MEDICAL TUESDAY . NET NEWSLETTER
Community For Better Health Care Vol IV,
In This Issue:
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health insurance benefits are state regulations that require insurers to cover specific
services and specific providers. Currently, there are 1,823 state-mandated
benefits among the 50 states, and an additional 295 mandates are now being
debated in state legislatures," says Jack Strayer, a representative of the
cover services ranging from acupuncture to in vitro fertilization. They cover
providers ranging from chiropractors to naturopaths. They cover bone marrow
In Strayer's Brief Analysis, he points out, "A citizen who lives in any one state can buy a toaster produced in any other state. The same citizen can also buy a lawnmower, a sofa, an automobile or virtually any other product - regardless of the state where the product is made.
freedom does not exist in the market for health insurance, however. Take
"Laws that keep people who live in one state from buying health insurance sold in other states balkanize the health insurance market and make it less competitive than it could be. As a result, people pay higher prices and have fewer choices than they would have if they could purchase insurance in a national marketplace.
"Consumers will get some relief, however, if Congress passes a bill proposed by Rep. John Shadegg (R-Ariz.). It would allow insurers licensed in any one state to sell insurance (under the rules of that state) to individuals and small groups residing in any other state. What difference will the Shadegg bill make?
"Avoiding Costly Mandated Benefits. Mandated health insurance benefits are state regulations that require insurers to cover specific services and specific providers. . . .
"These laws mean that if people buy insurance at all, they must purchase a bloated and expensive package of benefits designed by politicians. They are forbidden to buy insurance that reflects their own preferences, tailored to individual and family needs. A family of teetotalers is thus forced to buy protection against alcoholism, even though they neither want nor need such protection. A couple well past child bearing years is forced to buy in vitro benefits they do not plan to use. Catholics are forced to buy contraceptive coverage they find morally objectionable.
", , , 11 states require insurers to cover marriage counselors, four mandate coverage for naturopaths, three cover midwives, 11 cover acupuncturists and four require coverage for massage therapists. Other states have mandated such procedures as in vitro fertilization (15 states), port-wine stain birthmark removal (two states), and treatments for morbid obesity (four states).
"Compared to the costs of barebones insurance, these kinds of mandated benefits hike premiums considerably, thus pricing otherwise healthy people out of the market. In fact, studies estimate that as many as one of every four uninsured Americans has been priced out of the health insurance market by mandates.
"If mandates do so much harm, then why do they exist? Very few mandates have been enacted because of patient pressure. Almost all are the result of the lobbying power of special interest providers. And once a state-mandated health benefit is enacted, it is almost impossible to get it repealed.
states have been equally bad at limiting consumer choice and raising the cost
of insurance. For example, people who live on the
Shadegg bill, Minnesotans, at least in principle, would be able to purchase
insurance licensed in
"Avoiding Other Cost-Increasing Regulations. Another problem is the proliferation of state laws that make it increasingly easy for people to obtain insurance after they get sick. Guaranteed issue regulations (requiring insurers to take all comers, regardless of health status) and community-rating regulations (requiring insurers to charge the same premium to all enrollees, regardless of health status) are a free rider’s heaven. They encourage everyone to remain uninsured while healthy, confident that they will always be able to obtain insurance once they get sick.
"Moreover, as healthy people respond to these incentives by staying uninsured, the premiums required to cover costs for those who remain in insurance pools rise significantly. These higher premiums, in turn, encourage even more healthy people to drop their coverage. In general, all such legislation prevents risk from being accurately priced in the marketplace —that is, people cannot purchase pure insurance against risk; rather, they must purchase a politically designed package of specified medical benefits.
"Choosing Consumer Protections. Not all regulation is bad for consumers. For example, consumers have an interest in knowing that their insurer is solvent (that is, can pay the patient’s medical bills as they come due). Regulators that oversee solvency requirements, therefore, can perform a valuable service. Additionally, consumers have an interest in making sure that insurance companies play fair (for example, that they don’t cancel or raise rates for someone simply because he has the misfortune to get sick). Under the Shadegg bill, consumers will be more likely to get the benefits of these value-enhancing regulations without suffering the cost of value-reducing ones.
"Creating A Market for Regulation. What can we expect as a result of the Shadegg bill? Currently we have 50 states with 50 different sets of regulations. If all insurers licensed in each of the 50 states were willing to sell their products in the other 49 states, the typical consumer would have an opportunity to choose among 50 regulatory regimes.
"Defenders of mandated benefits and other forms of regulation frequently assert that these are “consumer protections.” Insurance companies, on the other hand, deride them as “special interest” legislation whose costs exceed their benefits. The Shadagg bill will allow these competing claims to be put to the market test. Those regulations that enhance the value of insurance (for example, whose benefits exceed their costs) are likely to win out in competition with those that do not.
"The law will also help better public policies replace inferior ones. A state that subsidizes risk pools for people who are uninsurable through no fault of their own will leave insurers free to charge lower and fairer prices to the healthy. Insurers in such a state are more likely to compete successfully in a national market than insurers in a state that attempts to help the uninsurable by legislating rules that raise everyone’s premiums.
"Conclusion. The Shadegg bill promises to usher in a new era in the evolving market for health insurance. Consumers will be able to shop in a national market, as opposed to 50 separate state markets. Regulatory regimes will compete against each other and those that survive will be those that add value to the product. Insurers will be able to offer products that meet individual and family needs without the cost-increasing burden of inefficient regulations."
Jack Strayer is
Read the entire report at www.ncpa.org/pub/ba/ba523/.
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richest of the 50 United States, with an economy that is seventh largest in the
international community of 192 countries, has 53 congressmen, the largest block
of votes in Washington. Each got a share of the transit money in the public
trough for their districts. Are there any lawmakers left in
Edward Epstein, Chronicle Staff Writer, headlined his report last
week: Highway bill puts state on high
He reports: "California came out a multibillion-dollar winner in the high-stakes struggle over the new $286.4 billion federal highway and transit funding bill finally making its way toward President Bush's desk after a two-year delay, state representatives said Thursday. . . .
"'This is a good-news bill for California,' said Rep. Ellen Tauscher, D-Walnut Creek, a House Transportation Committee member who served on the conference committee that ironed out differences between House and Senate versions of the bill.
"The final bill of several thousand
pages, which the House and Senate were expected to vote on today before
Congress recesses for its six-week summer break, means $4.4 billion more for
the state in highway funds, said Sen. Barbara Boxer, D-Calif. She was also a
member of the House-Senate conference committee. Under the old program,
"The new legislation also provides the state with $4.6 billion for transit programs over the life of the bill, which will expire in 2009. Mass transit across the country will get more than 18 percent of the bill's total money, or more than $50 billion, while $6 billion is set aside for transportation safety programs.
"In addition, the state will get more than $1 billion for specified road, bridge and transit projects across the state that virtually every member of Congress got inserted into the bill, Boxer reported. . . .
said she got $51.9 million for five projects in Contra Costa, the biggest of
which is $36 million for the Highway 4 widening project. The biggest project in
"Boxer estimated that the bigger federal highway and transit program will create 800,000 jobs. . . .
"In addition to California, whose 53 House members are by far the single biggest state bloc in the House, other donor states include Illinois, home of House Speaker Rep. Dennis Hastert, and House Minority Leader Rep. Tom Delay's Texas.
"Bush had initially proposed a $247 billion program to replace the transportation bill that expired in 2003. Since then, Congress has passed extensions to keep construction going, but it has become harder for state officials who rely on federal funds to provide a matching portion of money for projects to plan new work.
"Congress consistently proposed a higher amount, drawing a White House veto threat that provoked the deadlock. The House Transportation Committee originally wanted a $370 billion program.
"As the House and Senate passed new versions of their bills, Bush raised the limit on the amount of money he would accept to $256 billion, then $275 billion and then $284 billion. He has accepted the $286.4 billion figure that represents a compromise between the House and a higher Senate-passed figure. . . .
"The new highway bill also creates a commission to study ideas for raising more money for highway and transit programs.
"Among the ideas it will consider is basing fuel taxes on miles driven, not on the amount of fuel purchased. The reason is that rising fuel prices are encouraging motorists to buy more higher-mileage vehicles, which translate into less tax revenue while not cutting congestion on roads that still have to be maintained and eventually rebuilt. "
Epstein at firstname.lastname@example.org. To review the entire
article, go to
In Epstein's report the following day when this windfall had passed, he quotes Bob McCleary, executive director of the Contra Costa Country Transportation Authority, "I feel like it's Christmas. It's twice what we had been led to expect we would get." [Other California Representatives, however, reported the next day that they still didn’t get enough. With Federal funding, is there ever enough? Will 100 percent of all tax revenues come close to keeping the pigs at the trough satisfied?]
Note: Be sure to re-read and fully understand the last two paragraphs. There is a commission to "study ideas for raising more money" from us taxpayers including how to tax those individuals who are buying energy efficient cars, such as the popular Hybrids, that travel more miles on the roadways and pay less taxes because they don't drive gas guzzlers. The bureaucrats feel they are not paying their fair share for the road upkeep. Are you ready to have another federal bureaucracy monitor your mileage as well as every odometer in every car in the country?
Can you imagine health care pigging out at the same government trough where those who conserve health care costs will be taxed in a new and innovative way so that they don't avoid Medicare and health care taxes for being judicious in their medical costs?
Citizens and responsible people can never win with government in the equation. The equation should just be between the patients and their physician.
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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Q: What kind of health system does
A: The Australian healthcare system is mixed. Responsibilities for healthcare are divided between the federal and state governments, and both the public and the private sectors play a role. Australia spends about 8.5% of gross domestic product on healthcare, which compares favorably to spending in countries such as the United States (13.7%), Canada (9.5%), and England (7%).
Government programs underpin the key aspects of healthcare. Medicare, which is funded out of general tax revenue, pays for hospital and medical services. Medicare
Covers all Australians, pays the entire cost of treatment in a public hospital, and reimburses for visits to doctors.
There is no limit on fees charged by doctors. There is, however, a government-set fee schedule. Doctors can bill patients or send their bills directly to the government insurance authority, the Health Insurance Commission (HIC). If sent to the HIC, the payment is 85% of the government-set fee for out-of-hospital expenses and 75% of the government-set fee for in-hospital services; the money is paid directly to the doctor, and the doctor is not allowed to charge the patient an additional fee. About 75% of family physician services are directly billed to the HIC. If a doctor bills the patient directly, the patient then applies for the rebate of the government set fee.
Public hospitals are owned by the state. About 70% of beds are in public hospitals, and major teaching hospitals are public hospitals. Budgets for public hospitals are usually set on the basis of their case-mix, using an Australian version of Diagnosis Related Groups. In the past, the majority of private hospitals were owned by charitable organizations, but for-profit corporations – which are listed on the stock exchange – now own an increasing proportion. Private, freestanding surgical centers are a rapidly growing phenomenon. Few private hospitals have emergency departments, so, in an emergency, most Australians rely on the public hospital system.
Australia has a Pharmaceutical Benefit Scheme (PBS), which subsidizes the cost of medication. The scheme covers most prescriptions with some exceptions, such as Viagra. (Before approving a drug to be listed on the PBS, the government assesses its cost effectiveness.) Aged pensioners and people on low income pay A$3.60 (US$1.94 at an August 2002 exchange rate) out-of-pocket for pharmaceuticals, while others pay A$22.40 (US$12.07) per prescription. Both schemes have "safety nets" on total expenditure for a patient or family in a year: after 52 prescriptions, pensioners receive prescriptions at no charge; all others after spending A$686.40 (US$369.94), pay A$3.60 (US$1.94) per remaining script for that year. Pharmaceuticals (including nonprescription medications) account for about 12% of total health expenditure compared to about 19% spent on medical services.
Q. How is the healthcare system funded?
A: Government pays about 70% of healthcare costs (approximately 47% from the federal and 23% from state governments); the remainder is paid by non-government sources, e.g., insurance and private pay.
The share of costs varies significantly across service types. Public hospitals, for example, are about 48% federal, 45% state, and the balance private sector funded. Medical services, on the other hand, are 82% federal funded with the balance paid mainly by the patient.
Private health insurance (which covers about 8.6% net of health costs) receives a 30% subsidy from the federal government. Everyone is eligible for this subsidy. And 45% of the population has private health insurance; for a family, it costs between A$1,000 and A$2,000 per year (US$539 to US$1,078). People buy insurance directly from the insurance company (not via an employer). Insurance products are not risk-rated.
Q: What is the quality of care in each system?
Overall, quality of care in
Q: What are the current concerns among healthcare workers in the country?
A: One of the worldwide
fallouts of September 11 has been escalating costs of insurance and
re-insurance arrangements, and this has placed pressure on the medical
malpractice insurance in
Longer-term issues include concerns about the potential shortage of nurses in most states and the adequacy of equipment and capital funding, and general questioning about the level of financing of the system.
Q: What are the current concerns among patients?
A: The Australian healthcare system is in relatively good shape. Out-of-pocket costs are moderate and access to emergency care is good. However, there are a number of concerns for people without access to the pensioner-level subsidy for pharmaceuticals, especially for the chronically ill.
There are also extensive waiting times for elective surgeries at public hospitals. Although waiting lists for the most urgent elective surgery for heart disease and cancer are almost nonexistent, there are long waiting lists for orthopedic surgery (median wait for total hip replacement is 88 days; 10% of patients waited over 345 days in 1999 to 2000), and cataract surgery (median is 73 days; 10% waited more than 316 days). One of the attractions of health insurance is the ability to bypass public hospital waiting lists.
There are also problems of access
There is also a significant
problem of the health status of
To review the entire article
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Andrew Pollack reports in the New York Times that Medicare Law Impedes Flow of Immunity in a Vial
"Linda Swim, who has a
serious immune deficiency, went through two frantic months this spring when she
was unable to receive the treatment she usually gets every month. Her doctor
stopped treating her when Medicare reduced its reimbursement. Then three
hospitals near her home in
"'If you've got insurance and you've got a life-threatening illness, why the devil won't they treat you?' said Ms. Swim, who faces an increased risk of serious infections without the treatment.
"Ms. Swim and thousands of others have been caught in a swirl of developments surrounding intravenous immune globulin, a mundane product derived from donated blood plasma essential for some people.
physicians are dropping their Medicare patients, saying they can no longer
afford to treat them because of lower reimbursement rates. At the same time, prices
have risen sharply, and some hospitals say there is a shortage. Kaiser
Permanente, the big
"Used for people with immune problems, immune globulin, also called immunoglobulin or gamma globulin, is a collection of antibodies that provides sort of an immune system in a vial. About 50,000 Americans have the deficiency, some 7,000 of them Medicare patients, many younger than 65 because they are on disability, according to the Immune Deficiency Foundation, an advocacy group. 'We've got patients all over the country who are not getting treatment,' said Michelle B. Vogel, the group's vice president for government affairs.
"The change in Medicare reimbursement, mandated by the 2003 Medicare overhaul, appears to be intended in part to prevent potential overuse of the drug, which can cost $20,000 to $80,000 per year per patient.
"Medicare spent $300 million on immune globulin in 2004, its 10th biggest drug expenditure. That figure was up from $180 million the year before, even though the reimbursement rate had gone down.
"Much of the increased demand appears to be for uses, like some neurological disorders, not approved by the Food and Drug Administration. Varying degrees of evidence support such uses. Some neurological uses require doses three to four times as great as those for immune deficiency.
"'There's so much profit to make,' said Dr. Daniel Suez of Irving, Ms. Swim's doctor, who treats only immune deficiency patients. 'In the meantime, they drain all the resources.'
"Medicare's new reimbursement is based on "average selling price," which is supposed to be close to what the manufacturers actually charge. The rate is now about $42 a gram for the powdered product and $56 a gram for the liquid, down from $66 last year for either type of product and from about $78 in October 2003. A typical monthly infusion is 30 to 50 grams.
"Some doctors say prices have risen well beyond that level. So they are shifting patients from their offices to hospitals, which are still reimbursed under the old formula at about $80 a gram.
"'My partners felt we
could not continue to sustain these kind of losses,' said Dr. Roger Kobayashi
"Dr. Robert Dracker of
"The infusion clinic at
"A similar change in reimbursement occurred this year for cancer drugs, which are also typically infused in doctors' offices. But according to Medicare and to some cancer specialists, cancer patients have not been shifted en masse to hospitals, despite warnings last year by some oncologists. . . .
"On top of the Medicare issue, or possibly linked to it, is apparently a shortage that is making it harder for even non-Medicare patients to get treatment. "We're on allocation from every manufacturer," said Dr. Richard A. Wagner, director of drug use management for Kaiser Permanente. "We're only getting about two-thirds of what we normally purchase from them."
". . . There was a severe shortage in 1998 after two companies took their factories out of production to meet new quality standards. When those plants came back online there was a glut and plunging prices that prompted three manufacturers - Aventis, Bayer and Alpha Therapeutics - to exit the business. . . .
"Manufacturers insist that the supply of immune globulin is adequate and is up 80 percent since the 1998 shortage. Some buyers may not be getting enough temporarily, they said, because patients are moving from doctors' offices to hospitals.
"'You can't shift radically with that kind of change,' said Larry Guiheen, head of Baxter's North American biopharmaceutical business.
"Others said companies were allocating supplies to keep customers from ordering more than they needed in order to resell at higher prices.
"'It may be more lucrative for a physician's office to sell the product than use it for a Medicare beneficiary,' said Patrick M. Schmidt, president of FFF Enterprises, a large distributor of immune globulin. He and others said some small distributors were charging as much as $70 to $90 a gram. Most patients being dropped by doctors appear to be finding hospitals. Some patients and doctors, say, however, that hospital treatment is not ideal. Hospitals are a well-known source of infections, a risk to those with weak immune systems. Hospitals can take longer to do the infusion and actually charge Medicare more.
"'The first time I went
to the hospital was an absolute nightmare,' said Phyllis Glasser of
"Christina, 58, of Boynton Beach, Fla., who asked that her last name not be used because neighbors did not know she had immune deficiency, said her doctor forgave her 20 percent Medicare co-pay, but the hospital did not. After being billed $940 for her first two hospital infusions, she decided to forgo treatment, she said. . . .
"Ms. Vogel of the Immune Deficiency Foundation said private insurers, which often take cues from Medicare, were starting to cut reimbursements, meaning non-Medicare patients may also have trouble getting treatment. And in January, the reimbursement paid to hospitals will also be switched to the new formula."
To read the NCPA Health Policy Digest, go to www.ncpa.org/newdpd/dpdarticle.php?article_id=2006.
To read the entire editorial, go to www.nytimes.com/2005/07/19/health/policy/19immu.html.
Note: This article could have been improved by a comparison with other countries’ government-run Medicare plans. We know for certain that the $80,000 for immune shots would not occur on a regular basis in either Canadian Medicare or the UK National Health Service. I would seriously doubt if even a single injection would be available in very many of the other 192 countries' government-run health plans.
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Most patients understand that certain medications are cheaper than even paying their deductible and running it through their insurance company. For instance, one patient told me she could purchase 100 tablets of thyroid for $12 and her copayment for a one-month supply of 30 tablets was $15, which would be more expensive each month than the three-month cash price. Another patient told me she could purchase 100 prednisone tablets for $9 and her copayment for 30 tablets was $18. Thus a one-month supply through her insurance plan was twice what a three-month’s supply was when paying cash. So when I write prescriptions for long-standing common medications that only come in generics, I try to take the extra time to explain that they might want to check the cash price before handing over their insurance card.
Helen, who had been on thyroid since some doctor treated her obesity as a teenager with thyroid and thus destroyed her thyroid, sentencing her to a lifetime of medications, was also on occasional prednisone for her asthma. I mentioned that she might price those medications and find it best not to use her insurance card. She asked, "How can you get medicine without an insurance card?" I suggested that she could just pay cash if it's less than her copayment. "But how can the pharmacist dispense the medication without my insurance card?" she asked. I told her that the prescription I gave her was the authority for the pharmacy to dispense the medication and reiterated that she should pay cash if it's cheaper. "But how can that be, doctor?" she asked. After several additional explanations, she finally said in exasperation, "I don't understand you at all, doctor. I'll just keep using my HMO insurance card. After all, I paid a lot of money for that."
Bureaucratic third party medicine may be so entrenched in society that it will be difficult to get people to think again of cost-effective, private health care.
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This oddity is largely due to liberal
State and federal databases of reportable diseases are strictly confidential and aren't available to insurance companies or the press. They are used for internal research purposes, to track trends and to combat an outbreak. Information can be the most potent weapon that public health officials have in their arsenal.
The laboratory that identified the HIV case is supposed to concoct the
code for the patient based on elements of the patient's name and birth date.
The same goes for the doctor. The state is supposed to keep this information
together in a computer by linking the common codes. But when a finger hits the
wrong key, the code gets botched. The data become gibberish. The case of HIV,
in the eyes of the federal Centers for Disease Control and Prevention, cannot
be officially counted. And since some funding is based on a state's official
HIV case count, money to fight the disease may slip away. The state may lose as
much as $50 million by 2007 if
The same activist groups and legislators who backed this disaster of a
reporting system would normally be the first to complain about a federal cut in
Note: Treatable infectious diseases, such as tuberculosis and syphilis, were brought under control by appropriate reporting of cases and contacts to the public health department, which in turn contacted, tested and treated those exposed. The Public Health Department, responding to a powerful lobby that involved about one percent of the population, lost all sense of health, reason and direction, jeopardizing our nation's health, assuming that AIDS, a lethal and initially incurable and un-treatable virus could be controlled in secrecy. This lobby was so strong that initially blood banks did not test blood donors for HIV because that would step on the civil rights of those blood donors with the AIDS virus, not allowing them to give blood. Introducing this lethal virus into the blood bank system disseminated the AIDS virus into the essentially disease-free population of hemophiliacs, sickle cell anemics, cardiac surgery patients, and those requiring frequent blood transfusions. The AIDS immune deficiency epidemic has now increased the dissemination of syphilis and tuberculosis, both now resistant to drugs. AIDS will never be brought under control until every case and contact is identified, tested and treated if necessary. Tuberculosis and syphilis will then also again be controlled.
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Dr Edwards was discussing the sign at the door of the medical staff lounge as we were eating lunch. The sign stated that the HBO (Hyperbaric Oxygen Chamber) has immediate openings for chamber treatments. It asked that doctors search their patients diseases for approved indications for hyperbaric oxygen treatments such as wound healing, skin grafts, osteomyelitis, delayed radiation burns, bas emboli, gas gangrene, CO poisoning, decompression sickness, and the list went on. If you need help in referring your patient, please call the nurse in charge at this number. If you're not sure if your patient could benefit from hyperbaric oxygen, please call Dr ID or Dr PM.
The doctors in this group mostly viewed the large advertisement in a rather negative fashion. However, most understood the challenges of running a hospital and did not think negatively about the administrator, who happens to be well liked. They understand he's running a business to make money.
What seems to be lacking in all the discussion, as we mentioned last week in our Hippocrates column, is that so much of health care is working at cross purposes. With some interventionists saying Americans obtain only half as much health care as they could use, the doubling of health care costs would paralyze and bankrupt the entire system.
The question remains, “How can we keep the interventionists from destroying American Health Care?"
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8. Voices of Medicine: A Review of Various Local and Regional Medical Journals: Return to Solo Practice - The Young Female Athlete - The Trouble With Day Care - MICRA
Return to Solo Practice
Eric Holmberg, MD, a
Holmberg states "... in 1992, most young physicians I knew would have been happy to open their own offices or join existing practices to replace their happily retiring older colleagues. Today, however, the ravages of managed care, and the advent of a health system controlled by the insurance industry and neglected by government, have left a barren landscape for new physicians."
He had for some time thought about returning to a smaller model of care, "... and the shift finally seemed right last year," he states. "I didn’t intend to practice completely alone; but when partners did not readily materialize, I realized that solo practice was quite doable and perhaps in some ways for the best." After being on his own for almost a year and enjoying work once again, he's been able to fix nearly everything he was unhappy about previously.
"With the exception of a few out-of-town trips, I have taken all my own call during this time. Call is much less burdensome than I thought it would be, other than the need to be always available. Patients have both my home and cell phone, and they don’t abuse them. I know the patients who are calling, and I can access their charts and our appointment schedule over the Internet. I never have to quibble with the on-call doctor’s decisions. My patients seem quite happy, and the practice continues to grow steadily without the need for advertising."
He concludes that to be of real value to patients, the private-practice community needs to offer something unique. "We need to differentiate ourselves from the HMO model by being more accessible, flexible, and caring, and by knowing our patients as well as we possibly can. We have lost the early battles for information retrieval, system organization, and pharmacy management; but as we strive to improve these aspects of our practices, we should also offer the one alternative that patients are most enamored of: the chance to know and be known by your doctor." To read the featured article, go to www.scma.org/magazine/scp/sp05/holmberg.html.
A Gynecologic Perspective of The Young Female Athlete
Susan J. Spencer, M.D., who
practices obstetrics, gynecology and reproductive endocrinology in
"In 1992 The American College of Sports Medicine coined the term 'Female Athlete Triad.' This syndrome is defined as disordered eating, osteoporosis, and amenorrhea that occurs in women engaged in regular strenuous exercise or sports activities. For those of you accustomed to acronyms, I do not believe the authors wish to refer to the syndrome as 'FAT.'
"In the young female athlete, weight can become a preoccupation. Abnormal eating behaviors may arise in young women, but most vulnerable are those involved in athletic activities that are weight-bearing and favor leanness for performance, such as ballet and gymnastics.
"By the age of 10 years there is a demonstrable difference in concern about eating and weight between girls and boys. One study showed that by fifth grade 31 percent of girls are dieting, and by sixth grade, 62 percent are dieting to lose weight. Thus it appears that attempts to diet in an effort to control weight are common in prepubertal and pubertal girls. All it takes is a glance at Teen Vogue or Britney Spears’ latest video to realize that young girls are bombarded with images that reinforce abnormal eating patterns. Other factors thought to increase a young athlete’s risk for the disordered eating component of this triad include frequent weigh-ins, an overcontrolling parent or coach, and the social isolation of individual sports compared with team sports."
In summary, Spencer states there are potential health risks for young women in strenuous sports and exercise programs. "Physicians and parents need to be cognizant of the Female Athlete Triad. Supportive care for the adolescent, with collaboration between pediatrician, gynecologist, orthopaedist, and parents, greatly enhances recovery." To read the entire article, go to www.smcma.org/Bulletin/BulletinIssues/March05issue/A GynecologicPerspective.html.
The Trouble With Day Care
The Reverend David Feddes, in his Mother's Day radio message on the importance of motherhood, points out that a Canadian kennel will not place a new puppy in a home with both parents working. He states that equally damaging as a dog being at home with no master, evidence is increasing that a child without either parent at home has a significant chance of behavior problems.
Heide Lang, in a recent issue
of Psychology Today, discusses the
trouble with day care and questions whether scientists are telling parents the
whole truth? Stanley Greenspan, a
The raging debates around maternal guilt, work/family balance, money and childrearing often drown out scientific insights into the developmental pact of day care. But the latest findings from a huge, long-term government study are worrisome. They show that kids who spend long hours in day care have behavior problems that persist well into elementary school. About 26 percent of children who spend more than 45 hours per week in day care go on to have serious behavior problems at kindergarten age. In contrast, only 10 percent of kids who spend less than 10 hours per week have equivalent problems.”
are sweeping this information under the rug, hoping studies will churn out
better data soon,” argues Jay Belsky, a child development researcher at
Sonoma County Medical Association President Heather Furnas, MD, notes, “In the CIA thriller Spygame, Robert Redford’s secretary bemusedly questions his flurry of seemingly paranoid activity. He pauses a moment before asking her, “When did Noah build the ark? Before the rain …… before the rain.”
“Dark clouds are presently
gathering over MICRA (the Medical Injury Compensation Reform Act that
“How lucky are physicians in
“What are we up against? A
whole lot of money. The No. 1 priority of
Furnas concludes: "All of us need to pitch in to defend MICRA. If you specify MICRA on your CALPAC donation, 100% of your contribution will go directly to the cause, with none spent on administration. It’s going to take a lot of timber to build this ark, and I think I hear some thunder in the distance." To read the entire article, go to www.scma.org/magazine/scp/sp05/furnas.html.
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HEALTH CARE CRISES - The Search for Answers, Edited by Robert I Misbin, MD, Bruce Jennings, MA, David Orentlicher, MD, JD, and Marvin Dewar, MD, JD. University Publishing Group, Inc. Frederick, MD, 1995.
This volume is a collection
of papers presented in
Section I, deals with well-publicized cases in which family members insisted that artificial life support be maintained indefinitely on patients who were permanently unconscious. The courts sided with the families and against the health providers who did not wish to be forced to provide futile treatment. Given the millions of Americans who lack basic health care, it is hard to understand why over $100,000 per year should be spent to maintain a patient who is permanently vegetative.
The issues are tied to
considerable emotion. Rebecca D. Pentz, PhD, MD, discusses the surprisingly
strong statement by the
In section II, John H.
Fielder, PhD, has a chapter on Abusive Peer Review and Health Care Reform. Dr.
Fielder discusses three cases of Peer Review abuse: Dr Timothy Patrick formerly
Dr Fielder feels hospital bylaws are fatally deficient in due process and fail to protect competent doctors who are falsely accused. It provides a convenient means for unscrupulous hospitals and physicians to remove doctors who are a threat to their interest. He states that it is difficult for physicians who have received unfair peer reviews to succeed in a lawsuit against the hospital because of the extensive legal shielding of the peer review process by courts and legislatures. Dr Fielder predicts that with the growth of managed care, economic pressures on physicians will increase and we can expect to see a corresponding growth in abusive peer review.
This glimpse at two of the twenty chapters in this volume reflects the timeliness of the entire volume. Every one of our organization's leaders needs to be conversant with the issues at the forefront of medicine. I understand that Dr Fielder is spending his entire year of Sabbatical leave researching Peer Review. If his research supports his initial concerns, we should not only read this volume, but his next volume as soon as it is available.
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National Public Radio had a report on the success of Health Maintenance Organizations (HMOs). They suggested that there were other things beside health care that were expensive and we might apply HMO techniques to bring down their costs. The doctors in turn have formed Independent Practice Associations (IPAs) to protect their interests. I didn’t have my recorder in the car and so am describing this 100 percent from recall. My apologies to the author as I have probably missed a few words, in addition to missing her name.
Car Maintenance Organizations (CMO)
Everyone knows the price of cars is too high. To get the price down, we could form a car maintenance organization (CMO). Our CMO executives would tell the dealers that they would henceforth be re-imbursed at 60 percent of retail costs for the members of the CMOs that purchase cars. The CMO would sign up potential car buyers, which eventually would include almost everyone. The CMOs would enter into contracts with the various dealers to acquire the cars. The dealers, in order to protect themselves, would form Independent Dealers Associations (IDAs). As the number of consumers joining these CMOs increase, the car dealers would not have enough business to go solo and eventually would have to contract at the reduced price. Americans would enjoy the pleasure of driving their automobiles at a 40 percent savings.
Electric Maintenance Organizations (EMOs)
We also know that the price electricians charge is too high. The charge of $65 to come to your house, plus a labor charge of $65 for an hour or fraction thereof, can amount to $130 for a ten-minute job. If 47 million unfortunate Americans with hazardous wiring in their homes could not afford electrical upgrades, the need for an Electrical Maintenance Organizations (EMO) would become obvious. The deserving public living in electrically hazardous homes would join an EMO which would in turn contract with the electricians for their services at $35 a hour (which just happens to be what the latest data shows that doctors in the 25th percentile income, working 3,000 hours per year, are making). As more and more Americans sign up with an EMO, the electricians wouldn’t have any work unless they contracted with our EMO and so we would be able to get the electrician’s hourly rate down to $35 an hour. (Thus the EMOs would bring skilled labor down to the same cost as professional labor.)
Jock Maintenance Organizations (JMOs)
Everyone agrees that athletes are definitely making too much money and the charge to watch them play is becoming obscene. In fact the cost of seeing professional sports live is so high that deserving school kids have difficulty seeing their heroes in action. Why should a jock get $3 million dollars for 20 weeks of work? That’s $150,000 for a 30-hour week--about the same as the 50th percentile for family physicians for a 3000-hour work year. Sport fans should form a Jock Maintenance Organization (JMO) and the public would join these JMOs for the purchase of tickets to football, basketball, baseball, and hockey games that contracted with our JMO. As the coliseums become emptier and as the jock salaries fall, league managers would contract with our JMO to re-acquire fans. We and our deprived children would then be able to see NFL, NBA, NHL, AL and NL games at about 20 percent or $10 each, about the cost of seeing a doctor nowadays. And the players would learn to live on a doctor’s salary.
Lawyer Maintenance Organizations (LMOs)
Now there is one area in which I am sure we can all agree. Lawyers charge far too much. Not only do they charge too much, but also they bill us for all time spent on our behalf, even if not at work. They can be sitting at home on their toilet and reading our file while defecating and bill us for the time spent reviewing the file. They can be sitting in their office and call someone on our behalf while the conversion digresses to other business ventures and charge us the whole amount. I've personally experienced both. Once I had a appointment and was ushered into his office at exactly the appointed time. The attorney was on the phone and remained on the phone talking with someone else for 50 minutes. I began my discussion at until and thought it should be a 40 minute charge or certainly less than a full hour. He charged me the full 90 minutes alleging that I was with him for that period of time. On another occasion an attorney made a call to another attorney in another state for which I did a worker's compensation case and he stiffed me. My attorney spoke with him for more than an hour for "OGK" and charged me more than if I had simply written off the bill, which I ended up doing anyway. Hence, it cost me double.
If all clients joined an LMO, which would set the fee at say $40 an hour, about what the HMOs set the doctors fee, there would be a mad rush to join the LMO. Within weeks, the attorneys would sign up with the LMOs so they would at least have $40-an-hour clients when no $320-an-hour clients came in, or they would be selling their luxury cars and yachts. One attorney bragged that the best thing about a legal partnership, is that you can double bill. But an LMO would see attorneys charging for more than a 50-hour week and they would restrict the attorneys to time actually spent with the client and no longer could charge reviewing the file in the toilet or during lunch or while on their yacht in the absence of the client.
When clients complain that they were not receiving quality legal care, the LMO would start to come into the office and copy the attorney's records just like the HMOs copy the doctor's records. The LMOs would then get suspicious that a one-page handwritten scrawl didn't justify two hours of legal care and they would develop legal guidelines. They would then review the records a second time to see if quality had improved. If it hadn't, they would reduce reimbursement from $40 an hour to $35. If a second review three months later didn't show improvement, the LMO would just reduce the reimbursement to $30 an hour and inform the attorney that they could just keep going until he shaped up. (Exactly the words used by an HMO in disciplining a physician.)
There is one strategic difference between doctors and attorneys. If the reimbursement of attorneys gets down to zero, the attorney just might go out and charge $320 an hour again. At this point, so many clients are so unhappy that some would be willing to pay the exorbitant fee to get good legal counsel. HMOs still haven't found the bottom when doctors refuse to lose money. It's a morality play.
CEO Maintenance Organization (CEO-MO)
The HMO’s CEOs are definitely making obscene amounts of money. Even our local boys are making $5,000 ($5K) per hour. One national HMO CEO made $1 billion. Suppose he worked real hard, maybe three-fourths as hard as some doctors, and put in a 3,000-hour work year? That would be $333,000 per hour. (Even Bill Gates, the world’s wealthiest man only makes $55,000 per hour.) What we need is a CEO-Maintenance Organization (CEO-MO). People would join a CEO-MO, which in turn would purchase their HMO insurance. But they would only purchase HMO insurance from those that maintain a contract with our CEO-MO, which would require that their CEOs starve themselves on a primary doctor's average salary. They would also be required to keep their profit and overhead the same as Kaiser. This would mean they would have to reduce the fat from 33% to 8%, a 25% health-care cost savings. The shareholders would lose interest and the price per share would plummet. With the price per share below a quotable price, there would be no further interest in merger-mania with billion dollar CEO bailouts. The HMOs would then again become nonprofit and would again compete on an even basis with Kaiser, preserving the world's finest HMO structure, which would then be the best defense as an alternative to private practice. This would give all Americans a choice for private fee for service or real HMO care. Then with a few tweaks, we would be close to universal health care in a free market environment. Nirvana!
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$ 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. This week read the report on New York Medicaid Fraud May Reach Billions of Dollars at www.ncpa.org/newdpd/dpdarticle.php?article_id=2004&PHPSESSID=8788111628edf4666f72764bafbe88ab. When you spend other people's (taxpayers') money, there will always be fraud. There are no laws that can prevent it.
$ 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. In last weeks issue, she
reports that a week after The New York
Times published a dramatic series of articles about waste and fraud in New
York's Medicaid program, The Washington Post had its own series about the
crying need for reform in Medicare. For example, the Post describes complaints
$ Greg Scandlen, Director of the “Center for Consumer-Driven Health Care” at the Galen Institute, has a Weekly Health News Letter: Consumer Choice Matters. You may subscribe to this newsletter that is distributed every Tuesday by logging on at www.galen.org and clicking on Consumer Choice Matters. Archives are now located at www.galen.org/ccm_archives.asp. This is the flagship publication of Galen's new Center for Consumer-Driven Health Care and is written by its director, Greg Scandlen, an expert in Health Savings Accounts (HSAs).
$ The Heartland Institute, www.heartland.org, publishes the Health Care News, Conrad Meier, Managing Editor Emeritus. Read the OpEd article by Dr Richard Dolinar, “AMA Too Timid on Drug Advertising.” Dr Dolinar thinks that advertising is a very efficient and ultimately cheaper way for this information to be disseminated to patients. It allows patients to self-select and come to the office to determine if the drug will be of benefit to them. To read his entire line of logic, go to www.heartland.org/Article.cfm?artId=17490.
$ 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. Nelson
Hultberg has an excellent reprint on “Is Individualism Dead?” “Study any
account of the growth of
$ The Council
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/, where you reality check rumors.
$ The Independence
Institute, www.i2i.org is a
free-market think-tank in Golden,
$ 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. They have a new ethics course at www.nahu.org/education/NAHU_Ethics.htm.
$ Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Québécois 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. Enjoy a digression into Randian prose by the Rational Argumentator, Gennady Stolyarov II in his review of Gen Lagreca's Noble Vision. She offers her devastatingly efficient critique of government involvement in medicine, as she analyzes numerous broader questions. What do politicians seek when they impose regulatory programs? Why do some people cave in to the desire to conform at the cost of their selves and their values, while others persist in their loyalty to principles? In the process of analyzing these questions, she offers extensive rebuttals to the mentalities of collectivism, altruism, conformity, and utilitarianism." Don’t miss it at www.quebecoislibre.org/05/050715-5.htm.
$ The Fraser
Institute, an independent public policy organization, focuses on the role
competitive markets play in providing for the economic and social well being of
all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they
stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca
for an overview of the extensive research articles that are available. You may
want to go directly to their health research section at www.fraserinstitute.ca/health/index.asp?snav=he. Be sure to read the latest report in the wake of Dr Jacques
Chaoulli’s big Supreme Court win in
$ The Heritage
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. Read the current
Health Policy: The Healthcare system in the
$ 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. Lew has a recent article on Decentralization that is worth reading at www.mises.org/story/1872. 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
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) www.spn.org/newsite/main/. 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
Del Meyer, MD, CEO & Founder
Words of Wisdom
Jacques Chaoulli, M.D.: My dream is to show the world how to get rid of a new and subtle form of tyranny hidden under the cover of a Welfare State's compulsory health care program.
Pericles (430 BC): Just because you do not take an interest in politics doesn't mean politics won't take an interest in you.
On This Date in History - August 9
On this date in 1974, Gerald Ford succeeded Richard M Nixon, who resigned, as
President. This was the first time in American History that a man not chosen
even indirectly by the people became the President of the
Ten years ago today, the Grateful Dead's Jerry Garcia died of a massive heart attack. His last words were rumored to be: "Netscape opened at WHAT?" Netscape, not having one profitable quarter, was rumored to open at $28 a share. On this date ten years ago, Netscape didn't open at $28, but at $71 ending the day with a $1.7 billion market cap. The great Internet gold rush was on. It is still changing the world in thrilling and still unforeseen ways, according to Rich Karlgaard, publisher of Forbes, as reported in the Wall Street Journal today. It will also change health care as doctors see the possibilities in caring for their patients more efficiently.