Community For Better Health Care

Vol IV, No 21, Feb 14, 2006


In This Issue:

1.                  Featured Article: Genomes for All

2.                  In the News: Beating the Odds -The Real Jackpot Was Being Defibrillated

3.                  International Medicine: The Truth Is Dazzling: Capitalism = Prosperity

4.                  Medicare: Doctors Feel the Pain, Too

5.                  Medical Gluttony: Medical Tragedy

6.                  Medical Myths: Physicians Can Lose Their Skills Quickly

7.                  Overheard in the Medical Staff Lounge: The World's Finest and Purest Drinking Water

8.                  Voices of Medicine: The 1918 Spanish Flu Pandemic in San Mateo

9.                  From the Physician Patient Bookshelf: Healthy Competition - What’s Holding Back Health Care and How to Free It – Chapter 5 - Tax Policy and Health Care

10.              Hippocrates & His Kin: Just When I Thought I'd Heard It All, There Comes A New One

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

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The 3rd Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case study data. The 2006 conference will be held from April 17–19, 2006, in Washington, DC. For more information, visit

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1.      Featured Article: Genomes for All

Next-generation technologies that make reading DNA fast, cheap and widely accessible are coming in less than a decade. Their potential to revolutionize research and bring about the era of truly personalized medicine means the time to start preparing is now. By George M. Church, Professor of Genetics at Harvard Medical School. In Scientific American, January 2006, pages 46-54.

When the World Wide Web launched in 1993, it seemed to catch on and spread overnight, unlike most new technologies, which typically take at least a decade to move from first "proof of concept" to broad acceptance. But the Web did not really emerge in a single year. It built on infrastructure, including the construction of the Internet between 1965 and 1993, as well as a sudden recognition that resources, such as personal computers, had passed a critical threshold.

Vision and market forces also push the development and spread of new technologies. The space program, for example, started with a government vision, and only much later did military and civilian uses for satellites propel the industry to commercial viability. Looking forward to the next technological revolution, which may be in biotechnology, one can begin to imagine what markets, visions, discoveries and inventions may shape its outcome and what critical thresholds in infrastructure and resources will make it possible. . . .

The "$1,000 genome" has become shorthand for the promise of DNA-sequencing made so affordable that individuals might think the once-in-a-lifetime expenditure to have a full personal genome sequence read to a disk for doctors to reference is worth while. Cheap sequencing technology will also make that information more meaningful by multiplying the number of researchers able to study genomes and the number of genomes that can compare to understand variations among individuals in both sickness and health. .

"Human" genomics extends beyond humans, as well, to an environment full of pathogens, allergens and beneficial microbes in our food and our bodies. . . . 

To read the entire article (Subscription required) go to

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2.      In the News: Beating the Odds - The Real Jackpot Was Being Defibrillated

How a gamble on defibrillators turned Las Vegas into the safest place to have your heart give out. By KEVIN HELLIKER Staff Reporter of THE WALL STREET JOURNAL January 28, 2006; Page A1

When he thinks of all the places he might have suffered cardiac arrest, Jack Barlich feels lucky. If his heart had stopped at home, in a store or at city hall in Del Rey Oaks, Calif., where he was mayor, he might be dead.

Instead, it stopped as he was playing a winning poker hand at the MGM Grand in Las Vegas. What happened next that day in May 2003 impressed his wife, Irene. Security guards arrived within seconds, ascertained that he had no pulse and shocked his heart with a defibrillator. Five jolts later, it was beating again. "Thank goodness I'm a gambler," says Mr. Barlich, now 69 years old.

At a time when some big companies such as Wal-Mart Stores Inc. are just experimenting with keeping portable defibrillators around, a pioneer and the unrivaled model of the practice is the casino industry. Las Vegas casino security officers have restored the heartbeats of about 1,800 gamblers and employees in the past nine years, according to the Clark County Fire Department.

Medical research shows that casino visitors whose hearts suddenly stop survive at higher rates even than people who happen to go into cardiac arrest while visiting a hospital. "The safest place in America to suffer sudden cardiac arrest is a casino," says Bryan Bledsoe, a George Washington University emergency-medicine doctor and co-author of textbooks for paramedics.

All along the Strip, large casinos have the devices, technically known as automatic external defibrillators. Casinos’ security officers have become so adept with them that they usually decline offers of aid from physician bystanders. "The average radiologist or obstetrician isn't as well trained as our security officers," says David Slattery, an emergency-medicine physician who oversees the defibrillator program at MGM Mirage's 23 casinos. Mirage security officers Dave Kurau and Craig Kahrs have shocked five stalled hearts back to life each, as has Jeff Fiti at Harrah's Entertainment Inc.'s Rio casino.

Casinos' experience is contributing to calls for wider distribution and use of defibrillators across the country. The American Heart Association has just endorsed use of the devices by lay people, shifting from a policy that called for oversight by doctors. Singling out the casinos’ experience, the AHA said in a published statement last month that lay-person use of the devices is now shown to improve survival.

Defibrillation is far from a foolproof response to the dramatic crisis of sudden heart stoppage. Researchers have found that about 53% of people who suffer sudden cardiac arrest at casinos survive. While that rate far outstrips the national average survival from sudden cardiac arrest of well under 10%, even the best efforts of casino staffs mean that nearly half of stricken gamblers don't make it. Defibrillation works best in concert with chest compressions. . . .

Jim Alexander was working security at the Stardust about five years ago when a call sent him running to the stage of a ballroom-dancing competition, defibrillator in hand. The male half of a dancing pair had collapsed. After the defibrillator showed the man had no heartbeat, Mr. Alexander pushed a button and stood back while the device delivered a shock that brought back a pulse - and an ovation from onlookers. "I felt like I'd won the whole contest," Mr. Alexander says. . . .

[A] 63-year-old North Carolina textile worker named Thurman Austin came to Las Vegas with his wife in July of 1997. Mr. Austin gambled until late, rose early and smoked practically nonstop. He thought little of an episode of chest pain that came and went. But as Mr. Austin played slots one afternoon at the Stardust, he blacked out and cracked his head on a machine as he tumbled to the floor.

In less than three minutes, Stardust security officers were delivering a shock to Mr. Austin's chest. He remembers coming to. "I could hear everybody, especially my wife, but at first I couldn’t see anything," he says.

When Mr. Austin learned that the Stardust was one of just seven casinos taking part in the defibrillator experiment, he marveled at his good fortune: He wasn't even staying at that hotel but had dropped by to play just moments before the attack. "I really hit the jackpot that day," he says. . . .

Casinos' embrace of the devices owes a big debt to the efforts of a paramedic at the Clark County Fire Department, Richard Hardman. A decade ago, he realized that about 50% of the cardiac-arrest episodes his department dealt with took place at casinos. Mr. Hardman and fellow paramedics often found themselves arriving too late to help at the scene of a casino cardiac-arrest case. Invariably, standing next to the deceased victim was a casino security officer. . . .

Mr. Hardman, still a fire-department paramedic, also now does some consulting for casino industry, which he says earns him less than $10,000 a year. He says he no longer feels haunted by his failure to become a doctor. He was listed as an author on the New England Journal of Medicine study, and doubts that as a physician he could have been involved in anything more important. "To be thanked by people who say you saved their lives—that's extremely gratifying," he says.

To read the entire article (subscription required), please go to

Write to Kevin Helliker at

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3.      International News: The Truth Is Dazzling: Capitalism = Prosperity

John Blundell, Director of England’s Institute for Economic Affairs, praises The Heritage Foundation's Index of Economic Freedom

THERE are endless recipe books on how to make a soufflé, roast a pheasant, bake a walnut cake or create an exquisite salad. But this is the ultimate recipe book, and it is very different. It might be entitled The Wealth of Nations, but someone nicked that. Instead it carries the unlovely but apt title, 2006 Index of Economic Freedom - the link between economic opportunity and prosperity. It contains more than 400 pages of detailed figures and it comes from perhaps the most influential thinktank the world has seen, namely The Heritage Foundation in Washington DC.

I admit I am dazzled. I am intrigued. Here is the most exacting analysis of the nature of society of every nation from the mighty United States to tiny Cape Verde Islands published. As its discoveries chime so perfectly with my prejudices I'm naturally enthusiastic.

Why do some nations, often in adverse locations, prosper? Why are some, with lush soils and huge mineral resources, destitute?
The answers may be highly complex in detail but they could hardly be more plain in nature. Humanity prospers when it has freedom of trade. This could also be expressed as freedom of contract - that people can swap their goods and wares and services without control, regulations and taxes . . .

 Who is top of the league of such virtues? Hong Kong, Singapore, Ireland, Luxembourg and Iceland. Who is bottom? Zimbabwe, Myanmar, Iran and North Korea. Sudan, Iraq and Congo don't even rank, as they are so lawless. The UK, the US, Australia, Canada and New Zealand are up there with the best scores, but short of top marks. Perhaps it is the speed of rank change that is most intriguing.

I applaud Estonia, ranked seventh best in the world after only 15 years from being a Soviet province. Venezuela, once relatively rich and placid, is a basket case tumbling down the league table under Hugo Chavez’s weird perception that Cuba is a model to emulate.

It is worth being emphatic - there is no link whatsoever to natural resources. What has Iceland got? It is cold, dark and barren. Yet it has freedom. It thrives.

Russia, snug between Cameroon and Azerbaijan, is ranked at 122nd. It has vast endowments of mineral wealth and rich soils, but its citizens are not free.

Hong Kong and Singapore are anomalies of history. They are city states of Chinese folk but they still live under the halo of Anglo-Saxon rules - it is common law terrain. Myanmar and Zimbabwe used to be more prosperous but now are collapsing.

I would love to see the Index of Economic Freedom as a compulsory book in every classroom - except, of course, we do not believe in compulsion.

So, I assert what we all know intuitively, that prosperity and its first cousins productivity, security, clean water, or any other desirable civic blessing, is derived from trade. This may be expressed in the great engine that unites all of mankind, or at least those open enough to trade. This is the vast price mechanism that allows us to learn who wants what and when and where.

I think it close to a miracle that I can buy Chilean wines, Ghanaian chocolate, Kenyan beans and Australia beef at Tesco's prices, buy petrol from Kuwaiti, watch my Japanese television and play on my Californian keyboard. Expressed individually these are banalities, but in aggregate they are a marvel. . . .
But the index also alerts us to the hazard of interest groups always trying to compromise or pollute freedom of trade. The EU's agricultural autarchy is not merely corrupt. It brutalizes (sic) those people locked out. The authors of the Index of Economic Freedom eschew policy prescriptions, but I offer the insight Israel could enjoy greater peace if it adopted free trade and open borders. China and Taiwan can liberalise (sic) their trade so that differences would erode.

Note the migrations of humanity too. Nobody aspires to live in wretched lawless nations. We seek out the law-rich locations.

So here is a perfect birthday present if you know any aspiring politicians. They might grasp the crucial lesson, which is to focus on what only you can do, such as the rule of law, do it well, and by and large leave the rest to the market.

To read the entire article, please go to 
John Blundell is Director General of the Institute of Economic Affairs.
Buy now:
The Index of Economic Freedom Heritage Foundation, 20 pounds.

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4.      Medicare: Doctors feel the pain, too.

Frustration over dealing with new Medicare drug plan goes beyond patients. By Nancy Weaver Teichert—Bee Staff Writer, Saturday, January 28, 2006

Dr. Holly Leeds of Auburn is as upset and frustrated with Medicare's new drug plan as some of her patients, maybe more. The small print of many plans requires physicians to get a prior authorization for some medications their patients have relied on for years, she said. . . .

"I was on the phone for an hour trying to get a prior authorization," said Leeds, who is a general practitioner in a one-doctor office. "What hoops do I have to jump through?"

A patient may have chosen a Part D drug plan because it covers their medications. But the plan may require the doctor to get a prior authorization to prescribe the drug.

[It is an insult to a physician to discuss with the insurance carrier the medical needs of a patient.]

With more than 40 private plans with different drugs and procedures covered, much of the burden is falling on physicians to figure out how they work, said Dr. Jack Lewin, president of the California Medical Association.

"There are an awful lot of barriers to getting medication," said Lewin. "The bureaucratic complexity is very cumbersome."

While the drug plan gives many seniors and disabled people prescription coverage for the first time, Lewin predicted it will have to become less complicated to succeed. . . .

While health plans acknowledge there have been problems implementing drug coverage, officials said things are improving each day as they hire more staff and update data in the computer systems.

On Thursday, Leeds was trying to get a prescription for an arthritic patient who successfully used Celebrex for severe joint pain for the past two years. She said the patient’s new drug plan with HealthNet denied the prescription.

"The denial does not come with a telephone number, a list of alternatives or any other information to allow me to even start the process" to appeal, said Leeds. . . .

Dr. Francisco Prieto of Sutter Medical Group in south Sacramento said he’s run into trouble getting prior authorizations from several drug plans, even for insulin refills for two diabetic patients.

"I was pretty startled. How can you say no to insulin?" said Prieto, who had to fax a form to get the refill approved two days later. "I wrote some fairly snide comments. ‘Diabetic! On insulin! What more do you need!'" . . .

She believes the root of the problem is the drug plans have a financial incentive to put up hurdles to access to drugs, especially when they’re not paying for the consequences of hospitalization. . . . 

Margaret Reilly, assistant director of the Health Insurance Counseling and Advocacy Program, anticipates more calls from patients too. She said her counselors aren’t yet familiar with all the appeal processes.

"Not only are the physicians frustrated," she said, "by the time the poor patient gets to the physician there’s a huge level of frustration too."

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

- Ronald Reagan

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5.      Medical Gluttony: Medical Tragedy

Some time ago, I was taking my medical students on rounds teaching them physical diagnosis or how to examine patients. For patients that gave their permission, the students interviewed them to obtain their medical history and examined them to confirm the expected findings. As we were completing a patient in the cardiac unit, the students became curious about the lady in the next bed who glazed at the ceiling while her family was gathered around the bed conversing with each other. She seemed oblivious to their presence.

Her nurse was at the foot of the bed and we stopped and introduced ourselves. She explained that this 78-year-old patient was recovering from a 5-vessel coronary artery bypass graft (5V-CABG) operation. She also had Alzheimer's and had not recognized her family in five years. That was why she didn't know the members of her family around the bed. "Then why," we asked, "did she have this life prolonging procedure?" The nurse replied that her staff was also struggling with the same question.

For personal or primary care physicians, when the cognitive brain is no longer functioning as in dementia, especially of the Alzheimer's type, the management consists of providing appropriate supportive care to the patient until such time as a vital organ, such as the heart, lung or liver, fails. Support to the family continues while their loved one is kept comfortable until the end. Under no circumstances should life be extended by rejuvenating the heart for another decade or so, as with the 5V-CABG. Not only does this not benefit the patient, but it is an unnecessary burden on the family,  and the hundreds of thousands of dollars of unnecessary health care costs will eventually compromise health care for the more needy.

What is the answer to this excess or abuse? Conventional wisdom says we need more regulations to prevent this from happening. Medicare should police surgeons and hospitals to prevent this sort of unnecessary cost. However, this occurred under Medicare’s watch and the patient and her family were totally outside the decision-making process. Medicare is already the most micromanaged government health care system known -- far more abusive than any socialized national health service in the world.

But conventional wisdom is unwise and wrong.

This sort of abuse and excessive use can only be controlled by placing health care in a market environment (Medical MarketPlace) where the patient is responsible for a percentage of all costs. In our running draft of the ideal HealthPlan, the Medical MarketPlace controls costs with only a 10 percent co-payment on hospital care. That forces the hospital and the cardiac surgeon to provide full disclosure for all procedures. With a 10 percent co-payment for the $6500 surgical fee, the family would discuss whether or not their 10 percent portion or $650 was cost-beneficial for their mother. The hospital would also have to provide full disclosure of their bill, which would be on the order of $100,000. The family would then be able to determine if their 10 percent or $10,000 was cost beneficial to them. Excessive health care costs would have been stopped in its track and quality of care and quality of life would have improved dramatically.

Quality of care rises and healthcare costs fall when medicine operates in the Medical MarketPlace.

Health Care costs rise and Quality of Life diminished in a managed care environment.

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6.      Medical Myths: Physicians Lose Their Skills Quickly

After 35 years, the Physician-in-Chief of Wayne County General Hospital in Eloise, Michigan, fell out of favor with the politicians and returned to the practice of medicine. He said he maintained his scientific acumen by reading Scientific American, which he deemed the best running textbook of biology and medicine available. He was one of the best professors of medicine I had. Skills that are a part of us may be temporarily diminished, but never lost, and are quickly reclaimed.

At a recent medical meeting, I met a Pulmonologist that had practiced for 25 years and decided to relocate. He took time out to obtain a master's degree and then applied for hospital privileges. He was denied privileges to do bronchoscopies even though he had done more than a thousand. The hospital alleged that over the several years, he had lost his skills. None of the physicians, including a Pulmonologist, would verify his expertise. The doctors who were convinced of his skills had been so frightened by the hospital lawyers who advised them that they could be held liable for any therapeutic misadventures (which are part of the practice of medicine for all of us) that they all refused to authorize him to practice.

Although having completed his pulmonary fellowship, and being board certified in pulmonary medicine, the hospital made him repeat five months of his fellowship so they could be absolutely sure he had the appropriate skills. After moving again, this time to a university city, he was certified by the university professor as having the expertise to do bronchoscopies. He then moved back and was allowed to practice pulmonary medicine, including bronchoscopies, in this small rural hospital.

Why do physicians make their colleagues jump through unnecessary hoops, losing five months income and paying five months of tuition, because of legal paranoia? Does any other profession even presume they lose their skills while taking time off for an additional degree? Or just time off for family or leisure?

It's time for physicians to rise to the occasions, to call the shots for their own profession and be willing to support and defend each other – to be willing to take legal action against those that want to destroy our profession and our relationship with our patients.

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7.      Overheard in the Medical Staff Lounge - The U.S. has the world's finest and purest drinking water. What went wrong in San Francisco?

San Francisco has spent more than $2 million of taxpayers' money in recent years on bottled water, despite owning a pristine reservoir in the Sierra Nevada that is said to produce some of the country's best-tasting tap water. San Francisco is one of a handful of cities in the country that is not required to meet federal filtration rules because its water is so clean. The SF Public Utilities Commission is looking at any cost-effective ways to reduce bottled water spending. Some have suggested a jobs program for young people who would bottle water from the city owned Hetch Hetchy Reservoir in Yosemite National Park and distribute it to various offices and agencies.

The Mayor of Los Angeles is trying to cut the $90,000 the city spent on bottled water with a $1 million ad campaign praising the virtues of what comes out of its taps. (Government solutions always cost ten times as much as the problem. Both the $90,000 and the $1 million could be eliminated with just a stroke of the budget pen.)

I wonder if anyone in SF has thought of putting drinking fountains in the City Offices and Agencies?

Coverage issues should occur between the Insurance Company and the patient, not the doctor!

Doctors should only have to deal with their patient's diagnostic and therapeutic needs. If the patient has a problem with his insurance carrier, it should be the patient's responsibility to obtain the specifics about what is covered and then make another appointment with his doctors to re-discuss his medical problems and therapeutic alternatives. He/she can then write the appropriate prescriptions with the patient and the medical record in front of him/her.

It is totally inappropriate to tract a physician down during lunch or after hours to rehash the appropriate treatment without either the patient or the medical record in front of him/her. Why do we allow the inadequacies of insurance carriers and their formularies to force us to spend additional time with no pay when we've already evaluated the patient at half our usual fee? Would any other profession spend 50 percent more time on a client for bureaucratic hassling with no additional fees?

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8.      Voices of Medicine: The 1918 Spanish Flu Pandemic in San Mateo

The San Mateo County Medical Association Bulletin: SMCMA 1905-2005: A Memorable Journey

"It must have seemed a far-fetched notion in 1905. San Mateo County was sparsely populated; only a few doctors had settled here, and there wasn't a real hospital in sight. But 16 of these hardy medical souls met in San Mateo that September to sign the charter and make it official. The San Mateo County Medical Society was organized to 'promote the science and art of medicine and to conserve and promote public health.' Harry G. Plymire, M.D., of South San Francisco was named the first president . . . Among the first to sign the charter was a young physician who had come to San Mateo just months before, Norman D. Morrison, Sr., M.D. . . .

"In a few years these medical men were faced with a worldwide scourge: the Spanish influenza pandemic of 1918. Within less than a month of the county's first case being reported, 2000 cases were diagnosed and hospitals were full to overflowing. There was little to be done but let the contagion run its course. Tuberculosis was another disease that was afflicting San Mateo residents at the turn of the century. Treatments took many months and several sanitariums opened in the county to house patients. It wasn't until the introduction of streptomycin in 1944 that a quick cure was possible. . . ." To read more about the SMCMA's first 100 years, please go to 1905-2005.html.

Florida Medical Association Quarterly Journal: Doctor-Patient Relationship: Erosion of Trust? By M. P. Ravindra Nathan, MD, FACC, FACP
"One of the most challenging aspects of medical practice is communication with patients and their relatives, the touchstone for all doctor-patient interactions. Sad to say that the sacred relationship between the doctor and his patient has deteriorated considerably over the past few years. There seems to be a constant erosion of this mutual trust which is why they are asking for second and third opinions. I had my share of woes as well. Let me tell you my recent experiences.

"65 year-old, just-retired, somewhat obese business man whom I shall call Mr. Dugan, drove to the ER with chest pain one night. The first EKG showed extensive anterior wall myocardial infarction. He immediately suffered a cardiac arrest, but was promptly resuscitated and was put on a ventilator. His sons, executives from Long Island, showed up the next day, deeply upset and furious and demanded a conference with me right away. They had just one question, 'Our father has never been sick a day in his life. He walked into this hospital. Now he is in a coma! We want to know what happened.'

"I tried to tell them that their father had received excellent care. In fact, the ER crew worked diligently to resuscitate him. Finally, it took the combined public relation skills of the whole staff to pacify the family. I didn't have the heart to tell them that if their father had regular preventive medical check-ups and screenings for common cardiac risk factors, perhaps this catastrophe could have been averted. I expected them to be grateful for what we did, but their words implied negligence on the part of the ER staff!

"Suddenly my thoughts went back to some 30 years ago when I was a fellow in cardiology at the New Jersey College of Medicine, Newark, NJ. One night I was called to see a 56-year-old lady, Vivian, in cardiac arrest. She needed several shocks and other ancillary treatments, was on a respirator for three days, in a coma for two more days and finally survived miraculously. I attended to her earnestly for several days. During her next follow up visit to the cardiac clinic, Vivian showed me a golden bracelet she was wearing. To my surprise, the name engraved was mine! She said, 'Thank you for all that you have done. You are an angel!' And the grateful family gave me a small gift."
To read about other Doctor-Patient episodes, go to

The San Mateo County Medical Association Bulletin: Studies Give Clues About How Best to Reach Teens by Daniel J. Glatt, M.D.

Trends come and trends go. However, the continued experimentation and use of alcohol, tobacco, and other illicit drugs by our young people remains a real problem. Whether as a clinician or as a parent, many of us have witnessed firsthand the devastation and destruction that these can inflict on our patients and loved ones. Much frustration is generated when we cannot seem to help or "cure" those affected by alcohol, tobacco, or other illicit drugs.

How should we approach our teens and young adults about their (mis)adventures in experimentation? Should we present the "facts" about the dangers of drug use and abuse or should we "frame" the issue as a legal issue or a moral one? Although there may be no easy answer, especially in a 15-minute office visit, recent studies may help you focus your brief intervention with patients and their families.

In August 2005 The National Center on Addiction and Substance Abuse (CASA) at Columbia University reported that "teen perceptions of immorality, parental disapproval, and harm to health are far more powerful deterrents to teen smoking, drinking, and drug use than legal restrictions on the purchase of cigarettes and alcohol or the illegality of using drugs like marijuana, LSD, cocaine, and heroin."

   Teens who say their parents would be "a little upset" or "not upset at all" if they used marijuana are six times likelier to try marijuana than those whose parents would be "extremely upset."

   Teens who consider marijuana to be "not too harmful" or "not harmful at all" are eight times likelier to try marijuana than those who consider marijuana "very harmful" to the health of someone their age.

   Most teens say that legal restrictions have no effect on their decision to smoke cigarettes (58 percent) or drink alcohol (54 percent), and nearly half say that illegality has no effect on their decision to use marijuana (48 percent) or LSD, cocaine, and heroin (46 percent).

 "Laws restricting smoking and drinking and making illegal the use of drugs like marijuana and cocaine play a significant role, but we must recognize that morality trumps illegality in deterring teen smoking, drinking, and drug use," according to Joseph A. Califano, Jr., CASA's chairman and president and former U.S. Secretary of Health, Education, and Welfare.

An additional survey outcome that offers some interesting consideration is the relationship between R-rated movie viewing and drug use. This year's survey also found that 43 percent of 12 to 17 year olds see three or more R-rated movies each month either in theaters or on home video. These teens are seven times likelier to smoke cigarettes, six times likelier to try marijuana, and five times likelier to drink alcohol, compared with those who do not watch R-rated movies in a typical month. . . .

In the 2004 NSDUH, 60.3 percent of youths aged 12 to 17 reported that they had talked at least once in the past year with at least one of their parents about the dangers of drug, tobacco, or alcohol use. Among youths who reported having had such conversations with their parents, rates of current alcohol and cigarette use and past year and lifetime use of alcohol, cigarettes, and illicit drugs were lower than among youths who did not report such conversations.

So, where does all this leave us? These two recent reports seem to suggest that interventions that enhance the interaction of parents and their young adults do make a difference. Getting young adult patients and their parents to talk about drug use and abuse may be a great challenge, but proves necessary and effective. . . . To read the entire article, please go to

Dr. Glatt practices internal and addiction medicine in South San Francisco.

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9.      Book Review: Healthy Competition - What's Holding Back Health Care and How to Free It by Michael Cannon, & Michael D Tanner, Cato Institute, Washington, DC © 2005, ISBN 1-930865-81-3, 173 pp, $10. Part III - Underlying Diseases, Strong Medicine: Chapter 5 - Tax Policy and Health Care

Since World War II, the federal government has maintained an uneven playing field in health insurance markets. During the war, employers offered health benefits as a way to attract workers without running afoul of wartime wage controls. The federal government treated such benefits as a business expense exempt from taxation.


Eventually written into law, the tax exemption of employer-provided health insurance has two principal effects. First, it lowers the cost of employer-provided health insurance (including any medical care financed through such "insurance") relative to other goods and services. On the one hand, at a tax rate of 50 percent, purchasing $1 of goods requires $2 of pretax earnings. On the other hand, the same amount of pretax earnings buys $2 of health coverage. This preferential tax treatment makes the price of health insurance and medical care appear much lower relative to other expenditures, and encourages workers to purchase more coverage and consume more care than they otherwise would.


The second effect is that most Americans get their health insurance through employers, and most of their medical bills are paid by employers or insurers. In 2003, an estimated 60.4 percent of Americans obtained health insurance through an employer.  Already encouraged to over consume health care by distorted prices, workers are further insulated from the cost of their health care consumption because someone else is paying the bill.


Effects of the Tax Exclusion

The cost of health care has placed a steadily rising burden on employers and workers. For the past 16 years, the cost of health insurance has risen faster than both workers' earnings and inflation. Health insurance premiums for a family of four increased by more than 10 percentage points in each of the past 4 years and in at least 7 of the past 16 years. A study by Katherine Baicker and Amitabh Chandra of Dartmouth College estimates that a 10 percent increase in health premiums lowers wages by 2.3 percent, lowers a worker’s likelihood of being employed, and lowers hours worked. Another study estimates that rising health insurance premiums lead to a $1 reduction in health benefits for every $2 in reduced wages. . . .


Because employers see these higher costs in their budgets, they have attempted to constrain unnecessary spending with administrative controls that interfere with patients' medical decisions and how providers practice medicine. Employers have turned to managed care to control costs by restricting the number of providers and services eligible for coverage. In 1988, 27 percent of insured Americans were enrolled in some form of managed care plan. By 2004, that figure had risen to 95 percent. As a result, more patients must comply with bureaucratic rules over how their own health care dollars may be spent. One survey found that the strongest predictor of dissatisfaction with a health plan, as measured by unwillingness to recommend the plan to others, is lack of choice with respect to providers. In effect, managed care employs bureaucracies to constrain the consumption of patients who would constrain themselves if they were spending their own money. Managed care is a predictable outgrowth of America's overreliance on health insurance coverage.


Encouraging most Americans to purchase employer-provided health insurance has led to fewer choices both in the employer market and in the market for individual (as opposed to group) health insurance.

As noted earlier, 53 percent of workers offered employer-provided coverage have at most two options. Nearly 90 percent of companies with fewer than 200 employees offer only a single health plan. Consumers shopping in the individual health insurance market have their choices restricted by higher premiums and the necessity of paying with after-tax dollars.


The rising cost of health benefits is considered a significant factor behind wage stagnation and the reluctance of employers to hire more full-time workers. From 1989 to 2004, overall compensation rose by 12.7 percent, adjusted for inflation. But wages rose just 7.5 percent, while nonwage benefits increased 26.2 percent. Industry sectors that are most likely to offer health insurance to employees and offer the

most generous plans have suffered the biggest job losses in the past few years. Conversely, the greatest job growth has been in industries that offer few or less comprehensive health benefits.


Unlike nearly every other type of insurance, health insurance in the United States is tied to employment. When workers leave their jobs, they also leave their health benefits behind. Thus the tax exclusion

progressively decreases labor mobility and entrepreneurship by workers who fear losing health benefits. Studies have estimated that "job lock" reduces job mobility among married men by 22 percent and

married women by 33 percent and is growing.


By encouraging overreliance on health coverage, the tax exclusion leads to moral hazard. It not only encourages riskier behaviors (smoking, overeating, inactivity), it also discourages prudent behaviors (saving for future medical expenses, exercise, preventive care) by creating the expectation that one’s medical expenses are another’s responsibility.


Finally, it leavesAmericans substantially poorer. Harvard economist Martin Feldstein has estimated that the tax exclusion misallocates resources to health care that would have provided greater value if applied elsewhere. As a result, it cost Americans an estimated $126 billion in 2004.19 This amounts to a hidden tax of nearly $1,000 per household.


Despite the damage the tax exclusion does by promoting health coverage well beyond the value it provides, it enjoys considerable support. Many workers and employers oppose removing the exclusion

because doing so understandably appears to be a tax increase. Yet as Duke University professor Clark Havighurst notes, "a tax subsidy is insidious precisely because, in addition to being an off-budget public

expenditure, it can misallocate huge amounts of society’s resources, yet be entirely painless at the level of individual producers and consumers." The fact that the exclusion's $126 billion hidden tax is hidden makes it no less real.

To read the rest of Part III, Chapter 5 – Tax Policy and Health Care, please go to the Cato Bookstore: The price is only $10. At that rate, consider purchasing two or three and surprise your friends, who don't understand that government involvement in health care is destroying affordable health care, with a gift that keeps on giving. There are other excellent recent titles you may want to consider.

For Next month, read Part III: Chapter 6 - Government Health Programs

To read some of the other book reviews that are available, please go to

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10.  Hippocrates & His Kin: Just When I Thought I'd Heard It All, There Comes a New One.

Mrs. Marta came in a month or so ago to discuss not only her allergies, but also her bowel evacuation problem. She ate a lot of fiber and normally had large long stools. It became apparent that dietary changes would be difficult to implement. She stated that her stool had gotten so large that it was difficult to flush. Even with a Johnny plunger it clogged her water closet. It appeared that she emptied her entire sigmoid and left colon as one large long stool. Finally, she said the most irritating part was that the stool "slapped" against her thigh at the end of evacuation. This was a problem I couldn't recall Cecil & Loeb having discussed in their entire 2,376 page Textbook of Medicine, which we devoured as medical students. Not knowing what advice I could give, I suggested that she start the flush when her stool hit the water and perhaps both problems could be solved.

Well, she came in again last week and announced a success story. Not only did the stool flush down the sewer head first, but also so smoothly and completely that her thigh was spared the "slap." She thanked me profusely.

How can feigned Schizophrenia get you a medical discharge from the US Army?

Mr George came in for a pulmonary consultation. In going over his personal history, he related that he had spent three years in the United States Army, which he disliked so badly that he feigned schizophrenia to get out. He complained about auditory and visual hallucinations which he convince a psychiatrist were real. He was immediately given a medical discharge. He declined all service-connected benefits, was placed under the supervision of his parents and then proceeded to gainful employment. He rapidly advanced in his chosen field. He still ruminates on occasion if his subterfuge would haunt him someday, but after 18 years he feels he's home free. But still, every time there’s a fire in St Louis, he always reads the report to see if that military records facility was involved.

Running for Governor on a Tax-the-Rich Platform? The California Teachers Association is backing a candidate for governor who has promised to raise state income taxes from 9% to 11%.

Education is the largest item in the California state budget and already has had a $4.3 billion increase this year. California public schools, which spend two to three times as much educating a child than the private and parochial schools, want even more. School districts are closing schools because of decreasing enrollment saving huge tax dollars.

Since private and parochial schools score higher on achievement tests than public schools, maybe we should reduce the California public school budgets to improve quality.

How can family discord kill a parent?

Mr. Jones came in yesterday for his annual pulmonary review, chest x-ray, and pulmonary function tests in view of his 35 years of smoking. As I was completing the medical review of his family history, he told me that he was living with and taking care of his mother who was quite self sufficient for her 83 years. She had some mental lapses, which he thought were not unusual. His sister had been to visit her mother less than once a year for the past decade. After her last visit in August, she called out Adult Protective Services, who place his mother in a board and care with his sister in charge. After one week, it was too much for his sister, and she found a psychiatrist and attorney who had her declared incompetent and committed to an institution. His sister prevented my patient from visiting his mother whom he loved dearly. His mother deteriorated in just a few months to death by November 15, 2005.

His mother had frequently asked why her daughter disliked her so. All attempts at reconciliation were unsuccessful. He thinks his mother, who enjoyed her own home for 47 years before she was forced out, just gave up and died with no significant medical problems except some mild loss of memory.  He also observed that his mother was similarly estranged from her own mother in the previous generation. He stated he had observed in other cases that children treat their own parents similarly to how they observe their parents treat their grandparents.

Not a bad observation for a computer techie.

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11.  Restoring Accountability in HealthCare, Government and Society:


                      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 and register to receive one or more of these reports. There are a number of important studies on their opening page on health issues from the AARP pushing for a national formulary to N Carolina increasing Medicaid costs by nearly 50 percent. Two disasters in the making.

                      Pacific Research Institute, (, Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may subscribe at or access their health page at Just released: Foreign Government-Controlled Prescription Drug Prices May Result in 100,000 Lost Jobs to California According to New Pacific Research Institute Study at

                      The Mercatus Center at George Mason University ( is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. There are a number of excellent articles on their opening page to understand the costly effects of government regulations.

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

                      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 Be sure to read the report on Confusing Choices in Medicare? At

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to To join, go to Be sure to read Prescription for change:  Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn at

                      The Heartland Institute,, publishes the Health Care News, Conrad Meier, Managing Editor Emeritus until his untimely death last year. Be sure to read his classic "What Is Free-Market Health Care?" at

                      The Foundation for Economic Education,, 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. Remember: The more that the state plans, the more difficult planning becomes for the individual.

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

                      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 This week, read the Daily Medical Follies: "Woeful Tales from the World of Nationalized Health Care" at

                      The Independence Institute,, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter at Read about Why can't politicians in Washington, D.C. stop their compulsive spending?

                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read Martin Masse's editorial on what happens to good men when they get elected into politics?

                      The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at for an overview of the extensive research articles that are available. You may want to go directly to their health research section at Fraser Forum is a monthly review of public policy in Canada, with articles covering taxation, education, health care policy, and a wide range of other topics. Forum writers are economists, Institute research analysts, and selected authors, including those from other public policy think tanks. Click on publications, then search by Type of publication to browse Forum articles found at

                      The Heritage Foundation,, founded in 1973, is a research and educational Institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. This month catch up on Asbestos, the basis for the longest-running mass tort litigation in U.S. history, as well as the most expensive. Since the late 1960s, some 850,000 claim­ants have sued for asbestos-related injuries. The liti­gation has cost some $70 billion and 60,000 jobs, but little has gone to the truly injured. Lawyers and litiga­tion costs have consumed almost 60 percent of resources expended, and much of the rest has gone to claimants without real impairments. Yet the lawsuits are still coming, with up to $200 billion in additional claims on the horizon. Read about the efforts to take this out of the court system at

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at to obtain the foundation’s daily reports. Last week’s essay tells us: Psychics, fortune tellers, faith healers, and politicians all have something in common. To see what it is, go to You may also log on to Lew's premier free-market site at to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see; or to find out why anyone would want to be an MD today, see To read Lew's latest essay on the myth of Math and Science Shortages, go to

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

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

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of “educating for liberty.” It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. You may log on at to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the US News College rankings. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read this month’s Imprimus by Mark Steyn, Columnist for the Chicago Sun-Times, on America and the United Nations, at The last ten years of Imprimis are archived at

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Del Meyer

Del Meyer, MD, Editor & Founder

6620 Coyle Ave, Ste 122, Carmichael, CA 95608

Words of Wisdom

P. J. O’Rourke: When buying and selling are controlled by legislation, the first thing to be bought and sold are legislatures.

Mark Twain, (1866): There is no distinctly native American criminal class save Congress.

Earl Nightingale: The biggest mistake that you can make is to believe that you are working for somebody else. Job security is gone. The driving force of a career must come from the individual. Remember: Jobs are owned by the company, you own your career! 

Some Recent or Relevant Postings

CONSUMER-DRIVEN HEALTH CARE: Are Health Savings Accounts the Answer?

CLONING OF THE AMERICAN MIND - Eradicating Morality Through Education, by B. K. Eakman

THE CANCER WARD by Alexander Solzhenitsyn. Translated by Nicholas Bethel and David Burg

DOCTOR GENERIC WILL SEE YOU NOW - 33 Rules for Surviving Managed Care by Oscar London, MD,

On This Date in History – February 14

On this date in 1766, Thomas Malthus was born who argued that population increases in a geometrical ratio, unless checked, while the food supply increases in an arithmetical ratio. Scientific increases in food production have proved him wrong.

On this date, in the middle of American Heart Month, is Valentine's Day, the celebration dedicated to lovers, greeting card companies and the people that sell those heart-shaped candy boxes. Some still believe that the heart is often more right than the head.