MEDICAL TUESDAY . NET
Community For Better Health Care
Vol V, No 17,
In This Issue:
The 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
cost-effective and accountable
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Studies of pet dogs with cancer can offer unique help
in the fight against human malignancies while also improving care for man's
By David J. Waters and Kathleen Wildasin,
Imagine a 60-year-old man recuperating at home after prostate cancer surgery, drawing comfort from the aged golden retriever beside him. This man might know that a few years ago the director of the National Cancer Institute issued a challenge to cancer researchers, urging them to find ways to "eliminate the suffering and death caused by cancer by 2015." What he probably does not realize, though, is that the pet at his side could be an important player in that effort.
Reaching the ambitious Cancer 2015 goal will require the application of everything in investigators' tool kits, including an openness to new ideas. Despite an unprecedented surge in researchers' understanding of what cancer cells can do, the translation of this knowledge into saving lives has been unacceptably slow. Investigators have discovered many drugs that cure artificially induced cancers in rodents, but when the substances move into human trials, they usually have rough sledding. The rodent models called on to mimic human cancers are just not measuring up. If we are going to beat cancer, we need a new path to progress.
Now consider these facts. More than a third of American households include dogs, and scientists estimate that some four million of these animals will be diagnosed with cancer this year. Pet dogs and humans are the only two species that naturally develop lethal prostate cancers. The type of breast cancer that affects pet dogs spreads preferentially to bones--just as it does in women. And the most frequent bone cancer of pet dogs, osteosarcoma, is the same cancer that strikes teenagers.
Researchers in the emerging field of comparative oncology believe such similarities offer a novel approach for combating the cancer problem. These investigators compare naturally occurring cancers in animals and people--exploring their striking resemblances as well as their notable differences.
Right now comparative oncologists are enlisting pet dogs to tackle the very obstacles that stand in the way of achieving the Cancer 2015 goal. Among the issues on their minds are finding better treatments, deciding which doses of medicines will work best, identifying environmental factors that trigger cancer development, understanding why some individuals are resistant to malignancies and figuring out how to prevent cancer. As the Cancer 2015 clock keeps ticking, comparative oncologists ask, Why not transform the cancer toll in pet dogs from something that is only a sorrow today into a national resource, both for helping other pets and for aiding people?
For decades, scientists have tested the toxicity of new cancer agents on laboratory beagles before studying the compounds in humans. Comparative oncologists have good reason to think that pet dogs with naturally occurring cancers can likewise become good models for testing the antitumor punch delivered by promising treatments.
One reason has to do with the way human trials are conducted. Because of the need to ensure that the potential benefits of an experimental therapy outweigh the risks, researchers end up evaluating drugs with the deck stacked against success; they attempt to thrash bulky, advanced cancers that have failed previous treatment with other agents. In contrast, comparative oncologists can test new treatment ideas against early-stage cancers--delivering the drugs just as they would ultimately be used in people. When experimental drugs prove helpful in pets, researchers gain a leg up on knowing which therapies are most likely to aid human patients. So comparative oncologists are optimistic that their findings in dogs will be more predictive than rodent studies have been and will help expeditiously identify those agents that should (and should not) be tested in large-scale human trials.
Pet dogs can reveal much about human cancers in part because of the animals' tendency to become afflicted with the same types of malignancies that affect people. Examples abound. The most frequently diagnosed form of lymphoma affecting dogs mimics the medium- and high-grade B cell non-Hodgkin's lymphomas in people. Osteosarcoma, the most common bone cancer of large- and giant-breed dogs, closely resembles the osteosarcoma in teenagers in its skeletal location and aggressiveness. Under a microscope, cancer cells from a teenager with osteosarcoma are indistinguishable from a golden retriever's bone cancer cells. Bladder cancer, melanoma and mouth cancer are other examples plaguing both dog and master. In a different kind of similarity, female dogs spayed before puberty are less prone to breast cancer than are their nonspayed counterparts, much as women who have their ovaries removed, who begin to menstruate late or who go into menopause early have a reduced risk for breast cancer.
Canine cancers also mimic those of humans in another attribute--metastasis, the often life-threatening spread of cancer cells to distant sites throughout the body. Solving the mystery of how tumor cells metastasize to particular organs is a top research priority. When certain types of cancers spread to distant organs, they tend to go preferentially to some tissues over others, for reasons that are not entirely clear. Because metastasis is what accounts for most deaths from cancer, researchers would very much like to gain a better understanding of its controls. Studies in pet dogs with prostate or breast cancer might prove particularly useful in this effort, because such tumors frequently spread in dogs as they do in humans--to the skeleton. Indeed, research in pet dogs is already attempting to work out the interactions between tumor cells and bone that make the skeleton such a favorite site for colonization.
Scientists also have deeper theoretical grounds for thinking that pet dogs are reasonable models for human cancer. Evolutionary biologists note that dogs and humans are built like Indy race cars, with successful reproduction as the finish line. We are designed to win the race, but afterward it does not matter how rapidly we fall apart. This design makes us ill equipped to resist or repair the genetic damage that accumulates in our bodies. Eventually this damage can derange cells enough to result in cancer. In the distant past, our human ancestors did not routinely live long enough to become afflicted with age-related cancers. But modern sanitation and medicine have rendered both longevity and cancer in old age common. Much the same is true for our pets. Pet dogs, whom we carefully protect from predation and disease, live longer than their wild ancestors did and so become prone to cancer in their later years. Thus, when it comes to a high lifetime risk for cancer, pets and people are very much in the same boat.
Aside from acquiring cancers that resemble those in people, pet dogs are valuable informants for other reasons. Compared with humans, they have compressed life spans, so scientists can more quickly determine whether a new prevention strategy or therapy has a good chance of improving human survival rates. Finally, although veterinarians today are far better equipped to treat cancer than they used to be, the standard treatments for many canine tumors remain ineffective. Because most pet cancer diagnoses end in death, dog owners are often eager to enroll their animals in clinical trials that could save their pet's life--and possibly provide the necessary evidence to move a promising therapy to human clinical trials. . .
at Cancer Prevention
But cancer researchers are shooting for more than improved detection and better treatment; they also want to prevent the disease. Surprisingly, prevention is a relatively new concept within the cancer research community. What cardiologists have known for a long time--that millions of lives can be saved through the prevention of heart disease--is just now gaining traction in the cancer field. The term "chemoprevention" was coined 30 years ago to refer to the administration of compounds to prevent cancer, but scientists did not gather nationally to debate cutting-edge knowledge of cancer prevention until October 2002. . .
Bill Avoided Cancer
Because cancer in pet dogs is so commonplace, the animals might be able to assist in solving an age-old mystery. Almost everyone has an Uncle Bill who smoked two packs a day and never got lung cancer. So what factors determine cancer resistance? One way to tease out the answer is to find populations resistant to cancer and study them closely--their genetics, their diet and their lifestyle.
Such a population has been found--human centenarians. It turns out that most folks who live to be 100 die of disorders other than cancer. But it is nearly impossible to collect reliable information from a 102-year-old woman on her dietary habits and physical activity when she was a teenager or in her mid-40s. So one of us (Waters) asked a simple question: Is this phenomenon of cancer resistance in the oldest old operational in pet dogs? The answer is yes. Now by interviewing owners of very old pet dogs, comparative oncologists can construct accurate lifetime histories of "centenarian" dogs. Combine this prospect with the ability to collect biological samples (such as blood for genetic analysis and for tests of organ function) from very old dogs as well as from several generations of their offspring, and you have a unique field laboratory for probing the genetic and environmental determinants of cancer resistance. . .
Historically, comparative oncology research has been conducted in university-based hospitals and laboratories where veterinary oncologists are trained. But other organizations have begun to recognize the potential for this kind of research to translate into better care for people, and these institutions are now actively engaged in comparative oncology research. . .
The intriguing similarities between the cancers of people and pets--once a mere curiosity--are now being systematically applied to transform cancer from killer to survivable nuisance. Comparative oncologists are not inducing cancer in animals but are compassionately treating pet dogs suffering from the same kinds of lethal cancers that develop naturally in both man and man's best friend. They are putting our canine companions on the trail of a killer in ways that can save both pets and people.
DAVID J. WATERS and KATHLEEN WILDASIN share an
interest in stimulating fresh thinking about cancer. Waters is professor of
comparative oncology at
Read the entire article at www.sciam.com/print_version.cfm?articleID=C9F7F979-E7F2-99DF-3D97694D2A702FED.
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In the News:
Freedom Man, By Thomas
Milton Friedman may well have been the most important economist of the 20th century, even if John Maynard Keynes was the most famous. No small part of Friedman's achievement was rescuing economics from the pervasive and virtually unquestioned Keynesian orthodoxy that reigned in many places.
Ironically, Friedman began his career as a believer in both Keynesian economics and in the liberals' vision of the world with which it was so compatible. Yet, in the end, no one did more to dethrone both. It is doubtful whether Ronald Reagan could have been elected president in 1980 without the changes in public opinion produced by Friedman's work in the previous decades.
The Keynesians' belief that government policy could wisely make trade-offs between rates of inflation and rates of unemployment was epitomized in the Phillips Curve, which seemed to lend empirical support to that belief. Friedman dealt that analysis a body blow when he argued that it was not the rate of inflation which reduced unemployment but the fact that inflation exceeded expectations.
In other words, even a high rate of inflation would not reduce unemployment if inflationary policies became so common as to be expected. The "stagflation" of the 1970s -- with simultaneous double-digit inflation and double-digit unemployment -- validated what Friedman had said, in a way that no one could ignore.
Unlike so many intellectuals who have aspired to positions of power, Friedman preferred to remain outside of government and independent of politicians. His influence was nevertheless great because his ideas moved others, whether in the economics profession, in the general public or among policy makers.
Friedman's many contributions to economics, recognized by the Nobel Prize that he received in 1976, were only part of his contributions to society at large. His decades-long campaign to promote school vouchers has been enshrined in the foundation named for him and his wife, the Milton and Rose D. Friedman Foundation for Educational Choice. He was a compassionate conservative long before that term was coined, for the rich obviously do not need vouchers to get a decent education for their children.
Friedman's own personal background made him familiar
with the problems of those who begin life without the privileges of the elite
-- and of the importance of education as a way to advance beyond their
beginnings. Born in
As the central figure in the "
Although in recent years we were both members of the
Hoover Institution at Stanford University, we each lived miles away and neither
of us was physically present there with any great frequency, so the chance that
we would both be there on the same day was virtually nil. The last time I saw
Friedman in person was in 2004, when we were jointly interviewed on television.
Afterwards, he gave me a ride in his little sports car over to the Stanford
faculty club, where we joined a group for lunch. Then he drove back to his home
More recently, I happened to chat briefly with Friedman on the phone a few days before his death, and found his mind to be as clear and sharp as ever. That will always be a special memory of a very special man, one of the giants of our time -- intellectually, morally, and as a human being.
Mr. Sowell is the Rose and Milton Friedman Senior Fellow at the Hoover Institution, at Stanford. (A selection of excerpts from Mr. Friedman's op-eds for The Wall Street Journal is posted today on OpinionJournal.com1.)
Dr. Sowell's entire article is at http://online.wsj.com/article_print/SB116381313044126974.html (subscription required).
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3. International Medicine: To be a fit nation we have to be weaned off the NHS, By Eamonn Butler, in The Business, 17/09/2006
EVENTUALLY, the penny dropped. The Conservatives came to realise (sic) that New Labour (sic) was in fact New. They were no longer facing a government bent on gleeful re-nationalisation of the commanding heights: rather, it was putting many of their own ideas in place. And that is when they elected David Cameron.
Now, the penny has dropped on the other side too. The unions have realised that the reform agenda is for real. And even when Tony Blair steps down, its momentum will keep it rolling for some time to come.
The penny started to drop as the trade unions saw the spread of private companies providing health treatment paid for by the NHS. But it hit bottom with a loud clang this week, with the decision to outsource the NHS logistics system to DHL in a £1.6bn deal. The company will manage expenditure of £22bn a year, taking over the supply of 500,000 products – from safety-pins to hip joints – to 600 hospitals. It hopes to shave £1bn off NHS costs.
Unison, the public workers' union, were particularly furious, attacking it as "creeping privatisation". (sic)
Really? In what sense is it creeping? The private sector now designs and builds NHS hospitals, provides NHS operations, manages the buying-in of hospital services, and runs the back-office supply chain too. It is firmly ensconced in every part of the acute care system. . .
But as the saying goes – a billion here, a billion there, and soon the savings add up to serious money.
The unions extracted the promise that no more than 15% of NHS acute care would be provided by the independent sector. But now, privately, ministers are taking about raising that limit, to 30%, and maybe more, by 2012. With money getting tighter, they simply cannot turn down savings that competitive service provision brings.
The union opposition to these reforms is ironic, given
that about half of trade union members have some kind of private care of their
own. Indeed, in
So, the healthcare funding revolution has already started, and union members themselves are not being left behind. Politicians find it uncomfortable to talk about NHS funding, the biggest remaining bastion of the postwar welfare state. But there could be huge political rewards for the first group – Labour, Tory or unions – to admit openly that things have changed and to work out how to take the funding revolution forward in a coherent way. For the rest of us too: if the army can negotiate a discount of over 40% on its BUPA subscription just imagine what the much larger union movement could do for its members.
For its part, the independent healthcare sector seems woefully split and poorly placed to reinforce the funding and provision revolutions already under way. It grew up not having to excel; it just had to be a bit better than the NHS to attract patients and rack up margins of 30% and more.
All that changed, of course, when the government invited bidders to provide treatment and run centres for NHS patients. The home-grown private sector, which had never had to prove itself, was nowhere in the competition. Instead, firms such as the South African-based Netcare arrived with new ideas, including mobile eye clinics, which could mop up the waiting lists all round the country and do cataract surgery 10% cheaper than the NHS.
I welcome this, though I have misgivings. Private healthcare providers have changed from being genteel competitors to the NHS to being heavily dependent on it as their biggest customer. The cash tsunami is so big – the NHS budget will reach £92.6bn in 2007/08, nearly three times what it was when Labour took office – that there is a danger of the industry becoming a mere supplicant.
Too often I see private companies trying to get ministers to change this or that rule in their favour, when they should be telling them that their whole way of doing things is daft. If firms could just walk away from government cash, they would not get in such a pickle when things like overblown IT projects turn sour.
On the funding side, private insurers do not seem to have come to terms with the scale of the revolution either. They remain focused on group schemes, which are easier work than selling lots of small plans to individuals. The rise of the medical cash plans seems to have taken them by surprise. And those plans, which have mostly provided quite modest benefits up to now, are expanding into the areas traditionally served by the insurers.
Indeed, the future for the insurers must lie more with individuals. A company finance director might be interested in the bottom line of a group scheme but individuals are more interested in their own outcomes. And they can be induced, by lower premiums, to become better risks by looking after their health.
Which is exactly what the government wants to achieve, but cannot as long as the NHS remains the country's insurer. There is enormous potential for the insurance market if, together with ministers, it can work out a way to entice individuals away from NHS funding and into plans that rely more on their personal contributions but help them to achieve better health.
Insurers and providers could work together on this. There is no reason why unused capacity in the privately-run treatment centres should not be used on insured or self-funded patients. One could imagine treatment centres joining up with insurers or cash plans to offer cheaper rates for members who use their medical facilities rather than go elsewhere.
Studies and polls show that the people does not much mind who provides their healthcare, as long as it is provided. Likewise, there is growing public acceptance that people will have to take more responsibility for the cost of that care. The funding and provision revolutions have started.
As the unions are well aware. They believe, wrongly, that the only way to protect their members is by resisting all such reforms. And they are ready to fight, Blair or Brown, because now they realise that the fight is for real. If they win, it will put reform back at least 10 years. You can guarantee that the fight is going to be messy.
To read the entire article, go to www.thebusinessonline.com/Document.aspx?id=8B253F3E-A4AF-4C3D-84B1-048601F9B08F&doc_page=1.
The NHS does not give timely access to healthcare; it only gives access to a waiting list.
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4. Medicare/Medicaid: State may trim HMO mandates to rein in insurance costs
A task force established by Gov. Arnold
Schwarzenegger to draft a plan for dealing with skyrocketing health costs in
Administration aides said the proposal -- which would require approval by the Legislature -- is one of many under consideration as part of the long-awaited plan the Republican governor says he will unveil in his State of the State speech in January.
"Right now, the administration is combing through hundreds of ideas and concepts," said Adam Mendelsohn, the governor's communications director. "No idea is in, no idea is out, and there is no specific plan developed."
Michael Shaw, assistant director for the National Federation of Independent Business, said relaxation of some mandates would lower premium costs for small-business owners and allow them to provide coverage for more employees.
"The No. 1 reason that small businesses do not provide health care in many cases is that they simply can't afford it," said Shaw, whose organization has met with members of the governor's task force to urge them to repeal mandates.
Employers have complained about the more than 50 mandates since 1999, when Gov. Gray Davis signed health care legislation requiring HMOs to offer a host of treatment and preventive care services.
Included are coverage for a variety of mental illnesses, including anorexia and bulimia, cancer screenings and contraception. Employers blame the mandates for contributing to the 55 percent rise in insurance premiums in the last five years alone.
Schwarzenegger has said that reducing the ranks of the
more than 6 million uninsured people in
Schwarzenegger aides did not specify which mandates would be under consideration for repeal.
Shaw, whose organization represents 35,000 employers in the state, said that because group insurance plans are required to provide more benefits than individual plans, many small business have been priced out of the market.
"So we want to create a set of rules for all plans that treat individuals equally but do not cost people the ability to afford health care," he said.
Shaw said single men, for example, should not be forced to pay for maternity care "simply because the state determined that it should be part of health coverage."
But state Sen. Sheila Kuehl, who as a member of the
Assembly was involved in the crafting of the HMO mandates, said repealing some
of the requirements would not improve health care in
Kuehl, D-Santa Monica, this year wrote a bill that
would have insured all Californians and abolished the role of private insurance
Schwarzenegger vetoed the measure, Senate Bill 840, saying he opposes "government-run" health care. . .
To read the entire report, go to www.sacbee.com/111/v-print/story/79527.html.
Government is not the solution to our problems, government is the problem.
- Ronald Reagan
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A few collect unemployment checks in addition to their county pension when their return stints are over.
During the last 22 months, 27 former county employees returned to the county as retired annuitants and then collected unemployment payments when those jobs ended -- costing the county $128,910.
Eleven filed multiple claims within that 22-month period -- yo-yoing from post-retirement short-term county jobs to collecting unemployment money and back.
In one instance, an eligibility specialist who retired
in 1992 after 11 years at the county filed five unemployment claims between
Using as an inspiration legislation aimed at stopping
state employees from "triple dipping,"
"It should be understood that such employment is temporary in nature," said board Chairwoman Roberta MacGlashan. "I support pursuing the legislation."
State law limits so-called retired annuitants to 120 days or a total of 960 hours of work a year. It doesn't limit their ability to collect unemployment when that time expires or when they are let go due to "lack of work."
Of the 27
The county has 486 people working as retired annuitants. . .
A 2003 legislative investigation found that in the three previous years, 170 retired annuitants in the Employment Development Department -- which administers unemployment insurance -- had received unemployment insurance.
Legislators dubbed the practice "triple dipping" because workers could garner income from three sources: pensions, retired annuitant pay and unemployment insurance. . .
In response to the state action,
Judy Hammond, spokeswoman for
To deal with the problem,
Jon Coupal, president of the Howard Jarvis Taxpayers Association, said the county push is a good first step toward pension reform.
"We think this is a very positive, although very minor, first step," said Coupal. "It seems to us to be a no-brainer to prohibit this."
To read the entire report, go to www.sacbee.com/302/v-print/story/77941.html.
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With the war on poverty as implemented through the
great society of the 1960s to end poverty, relative poverty has increased. The
simultaneous implementation of massive government health-care programs to
seniors (Medicare) and the poor (Medicaid) has caused relative access to
decrease. With the government acknowledging their inability to manage health
care and consequently contracting out to private For-Profit Health Maintenance
Organization, lack of access is increasingly frustrating patients. They go
through administrative loops trying to achieve access, lay the blame on doctors
and hospitals, and fail to see the real cause for their delays in obtaining
health care. The local county and city charity hospitals, where anyone could go
for healthcare and to see a doctor and nurse at anytime of day or night, have
disappeared because of massive federal government programs.
The recent Nobel Prize to Chittagong University
Economics Professor Muhammad Yunus of
The recent report in The New Yorker by Connie Bruck gives an excellent, albeit lengthy, discussion of "Millions for Millions." It shows how bureaucracy in any endeavor can destroy noble intentions. It adds another spike to the myth that either the non-profit world or governments can eliminate poverty. It should open up a debate about the corollaries in the health-care world.
Over the Labor Day weekend of 1995, a ponytailed,
bearded young software engineer named Pierre Omidyar wrote a code that enabled
people to buy and sell items on the Internet. In the first few weeks after the
program was introduced, items ranging from a Maxx comic book to a 1952
Rolls-Royce Silver Dawn changed hands. That program eventually became eBay. Not
long after the company went public, in 1998, Omidyar's share of the stock
offering was roughly ten billion dollars, and he became the richest
thirty-two-year-old in the world. He found the experience slightly
unsettling—he told friends that he had never planned to get rich—and he
continued driving his Volkswagen Golf. With his wife, Pam, he started a
foundation to give away large sums of money, but he was frustrated by the
constraints and inefficiencies of the nonprofit world. Omidyar was searching
for a way to change things on a grand scale, and, like many other highly
successful young West Coast entrepreneurs, he became interested in a field
called microfinance, or microcredit. In November, 2004, he and Sergey Brin and
Larry Page, the co-founders of Google, and other leaders of the high-tech
community gathered at the
"I would love investors and donors to really think about this," Omidyar said, earnestly. "There is a difference between undemanding capital"—contributed by donors, who expect nothing in return—"and demanding capital," which requires transparency of financial reporting and an appropriate reward for risk. His goal, he says, is "to shrink the undemanding source of capital and grow the other." That mission, however, might be complicated by the recent entry of some of his colleagues in the technology community, including Bill Gates, Michael Dell, Sergey Brin, and Larry Page. Omidyar believes that there is a role for philanthropic capital in carefully delineated areas like funding research and building infrastructure. But if these foundations commit large sums to other kinds of enterprises—as the Gates Foundation did in its grant to Pro Mujer, a microfinance organization that Omidyar told me he would not support—then his effort could become more difficult. The "cycle of creative destruction" might be slowed. Regarding his colleagues' grants, Omidyar said, somewhat stiffly, "I would hope that businesspeople would see the value of a business-oriented approach."
To read the entire article, please go to www.newyorker.com/printables/fact/061030fa_fact1.
[Microcredit is successful in eliminating poverty because the purchasers are participants in the economic transaction. Health care for the poor, such as Medicaid, will become successful when the poor are participants in the economic transaction of obtaining health care benefits. A health plan with a 10% co-payment for hospital stays ($100 per $1000 hospital day) could be a 1% co-payment or $10 per day for Medicaid recipients. A 20% co-payment for a $2000 outpatient minor surgery could become a 2% or $40 co-payment for a Medicaid patient. Many of the finer cars in my office building parking lots are driven by Medicaid patients. Ten dollars and forty dollars participatory involvement by Medicaid patients would make them excellent utilizers of their health care dollars. This would eliminate the need for much of the bureaucratic oversight, saving even more dollars.]
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MedicalTuesday last month quoted Dr. Francis J. Crosson, M.D. Executive Director of The Permanente Federation as saying:
There is a growing crisis of confidence in the land about whether our country has a workable plan to achieve rational, sustainable health care for all Americans.
It is a crisis of confidence made worse by the fact
that the physician voice, the responsible voice of the profession of medicine,
is often absent from or ineffective in the public debate. I believe that this
void of physician leadership can and must be filled by
Dr Ruth: Doctors not only don't have an effective voice, there is no voice that speaks for us. That's why the government will take over and run health care. They can't do worse.
Dr Dave: Not only will government medicine be worse, it will make medicine less accessible to our patients than our present system.
Dr Sam: The real problem is our professional organizations that continually support single-payer health care publicly and by supporting initiatives giving citizens the allusion that most doctors are for socialized medicine. We have to stop that. We should tell the leaders of our medical societies to change course or drop our membership in them since they no longer represent us.
Dr Yancy: I've never joined the local medical society and you guys should also stop paying dues. You're feeding a lion that's eating us alive. You're masochistic.
Dr Rosen: Maybe Dr Crosson is telling us, without saying so, that the future of American Medicine lies with groups like his and other large multispecialty groups. The Medical Societies were formed by solo practitioners and then small groups for educational and colleagual purposes. This has now been replaced by the large groups, which have huge educational conference programs. Permanente has several weekly conferences in each of their more-than-a-dozen medical buildings just in our community. Their physicians can easily obtain nearly a hundred hours of CME while having lunch.
Dr Milton: That's very true. The solo practitioners used to go to Medical Society Meetings every month on a Tuesday for colleagual and educational programs. The primary reason for their existence evaporated when they eliminated the monthly meetings. On some months, I've seen their now quarterly meetings decrease to 30 in attendance. In a community of 3,000 physicians, only one percent saw fit to come. Most of them came out of past loyalty. The local societies will disappear from our scene without major reform.
Dr Rosen: The same problem occurred in our state society. The yearly scientific meetings were grand occasions to renew acquaintances once a year and to hear academics from the medical schools around the state. Every specialty had sessions as well as general medical sessions. Thousands came. The meetings just disappeared. And the state society membership dropped in half. Any bets on when they'll fold?
Dr Yancy: They would fold in five years if all of you just stopped resuscitating them with outlandish dues while Medicare, Medicaid, and FP-HMOs keep cutting our income.
Dr Dave: That's why they're so desperately trying to get the state to take over our profession. They want to be the power broker between us and the government, just like the British Medical Association and the National Health Service. The BMA and the NHS have been in bed so long together, that the BMA is now fighting the efforts to privatize health care. So, whether you put a B or a C or an A in front of the MA, aren't they all alike?
Dr Rosen: Yes, Dr Crosson is correct. The profession of medicine needs a responsible voice. It looks like groups have one. We need one for the solo practitioners.
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8. Voices of Medicine: Will Physicians Become Technicians Looking Towards Wealth?
The Bulletin, Published Monthly by the
OPEN FORUM: by David S. Gans, M.D.
A county, thirty years ago Thursdays from 2 to 4. The worst hours of my medical week. That is when we advocated for our renal failure patients, competing with the other residents and fellows to obtain a precious dialysis slot. The winners lived and the losers often died.
Meanwhile the hospitals in the more affluent parts of town had empty dialysis beds for which, we were told, our patients were unfortunately not suitable. It wasn't that they were poor per se, it was that their poverty was "symptomatic of a kind of sloth that made them poor dialysis candidates" (never mind that the relevant studies outcome suggested that these kind of patients with lower expectations did better on dialysis than the driven yuppie).
Then a miracle occurred. Medicare assumed financial
responsibility for patients on dialysis and would pay the unit $500 a dialysis,
plus $125 per visit to the MD rounding on the patient. The very next meeting
nephrologists from all over
I believe that we have a secularly sacred duty to guard the doctor/patient interface. This interface should be controlled by the doctor and the patient, each who have support groups and ways of being monitored. Certainly insurance companies have the right not to be defrauded and certainly insurance companies have the right to check to make sure they are not being defrauded, but this is far different than what is going on in managed care today. The degradation of the doctor/patient interface is so profound that insurance companies and regulatory agencies even try to control the very language of medicine. And what do we hear back from the doctors? First and Foremost are the complaints about our loss of income and our deteriorating working conditions, which seems presented as equivalent to or even more important than the loss of control of the doctor/patient interface. Once the people that control our pay rates (the various bureaucracies and insurance companies) see this they know "what they take us for" and that they are only negotiating about price. Clearly anybody who wants a doctor to be financially uncomfortable is crazy. Do you really want your physician worrying about where he or she is going to get the mortgage payment or the grocery money rather then being able to focus completely on their patients when they are working?
Having said that, there is a difference, however, between being secure and comfortable and being wealthy, and having said that, the elephant in the room is we never sit down as a group and discuss what is reasonable for us physicians to make. Furthermore we never sit down as a group and discuss why different specialties should make different amounts of money and what the rational basis for these differences are, other than simply the intensity of work done and the time worked. If we could somehow come to some understanding amongst ourselves we could again regain control of the doctor/patient interface and be significant contributors to the shape of health care in our country. I think this conversation amongst ourselves is necessary and vital. Without it we are not going to be able to control those things which traditionally we are ethically obligated to control. We have in effect by selling away this control effectively demonstrated our potential for corruptibility. In conjunction with a series of Med Society meetings discussing the future shape of health care in this county, I would hope that the Medical Society might sponsor a series of discussions about our income and what it might appropriately be.
I personally think that if we can take care of our guild and our patients a reasonable income will follow. However, if we focus on our income and benefits, we will become technicians who are no longer members of an ethics-based guild practicing an ancient honorable craft. Furthermore, we will be in the dilemma so aptly described by the Buddhist aphorism "Do not accept responsibility for that which you
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9. Book Review: The Cure by David Gratzer, MD
The Market and Its Medicine Solving the health-care "crisis" means not
more government involvement but less. By Stephen Moore, WSJ,
About 10 years ago, I broke my leg playing basketball. After I came out of surgery, with a cast stretching from my ankle to the top of my leg, an orderly asked me whether I had ever used crutches before. I hadn't, so he showed me what to do, swinging through them from one end of the room to the other. The whole lesson lasted about 90 seconds. When I got my hospital bill, I saw that I had been charged $150 for "gait training on crutches." I did what all insured Americans do: I forwarded the bill to my insurance company. Why should I care? I wasn't paying for it.
One of the problems with American health care, as David Gratzer notes in "The Cure," is precisely a payment system that takes the patient out of the equation. In the early 1960s, the average American paid out of pocket one of every two dollars that he spent on health care; today the figure is one dollar in seven. The inevitable effect is hugely wasteful spending (and inflated hospital bills like mine). In fact, per-patient costs have gone up almost exactly in inverse proportion to the share of spending borne by the consumer.
Dr. Gratzer cites a remarkable Rand Corp. study that tracked health-care spending by 2,000 families over eight years. The families who got free health care spent 40% more than the families with cost-sharing arrangements. And yet the health outcomes for the two groups were the same. The lesson: Market-based health insurance systems, such as health savings accounts, cut out inefficiencies and lower costs without compromising quality.
Dr. Gratzer, a physician from
And it isn't only health-care "delivery" that is affected by suppressing market forces. Dr. Gratzer rightly spends part of "The Cure" celebrating the medical marvels that a dynamic, capitalist economy has helped to make possible by allowing capital to flow in productive directions. "Death due to cardiac disease has fallen by nearly two-thirds in the past five decades," he writes. "Polio is confined to the history books. Childhood leukemia, once a death sentence, is now almost always curable. Depression and mental illness are now treatable. . . . The death rate from heart attack and heart failure has fallen by more than half since 1950." In short, the medical progress of the past 50 years has been breathtaking. . .
To complain about the cost of heart surgery or cancer treatment by comparing it to the inflation-adjusted price in the 1960s or '70s is to miss the point: You died 30 years ago, and you live today. The cost of my leg surgery would have been a lot cheaper in the 1960s, but I wouldn't be able to play tennis or even run after the surgical repair was done, as I can now. How much is it worth to a family with a child who has leukemia to be able to treat her and give her a full life? The families I know who have seen their children recover say that they would have given up everything they own for today's miracle cures. Yet it's become a great American pastime for patients and politicians to whine about the "high cost of drugs" and other treatments that save lives.
All of which can lead to demagoguery and calls for a
nationalized health insurance system of the sort that Hillary Clinton and Howard
Dean are always so keen to recommend. Such calls may grow louder soon:
Mr. Moore is senior economics writer for The Wall Street Journal editorial page. You can buy "The Cure" from the OpinionJournal bookstore.
To read the entire review (subsciption required), go to http://opinionjournal.com/la/?id=110009344.
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Question: Since when have nurses become a political force in California? We have been overrun by mailers from them this election, and they even took out a number of full page political support ads in the San Jose Mercury News. They recommend only liberals, some of which seem grossly incompetent. . . What do the nurses expect in return? Why not stick to medicine?-- Phil Russell, Saratoga.
Answer: California Nurses Association aspires to become a national nurses union and to do so, adopts a very militant attitude to attract new members. It had hoped that by spsonsoring a ballot measure to limit corporate involvement in ballot measure campaigns (Proposition 89) it would set the stage for a universal health care measure and further enhance its national standing. Ditto for its in-your-face opposition to Arnold Schwarzenegger. But Schwarzenegger won in a landslide and Proposition 89 was overwhelmingly defeated, so one would conclude that the nurses suffered a big setback this week. -- Dan Walters, Columnist, The Sacramento Bee
Why are Doctors for Government Medicine?
It's not only the nurses' organizations, but doctor's organizations that are for government medicine. Are both organizations working against their own members' welfare? Do these professional organizations give a bad image to the public in regards to their members? Don't the sick and dying assume that doctors and nurses think like their fringe leadership? Do both professional groups need to find another professional organization to represent them?
Question: I have nothing but terror about
Nancy Pelosi and movement of the Democrats in the House. . . Do you have any
information that might change my opinion?
-- Mickey Mathis, Brownwood, Texas
Answer: Nancy Pelosi is a member of a
family that has long been prominent in Baltimore politics and is fundamentally
a pragmatist who, interestingly, is considered to be a moderate by San
Francisco standards. That makes her a liberal by national standards, certainly,
but Democrats won the House by fielding centrist candidates in swing districts.
. . Those factors, plus the fact that Bush will be president for two more
years, severely limits Pelosi's ability to make any sharp changes in national
policy. The system just doesn't allow hard turns one way or the other.
-- Dan Walters
Six Laws in Three Weeks.
Incoming House Speaker Nancy Pelosi has told fellow Democrats she wants to pass the party's six top legislative items before President Bush delivers his State of the Union Address. Within three weeks, she wants to raise minimum wage (Why do we want to hurt the poorest of the poor?), expand taxpayers' forced contribution to embryonic stem cell research with a total disregard for some with a moral objection, force drug companies to reduce their prices for Medicare Drugs, repeal an unspecified series of tax breaks, have taxpayers or lenders fund a bigger part of student loans, among others.
Well, maybe two laws a week
isn't so bad. The
Does Free Health Care Improve Your Health?
Dr. Gratzer cites a remarkable Rand Corp. study that tracked health-care spending by 2,000 families over eight years. The families who got free health care spent 40% more than the families with cost-sharing arrangements. And yet, the health outcomes for the two groups were the same. The lesson: Market-based health insurance systems, such as health savings accounts, cut out inefficiencies and lower costs without compromising quality.
Free Health Care Does NOT Improve Your Health; It Just Costs 40 Percent More
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• The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. This week, consider reading Professor David Deming on the Irrational Hysteria On Global Warming at http://eteam.ncpa.org/news/media-shows-irrational-hysteria-on-global-warming.
• 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 peruse the current California Focus: Californians at disadvantage with HSAs at www.pacificresearch.org/press/opd/2006/opd_06-12-07de.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 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. This month read Honoring Milton Friedman By Grace-Marie Turner.
• 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 and review the Latest Kaiser Family Foundation Report go to www.chcchoices.org/publications.html. To join, go to www.chcchoices.org/join.html.
• The Heartland Institute, www.heartland.org, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care? at www.heartland.org/Article.cfm?artId=10333.You may sign up for their health care email newsletter at www.heartland.org/Article.cfm?artId=10478.
• 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. This month, be sure to read The Goal is Freedom at www.fee.org/in_brief/default.asp?id=966.
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/. This week, read the Daily Medical Follies: "Woeful Tales from the World of Nationalized Health Care" at .
Independence Institute, www.i2i.org, is a free-market think-tank in Golden,
• Martin 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 the plea for Libertarians to Forget Party Politics at www.quebecoislibre.org/06/061126-3.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. This month, be sure to read Waiting Your Turn: Hospital Waiting Lists in Canada at www.fraserinstitute.ca/shared/readmore.asp?sNav=pb&id=863.
• 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. This month, be sure to read about how government funding is also ruining our sister profession and education: Federalism in Education at www.heritage.org/Research/Education/bg1987.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 the warning of How Middle of the Road Politics leads to Socialism at www.mises.org/story/2370. 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.
• The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]
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Words of Wisdom
Elisabeth Kübler-Ross (1969): We have to ask ourselves whether medicine is to remain a humanitarian and a respected profession or a new but depersonalized science in the service of prolonging life rather than diminishing human suffering.
Dwight D Eisenhower: There are a number of things wrong with
Mark Twain: The only difference between the taxman and a taxidermist is that the taxidermist leaves the skin.
Some Recent or Relevant Postings
HOW TO LOWER YOUR CHOLESTEROL Without Drugs: www.delmeyer.net/MedInfo2006.htm
HOW TO LOSE WEIGHT WITHOUT DIETING or How I lost My 30 Pounds: www.delmeyer.net/MedInfo2006.htm#How to Lose Weight Without Dieting
CLONING OF THE AMERICAN MIND - Eradicating Morality Through Education, by B. K. Eakman: http://healthcarecom.net/bkrev_CloningOfTheAmericanMind.htm
SAVING CHILDHOOD - Protecting Our Children from the National Assault on Innocence, by Michael Medved and Diane Medved, PhD: http://healthcarecom.net/bkrev_SavingChildhood.htm
There are some public figures whose obituaries can be written years in advance. Milton Friedman was not one of them.
Arguably the greatest economist of the 20th century, he won his Nobel Prize 30 years ago. His classic "Capitalism and Freedom" was published 44 years ago. He died yesterday at the age of 94, but as the op-ed running nearby attests, he was active in writing about, thinking about and explaining how economics affects our world until the end.
In today's feature, he updates and re-examines
conclusions he reached about the Great Depression in "A Monetary History
This insight flowed from Professor Friedman's conviction that "money matters." As the Royal Academy of Sweden noted in announcing his 1976 Nobel, Friedman's was a lonely voice in arguing for the importance of the money supply in economics when he began writing about it in the 1950s.
By the late 1970s, stagflation -- the combination of
high inflation and high unemployment -- had made it obvious that the
then-dominant Keynesian model had some large holes. These included the effect
of the money supply on inflation and the fact that inflation and employment did
not move in lockstep as some of Keynes's disciples asserted. It was a seminal
insight, creating what became known at the
In awarding its Nobel in 1976, the
First, he had shown that men are no fools. People spend money in accordance with their income expectations over the long-term, not in response to one-time "stimuli" from the government. This is known as the "permanent income" hypothesis, and it called into question Keynesian notions of how short-term stimulus affects the economy. In addition to his monetary insights, Mr. Friedman questioned the degree to which fiscal policy could be used to "fine-tune" the economy by adjusting spending, tax or monetary policy. Today we take for granted that all of these operate with a lag, but it was Milton Friedman who first highlighted the problem.
For all of his academic accomplishments, Professor Friedman's role as a popularizer of free-market principles was arguably more important. He wrote a column in Newsweek for 18 years starting in 1966, preaching the importance of economic freedom to a generation that had never heard such things in school. His 1980 book, "Free to Choose," was a best seller, and the videos that accompanied it were smuggled behind the Iron Curtain like seeds of revolution. . .
In truth, Professor Friedman always argued with civility and a bracing wit. One of his best barbs on the size of government: "Given our monstrous, overgrown government structure, any three letters chosen at random would probably designate an agency or part of a department that could be profitably abolished." And he popularized "There is no such thing as a free lunch."
In "Two Lucky People," written with his wife, Rose Friedman, who survives him as a distinguished economist in her own right, Mr. Friedman well described the role of a public intellectual: "We do not influence the course of events by persuading people that we are right when we make what they regard as radical proposals. Rather, we exert influence by keeping options available when something has to be done at a time of crisis."
On the death of Ronald Reagan, whom he advised, Mr. Friedman wrote on these pages that "few people in human history have contributed more to the achievement of human freedom." The same can and long will be said of Milton Friedman. To read the entire editorial (subscription required), please go to
On This Date in History - December 12
On this date in 1955, the Ford Foundation
gave the largest philanthropic gift ever put together at that time of one-half
billion dollars for
On this date in in1899, the Golf Tee was
patented by George F. Grant of
Speaker's Lifetime Library, © 1979, Leonard and Thelma Spinrad