman, he told us what he would have told that patient.
What a contrast of events occurring the same morning - one patient who understands the value of medical care and another who has no concept of what a professional five-minute interruption is worth. He refuses to recognize the overhead cost of those five minutes or the value or his time to drive to the office, paying $2.50 a gallon to save fifty cents.
When an entitlement is essentially free, the only future that those who think they're entitled can see is more gouging of the taxpayer's dollar, not realizing they too are taxpayers.
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Some think that a doctor in
politics knows the answer not only to health care issues, but other issues as
well. That may not be the case. DANIEL HENNINGER, in a recent column about
immigration and law, states: "Respect for the law" is part of the
American bedrock. As Alexis de Tocqueville rightly said, each voter indirectly
contributes to the making of our laws, and "however irksome an enactment
may be, the citizen of the
Another 19th-century Frenchman close to the hearts of American conservatives is Frederic Bastiat, who had a further thought: "The surest way to have the laws respected is to make them respectable." Is our immigration law "respectable"? Need you ask?
It's not a coincidence that
the first push-back Immigration Act emerged in the Roaring Twenties, another
period of abrupt social disruption and anxiety with heavy immigrant inflows
To read the entire Henninger's WonderLand column, please go to (subscription required) http://online.wsj.com/article_print/SB114376883496913068.html
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Mrs. Ackford, who had very high cholesterol, tried a low-fat diet but was unable to reduce her cholesterol on a six-month recheck. She was placed on one of the statin drugs. She stated she had been on one of them previously and it had created some bowel problems. She called back a week later indicating that this one also caused bowel problems. What problems? It created a large amount of gas (known as flatus for the medically sophisticated).
She stated that she tried to take it at night, but it
was good that she was widowed because if she were sleeping with a gentleman,
he'd divorce her. She tried to take it in the morning and by midmorning,
she had to cancel all get-to-gethers with her friends for fear of alienating
them. She claimed that if she had wings, she's sure she could have flown to
What's a Proper English Lady to Do?
I Wish I Still Had My Invalid Wife to Care for
About three years ago, Mr. Jack, during his annual pulmonary review, testing, and plan for the next year of his medical life, began to shed tears. He said his wife was getting more demented and physically incapacitated from the stroke she had sustained. Even in retirement, he had great difficulty managing his own home because she had become a 24-hour-a-day responsibility. He no longer felt safe to leave her just to do some grocery shopping or run brief errands. In trying to obtain help, he finally decided a nursing facility was more affordable than in-home care. He looked up at me through his tear-stained eyes as said, "Do you think God will forgive me for neglecting to care for my wife to the end?"
He made six-hour visits to the nursing home every day and took her home on Friday night so they could spend the weekend together in the home they had shared for more than forty years. He said, "I just wanted her close to me where I had always seen her all those years. That way I can also hold her next to me for three nights a week before I take her back on Monday." It's just the closeness that I cherish. He continued, "You know, doctor, last weekend as I was holding her close to me, she said, 'Jack, I have this wonderful feeling in my pelvis like I had when we were young. Do you suppose you could make love to me again?'"
Mr Jack said that he'd not been able to provide any marital relations to her since his prostate surgery ten years ago. In those days they didn't have potency drugs. He said he'd heard an advertisement for Levitra, the wonder drug. "You suppose I could try that?" I did give him a prescription.
This year he announced that his wife died two months ago. "I wish she was still here for me to care for. I'd love to care for her another six years. I'm sorry I ever shirked my spousal responsibilities to care for her and placed her in a nursing facility. I wish she were still in my arms every day, even though she may not have recognized me towards the end. She was such a wonderful wife, mother, homemaker, and companion. I miss her so."
When voices from so many fronts judge some stages of human life as having no value, that euthanasia is the kindest thing to do for people with lives not worth living, much like Hitler of yesteryear, it's good to see such lives having value to those with whom they were shared.
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8. Voices of Medicine: The Price of Automotive Love by Lauren Bower, MD
down the roadway at ,
I slide into a "
A week later, at a crawl in rush-hour traffic, I whine, "I could walk faster than this" - until I find that the real victim, a teenager still clutching her cell phone, has been taken by ambulance to the nearest trauma center.
Physicians, like most Americans, have a love-hate relationship with the automobile. We are hooked on the convenience of going where we want, when we want. But the freedom the personal vehicle gives us comes with a hefty price. The articles in this issue of Sonoma Medicine give us a bill of particulars.
For starters, Beth Dadko, MPH, paints a frightening picture of the all-too-human perils of teenage driving, the leading cause of death and hospitalizations for local 15- to 19-year-olds. She offers useful suggestions for how physicians can help reduce this tragic loss of life and limb. To read "The Biggest Threat to Teenagers," go to www.scma.org/magazine/scp/wn06/dadko.html.
Next, Dr. Richard Jackson, Monica Rai, and Megha Doshi detail the direct health care costs of vehicular accidents. They also examine the more common - and much more insidious - costs to our collective health of the sedentary lifestyle the automobile promotes. Obesity, hypertension, and depression are all on the rise. To read "Driving Ourselves Sick," go to www.scma.org/magazine/scp/wn06/jackson_etal.html.
Fortunately, there are alternatives to traffic. Some people have found ways to integrate regular exercise into their daily routine while avoiding the twice-daily rush-hour drive. One of them, Dr. Mark Berenson, describes the perils and pleasures of bicycle commuting. To read "See You In The Bike Lane," go to www.scma.org/magazine/scp/wn06/berenson.html.
Another alternative, explained by Dr. Brien Seeley, is the true-to-life science fiction of personal air vehicles (PAVs). The idea of a flying machine in every garage is no longer the exclusive purview of Jetson cartoonists. The first annual NASA-sponsored competition for PAVs is to be held at the
The concept of "walking districts" is introduced by a local housing developer, Alan Strachan. This reversal of the American trend to group like with like - ticky-tacky suburb here, office-building cluster there - seems new and revolutionary, yet recalls the layout of a medieval European village. Placing work and living spaces in closer proximity may have social as well as economic and ecological benefits, yielding a happier, healthier community. To read "Financial Tools for Inducing Smart Growth," go to www.scma.org/magazine/scp/wn06/strachan.html.
Love it or hate it, the automobile is here to stay. So buckle up, play soothing tunes to calm your inner road warrior, watch for speeding cyclists passing you on the right, and dream of
Dr. Bower, a
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9. Book Review: Healthy Competition - What's Holding Back Health Care and How to Free It by Michael Cannon & Michael D Tanner, Cato Institute, Part III: Chapter 7 Healthy Choice and Competition or Controls.
Health care may be the most
intensively regulated sector of the
Christopher Conover of
Conover labels the social
cost of health care regulations "a $169 billion hidden tax" and
offers a number of ways to comprehend its magnitude. Health care regulation
costs Americans more than they spend on gasoline and oil ($165.8 billion in
2002) or on pharmaceuticals ($162.4 billion in 2002). "Spread across all
households, health services regulation cost the average household an estimated
$1,546 in 2002." Over the next 10 years,
health care regulation will cost consumers three times the cost of the new
Medicare prescription drug benefit. Such regulation makes health insurance
unaffordable for an estimated 7.5 million Americans, or one-sixth of those who
are uninsured on any given day. Finally, health care regulation reduces
societal income and with it society's ability to purchase products that protect lives (e.g., safer homes, safer automobiles). Conover estimates that this effect induces an
additional 22,200 deaths per year - 4,000 more deaths than the
The cost of health care
regulation is equal to roughly 10 percent of all
Conover does find that some
regulations are on balance helpful. In
his overall estimate, these net benefits hide part of the cost of the remaining
regulations - those that do more harm than good. Taken by itself, this latter
group imposes net costs of $204.2 billion annually. It also gives policymakers a
good place to begin deregulating
In numerous industries, deregulation has spurred greater consumer choice and competition, which has led to increases in quality and productivity, as well as reduced prices. A consumer-directed health care agenda would deregulate the health care industry to increase competition and give consumers greater freedom of choice, including the ability to choose the level of regulatory and legal protection they desire.
State and federal governments have enacted layers of regulation that place restrictions on the pricing, composition, administration, and cancellation of health insurance policies. Regulations that restrict insurers' ability to offer and price health insurance according to risk force low-risk customers to subsidize high-risk customers, and price low-risk and low-income consumers out of the market.
Many health insurance regulations are meant to correct the unintended consequences of other laws and regulations. Such regulations include those laws that require employers to provide health benefits to former employees, as well as those that require insurers to cover services from providers that may otherwise be excluded from coverage. In many cases, health care regulations are an attempt by private interests to seek private gain. For example, states have enacted an estimated 1,823 separate benefit mandates that require health insurers to cover particular services, including "acupuncture, massage therapists and hair prostheses (wigs)." The most vocal proponents of laws requiring consumers to purchase acupuncture, massage therapy, and chiropractic coverage are (not surprisingly) acupuncturists, massage therapists, and chiropractors.
The costs of health insurance regulation are substantial. Conover finds that some health insurance regulations yield benefits in excess of their costs. However, the remaining regulations impose annual costs of $46.6 billion in excess of the benefits they provide. Grace-Marie Arnett (Turner) and Melinda Schriver of the Galen Institute found that the 16 states that most aggressively regulated their health insurance markets in the 1990s saw their uninsured populations grow eight times faster than other states. The FTC cautions legislators on the harms of benefit mandates:
Governments should reconsider whether current mandates
best serve their citizens' health care needs. When deciding
whether to mandate particular benefits, governments should
consider that such mandates are likely to reduce competition,
restrict consumer choice, raise the cost of health insurance,
and increase the number of uninsured Americans.
Some states already see the
wisdom of deregulation. After leading the trend toward greater regulation in
the 1990s, officials in
The Newtonian principle of gravitation is now more firmly established, on the basis of reason, than it would be were the government to step in, and to make it an article of necessary faith. Reason and experiment have been indulged, and error has fled before them . . . Subject opinion to coercion: whom will you make your inquisitors? Fallible men; men governed by bad passions, by private as well as public reasons.
Thomas Jefferson, Notes on the State of
To read the rest of Part III, Chapter 7 Health Choice and Competition or Controls - please go to the Cato Bookstore: www.catostore.org/index.asp?fa=ProductDetails&method=cats&scid=33&pid=1441272. The price is only $10. At that rate, consider purchasing two or three and surprise those friends, who don't understand that government involvement in health care is destroying affordable health care, with a gift that keeps on giving. There are other excellent recent titles you may want to consider.
For Next month, read Part III: Chapter 8 Medical Malpractice Reform
To read some of the other book reviews that are available, please go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
Cinematic OpEd Review: "Why We Fight"
"Why We Fight" exposes "the demon of error" in our Millitary-Industrial Complex
Warning: movie spoiler alert. If you have not seen "Why We Fight," consider seeing the film before reading further.
[Note:James Murtagh has spent 20 years as an Intensive Care Unit physician at a major Southeast hospital. ]
-Look upon our
works, yea mighty, and despair. (apologies to Shelly's
-It is nowhere written that the American empire goes on forever. (Jared Diamond)
By now, Americans are no
longer worried about whether the invasion of
Eugene Jarecki's film "Why We Fight" shows war, especially war fought secretly and deceptively, since the time of ancients, often destroys both victor and vanquished.
Homer may have been the first to describe "Blowback," or the unintended consequences of war. Both Greek and Trojan societies were destroyed in Homer's mother of all ancient wars. Even victorious king Agamemnon was assassinated on his return. The conquerer Achilles was left lamenting he would rather be a slave of a peasant than ruler of the strengthless dead.
It was the end of the golden era
Today, war aftermath on the homefront brutalizes us, numbs us to loss of
freedom, wiretapping and torture, loss of treasured alliances, loss of
security, and it appears Greek tragedy repeated again.
Sophocles heard the long note of tragedy long ago on the Agean, as ignorant armies clashed by night.
War has not led to an Open society for either
Can we vow that we will not shed "blood for oil?" Given that our society is absolutely besotted by the need for oil, is there an alternative?
Eisenhower's farewell address on
In another cycle of Greek tragedy, Herodotus showed free armies of the Greeks were inspired to fight harder by the corrupt luxury of the Persian despots, exemplified by the tent of Xerxes.
Now, our elites must ask if Americans will fight to retain the luxuries in the increasing wealth-stratified Enron nation for the top 1% of the population which is rapidly becoming an oligarchy.
Oil is running out rapidly, guaranteeing world conflict. Paul Roberts in "The End of Oil" shows the world has less than 30 years of fuel left. Mass starvation and cold is coming unless we do something drastic.
Pulitzer Prize-winning author Jared Diamond writes that the world at the end of oil appears infinitely worse than a nuclear Armageddon, which by comparison could be quick and merciful. The struggle for life between individual people and nations as oil dwindles would be slow and horrifying, possibly leading to grizzly horrors in "societal failure" as cannibalism.
Al Gore demands that humanity "make the effort to save the global environment the central organizing principle of our civilization."
"Why We Fight" is chock-full impeccable,
staunch conservatives. "The
"When war becomes this profitable, you're going to have more war," notes a CIA analyst. But what happens when war is not only profitable, but deemed essential to the survival of a nation addicted to oil?
I am a lung doctor, and we have a wry saying, "Everyone stops smoking eventually." Well, eventually everyone will eventually not use oil, because we are going to run out of it. The question is, will the end of oil also be the end of society? Will the end of oil be the end of us, or the beginning of something new?
In a sense, "Why We Fight" is the documentary twin of George Clooney's "Syriana," which declares that "Corruption? Corruption is our protection! Corruption keeps us safe and warm! Corruption... is why we win!"
Other recent films echo this Greek tragedy cycle and link the loss of freedom and war. "Good Night, Good Luck" is a metaphor for loss of press freedom since the war unmatched since the days of McCarthy.
The heartbreak of one American father was in the end linked to the heartbreak
of another father in
J. Murtagh Jr., MD,
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10. Hippocrates & His Kin: Is the Health-Care Customer Always Right?
By Perry Solomon, M.D., WSJ,
In regard to Vernon Smith's March 8 editorial page commentary "Trust the Customer!1": His suggestion of "channeling third-party payment allowances through the patients . . . who are choosing and consuming the service," so that they can control costs, really does nothing to meet this end. The large insurance groups have already negotiated discounts with the hospitals and medical- care providers on the services they provide. A hospital may bill $10,000 for a surgical procedure that has been pared down to $2,500 by the insurance company. If the patient can now pay the $2,500 to the hospital, how does this help lower costs? The discounts that the Amish and Mennonites received in Lancaster County, Pa. (40% for cash payments) was just an example of being "self-insured" and negotiating in the same way the insurance companies did.
The notion of the ability of patients to "make choices" and become "competent" is slightly simplistic. A patient really has no metric to measure the care he is receiving. There are basic studies about "quality" and "outcomes" for hospital care, but these are fraught with danger, as there are so many variables that enter into these results that they can render these studies practically meaningless. The same evaluations for physicians are practically nonexistent and probably will not matter anyway.
Also, patients have different perspectives of their physicians apart from those that can be objectively measured. Would they rather receive their medical care from a sympathetic and kind physician who spends a great deal of time listening to their complaints but may not be the most stellar physician clinically, or an arrogant, unemotional one who spends as little time listening as possible but one who has been rated "the best" by some subjective evaluation?
The comments that "Service providers are oriented to whoever pays: physicians to the insurance companies" is absolutely true. But it is usually an orientation that is acrimonious and adversarial, since these companies want to pay less than the physician wants to receive. Is this the type of relationship a patient wants with his doctor by holding his fee over his head in return for treatment? Right now both parties can "blame" the insurance company and get on with the doctor-patient relationship, one that should be built on trust and mutual respect -- not negotiation skills.
Crystallizing the cause of the uncontrolled rise of health-care costs by Albert Fuchs, M.D.
I am grateful to Mr. Smith for crystallizing the cause of the uncontrolled rise of health-care costs. When a service is provided to one party (the patient) but paid largely by another (the insurance company) there is no incentive to reduce costs. There is also a second adverse effect to such an arrangement that Mr. Smith did not mention: There is no incentive to improve quality.
The physicians who allow insurers to set the price for their services have very little incentive to delight their patients. They can increase their earnings only by seeing more patients at the fixed price. It's not surprising that patients increasingly complain that the amount of time, attention and counseling they receive from their physician is lacking.
By withdrawing from all relationships with insurance companies and asking my patients to pay me directly for my services, I am applying Mr. Smith's advice. Many other doctors are as well -- we're trusting the customer. When the patient pays me, he is very attentive to my fees, and I am very motivated to deliver excellent care.
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The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Devon Herrick wrote Twenty Myths about Single-Payer Health Insurance, which we reviewed in this newsletter the first twenty months, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. Be sure to read the current policy reports at www.ncpa.org/newdpd/dpdarticle.php?article_id=3144&PHPSESSID=5481dd93e548ac5c17fac37d6d022040.
Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may subscribe at www.pacificresearch.org/pub/hpp/index.html or access their health page at www.pacificresearch.org/centers/hcs/index.html. Be sure to read: Three Strikes for Health Freedom: A Review of Recent Books on Health Reform at www.pacificresearch.org/pub/hpp/2006/hpp_03-06.html.
The Mercatus Center at
The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. www.nahu.org/publications/hiu/index.htm. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business. Be sure to review the current articles listed on their table of contents at hiu.nahu.org/paper.asp?paper=1. To see my recent column, go to http://hiu.nahu.org/article.asp?article=1328&paper=0&cat=137.
The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. A new 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. To read last week's posting on HSAs, please go to www.galen.org/ccbdocs.asp?docID=879.
Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to www.chcchoices.org/publications.html. To join, go to www.chcchoices.org/join.html. Be sure to read 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. www.chcchoices.org/publications/cpr9.pdf
The Heartland Institute, www.heartland.org, publishes the Health Care News, formerly edited by the late Conrad Meier. To read his legacy on What is Freemarket Health Care, please go to www.heartland.org/Article.cfm?artId=10333.
The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. To receive your Notes from FEE, please register at www.fee.org/publications/notes/.
for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as
CEO for five years, is an association of insurance companies, actuarial firms,
legislative consultants, physicians and insurance agents. Their mission is to
develop and promote free-market solutions to
The Health Policy Fact Checkers is a great resource to check the facts for accuracy in reporting and can be accessed from the preceding CAHI site or directly at www.factcheckers.org/. This week, read the Daily Medical Follies: "Woeful Tales from the World of Nationalized Health Care" at www.factcheckers.org/showArticleSection.php?section=follies.
Independence Institute, www.i2i.org, is a free-market think-tank in Golden,
Masse, Director of Publications at the Montreal
Economic Institute, is the publisher of the webzine: Le Quebecois Libre.
Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles,
some of which will allow you to brush up on your French. You may also register
to receive copies of their webzine on a regular basis. This month, read Martin
Masse's latest speech:
The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section at www.fraserinstitute.ca/health/index.asp?snav=he. Be sure to read their latest: Solutions for Health Care Issues at www.fraserinstitute.ca/shared/readmore.asp?snav=pb&id=829.
The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site at www.heritage.org/research/healthcare/index.cfm
The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. Be sure to read about our Third Industrial Revolution by Hans F. Sennholz at http://www.mises.org/story/2105. You may also log on to Lew's premier free-market site at www.lewrockwell.com to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone would want to be an MD today, see www.lewrockwell.com/klassen/klassen46.html.
CATO. The Cato Institute (www.cato.org) was founded in 1977 by Edward H. Crane,
with Charles Koch of Koch Industries. It is a nonprofit public policy research
foundation headquartered in
The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.
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Stay Tuned to the MedicalTuesday.Network and Have Your Friends Do the Same
Please note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.
ALSO NOTE: MedicalTuesday receives no government, foundation, or private funds. The entire cost of the website URLs, website posting, distribution, managing editor, email editor, research and writing is solely paid for and donated by the Founding Editor, while continuing his Pulmonary Practice, as a service to his patients, his profession, and in the public interest for his country.
Del Meyer, MD, Editor & Founder
Words of Wisdom
Oliver Wendell Holmes, 1858: (The Autocrat of the Breakfast-Table) Put not your trust in money, but put your money in trust.
Henry D Thoreau, 1854: (Walden) A man is rich in proportion to the number of things he can afford to let alone.
P. J. O'Rourke: When buying and selling are controlled by legislation, the first things to be bought and sold are legislatures.
Mark Twain, (1866): There is no distinctly native American criminal class save Congress.
A government of laws is a government of lawyers.
A lawsuit helps keep the lawyers clothed.
A lawyer's briefs aren't.
Necessity hath no law.
Some Recent Postings
HealthPlanUSA Quarterly for January 2006: www.healthplanusa.net/January06.htm
HealthPlanUSA Quarterly for April 2006: www.healthplanusa.net/April06.htm 7
OpEd/Cinematic Reviews: www.delmeyer.net/CinematicOpEdReviews.htm
Medicare Reform: Pharmacy Benefit Program - What Must be Done - A Clinicians Point of View: www.delmeyer.net/hmc2005.htm
Lennart Meri, a former Estonian president, died on March 14th, aged 76. Estonia was ruled by Swedish kings, German noblemen or Russian tsars. They did not manage to establish a nation-state for themselves until 1918, when they seized their independence in the aftermath of the Russian revolution. Freedom was short-lived. In 1940, Estonia was annexed by the Soviet Union. German and then a further dose of Soviet occupation followed, until independence was once again declared, in 1991. To read the entire Obit, please go to www.economist.com/people/displayStory.cfm?story_id=5655082.
On This Date in History April 11
On this date in 1951, Truman removed General MacArthur from the Korean War command.
One this date in 1947, Jackie Robinson broke the major league color barrier.