Community For Better Health Care

Vol IV, No 22, Feb 28, 2006


In This Issue:


1.      Featured Article: Some Smokers Pay More for Health Benefits

By LISA CORNWELL, Associated Press Writer, February 16, 2006

CINCINNATI (AP) - Smokers squeezed by soaring cigarette costs and workplace smoking bans are increasingly being hit with another cost increase - this time for health insurance.

A growing number of private and public employers are requiring employees who use tobacco to pay higher premiums, hoping that will motivate more of them to stop smoking and lower health care costs for the companies and their workers.

Meijer Inc., Gannett Co., American Financial Group Inc., PepsiCo Inc. and Northwest Airlines are among the companies already charging or planning to charge smokers higher premiums. The amounts range from about $20 to $50 a month.

"With health care costs increasing by double digits in the last few years, employers are desperate to rein in costs to themselves and their employees," said Linda Cushman, senior health care strategist with Hewitt Associates, a human resources consulting and services firm.

She said the practice of smoker surcharges is becoming such a significant trend that this year, it will be part of Hewitt's annual survey of companies' current and future health care plans.

Cushman said a general benefits survey of 950 U.S.-based employers last year showed that at least 41 percent used some form of financial incentives or penalties in their health care plans.

She estimates that at least 8 percent to 10 percent of the businesses probably aimed some of the incentives or penalties at smokers and says that percentage is growing.

"With smokers costing companies about 25 percent more than nonsmokers in the area of health care, it just makes good business sense," she said. . . .

The Centers for Disease Control and Prevention estimates $92 billion in lost wages annually in the United States from smokers who die prematurely. In addition, the economic cost of smoking includes $75.5 billion per year in direct health care costs.

"In addition to employers having to pay out more in health care costs, public opinion is now solidly on the side of eliminating smoking and workers are realizing increasingly that they are having to pay for others' lifestyle choices," said Helen Darling, president of the National Business Group on Health, a nonprofit agency representing more than 200 of the nation's large employers.

Gannett Co., the nation's largest newspaper publisher, this year began charging its employees who smoke an extra $50 a month for the company's insurance coverage. "We have some strong feelings that smoking is really bad for employees, and a healthier employee is better for us," said Tara Connell, a spokeswoman for the McLean, Va.-based company.

PepsiCo Inc., based in Purchase, N.Y., has been charging employees who use tobacco $100 annually for a couple of years, and Grand Rapids, Mich.-based Meijer Inc. started charging smokers $25 a month this year. That fee is dropped if smokers complete a smoking-cessation program, said Meijer spokeswoman Judith Clark.

Cincinnati-based American Financial Group holding company and its subsidiaries waive the $37.92 monthly fee for a year if smokers make a good-faith effort and complete the company's stop-smoking program, said Scott Beeken, a vice president with the Great American Insurance Group subsidiary. If the employee starts smoking, the fee would be reinstated the next year.

About 35 workers were expected to enroll if the voluntary program had not included the financial incentive, but 325 have signed up so far. "The charge probably was a motivating factor," Beeken said.

Public employers also are requiring smokers to pay for their habit. The state of Alabama on Oct. 1 began charging $20 a month extra per employee insurance contract. The charge applies if anyone covered under a contract - such as a spouse - smokes. Georgia charges $40 a month for smokers covered under the state's health plan. Employees caught lying on their insurance form about whether they smoke could lose their insurance for a year. . . .

Employers say the surcharges are incentives rather than penalties, but that's not the way many smokers see it. . . .

Some employers have turned to even stronger measures to discourage smoking. Weyco Inc., an Okemos, Mich.-based medical benefits administrator, fires employees who smoke even if it is on their own time. . . .

To read the entire article, go to

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2.      In the News: The Maternal Brain - Does Motherhood Make Women Smarter?

Pregnancy and motherhood change the structure of the female mammal's brain, making mothers attentive to their young and better at caring for them.

By Craig Howard Kinsley and Kelly G. Lambert, who hold professorships in Neuroscience in their respective Departments of Psychology.  In Scientific American, January 6, 2006, pages 72-79.

Mothers are made, not born. Virtually all female mammals, from rats to monkeys to humans, undergo fundamental behavioral changes during pregnancy and motherhood. What was once a largely self-directed organism devoted to its own needs and survival becomes one focused on the care and well-being of its offspring. Although scientists have long observed and marveled at this transition, only now are they beginning to understand what causes it. New research indicates that the dramatic hormonal fluctuations that occur during pregnancy, birth and lactation may remodel the female brain, increasing the size of neurons in some regions and producing structural changes in others. 

Some of these sites are involved in regulating maternal behaviors such as building nests, grooming young and protecting them from predators. Other affected regions, though, control memory, learning, and responses to fear and stress. Recent experiments have shown that mother rats outperform virgins in navigating mazes and capturing prey. In addition to motivating females toward caring for their offspring, the hormone-induced brain changes may enhance a mother rat's foraging abilities, giving her pups a better chance of survival. What is more, the cognitive benefits appear to be long-lasting, persisting until the mother rats enter old age. . . .

Interestingly, once the reproductive hormones initiate the maternal response, the brain's dependency on them seems to diminish, and the offspring alone can stimulate maternal behavior. Although a newly born mammal is a demanding little creature, unappealing on many levels-it is smelly, helpless and sleeps only intermittently-the mother's devotion to it is the most motivated of all animal displays, exceeding even sexual behavior and feeding. Joan I Morrell of Rutgers has suggested that the offspring themselves may be the reward that reinforces maternal behavior. When given the choice between cocaine and newly born pups, mother rats choose pups. . . . 

To read the entire article (Subscription required), go to

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3.      International Medicine: Ethical Principles Such As Patient Autonomy Vary Outside of the USA. See ACLS: Principles and Practice, American Heart Association

There has been an increased effort in recent years to have international standards for cardiopulmonary resuscitation (CPR), basic life support (BSL), and advance cardiovascular life support (ACLS). Review of the latest handbook emphasized some important international differences as well as emphasizing the most important advance in the last 25 years, the Automated External Defibrillator or AED.

Definition of "Patient Autonomy:" The ethical principle of patient autonomy holds that every competent adult has a right to make informed, binding decisions about his/her health care. Commentators and reviewers also use the term patient ‘self-determination' in a context synonymous with patient autonomy. This principle includes the right to decide to forego CPR attempts in the event of a cardiac arrest. Most western cultures respect and honor patient autonomy as a core ethical principle. Citizens of the United States experience patient autonomy unlike any other community in the world -- patient autonomy is defined in the legal system and is enforced through laws.

Conditions for "Autonomy:" Patient autonomy requires that the patient have the ability to communicate and the mental capacity to accept or reject medial interventions, including attempted resuscitation. The "default assumption", in most western countries is that all adult patients possess autonomous decision-making capacity. In fact, in the United States a legal action-not a medical action-is required before an individual can be declared incompetent to make end-of-life decisions. In other countries competence can be established on a medical basis, such as psychiatric illness.  Legal actions and court decisions are not required. 

"Obstacles to Patient Autonomy

A number of studies over the past decades have identified numerous obstacles to the practical realization of patient autonomy. The gap between the ideal and the reality of patient autonomy remains large:

§         Failure to prepare advance directives.

To exercise their right to make decisions about their healthcare, people actually must make and express those decisions. People rarely plan for future illness. They do not enjoy talking about death or the end of life, and they do not want to prepare advance directives or discuss CPR. Consequently they do not. Physicians share the same aversions and seldom discuss advance directives, even with their seriously ill patients.

§         Failure to understand CPR and its consequences.

The public generally overestimates the probability of survival from cardiac arrest, or they overestimate the frequency of severe neurological deficits with survival. The fact is that many studies describe the quality of life for survivors of cardiac arrest as acceptable.

§         Gaps in physician knowledge

Physicians often fail to learn or understand a patient's perceptions of CPR, resuscitation outcomes, or quality of life. Discussions can also be complicated by physician misconceptions and the inability of physicians to accurately predict chances of survival from cardiac arrest.

§         Different opinions on what constitutes a "good" quality of life

Younger physicians, for example, might think an inability to remain ambulatory, active, and involved in recreation would be an unacceptably poor quality f life. Their senior patients, in contrast, might require only daily communication with friends and loved ones to  experience a "good" quality of life.

§         Surrogate decision makers not the answer

Surrogate decision makers, acting on behalf of incompetent patients, do not always reflect patient preferences. The superior approach is to establish patient preferences before a severe clinical deterioration.

§         Administrative mandates not the answer.

Current regulations mandate some attention to whether a patient being admitted to a hospital has a "living will" or an "advance directive." Although well-intentioned, the Patient Self-Determination Act of 1991 has resulted in administrative behavior that falls far short of the goals of having an advance directive in place for every patient. There is no regulatory substitute for a concerned physician sitting down with his/her patient to discuss end-of-life issues."

Patient Autonomy-"It's the Law."

"… Healthcare institutions are required to facilitate completion of advanced directives if patients desire them. The requirements were designed to encourage use of advanced directives, but there is little evidence of increased use. Advanced directives have had minimal impact on resuscitation decisions in the United States despite numerous laws and education initiative. Such laws do no exist in most other countries."

To read the entire chapter 2:  Patients, Families, and Providers: Ethical Aspects of CPR and ECC (emergency cardiovascular care), visit your local heart association. To take your BLS training (every citizen should take this course) or ACLS training (Every health care worker should take this course.), find the site nearest you at Why?

In 2000, more than 5 million people were evaluated in the U.S. Hospital Emergency Departments for Chest Pain. Of these, 2.5 million were diagnosed with acute ischemic syndrome. Of these, 1.4 million were admitted with unstable angina. Each year, 1.1 million Americans experience a myocardial infarction. Of these, 500,000 die within one year. One-half of these deaths occur within the first hour with most of these never reaching the hospital emergency departments. More than 90 percent of these deaths are caused by ventricular fibrillation, the type that can be treated in the community with the relatively new AED devices. AEDs are now found in many public and some private establishments that have CPR or BLS trained individuals on their staff that can defibrillate such an individual within three minutes. The 911 ACLS team generally arrives in 5-7 minutes, which is very fast, but may be too late to save the heart and brain. Both teams, the 911 and the in-house if there is one, however, should be called immediately when a person collapses or becomes comatose.

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4.      Medicare: [The] Elephant in the Room

Budget Wish Lists Come and Go, But 'Entitlements' Outweigh All

They Cost $3 Billion a Day, Rise 8% a Year, Leave Bush Little Room to Maneuver

By JACKIE CALMES  Staff Reporter of THE WALL STREET JOURNAL February 3, 2006

President Bush on Monday will tell the nation what he wants done with the budget next fiscal year. But the significance of his proposals and Congress's response is dwarfed by one daunting fact: Some 84 cents of every dollar the government spends is essentially committed before he and the legislators even have at it.

That is the amount that goes to three all-but-untouchable elements: interest on the federal debt; defense and homeland security; and, above all, "entitlements" programs such as Medicare, Medicaid and Social Security.

It leaves just one-sixth of spending for nearly everything else the government does domestically, from secretaries' salaries to research -- what is known in budget jargon as "discretionary" spending. 

Entitlements are the real elephant in the room. Formulas for spending on these social programs are set by law. Anyone eligible can collect. And the programs are growing far faster than either inflation or the economy, some 8% a year.

Medicare, at $391 billion this year, is close to equaling the entire domestic discretionary slice of the budget. Add in Social Security and the federal share of the state-run Medicaid program for the poor, and the big-three entitlements total $1.1 trillion for this year -- $3 billion a day. This spending is the big issue in the federal budget, not post-Katrina rebuilding, headline-grabbing pork like Alaska's ridiculed bridge to nowhere, or even the costly war in Iraq.

"The 2005 Pig Book" put out by the conservative Citizens Against Government Waste identified 13,997 earmarked projects costing $27.3 billion. Yet even if Congress repealed every one of them, it would cut just 1/100th of the budget. Meanwhile, spending on the three main entitlement programs is set to rise $93 billion in the coming fiscal year.

Similarly, Mr. Bush said in his State of the Union speech Tuesday he has identified 140 programs to cut or end. "We will save the American taxpayer another $14 billion next year," he said. He got applause, but that is 0.5% of the budget.

With so little maneuvering room, Mr. Bush, to hold down deficits, sometimes has to rob from his own domestic initiatives to fund others. In education, he now espouses new college grants for low-income math and science students, but he hasn't pushed for increased Pell grants for poor students, as he campaigned to do. And the government has less fiscal flexibility to respond to disasters like Katrina: To help pay for hurricane aid last fall, Congress cut both domestic and defense funding 1% across the board.

To trim spending in the fiscal year ending Sept. 30, Mr. Bush and Congress essentially froze discretionary domestic programs at $386 billion, according to figures from the Congressional Budget Office and the liberal Center on Budget and Policy Priorities. And that doesn't account for inflation or population growth. For next fiscal year, Mr. Bush again wants to reduce such funding below a nominal freeze that doesn't allow for inflation.

The president addressed entitlements in his State of the Union speech by calling for a bipartisan commission to offer solutions. "The rising cost of entitlements is a problem that is not going away," he said. But skeptics abound in both parties. What is missing, they say, is political will and trust. Even some supporters predict Mr. Bush will end up doing what he has vowed in nearly every stump speech that he won't: Leave these problems to a future president and Congress. In that course, he would follow President Clinton, who also hoped to shore up the popular programs but who was defeated by political paralysis.

This will not get done in this president's term," predicts Republican Rep. Jim Kolbe of Arizona, a longtime advocate of entitlements reform. Yet presidential leadership is essential, he adds, because "Congress is never going to be willing to deal with this, because the members are always up for re-election, every two years" in the case of the House.

Few dispute the staggering dimensions of the problem. Mr. Bush and analysts in and out of government use the same word to describe the fiscal trend: unsustainable.

Social Security spending now equals 4.2% of the gross domestic product, the value of all goods and services the U.S. economy produces. Under current policy, it will rise to 6.4% in 2050, according to the CBO. Medicare and Medicaid combined now are about 4.5% of GDP. Fueled both by changing demographics and by rising health costs, the health programs are projected to balloon, by 2050, to as much as 22%. Yet the entire federal budget has averaged only about 20% of GDP since the end of World War II.

Moreover, federal taxes don't cover even 20%. They average 18% of GDP -- hence the persistent budget deficits.

Budget-watchers have long used metaphors such as tsunami or iceberg to warn of the fiscal problem looming as the postwar baby-boom generation nears retirement. For 30 years, the U.S. has had a constant ratio of 3.3 workers contributing payroll taxes for every beneficiary collecting Social Security benefits, according to Social Security Administration actuaries. The ratio is now declining. By 2040, there will be just two for each retiree, the actuaries say. And many future retirees are expected to live longer than those in the past, spending about a third of their entire lives in the retirement stage.

Robert Reischauer, head of the Urban Institute think tank and a former CBO director, popularized the tsunami comparison. Now he draws a parallel to global warming, slow and nearly imperceptible. He says the nation and economy may be forced to adjust to spending more on entitlements, but doing so would bring painful dislocations and even the extinction of some beneficial programs in other parts of the budget.

The pressures are visible in the five-year window of projected spending that Mr. Bush's new budget will address. In 2008, the first of the 77 million baby boomers turn 62 and qualify for Social Security's early-retirement benefits. In 2011, the first of the wave will become eligible for Medicare. Social Security is projected to start running annual deficits by 2017. Medicare's hospital-care trust fund already is paying out more annually than it's collecting in payroll taxes.

When Mr. Bush accepted Republicans' nomination at their 2000 convention, he charged that the Clinton administration had squandered the opportunity to fix these Social Security and Medicare problems. "They have not led," he said. "We will." Mr. Bush proposed an overhaul of Social Security last year, but Congress refused to follow his lead. As for Medicare, rather than reining in its cost, Mr. Bush in 2003 signed into law a new prescription-drug benefit. It layers on massive new Medicare costs that are twice the entire value of Social Security's future promises. . .

More recently, these congressional leaders have struggled for months to muster Republican votes to pass a deficit-reduction bill lowering Medicare and Medicaid spending by almost $50 billion over 10 years. That would equal less than 0.6% of the projected spending on the two health-care programs over the coming decade. . . .

Cost-saving options on Social Security could be simple and straightforward. They include slightly increasing retirement ages; reducing annual cost-of-living increases and the formula for computing retirees' initial benefit; and expanding the amount of income subject to Social Security payroll taxes so the biggest earners pay more. Neither party will do any of this without political cover. . .

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

- Ronald Reagan

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5.      Medical Gluttony: How Can We Avoid or Diminish It? 

Mr Norman came in last week complaining that for about six weeks, since about Thanksgiving, he had been gagging, trying to remove phlegm caught in his throat. He was also short of breath. He didn't seek medical attention since he thought it was not severe and would pass. He visited his daughter in Marin County north of San Francisco about mid-January. He was unable to sleep and his daughter took him to the local "doc-in-a-box" clinic. The clinic examined him and immediately sent him to the local hospital emergency room. He thinks their concern was his heart.

He spent a half day in the emergency department undergoing all sorts of blood tests, electrocardiograms, chest x-rays, sinus x-rays and allergy evaluations. He was sent home on corticosteroids, both orally and by nasal spray. He had completed the two-week steroid burst on the day he was seen in our office.

His complaints at this time were that he was gagging on thick phlegm caught in his throat and he had shortness of breath. These symptoms were not significantly different from his problems during the Thanksgiving and Christmas season. No one had given him antibiotics for the green pus in his throat. On examination, he had forced expiratory wheezing which he had not previously appreciated. Pulmonary function tests revealed an initial expiragraph that was normal but made his wheezing worse. The second expiragraph was about two-thirds normal for his age. The third expiragraph was about one-third normal indicating rather significant bronchospastic disease consistent with asthma.  A stethoscope was no longer required to hear this wheezing.

The post bronchodilator test revealed a 100 percent improvement over his third expiragraph, which was still about two-thirds normal. He responded to a generic antibiotic and a generic bronchodilator.

Some observations:

The patient had been happy with the treatment he received at both the "doc-in-a-box" and the emergency department of his daughter’s hospital. But as his hour with me progressed, he began to realize that they had not helped him. His symptoms were unchanged and essentially still not treated.

He was very proud to have brought eight pages of information to the office for me to read. Three pages were related to an allergy program to implement in his home, one page was a complete blood count, one was a chemistry panel (kidney and liver functions - patients assume that these contain cholesterol, lipids, PSA and a host of other tests but they generally do not), one was an ECG, and there were several pages of disclosures to reduce medical liability or comply with government intrusive regulations. However, there were no x-ray reports of either his chest or sinuses. These eight pages essentially had no significant medical value for his "emergency situation" even though the costs may have been substantial.

It is difficult for us to get charges from the hospitals - perhaps because many hospital administrators receive this newsletter. However, we never mention any hospital, administrator, physician or nurse by name. Our only goal is to highlight generic problems and look at possible solutions for the benefit of the health and well being of our patients. In the Emergency Department, tests are done on a rather continuous basis. We have never seen an emergency department bill which was less than one thousand dollars an hour. We can safely assume that his six hours in the emergency room cost $5,000 or more. From past experience, we have seen HMO reimbursement for these kinds of charges at $600 to about $900.

The patient's one hour in my office included a $100 office call (anticipated reimbursement from his HMO at $60) and a $200 pulmonary function test (anticipated reimbursement from his HMO at $75). However, it yielded the diagnosis, which formed the basis of the treatment plan. The office call continues to be the most economical, appropriate, and cost effective value and charge in medicine.

When a patient obtains test in different offices, or different communities, the overview of the medical evaluation is lost. Since he allegedly had a chest x-ray, which he stated was normal, I did not repeat it even though the last one I had was obtained a year earlier. Using a patient's verbal reports in our experience can be hazardous because they may be abnormal or at least have clues to the illness being treated.

The patient was outside of the diagnostic decision-making process in the hospital but was an active participant in my office. A fixed co-payment did not reduce the charge. Only the strong arm of the insurance carrier (or in other instances the government) forcibly reduced the payment of the charges. This could have been accomplished with equal force in the free market environment with the patient in charge had there been a percentage co-payment. The hospital would then have been forced to give full disclosure at every step of the unnecessary diagnostic evaluation. The patient could have then stopped the unnecessary testing probably after he realized he had a normal chest x-ray and electrocardiogram. This would have amounted to about one-tenth the charges and thus been more effective than the strong arm of an insurance or government bureaucracy. And the hospital could have gotten paid in full for the emergency visit along with the chest x-ray and ECG. This would then have brought about transparency in hospital billing and payments that could then be understood.

Managed care with all this forcible reduction without recourse has not significantly altered the course of spiraling health care costs, despite making many insurance executives very, very wealthy.

Medicare got it right in 1965 by requiring a 20 percent co-payment on outpatient medicine. However, it was lost when they allowed the deductibles and co-payments to be insured. Deductibles and co-payments are never an insurable item.

Re-instituting percentage co-payments would solve the health care cost problem within one year.

Charges would drop and reimbursements would be reasonable.

Insurance carriers, doctors, hospitals, providers, and patients would all be happy again.

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6.      Medical Myths: Pay for Performance Will Improve Quality of Health Care

Medicare has various initiatives to encourage improved quality of care in all health care settings where Medicare beneficiaries receive their health care services, including physicians' offices and ambulatory care facilities, hospitals, nursing homes, home health care agencies and dialysis facilities.

Through these collaborative efforts, CMS (Center for Medicare and Medicaid Services) is developing and implementing a set of pay-for-performance initiatives to support quality improvement in the care of Medicare beneficiaries. In addition to the initiatives for hospitals, physicians, and physician groups described below, CMS is also exploring opportunities in nursing home care – building on the progress of the Nursing Home Quality Initiative – and is considering approaches for home health and dialysis providers as well. Finally, recognizing that many of the best opportunities for quality improvement are patient-focused and cut across settings of care, CMS is pursuing pay-for-performance initiatives to support better care coordination for patients with chronic illnesses.

The administrative costs of this needless study have not been calculated nor will they be. The decreasing quality in health care is caused by government and administrative intrusion into a medical environment envied by the entire world. Any administrative attempt to improve quality will result in a hugely expensive increase in health care costs. Physicians' clinical judgment has always kept the health care costs at the highest quality for the lowest possible cost. To mandate quality issues that may or may not be justified, will just increase the cost of an already exorbitantly expensive national health care program. It will drive health care costs out of sight, increase the drag in an efficient health care system, increase morbidity, and further jeopardize quality of care. Each unsuccessful attempt to control a smooth running health care system seems to whet bureaucratic appetite for control of the profession.

To see how this bureaucracy that doesn't understand the health care system they want to control, please scroll down to Section 8 – VOM and Dr Luther Cobb's comments on controlling that portion of health care that is relatively simple that a government employee can understand. Be sure to note the perspective that organizations that are cooperating are doing so reluctantly.

Pay for Performance Will NOT Improve Quality, but It Will Increase Health Care Costs

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7.      Overheard in the Medical Staff Lounge: Another Cause Of Homelessness-Federal Taxes

Twenty years after a flood washed away much of their lives, thousands of Yuba County California residents are getting hit by another flood-related disaster: their tax bills. . . .

Many of the victims of both floods apparently didn't know that the payouts - which ranged from a few thousand to several million dollars - were taxable, said David Shaw, a Yuba City tax expert whose practice represents several hundred of the 1986 flood victims.  . . .

But 58-year-old Johnny Wooten, who is disabled from a back injury and four hernia operations, was more resigned. Of his $75,000 settlement, about $25,000 went to lawyers and the rest he put into the bank. "I haven't touched nothing because the government scares me," he said. "I've lived here for 26 years and my house is paid for, but if you don't pay your taxes, the government can put you out on the road."

Now we know that federal taxes are another cause of homelessness.

[If 33 to 40 percent went to attorneys, with a federal marginal tax rate of 37 percent and state tax rate of 9 percent, the actual insurance benefit to the victims is on the order of 15 to 20 percent.]

The Bee's Clint Swett can be reached at (916) 321-1976 or

Locked Bedroom Door -- Cause Of Being Burned Alive – By Cigarettes

During the medical interview on discussing the family history, the patient mentioned that she lost one of her seven sons in a fire. He was living with his grandmother, her mother, in the former garage converted into a bedroom and had retired for the night. He always locked his bedroom door at night. He was having a cigarette in bed and it apparently caused a sudden and very hot fire. Her mother could not enter the bedroom because of the locked door. The fire truck responding to a 911 call had made a wrong turn, which delayed it several minutes. The garage was engulfed in flames almost immediately. When the firemen entered, her son was on fire, having apparently been burned to a cinder.

Two Rules for Living: Don't lock your bedroom door in a house where only your family members live. Don't smoke. If you must, never smoke in bed. It's a painful way of dying.

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8.      Voices of Medicine: Is There Some Level Beyond Which Our Tolerance for Intrusion Will Be Exhausted? By Luther F. Cobb, M.D., President, Humboldt-Del Norte County Medical Society

Guest editorial in Mendocino – Lake Physicians' News:

The elephants are dancing in Washington, but it's a minuet, not the jitterbug. As I write this, only two months remain until the SGR (Sustainable Growth Rate) formula is due to operate to reduce Medicare reimbursement by about 5%. As you probably know, the SGR formula links Medicare reimbursement to the gross national product, which basically has nothing to do with the growth of the Medicare population or their medical needs. The good news, we are told, is that Congress really, truly does understand that this is a bad formula and doesn't want to let this reimbursement rate fall at the level that is scheduled. The bad news is that Congress is demanding "something in return." This appears, will be Pay For Performance, or P4P for you lovers of hip-hop style acronyms.

Paying For Performance. That sounds like something we should all get behind, like apple pie, motherhood, and the flag.  (Come to think of it, even those are controversial these days). The basic underlying idea is that, as Medicare is currently run, every "provider" (I hate that word!) is reimbursed at the same rate for the same CPT–coded level of service. Of course with fudge factors added in for geographic variations, etc. (And again those are the source of much consternation as well.) So, shouldn't we reimburse the ones who do the very best work at a higher rate? Won't that save lives, add to quality, and reduce all those preventable deaths we all know are out there being killed by less competent "providers"?

Well, to re-use a very trite phrase, the devil is in the details. How exactly do we measure ‘quality"? It's not as if it is a new concept, or that physicians and lay groups haven't been trying for a very long time to do exactly that. Now, of course, if it's going to be worth MONEY, it's going to be worth a fight too. I have talked with folks at the CMA who are intimately involved with this process, including Ron Bangasser, M.D., a former CMA President and a really smart and energetic guy. It turns out that the factors they're looking at are things like hemoglobin A 1 c levels in the diabetics in your patient population, or whether patients get beta blockers, things that are pretty non-controversial and, most important of all, easily measured. I asked Ron whether they had come up with any criteria for my field of general surgery. After all, there are a lot of operations done every year on Medicare patients, a great proportion of which are done by general surgeons. Would infection rate, post-op thrombo-embolic complications, length of stay, be included? How about a careful, time-consuming plastic closure of the surgical incision, instead of staples? Wouldn‘t patients like that? Would that be quality'? Well, Ron confessed, the working groups couldn't come up with a single criterion for surgery that they thought would withstand scrutiny. So, there will be NO criteria for surgery, at least as things currently stand. Well, maybe that's a good thing. It certainly seems to me that the criteria being proposed for quality indicators have the character of the old joke about the drunken man looking under a lamppost outside a bar for his lost house keys. A similarly inebriated friend volunteered to help, and after looking fruitlessly for a while and not finding the keys, asked the fellow where he lost the keys. Halfway down the block, he was told. The question naturally followed why are you looking here? The answer, of course, was that the light was better under the lamppost. 

Because these criteria must be objective and verifiable, they almost have to be limited in impact. I also think they're highly likely to be unfair. I could be wrong, and maybe this really is the best thing that could happen. But it reminds me of the debate at the time of he original passage of the Medicare legislation. When AMA representatives expressed concern about the control that was being given up over the practice of medicine, they were reassured that "the only thing that will change will be the signature at the bottom of the check." I think we all know how that turned out. What will be reimbursed under these rules will be things that will be quantifiable and clear-cut, which will practically demand electronic medical records and data retrieval. This could well be a huge unfounded mandate, because whatever the P4P reimbursements, I really doubt they'll cover the cost of the currently available EMR systems, which still, of course, aren't interoperable. A lot of this information will go whizzing over the Internet also. Despite HIPAA, I suspect a lot of this information will get out; after all, we hear almost weekly of equally sensitive information, like credit card numbers being stolen by hackers. This criteria may be simple and straightforward now, there's a huge potential for creeping imperceptibly into more basic areas that may threaten our independence as physicians. In a lot of ways, this concept reminds me of the "No Child Left Behind" federal education legislation, which is wreaking havoc in public education as we watch from the sidelines. Just ask any public-school teacher whether "teaching to the test" is improving their students' educational performance.

So, maybe I'm just a technophobic curmudgeon. Certainly my skepticism won't be the deciding factor in whether this gets through Congress or not, because it's pretty much a done deal. I just suggest we watch out, pay attention, and consider whether there is some level beyond which our tolerance for intrusion will be exhausted.

This article had not been posted at publication time.

To read more Voices of Medicine, please go to

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9.      Book/Movie Review: "Good Night, And Good Luck"

Of Witch Hunts, Red Scares, and Guantanamo, by James J. Murtagh, M.D.

George Clooney shows that false patriotism is the first refuge of a scoundrel

Warning: movie spoiler alert. If you have not seen "Good Night, And Good Luck," consider seeing it before reading

And the {Scape}Goat shall bear upon him all their iniquities unto a Land not inhabited." (Leviticus 16:22)

Was Salem 1659 an aberration? How badly did the red scare harm our nation's security? George Clooney has produced a spectacular allegory that explains why citizens must forever be vigilant if they want to live free, and that the press must have backbone.

Clooney shows, as Miller showed previously in "The Crucible," that in desperate times, citizens are depressingly predictable, and burn for short cuts and scapegoats. Mobs lynch scapegoats, or burn them at stakes, or torture them, intern them in camps, or simply blacklist them. Good people look the other way, rationalizing desperate times make due process impossible. But when are times not desperate?

The press fears the mob, not wanting to be accused of obstructing, or being liberal, or biased in another way, or unpopular, or to lose subscriptions or advertisers. No press wants to be called a scapegoat lover, witch lover, commie lover, etc. This is how national tragedies occur. And when the press repeatedly forgets how it failed during a prior emergency, the cycle worsens.

"Good Night, And Good Luck," brilliantly shows Edward R. Morrow's fight against McCarthy. America faced the very real threat of the cold war and the nuclear arms race. However, unscrupulous McCarthy escalated risk, exploited fear, with highly sophisticated psychological scapegoating.

The scapegoat originates in Leviticus 16.  The community projected its troubles ritually on a sacrificial goat that was driven off into the wilderness on Yom Kippur Day of Atonement. Psychologically, the community may have felt better, but blaming the scapegoat was a bit of witch doctoring that only prevented real solutions from being found. 

McCarthy gained power by falsely accusing good men of being Communists. This prevented confrontation of real threats, and ultimately made a mockery of the entire problem. The scapegoating was counterproductive.

Murrow, with unflinching integrity, faced down McCarthy, his network, and his sponsors. Can anyone imagine that Murrow would not have outed the faulty intelligence that preceded the current war? Murrow, a decorated war correspondent, would never have allowed violations of the Geneva Convention.

Puritans of Salem, 1659 were every bit as terrified of witches as we are today of our adversaries. The population demanded due process be suspended.

However, if one is going to try and decide who is a good witch and who is a bad witch, one needs a definition of what a witch is. The same with the red scare. Being a card carrying-communist meant as little then as carrying an ACLU card now.

Ironically, the whole concept of law originated in of all places Iraq with the Babylonian king Hammurabi in 1780 BC. He came up with the bedrock principle of the rule of law that the accused must always face his accuser. The Hammurabi law was an alternative to scapegoating. Abraham, who lived in Babylon at the time of Hammurabi, is believed to have introduced these laws into Hebrew custom.

Hammurabi was clear. There must be due process. However, age after age somehow authority forgets this bedrock, we end up with an Inquisition, a crusade, a gulag, a concentration camp, a red scare or a witch trial.

Some claim a trade off between due process and national security is inevitable. They are dead wrong. Lack of due process always makes a society less safe. Without due process, the innocent will be locked up and the criminals will go free. To get tough on crime, we must be tough on due process. That way, we know that the truly guilty are punished. To get tough on terror, we must have scrupulous due process, and we must have probing intelligence that spares no one.

The very people who have advocated getting tough on crime have also advocated soft inquiries into intelligence failures. We must have intelligence that we can absolutely rely on that will stand up to international scrutiny. The folly of simply pointing a finger and claiming "weapons of mass destruction" has led us down a path that of great insecurity.

Indeed, if we accuse a criminal of the wrong crime, the criminal is going to get off, and the whole process will become a laughing stock, as McCarthy did. The US had real security concerns that were hugely put back by McCarthy's arrogant abuse of power, and reckless disregard for due process.

US policy makers need to see "Good Night, And Good Luck." They need to ask, do we want the rule of law, or do we want scapegoating? Due process is our best guarantee of security, and it is time we all knew it.

This review/OpEd piece is posted at To read Dr Murtagh's resume and other reviews and OpEd pieces, go to

To read more book reviews, please go to

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10.  Hippocrates & His Kin: The Emperor Is Wearing No Clothes

Pay for Performance (P4P) Incentive Programs in Healthcare: Moving Beyond the Early Stages of Market Adoption - Individual Registration Fee: $195

P4P programs continue to grow in popularity from 35 last year to 80 today. Healthcare Web Summit and the authors of the 2003 national study on provider pay for performance (P4P) programs, invite you to attend their upcoming national audio conference and web summit on 2004 study results. Twelve leading national organizations on quality and performance measurement expressed support for the study this year 

The summit will cover trends, measures used, implications, and valuable lessons learned from the experiences of 50 P4P sponsors (health plans, government, and employer coalitions). Faculty will also share insights on how P4P sponsors are leveraging their metrics for other strategic initiatives such as consumer transparency and tiered networks. 

To enroll, you may spend your money at

Since America already has the highest quality of health care in the world, entrepreneurs can make money spinning false cover-ups for unnecessary government programs like the rogues did in making the emperor's "new clothes." But will anyone be brave as the little lad who said out loud,

But The Emperor Has No Clothes.

Senior Citizens' Residences –Individuality Still Shows Through

On a recent tour of The El Camino Gardens, where a number of my patients live, the tour guide was a nonagenarian retired bank Founder and CEO, who was widowed a few years earlier. His apartment was part of the tour. It had a kitchen, spacious living room, office, bedroom and private garden. Three meals were served each day in a lovely dining room. There were private dining rooms and bedrooms for rent to residents who had visiting family or guests. There were lounges, a country store, and snack rooms to alleviate hunger pangs or just to socializing both day and night. The doors were all decorated as part of a contest. One had a simple sign: “Satisfaction is when your own children have teenagers of their own.” A number of the residents were retired widows. Some of them had compiled a book to memorialize their service to their country. These women had helped the war effort by working in defense plants across the nation while their husbands were off to fight the war. The title of their book was

“Rosie, the Riveter.”

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11.  Restoring Accountability in HealthCare, Government and Society


                      John and Alieta Eck, MDs, for their first-century solution to twenty-first century needs. With 46 million people in this country uninsured, we need an innovative solution apart from the place of employment and apart from the government. To read the rest of the story, go to and check out their history, mission statement, newsletter, and a host of other information. For their article, "Are you really insured?," go to The Eck's are busy in Antigua and Barbuda developing an innovative and comprehensive health system for the country. You may want to start planning to take a month each year to practice in this resort environment. Their medical board includes John and Alieta Eck, MDs.

                      PATMOS EmergiClinic - - where Robert Berry, MD, an emergency physician and internist practices. Here is his story: Three years ago, I left ER medicine to establish a primary care clinic in a town of about 15,000 in northeast Tennessee - primarily for the uninsured, but also for anyone willing to pay me for my care at the time of service. I named the clinic PATMOS EmergiClinic - for the island where John was exiled and an acronym for "payment at time of service." I have no third party contracts...not commercial, not Medicare, TennCare or worker's compensation. My practice today has over 6,000 patient charts. My patients are typically between 5-50 years old, but I do have a significant number of Medicare patients. A year ago, over 95 percent of the patients I saw had no insurance. Today, that figure may be 75 percent. But even those with insurance learn a simple lesson when they come to me: health insurance does not equal healthcare, at least not at my clinic. I clearly tell my patients how much a visit will cost. Everything is up front and honest. I will prepare a billing claim for my patients with insurance, for a small fee, but I expect them to pay me when I see them. Because I need only one employee in my office, my costs are low. For the same services, I charge about 60 percent of charges made by other local clinics, 40 percent of what the local urgent care clinic charges and less than 20 percent of what the local ER charges. I am the best bargain in town. My income last year was about average of an ER doc - not great - but I'm free and having fun. If I can do it, caring for the uninsured in a small rural town, any doctor can.

                      PRIVATE NEUROLOGY is a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. Dr Huntoon does not allow any HMO or government interference in your medical care. "Since I am not forced to use CPT codes and ICD-9 codes (coding numbers required on claim forms) in our practice, I have been able to keep our fee structure very simple." I have no interest in "playing games" so as to "run up the bill." My goal is to provide competent, compassionate, ethical care at a price that patients can afford. I also believe in an honest day's pay for an honest day's work. Please Note that PAYMENT IS EXPECTED AT THE TIME OF SERVICE. Private Neurology also guarantees that medical records in our office are kept totally private and confidential - in accordance with the Oath of Hippocrates. Since I am a non-covered entity under HIPAA, your medical records are safe from the increased risk of disclosure under HIPAA law.

                      Michael J. Harris, MD - - an active member in the American Urological Association, Association of American Physicians and Surgeons, Societe' Internationale D'Urologie, has an active cash'n carry practice in urology in Traverse City, Michigan. He has no contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is nationally recognized for his medical care system reform initiatives. To understand that Medical Bureaucrats and Administrators are basically Medical Illiterates telling the experts how to practice medicine, be sure to savor his article on "Administrativectomy: The Cure For Toxic Bureaucratosis" at

                      Dr Vern Cherewatenko concerning success in restoring private-based medical practice which has grown internationally through the SimpleCare model network. Dr Vern calls his practice PIFATOS - Pay In Full At Time Of Service, the "Cash-Based Revolution." The patient pays in full before leaving. Because doctor charges are anywhere from 25–50 percent inflated due to administrative costs caused by the health insurance industry, you'll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year! To read the rest of the story, go to

                      Dr David MacDonald started Liberty Health Group. To compare the traditional health insurance model with the Liberty high-deductible model, go to There is extensive data available for your study. Dr Dave is available to speak to your group on a consultative basis.

                      Madeleine Pelner Cosman, JD, PhD, Esq, has made important efforts in restoring accountability in health care. She has now published her important work, Who Owns Your Body. To read a review, go to Please go to to view some of her articles that highlight the government's efforts in criminalizing medicine. For other OpEd articles that are important to the practice of medicine and health care in general, click on her name at

                      David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at To read his "Lessons from the Past," go to For additional articles, such as the cost of Single Payer, go to; for Health Care Inflation, go to

                      Dr Richard B Willner, President, Center Peer Review Justice Inc, states: We are a group of healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have experienced and/or witnessed the tragedy of the perversion of medical peer review by malice and bad faith. We have seen the statutory immunity, which is provided to our "peers" for the purposes of quality assurance and credentialing, used as cover to allow those "peers" to ruin careers and reputations to further their own, usually monetary agenda of destroying the competition. We are dedicated to the exposure, conviction, and sanction of any and all doctors, and affiliated hospitals, HMOs, medical boards, and other such institutions, who would use peer review as a weapon to unfairly destroy other professionals. Read the rest of the story, as well as a wealth of information, at Be sure to visit their site to get an update on their response to the Hurricane and new phone numbers.

                      Semmelweis Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD, FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD, Secretary-Treasurer; is named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician who has been hailed as the savior of mothers. He noted maternal mortality of 25-30 percent in the obstetrical clinic in Vienna. He also noted that the first division of the clinic run by medical students had a death rate 2-3 times as high as the second division run by midwives. He also noticed that medical students came from the dissecting room to the maternity ward. He ordered the students to wash their hands in a solution of chlorinated lime before each examination. The maternal mortality dropped, and by 1848 no women died in childbirth in his division. He lost his appointment the following year and was unable to obtain a teaching appointment Although ahead of his peers, he was not accepted by them. When Dr Verner Waite received similar treatment from a hospital, he organized the Semmelweis Society with his own funds using Dr Semmelweis as a model: To read the article he wrote at my request for Sacramento Medicine when I was editor in 1994, see To see Attorney Sharon Kime's response, as well as the California Medical Board response, see Scroll down to read some very interesting letters to the editor from the Medical Board of California, from a member of the MBC, and from Deane Hillsman, MD. To view some horror stories of atrocities against physicians and how organized medicine still treats this problem, and now similar stories in the US military, please go to

                      Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP), is making efforts in Protecting, Preserving, and Promoting the Rights, Freedoms and Responsibilities of Patients and Health Care Professionals. For more information, go to

                      Robert J Cihak, MD, former president of the AAPS, and Michael Arnold Glueck, M.D, write an informative Medicine Men column at NewsMax. Please log on to review the last five weeks' topics or click on archives to see the last two years' topics at This week's column The Health of the Union Doesn't Include Health Care can be found at  

                      The Association of American Physicians & Surgeons (, The Voice for Private Physicians Since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians.  Be sure to scroll down on the left to departments and click on News of the Day to understand the dynamic changes in who is working for doctors and their patients and who is working with the government against us. The "AAPS News," written by Jane Orient, MD, and archived on this site, provides valuable information on a monthly basis. Be sure to read this months news on Unhealthy Competition at Scroll further to the official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents page of the current issue, or go directly to

                      Plan now to attend the AAPS 63rd Annual Meeting in Phoenix, AZ.
September 13-16, 2006. For more information, go to


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Please note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

ALSO NOTE: MedicalTuesday receives no government, foundation, or private funds. The entire cost of the website URLs, website posting, distribution, managing editor, email editor, and the twenty hours per week of writing is solely paid for and donated by the Founding Editor, while continuing his Pulmonary Practice, as a service to his patients, his profession, and in the public interest for his country.


Del Meyer       

Del Meyer, MD, CEO & Founder

6620 Coyle Avenue, Ste 122, Carmichael, CA 95608

Words of Wisdom

Voltaire (1764) The art of government consists of taking as much money as possible from one party of citizens to give to the other.

Pericles (430 BC) Just because you do not take an interest in politics doesn't mean politics won't take an interest in you.

Mark Twain (1866) No man's life, liberty, or property is safe while the legislature is in session.

Ronald Reagan The government is like a baby's alimentary canal . . . with a happy appetite at one end and no responsibility at the other.

Some Recent or Relevant Postings

THE BEST OF MEDICAL HUMOR - A Collection of Articles, Essays, Poetry, and Letters Published in the Medical Literature, 2nd Edition, By Howard J Bennett, MD, Hanley & Belfus, Inc., 1997, Philadelphia, 181 pp.

AGE RIGHT - Turn Back the Clock with a Proven Personalized Antiaging Program by Karlis Ullis, MD, with Greg Ptacek, Simon & Schuster, New York, 1999, 320 pp, $23. ISBN 0-684-84197-5.

DOCTORING - The Nature of Primary Care Medicine by Eric J Cassell, MD. Oxford University Press, New York, Oxford, 1997, 206 pages, $24.

HEALTH INSURANCE UNDERWRITER, The Provider’s Perspective by Del Meyer, MD, February 2006,

On This Date in History – February 28

On this date in 1882, Geraldine Farrar was born. Even in American, there was an ingrained prejudice against American opera singers, that many felt it necessary to change their names to sound Italian in order to be accepted on the operatic stage. Geraldine Farrar became so glamorous an American opera star that she paved the way for an end of a senseless prejudice.

On this date in 1854, the Republican Party was founded with a common cause, the abolition of slavery.

On this date in 1901, Linus Pauling was born. He was a renowned scientist, humanitarian, and advocate of vitamin C, as well as searching for cures for cancer and heart disease.

On this date in 1915, Zero Mostel was born. He was best known for his starring role as Tevye in the Broadway musical Fiddler on the Roof.

On this date in 1940, Mario Andretti was born.  He was known as a champion racecar driver.