Community For Better Health Care

Vol VII, No 3, May 13, 2008


In This Issue:

1.                  Featured Article: The Morality of Admitting so many Students to Classes they cannot Pass

2.                  In the News: Lean is Invading Health Care

3.                  International Medicine: The Private Cost of Public Queues

4.                  Medicare: Medicare spending will consume nearly the entire federal budget by 2082.

5.                  Medical Gluttony: Sacramento Hospitals Bulking Up

6.                  Medical Myths: Government can control disasters.

7.                  Overheard in the Medical Staff Lounge: Physicians need help in reducing health care costs

8.                  Voices of Medicine: Mixed feelings after lecturing for Saudis

9.                  From the Physician Patient Bookshelf: False Hopes

10.              Hippocrates & His Kin: A New Way to Cut Health Care Costs

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

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The Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable 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 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. The third year it was 50 percent, indicating open forums such as these are critically important. The 4th Annual World Health Congress was held April 22-24, 2007 in Washington, D.C. That year, many of the world leaders in healthcare concluded that top-down reforming of health care, whether by government or insurance carrier, is not and will not work. We have to get the physicians out of the trenches because reform will require physician involvement. The 5th Annual World Health Care Congress was held April 21-23, 2008 in Washington, D.C. Physicians were present on almost all the platforms and panels. This year, it was the industry leaders that gave the most innovated mechanisms to bring health care spending under control. The solution to our health care problems is emerging at this ambitious congress. Plan to participate: The 6th Annual World Health Care Congress will be held April 14-16, 2009 in Washington, D.C. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2008. The 5th Annual World Health Care Congress – Europe 2009 will meet in Brussels, May 13-14, 2009. For more information, visit The future is occurring NOW.

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1.      Featured Article:  The Morality of Admitting so many Students to Classes they cannot Pass
Atlantic Monthly June 2008

In the Basement of the Ivory Tower by Professor X

The idea that a university education is for everyone is a destructive myth. An instructor at a "college of last resort" explains why.

I work part-time in the evenings as an adjunct instructor of English. I teach two courses, Introduction to College Writing (English 101) and Introduction to College Literature (English 102), at a small private college and at a community college. The campuses are physically lovely - quiet havens of ornate stonework and columns, Gothic Revival archways, sweeping quads, and tidy Victorian scalloping. Students chat or examine their cell phones or study languidly under spreading trees. Balls click faintly against bats on the athletic fields. Inside the arts and humanities building, my students and I discuss Shakespeare, Dubliners, poetic rhythms, and Edward Said. We might seem, at first glance, to be enacting some sort of college idyll. We could be at Harvard. But this is not Harvard, and our classes are no idyll. Beneath the surface of this serene and scholarly mise-en-scène roil waters of frustration and bad feeling, for these colleges teem with students who are in over their heads.

I work at colleges of last resort. For many of my students, college was not a goal they spent years preparing for, but a place they landed in. Those I teach don't come up in the debates about adolescent overachievers and cutthroat college admissions. Mine are the students whose applications show indifferent grades and have blank spaces where the extracurricular activities would go. They chose their college based not on the U.S. News & World Report rankings but on MapQuest; in their ideal academic geometry, college is located at a convenient spot between work and home. I can relate, for it was exactly this line of thinking that dictated where I sent my teaching résumé.

Some of their high-school transcripts are newly minted, others decades old. Many of my students have returned to college after some manner of life interregnum: a year or two of post-high-school dissolution, or a large swath of simple middle-class existence, 20 years of the demands of home and family. They work during the day and come to class in the evenings. I teach young men who must amass a certain number of credits before they can become police officers or state troopers, lower-echelon health-care workers who need credits to qualify for raises, and municipal employees who require college-level certification to advance at work.

My students take English 101 and English 102 not because they want to but because they must. Both colleges I teach at require that all students, no matter what their majors or career objectives, pass these two courses. For many of my students, this is difficult. Some of the young guys, the police-officers-to-be, have wonderfully open faces across which play their every passing emotion, and when we start reading "Araby" or "Barn Burning," their boredom quickly becomes apparent. They fidget; they prop their heads on their arms; they yawn and sometimes appear to grimace in pain, as though they had been tasered. Their eyes implore: How could you do this to me?

The goal of English 101 is to instruct students in the sort of expository writing that theoretically will be required across the curriculum. My students must venture the compare-and-contrast paper, the argument paper, the process-analysis paper (which explains how some action is performed - as a lab report might), and the dreaded research paper, complete with parenthetical citations and a listing of works cited, all in Modern Language Association format. In 102, we read short stories, poetry, and Hamlet, and we take several stabs at the only writing more dreaded than the research paper: the absolutely despised Writing About Literature.

Class time passes in a flash - for me, anyway, if not always for my students. I love trying to convey to a class my passion for literature, or the immense satisfaction a writer can feel when he or she nails a point. When I am at my best, and the students are in an attentive mood - generally, early in the semester - the room crackles with positive energy. Even the cops-to-be feel driven to succeed in the class, to read and love the great books, to explore potent themes, to write well.

The bursting of our collective bubble comes quickly. A few weeks into the semester, the students must start actually writing papers, and I must start grading them. Despite my enthusiasm, despite their thoughtful nods of agreement and what I have interpreted as moments of clarity, it turns out that in many cases it has all come to naught.

Remarkably few of my students can do well in these classes. Students routinely fail; some fail multiple times, and some will never pass, because they cannot write a coherent sentence.

In each of my courses, we discuss thesis statements and topic sentences, the need for precision in vocabulary, why economy of language is desirable, what constitutes a compelling subject. I explain, I give examples, I cheerlead, I cajole, but each evening, when the class is over and I come down from my teaching high, I inevitably lose faith in the task, as I'm sure my students do. I envision the lot of us driving home, solitary scholars in our cars, growing sadder by the mile. . .

I wonder, sometimes, at the conclusion of a course, when I fail nine out of 15 students, whether the college will send me a note either (1) informing me of a serious bottleneck in the march toward commencement and demanding that I pass more students, or (2) commending me on my fiscal ingenuity - my high failure rate forces students to pay for classes two or three times over.

What actually happens is that nothing happens. I feel no pressure from the colleges in either direction. My department chairpersons, on those rare occasions when I see them, are friendly, even warm. They don't mention all those students who have failed my courses, and I don't bring them up. There seems, as is often the case in colleges, to be a huge gulf between academia and reality. No one is thinking about the larger implications, let alone the morality, of admitting so many students to classes they cannot possibly pass. The colleges and the students and I are bobbing up and down in a great wave of societal forces - social optimism on a large scale, the sense of college as both a universal right and a need, financial necessity on the part of the colleges and the students alike, the desire to maintain high academic standards while admitting marginal students - that have coalesced into a mini-tsunami of difficulty. No one has drawn up the flowchart and seen that, although more-widespread college admission is a bonanza for the colleges and nice for the students and makes the entire United States of America feel rather pleased with itself, there is one point of irreconcilable conflict in the system, and that is the moment when the adjunct instructor, who by the nature of his job teaches the worst students, must ink the F on that first writing assignment.

Recently, I gave a student a failing grade on her research paper. She was a woman in her 40s; I will call her Ms. L. She looked at her paper, and my comments, and the grade. "I can't believe it," she said softly. "I was so proud of myself for having written a college paper."

From the beginning of our association vis-à-vis the research paper, I knew that there would be trouble with Ms. L.

When I give out this assignment, I usually bring the class to the college library for a lesson on Internet-based research. I ask them about their computer skills, and some say they have none, fessing up to being computer illiterate and saying, timorously, how hopeless they are at that sort of thing. It often turns out, though, that many of them have at least sent and received e-mail and Googled their neighbors, and it doesn't take me long to demonstrate how to search for journal articles in such databases as Academic Search Premier and JSTOR.

Ms. L., it was clear to me, had never been on the Internet. She quite possibly had never sat in front of a computer. The concept of a link was news to her. She didn't know that if something was blue and underlined, you could click on it. She was preserved in the amber of 1990, struggling with the basic syntax of the World Wide Web. She peered intently at the screen and chewed a fingernail. She was flummoxed.

I had responsibilities to the rest of my students, so only when the class ended could I sit with her and work on some of the basics. It didn't go well. She wasn't absorbing anything. The wall had gone up, the wall known to every teacher at every level: the wall of defeat and hopelessness and humiliation, the wall that is an impenetrable barrier to learning. She wasn't hearing a word I said.

"You might want to get some extra help," I told her. "You can schedule a private session with the librarian."

"I'll get it," she said. "I just need a little time."

"You have some computer-skills deficits," I told her. "You should address them as soon as you can." I don't have cause to use much educational jargon, but deficits has often come in handy. It conveys the seriousness of the situation, the student's jaw-dropping lack of ability, without being judgmental. I tried to jostle her along. "You should schedule that appointment right now. The librarian is at the desk. "

"I realize I have a lot of work to do," she said.

Our dialogue had turned oblique, as though we now inhabited a Pinter play. . . .

At our next meeting after class in the library, Ms. L. asked me whether she could do her paper on abortion. What exactly, I asked, was the historical controversy? Well, she replied, whether it should be allowed. She was stuck, I realized, in the well-worn groove of assignments she had done in high school. I told her that I thought the abortion question was more of an ethical dilemma than a historical controversy.

"I'll have to figure it all out," she said.

She switched her topic a half-dozen times; perhaps it would be fairer to say that she never really came up with one. I wondered whether I should just give her one, then decided against it. Devising a topic was part of the assignment.

"What about gun control?" she asked.

I sighed. You could write, I told her, about a particular piece of firearms-related legislation. Historians might disagree, I said, about certain aspects of the bill's drafting. Remember, though, the paper must be grounded in history. It could not be a discussion of the pros and cons of gun control.

"All right," she said softly.

Needless to say, the paper she turned in was a discussion of the pros and cons of gun control. At least, I think that was the subject. There was no real thesis. The paper often lapsed into incoherence. Sentences broke off in the middle of a line and resumed on the next one, with the first word inappropriately capitalized. There was some wavering between single- and double-spacing. She did quote articles, but cited only databases - where were the journals themselves? The paper was also too short: a bad job, and such small portions.

"I can't believe it," she said when she received her F. "I was so proud of myself for having written a college paper."

She most certainly hadn't written a college paper, and she was a long way from doing so. Yet there she was in college, paying lots of tuition for the privilege of pursuing a degree, which she very likely needed to advance at work. Her deficits don't make her a bad person or even unintelligent or unusual. Many people cannot write a research paper, and few have to do so in their workaday life. But let's be frank: she wasn't working at anything resembling a college level.

I gave Ms. L. the F and slept poorly that night. Some of the failing grades I issue gnaw at me more than others. In my ears rang her plaintive words, so emblematic of the tough spot in which we both now found ourselves. Ms. L. had done everything that American culture asked of her. She had gone back to school to better herself, and she expected to be rewarded for it, not slapped down. She had failed not, as some students do, by being absent too often or by blowing off assignments. She simply was not qualified for college. What exactly, I wondered, was I grading? I thought briefly of passing Ms. L., of slipping her the old gentlewoman's C-minus. But I couldn't do it. It wouldn't be fair to the other students. By passing Ms. L., I would be eroding the standards of the school for which I worked. Besides, I nurse a healthy ration of paranoia. What if she were a plant from The New York Times doing a story on the declining standards of the nation's colleges? In my mind's eye, the front page of a newspaper spun madly, as in old movies, coming to rest to reveal a damning headline:


Illiterate Mess Garners ‘Average' Grade

Adjunct Says Student ‘Needed' to Pass, ‘Tried Hard'

No, I would adhere to academic standards, and keep myself off the front page.

We think of college professors as being profoundly indifferent to the grades they hand out. My own professors were fairly haughty and aloof, showing little concern for the petty worries, grades in particular, of their students. There was an enormous distance between students and professors. The full-time, tenured professors at the colleges where I teach may likewise feel comfortably separated from those whom they instruct. Their students, the ones who attend class during daylight hours, tend to be younger than mine. Many of them are in school on their parents' dime. Professors can fail these young people with emotional impunity because many such failures are the students' own fault: too much time spent texting, too little time with the textbooks.

But my students and I are of a piece. I could not be aloof, even if I wanted to be. Our presence together in these evening classes is evidence that we all have screwed up. I'm working a second job; they're trying desperately to get to a place where they don't have to. All any of us wants is a free evening. Many of my students are in the vicinity of my own age. Whatever our chronological ages, we are all adults, by which I mean thoroughly saddled with children and mortgages and sputtering careers. We all show up for class exhausted from working our full-time jobs. We carry knapsacks and briefcases overspilling with the contents of our hectic lives. We smell of the food we have eaten that day, and of the food we carry with us for the evening. We reek of coffee and tuna oil. The rooms in which we study have been used all day, and are filthy. Candy wrappers litter the aisles. We pile our trash daintily atop filled garbage cans.

During breaks, my students scatter to various corners and niches of the building, whip out their cell phones, and try to maintain a home life. Burdened with their own assignments, they gamely try to stay on top of their children's. Which problems do you have to do? … That's not too many. Finish that and then do the spelling … No, you can't watch Grey's Anatomy.

Adult education, nontraditional education, education for returning students - whatever you want to call it - is a substantial profit center for many colleges. Like factory owners, school administrators are delighted with this idea of mounting a second shift of learning in their classrooms, in the evenings, when the full-time students are busy with such regular extracurricular pursuits of higher education as reading Facebook and playing beer pong. If colleges could find a way to mount a third, graveyard shift, as Henry Ford's Willow Run did at the height of the Second World War, I believe that they would.

There is a sense that the American workforce needs to be more professional at every level. Many jobs that never before required college now call for at least some post-secondary course work. School custodians, those who run the boilers and spread synthetic sawdust on vomit, may not need college - but the people who supervise them, who decide which brand of synthetic sawdust to procure, probably do. There is a sense that our bank tellers should be college educated, and so should our medical-billing techs, and our child-welfare officers, and our sheriffs and federal marshals. We want the police officer who stops the car with the broken taillight to have a nodding acquaintance with great literature. And when all is said and done, my personal economic interest in booming college enrollments aside, I don't think that's such a boneheaded idea. Reading literature at the college level is a route to spacious thinking, to an acquaintance with certain profound ideas, that is of value to anyone. Will having read Invisible Man make a police officer less likely to indulge in racial profiling? Will a familiarity with Steinbeck make him more sympathetic to the plight of the poor, so that he might understand the lives of those who simply cannot get their taillights fixed? Will it benefit the correctional officer to have read The Autobiography of Malcolm X? The health-care worker Arrowsmith? Should the child-welfare officer read Plath's "Daddy"? Such one-to-one correspondences probably don't hold. But although I may be biased, being an English instructor and all, I can't shake the sense that reading literature is informative and broadening and ultimately good for you. If I should fall ill, I suppose I would rather the hospital billing staff had read The Pickwick Papers, particularly the parts set in debtors' prison. . .

Sending everyone under the sun to college is a noble initiative. Academia is all for it, naturally. Industry is all for it; some companies even help with tuition costs. Government is all for it; the truly needy have lots of opportunities for financial aid. The media applauds it - try to imagine someone speaking out against the idea. To oppose such a scheme of inclusion would be positively churlish. But one piece of the puzzle hasn't been figured into the equation, to use the sort of phrase I encounter in the papers submitted by my English 101 students. The zeitgeist of academic possibility is a great inverted pyramid, and its rather sharp point is poking, uncomfortably, a spot just about midway between my shoulder blades.

For I, who teach these low-level, must-pass, no-multiple-choice-test classes, am the one who ultimately delivers the news to those unfit for college: that they lack the most-basic skills and have no sense of the volume of work required; that they are in some cases barely literate; that they are so bereft of schemata, so dispossessed of contexts in which to place newly acquired knowledge, that every bit of information simply raises more questions. They are not ready for high school, some of them, much less for college.

I am the man who has to lower the hammer.

We may look mild-mannered, we adjunct instructors, but we are academic button men. I roam the halls of academe like a modern Coriolanus bearing sword and grade book, "a thing of blood, whose every motion / Was timed with dying cries."

I knew that Ms. L.'s paper would fail. I knew it that first night in the library. But I couldn't tell her that she wasn't ready for an introductory English class. I wouldn't be saving her from the humiliation of defeat by a class she simply couldn't handle. I'd be a sexist, ageist, intellectual snob.

In her own mind, Ms. L. had triumphed over adversity. In her own mind, she was a feel-good segment on Oprah. Everyone wants to triumph. But not everyone can - in fact, most can't. If they could, it wouldn't be any kind of a triumph at all. Never would I want to cheapen the accomplishments of those who really have conquered college, who were able to get past their deficits and earn a diploma, maybe even climbing onto the college honor roll. That is truly something.

One of the things I try to do on the first night of English 102 is relate the literary techniques we will study to novels that the students have already read. I try to find books familiar to everyone. This has so far proven impossible. My students don't read much, as a rule, and though I think of them monolithically, they don't really share a culture. To Kill a Mockingbird? Nope. (And I thought everyone had read that!) Animal Farm? No. If they have read it, they don't remember it. The Outsiders? The Chocolate War? No and no. Charlotte's Web? You'd think so, but no. So then I expand the exercise to general works of narrative art, meaning movies, but that doesn't work much better. Oddly, there are no movies that they all have seen - well, except for one. They've all seen The Wizard of Oz. Some have caught it multiple times. So we work with the old warhorse of a quest narrative. The farmhands' early conversation illustrates foreshadowing. The witch melts at the climax. Theme? Hands fly up. Everybody knows that one - perhaps all too well. Dorothy learns that she can do anything she puts her mind to and that all the tools she needs to succeed are already within her. I skip the denouement: the intellectually ambitious scarecrow proudly mangles the Pythagorean theorem and is awarded a questionable diploma in a dreamland far removed from reality. That's art holding up a mirror all too closely to our own poignant scholarly endeavors.

To read the entire article, go to 

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2.      In the News: Lean is Invading Health Care by James P. Womack

How do we judge the progress of the Lean Movement? One critical indicator is our success in extending lean thinking to new industries and activities. In recent years, I have been greatly encouraged that lean thinking is moving far beyond its origins in manufacturing to distribution, retailing, maintenance and overhaul, consumer services, construction, and – perhaps most striking – healthcare. Indeed, the latter may be the most energetic area of lean practice today.

However, I have been concerned about our prospects for changing the thinking of investors, and specifically the giant private-equity investment firms that now control large parts of the economy. While we have gained a strong foothold in financial services, this has been at the operating level. Most efforts to date have focused on how value streams within financial firms can be made lean -- for example, those for processing loans or making credit checks. This is important work but it is on a different level from how financial firms think about investments and specifically how they might instigate lean transformations in the firms they control in many industries.

I was therefore delighted recently when I was contacted by one of the largest private-equity firms, an organization with dozens of firms in its investment portfolio garnering perhaps 100 billion dollars in total sales. This type of firm pools private investment funds to buy companies, in hopes of quick "turnarounds" with re-sale of these firms at much higher prices.

The partner contacting me noted that conditions in this industry have changed with the credit crisis and weak equities markets. Instead of selling firms after two or three years it may be necessary to hold onto them for a long time, even a decade, before they can be sold to advantage. His question was a simple one: "Given that we may now need to hold firms for many years, how can we take the long view. Indeed, how can we turn firms into the ‘Toyota' of their industries in order to maximize their price when they are sold?"

I was delighted to engage in this conversation. But to avoid any misunderstanding I needed to start by comparing a traditional private equity "turnaround" with a "lean transformation". In the former, the objective to this point has been to go quickly to produce a dramatic bottom-line result. This has often meant:

• "Rolling up" two or more companies in the same industry to reduce competition and increase prices to consumers.

• Negotiating lower wages and benefits.

• Cutting spending on long-term development projects not critical to the firm's strategic plan.

• Reducing headcounts in activities judged non-essential.

• Restructuring the balance sheet to add bank debt, often creating instant dividends for the private equity firm but high levels of long-term debt for the firm once it is sold.

• Re-negotiating prices with suppliers, on threat of loss of business.

These actions quickly shift wealth from customers, employees, suppliers, and former owners to the new owners. This may do more good than harm, because otherwise the firm in question may completely fail. But it is often unclear that any additional value has been created in the sense of better satisfying customer needs with a given amount of human effort and capital investment. And, from society's standpoint, the only way to increase living standards is to change the ratio of human effort and capital going into firms to the amount of value coming out. Otherwise the outcome is basically zero- sum, with some winners and some losers.

By contrast, the objective of a lean transformation is to analyze the core value creating processes of organizations in light of customer needs (which may have changed), then figure out how to create more value with the same resources so the organizations can grow and society can prosper. It's the difference between shifting wealth from one party to another and creating more value, ideally value that can be shared with customers, employees, suppliers and owners. (Note that I never use the term "adding value" because this is an accounting convention for the difference between the input costs of a firm and its output prices. Often I find that only cost is added by the firm as inputs are converted to outputs, not value from the customer's standpoint.)

I was relieved that after a frank discussion of the differences between traditional and "lean" private equity, the firm in question was still interested in pursuing lean. Indeed, this firm has now launched a wide range of experiments to "lean" the processes of its portfolio firms, and other private equity firms are now following its lead. It is far too soon to know how much progress will be made along this new path. But I'm heartened that an industry I feared I would never hear from is now actually listening.

As I always tell audiences, managers (and owners) will try anything that is quick and easy even if it doesn't work (e.g. many of the traditional methods of private equity in the current environment) before they try anything long and hard that does work (e.g. intense process analysis linked to customer needs to create more value from the same resources.) So perhaps the massive private-equity industry, by virtue of the recent shifts in the global economy, is now ready to tackle long, hard things which do work.

James P. Womack

Founder and Chairman

Lean Enterprise Institute

P.S. As I travel to visit companies and make presentations on lean thinking, I am bemused by the perception that LEI is a private consulting firm. While our faculty members and authors make most of their living in independent consulting businesses, LEI itself is a non-profit organization with no owners and no consulting contracts. We are chartered to teach courses, hold management seminars, write and publish books and workbooks, and organize public and private conferences. We use the surplus revenues from these activities to conduct research projects and to support other lean initiatives such as the Lean Education Academic Network ( and the Lean Global Network ( Our activities are a continuation of the educational work I did for many years at MIT, directly across the street from our LEI office in Cambridge, MA.

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3.      International Medicine: The Private Cost of Public Queues by Nadeem Esmail

This past October, The Fraser Institute released its seventeenth annual measurement of waiting times for medically necessary treatments in Canada (Esmail and Walker with Bank, 2007). This most recent measurement shows that the national median waiting time from appointment with a specialist to treatment rose slightly from 9.0 weeks in 2006 to 9.1 weeks in 2007. Put simply, the impact of waiting times from specialist to treatment on Canadians in 2007 was similar to that in 2006.

But the measurement of waiting times, or the examination of the absolute delay Canadians must endure in order to receive medically necessary care, is only one way of looking at the burden of waiting for health care. We can also calculate the privately borne cost of waiting: the value of time that is lost while waiting for treatment. While the absolute delay Canadians endured in 2007 was similar to that in 2006, it is entirely possible that the value Canadians place on time has changed over the past year in such a way that a marked change in the impact of wait times for treatment has taken place.

The privately borne cost of waiting for care

One way of estimating the privately borne cost of care in Canada was originally developed by Steven Globerman and Lorna Hoye (1990).They calculated the cost of waiting by estimating the amount of time that could not be used productively by a patient while he was waiting for treatment.

Globerman and Hoye's methodology is relatively simple. First, the number of patients who are waiting for treatment is multiplied by the wait times for those treatments in order to derive an estimate of the total number of weeks all patients will spend waiting for care.  This value is then multiplied by a measure of the proportion of time spent waiting for treatment that is rendered unproductive by the physical and emotional impact of an untreated medical condition. The monetary value of this lost productive time is then estimated.  In 2007, an estimated 827,429 Canadians were waiting for care after an appointment with a specialist (table 1).

These Canadians waited, on average, 9.1 weeks for treatment though those wait times varied               significantly when broken down by province and medical specialty (table 2). Multiplying the number of Canadians waiting in each of the 12 medical specialties in each of the 10 provinces by the weighted median wait time for that medical specialty in that province gives a rough estimate of the total amount of time that Canadians waited for treatment in 2007: about 9.99 million weeks this year. This estimate is slightly greater than the estimate of 9.86 million weeks for 2006 (Esmail, 2006).   

Globerman and Hoye's original estimate for the cost of waiting, which came from responses to a survey of physicians, used specialty-specific measures of the proportion of patients who were "experiencing significant difficulty in carrying on their work or daily duties as a result of their medical condition." The proportions they estimated ranged from 14% of patients in gynaecology to 88% in cardiovascular surgery, and averaged 41% overall (Globerman and Hoye, 1990; Esmail and Walker with Bank, 2007). However, the estimates of lost productivity measured by Globerman and Hoye cannot necessarily be applied today because of advances in the medical system's ability to deal with pain and discomfort through pharmaceuticals. These advances may allow many Canadians who are suffering significant difficulties to function at a higher level today than they would have in 1990, or even to maintain their normal activity levels. For this reason, this author's estimation of the cost of waiting in 2007 uses a Statistics Canada finding that 11.0% of people were adversely affected by their wait for non-emergency surgery in 2005 (Statistics Canada, 2006). This percentage is below even the lowest specialty specific measure estimated by Globerman and Hoye (1990).


An assumption that 11.0% of people waiting for treatment in 2007 experienced significant difficulties in their daily lives as a result of their medical condition, and thus lost productivity while waiting for treatment, results in an estimate that nearly 1.1 million weeks were "lost" while patients waited for treatment. However, because this estimate is based on the assumption that all individuals face the same wait time for treatment in each specialty/province combination, it is mathematically equivalent to assuming that 11.0% of the productivity of all Canadians waiting for care was lost to a combination of mental anguish and the pain and suffering that accompany any wait for treatment. Multiplying this lost time by an estimate of the average weekly wage of Canadians in 2007 (given in table 3), which provides an estimate of the value of lost time to each individual,6 gives an estimate of the cost of the productive time that was lost due to individuals waiting for medically necessary treatment in 2007 (table 4).

The estimated cost of waiting for care in Canada for patients who were in the queue in 2007, according to calculations based on the methodology produced by Globerman and Hoye (1990), was slightly more than $793 million. That cost works out to an average of about $959 for each of the estimated 827,429 Canadians waiting for treatment in 2007. Alternatively, that cost works out to roughly $8,716 for each individual among the 11.0% percent of patients in the queue who were suffering considerable hardships while waiting for care.

Of course, this figure is a conservative estimate of the private cost of waiting for care in Canada. This estimate assumes that only those hours during the average work week should be counted as lost. It places no intrinsic value on the time individuals spend waiting in a reduced capacity outside of the working week. Valuing all hours of the week, including evenings and weekends but excluding eight hours of sleep per night, at the average hourly wage (given in table 3) would increase the estimated cost of waiting to more than $2.42 billion, or about $2,919 per person. . .

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Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791

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4.      Medicare: Medicare spending will consume nearly the entire federal budget by 2082.


According to the Congressional Budget Office (CBO), if Medicare spending continues to grow at the historical growth rate of total health care spending:

The CBO also found that if federal income tax rates are adjusted to allow the government to continue its current level of activity and balance the budget:

Source: Pamela Villarreal, "Social Security and Medicare Projections: 2008," National Center for Policy Analysis, Brief Analysis No. 616, April 30, 2008.

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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: Sacramento Hospitals Bulking Up

UC Davis, Sutter, Catholic Healthcare West and Kaiser to add 3.5 million square feet.

By Dorsey Griffith -  Sunday, May 4, 2008

The housing industry is in a free fall. Businesses are struggling. And city and county governments face mounting budget deficits.

But try navigating the construction maze created by Sutter Health's projects in Sacramento's midtown, or look for parking at Kaiser's South Sacramento Medical Center, where backhoes and bulldozers have ripped into what seems like every square inch of ground.

A massive construction boom by the area's four big hospital groups has become a bright spot in the region's otherwise gloomy economic panorama.

The expansion represents the largest ever in the Sacramento area for UC Davis Health System, Sutter Health, Catholic Healthcare West and Kaiser Permanente. Together, the more than 3.5 million square feet of construction could fill eight Arco Arenas.

The regional price tag: $2.6 billion, more than two times the city of Sacramento's annual budget, or enough to buy about 8,650 new homes at $300,000 apiece.

The makeover is expected to add as many as 2,000 health care jobs to the local economy by 2013, and already has generated hundreds of local construction jobs. . .

The growth of the health care industry is nearly unique in Sacramento's economic picture, said Ryan Sharp, director of the Sacramento Regional Research Institute.

Other than state government, health care was the only economic sector that grew in the six-county region between February 2007 and February 2008.

"Health care has been a solid performer for our economy for a long time," Sharp said. "As others have gone up and down, it has been a stable provider of job growth for the region. It will help minimize the downturn."

As brick and mortar are put down, however, questions linger about the need for such ambitious expansion.

Bucking the trend

When it comes to new hospital beds, Sacramento's plan appears to buck the trend across the country, where per-capita bed rates have dropped steadily nationwide over the past 50 years to about three per 1,000 people. . .

Consider what's on Sacramento's horizon:

• More than 800 new hospital beds, including at least 90 new emergency room beds and about 80 intensive-care beds for infants and children.

• A 40-bed acute rehabilitation center for the care of patients recovering from strokes, orthopedic surgery, brain and spinal cord injuries and other trauma.

• A state-of-the-art communications hub for telemedicine, which will extend medical attention to rural reaches of Northern California.

• A stem cell research center.

• More than a million square feet of new clinics, medical offices and outpatient surgery suites.

• More than 2,000 new hospital parking spaces.

Other perks in the pipeline for patients: lots of private, family-friendly rooms, convenient walkways connecting clinical units, and modern floors painted in soothing colors, with plenty of art.

What's driving the boom?

Looming state earthquake safety requirements for hospitals are a major factor behind the expansion, but do not account for all of it.

Hospitals – many of them dated and ill-equipped for new medical technology – had long put off major renovation and expansion, explained Robert David, chief deputy director at the Office of Statewide Health Planning and Development.

"Back in the early 1990s … managed care companies negotiated contracts that were very unfavorable to hospitals, and they all lost gobs of money," he said. "(Hospitals) had no money for capital improvements."

That changed, he said, when hospitals merged into systems, gained financial leverage and negotiated better rates. . .

A shadow of doubt

Whether the massive expenditures will prove prudent down the road, however, is a matter of opinion.

Maribeth Shannon, who tracks market trends for the California Healthcare Foundation, said that while Sacramento has historically operated its hospitals very efficiently, huge cuts in reimbursement rates from federal and state health insurance programs could make it hard to justify such an investment.

"It's just amazing all this can get funded given the outlook for Medicare and Medi-Cal cutbacks," Shannon said. "They have strong stomachs." . . .

But there's no guarantee the billions spent on new and spruced-up buildings will yield better outcomes or lower bills for patients with heart attacks, broken legs or kidney failure. Research shows more services lead to higher utilization and costs – but not necessarily better results for patients.

"What are we getting for all this money in terms of the quality of care and its cost?" asked Chris Ohman, CEO of the California Association of Health Plans, which represents the insurance industry. "The big deal is, we don't really know."


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6.      Government Myths: Government can control disasters.

How Government Makes Disasters More Disastrous, By Thomas A. Bowden

In a speech from New Orleans last week, Republican presidential candidate John McCain lashed out at the Bush administration for its response to Hurricane Katrina. McCain's remarks, which appeared calculated to make disaster relief a key campaign issue, revived harsh memories of the savage storm that inundated the Mississippi Delta in late August 2005, leaving more than 1,800 people dead and causing widespread property damage.

Although the floodwaters long ago receded, government officials are still counting the disaster's costs. Earlier this year, the U.S. Army Corps of Engineers disclosed that 489,000 claimants are seeking damages caused by poorly designed levees. Of those claimants, 247 want more than $1 billion each, including one whopper for $3 quadrillion (a stack of a quadrillion dollar coins would reach beyond Saturn).

The tax dollars spent resolving those claims will augment the tens of billions already paid to restore and repopulate New Orleans, a below-sea-level bowl situated precariously amidst a lake, a major river, and a gulf, in a known path for hurricanes.

Disasters can sometimes shock a nation into questioning entrenched practices. But Hurricane Katrina, perhaps the worst natural disaster ever to befall America, has failed to spark serious challenge to long-standing government policies that actively promote building and living in disaster-prone areas.

The Katrina tragedy should have called into question the so-called safety net composed of government policies that actually encourage people to embrace risks they would otherwise shun--to build in defiance of historically obvious dangers, secure in the knowledge that innocent others will be forced to share the costs when the worst happens.

Without blaming the victims for having followed their own government's lead, it is time to question whether those policies should continue.

The first strands of today's safety net were spun in the nineteenth century, as the Army Corps of Engineers shouldered the burden of constructing and maintaining levees and other flood controls along the Mississippi River. From then to now, Congress and the states have responded to each new flood by installing newer, higher, and stronger barriers at public expense, as if the preservation of a city like New Orleans in its historical location were a self-evident necessity.

Throughout the twentieth century, new strands were woven into the safety net, first in the form of loans to disaster victims, then by direct grants, infrastructure repairs, loan guarantees, job training, subsidized investments, health care, debris removal, and a host of similar rehabilitative measures.

In 1968, the National Flood Insurance Program began supplying subsidized coverage for structures and their contents in flood-prone areas. Similar state-subsidized insurance programs arose for hurricanes in Florida and earthquakes in California. In 1978, the Federal Emergency Management Agency was created to coordinate the increasingly complex job of government disaster response.

At each juncture, more aid was funneled to disaster victims without serious challenge to the wisdom of encouraging people to occupy vulnerable locations.

In response to Mississippi floods, Florida hurricanes, and California earthquakes, the number of major disaster declarations almost doubled from the 1980s to the 1990s, from an annual average of 24 up to 46. At century's end, Congress was paying an average of $3.7 billion a year in supplemental disaster aid, with state taxpayers contributing many millions more. As of August 2007, Katrina relief alone had cost federal taxpayers $114 billion.

By gradual steps, this disaster safety net became part of the legal landscape, taken for granted by private investors and owners deciding to undertake new projects or rebuild storm-damaged areas. Relief programs--by minimizing, disguising, and shifting the real risks of defying natural hazards--became an active force distorting private decision-making and inviting even worse future tragedies.

Thus if a pre-Katrina Mississippian asked himself, "Should I build my house 10 feet above sea level, a quarter-mile from the Gulf Coast?" the answer came back: "Sure, why not? The government will look after me if disaster strikes."

This entitlement mentality ensured that each new tragedy would generate fresh demands to expand the safety net. In Katrina's aftermath, those demands centered on State Farm, which dared to deny certain claims under homeowners policies that covered wind damage but expressly excluded floods. Mississippi's attorney general immediately sued to void flood exclusion clauses as "unconscionable" and "contrary to public policy" and even launched a criminal investigation of State Farm's claims adjusting practices.

Last year, a jury inflamed by adverse public opinion awarded $1 million in punitive damages against State Farm for having stood on its contract rights in a dispute involving a single house. That case was recently reversed on appeal, but the victory is cold comfort for State Farm, which in the meantime elected prudently to calm the litigation storm by paying tens of millions of dollars to settle claims for unproven wind damage. Voila! The safety net had a brand new strand, woven at the insurance company's expense.

Disgusted, State Farm announced last year that it would cease writing new homeowners policies in Mississippi.

As more private insurers withdraw from high-hazard areas--or raise their rates to reflect the staggering legal and public relations costs of offering disaster insurance--a predictable lament arises: the free market has failed, and government must fill the vacuum so that the statist safety net remains strong. Thus it surprises no one to hear Florida Gov. Charlie Crist challenging this year's presidential candidates to support creation of a federal catastrophic fund that would keep insurance premiums artificially low in disaster-prone areas across the country.

But the solution is not more of the market distortions and perverse incentives that have lured so many people into harm's way. The solution is to replace the prevailing entitlement mentality with a free market in disaster prevention, insurance, and recovery.

In a free market--without tax-paid levees, government disaster relief, or subsidized insurance--anyone who contemplates building or buying property in a high-hazard area will need to face hard facts about the local history of natural disasters, the efficacy and cost of preventive measures, and the availability of insurance. . .

With their own lives and wealth at stake, people will have every incentive to evaluate risks objectively. And if hardy souls still choose to occupy and fortify New Orleans, or build on an earthquake fault, or live in a tornado alley, the risk and reward will be theirs alone. No longer will government make disasters more disastrous by pretending that citizens have a right to defy the forces of nature at others' expense.

Thomas A. Bowden is an analyst at the Ayn Rand Institute, focusing on legal issues. Mr. Bowden is a former attorney and law school instructor who practiced for twenty years in Baltimore, Maryland. The Ayn Rand Institute promotes Objectivism, the philosophy of Ayn Rand--author of "Atlas Shrugged" and "The Fountainhead." Contact the writer at

To read more, go to

Government health care subsidies also create health care disasters.

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7.      Overheard in the Medical Staff Lounge: Physicians need help in reducing health care costs.

Dr. Rosen: I think we have a crisis in our profession.

Dr. Ruth: How so?

Dr. Rosen: The government, Medicare, Medicaid, health insurers in general and HMOs all expect us to control health care costs. They expect us to be the cops on patients we serve.

Dr. Sam: I just tell my patients that the fancy test they are wanting is not reasonable.

Dr. Ruth: If that works, that must keep your profile very low and your HMO bonuses very high.

Dr. Sam: Well, my bonuses at the end of each quarter are nearly one third of my income.

Dr. Rosen: Isn't that manipulation galling to you?

Dr. Sam: Well, no. I'm done fighting the system. I will comply with whatever they recommend and collect my maximum compliance rewards.

Dr. Rosen: Rewards? Isn't that subterfuge?

Dr. Ruth: I have the same problem even though I basically do what Sam does. I have family responsibilities and no interest in being a crusader or a hero. I want to be the best doc that I can be while working in the system foisted upon us by the powers that be.

Dr. Rosen: My, aren't we compliant? But won't this sort of compliance eventually bury us all?

Dr. Ruth: By that time, my kids will be married and I will settle for a life of being a grandma since I've missed much of the rewards of being a mother.

Dr. Rosen: I admire your honesty. Don't you think there are a lot of doctors in that situation, probably more women than men?

Dr. Ruth: I'm sorry to have come to this realization. When I graduated, I had a determination that I would out work any male and I did for nearly a decade. But priorities change. And mine are changing. I'm sorry that it was managed care that changed mine. But my family will be richer for the experience.

Dr. Rosen: Aren't you turning your profession into a job?

Dr. Ruth:  Yes. To me medicine has become a job that pays my mortgage and bills. Not much more.

Dr. Sam: Now that our professional organizations have convinced doctors that bureaucratic government medicine is the favored way to practice by 60 percent of us, I no longer will give any resistance. I will also treat my profession as a job. When the government wolves take over, the sheep and their Shepherds - our patients and us - will have no options. The wolves are no more interested in the welfare of the sheep than the government is interested in the welfare of our patients or us. But I really think it was our fault and it's too late to correct. I'm sorry to say, the wolves will eat the sheep. As Shepherds, with as high an IQ as any profession, we can find another calling.

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8.      Voices of Medicine: A Review of Local and Regional Medical Journals and the Lay Press

Inside Medicine: Mixed feelings after lecturing for Saudis, By Dr. Michael Wilkes – Sacramento Bee, May 11, 2008

The large, modern, wood- paneled hospital auditorium was filled to capacity as I finished my lecture at a new medical school in Riyadh, Saudi Arabia.

I had decided to make a special effort not to ignore the distant back-left corner of the auditorium. That is where the 100 or so female doctors were sitting. They all appeared to be dressed alike, wearing the jet-black abaya (robe), a head shawl, and a feesha, or facial covering. All that could be seen were their dark-brown, inquisitive eyes. Just below the hem of their robe was the only fashion statement visible – shoes of all sorts of designs and colors from shimmering gold and silver to a pair of bright-red sneakers.

Following the lecture, there was a flurry of questions from the audience, but none from the women. During the short break that followed I was surrounded by women who had insightful, informed medical questions. Many of the women spoke English far better than their male counterparts. It was an odd feeling, as not one person looked me in the eyes when they asked a question. After 20 minutes there was only one woman left. Her veil was unusually low on her face – almost to her neck – allowing me to see her entire face. She wore dark mascara and tiny, gold earrings. Below her robe I could barely make out the hem of her white slacks.

She shook my hand – the men all greeted me with a handshake as they introduced themselves. But such contact between a man and a woman is strictly forbidden in Saudi Arabia. 

"I could see you are making a special effort to speak to the women doctors," she said.

She introduced herself to me as Anna, and appeared to be in her mid-30s. She asked permission to ask me a personal question, then went on to explain that for nine years she had lived in California, where she and her brother went to school, hoping she would learn the skills of an American pediatrician and bring them back to Saudi Arabia to train future doctors. . .

Anna had been back in Saudi Arabia for two years. As we spoke, we strolled toward the back of the auditorium and sat down on two folding chairs. She described how much she appreciated having a chance to train in the United States. She reported learning so much – some of it medicine, but some not. She made a number of friends, learned to drive a car and to have the confidence enough to socialize as an equal with men, to wear western clothing, and to learn about other religions and worldviews. She also learned to advocate for herself.

But the blessing was mixed. She now finds her life in Saudi Arabia intolerable – both personally and professionally. She cannot build her career because men are threatened by her knowledge and her ideas for change; they won't even meet with her. Socially, she can't go out at night or socialize with men. Professionally, she must sit in the back of the auditorium, she can train only females, and she must wear traditional attire.

Her question to me was simple: Should she stay and try to change the system so other women would benefit? She described this route as amounting to a lifetime of battles, a stagnant career and the likelihood that she might never find a husband who would tolerate her free spirit and western thoughts.

Or, she could return to the United States, where she would be welcomed back to her old job and live her life as she wished, although this would bring shame to her family. . .

Out of nowhere, an older woman came up to Anna and whispered something in her ear. As the woman walked off she told me, "I must go. It is not proper for me to be sitting here with you without another woman present."

We were, after all, sitting in the back of a 500-person auditorium. I asked if she'd prefer to step outside the building, where there were many women (the men were all congregating in the air-conditioned lobby).

"No, this would not be proper for you to join the women."

I asked if we could talk later, but she didn't reply. Over the next week I looked for her in the auditorium.

Each time I spotted her she gave me a little wave. But she never came up to me again.

As Americans reach out to train foreign doctors, nurses and researchers, our intentions are great, and in most cases I hope that their society ends up the better for our efforts.

But I wonder how often we create internal chaos for those who come to learn science, but also learn about the American way of life that can not be duplicated back home.

About the writer: Michael Wilkes, M.D., is a professor of medicine at the University of California, Davis. Identifying characteristics of patients mentioned in his column are changed to protect their confidentiality. Reach him at

To read the entire VOM, go to


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9.      Book Review: From our archives: False Hopes

FALSE HOPES - Why America's Quest for Perfect Health Is a Recipe for Failure by Daniel Callahan, Simon & Schuster, New York, 1998. 330 pp,$24, ISBN 0-684-81109-X

Daniel Callahan, cofounder of the Hastings Center and the Director of its International Programs, takes on the entire medical establishment--doctors, nurses, hospital administrators, medical researchers, and pharmaceutical and medical technology companies--all of whom he believes are united in a relentless pursuit of unlimited medical progress, stopping at nothing short of the conquest of all disease and the indefinite extension of life spans (see last month's review of Schwartz' Life Without Disease - The Pursuit of Medical Utopia). 

The Hastings Center is an avant-garde institution where any idea can be explored (see "Duty to Die" in the HHK column in this issue of the Journal). Callahan, as the president of the Hastings Center from 1969 to 1996, must be taken seriously. In the preface, he presents his political leanings, aligning himself with the Clintons in their quest for healthcare reform. He bemoans the fact that no plan made it through Congress--not one bill, not a single reform. Callahan is even more appalled that at the next presidential election, both candidates all but ignored the issue.

Initially, the reason he takes this stance is not clear. However, he soon points out that the universal, if poorly financed and often corrupt, healthcare systems in China, Southeast Asia, and in much of Latin America, are turning to the marketplace and accepting privatization as their new gospel. He finds it most unsettling that the popular, well managed, equitable health care systems of Western Europe have begun to unravel in the post WW II welfare state. These systems, beset with rising costs, are high on the budgetary hit lists of political leaders who are looking to the marketplace to reduce public benefits, thus securing their own future.

Callahan realizes that if everyone is having a problem, and all are looking for answers, there must be an underlying basic issue. Almost all healthcare reform efforts assume that the solution lies in better organization and financing. Callahan then observes that no matter how much money is spent and no matter what the health gains may be, they never seem to be enough. Conventional solutions do not address the real problem. No matter how much progress, they always seem insufficient to meet the "needs" of the day.

The most cherished and celebrated aims, commitments, and values of modern medicine are beginning to give us trouble. But challenging these ideas, Callahan reflects, is not new. Rene Dubois in his 1954 book Mirage of Health questioned the then imminently anticipated total conquest of disease and stated this would not happen, not soon, not ever. In the 1970s, theologian Ivan Illich, British physician John Powles, American physician Rick Carlson, and British professor of social medicine, Thomas McKeown, each showed in a systematic way that there is no clear correlation between population health and medical care. Carson boldly predicted the diminishing impact of physicians and hospitals on health by the year 2000.

Callahan emphasizes that "A serious transformation will require taking money away from the acute-care sector, including research into the cure of many lethal diseases, and using it instead on prevention research and massive educational efforts designed to change health-related behavior." Callahan asserts that sustainable medicine will do the following: give priority to preventing and treating diseases that afflict the many rather than finding cures for diseases that effect the few, improve the quality of life for the elderly rather than extend life indefinitely, and focus on primary care and public health measures that benefit society as a whole rather than satisfying the health needs of individuals.

Callahan as an ethicist explores topics and issues on which to base future dialogue as well as change the direction of the debate. But he doesn't give us the final answer. He does point out that many Americans are bypassing traditional physicians and hospitals and are going to alternative medicine practitioners whom they pay from their own pockets. According to some estimates, these visits exceed those to traditional practitioners. This demonstrates that patients will pay for what they perceive as valuable.

However, Callahan's prejudices outlined in the preface, may prevent an objective extension of the excellent groundwork he has developed. He might also have mentioned that the current debates in Britain and Europe include proposals for a significant transfer of costs from the national health systems to the individual through major co-payment plans, not only for office visits, but also for hospital stays in some instances. That may not be politically correct, but it would be a giant step toward what is economically correct for our patients.

Del Meyer, MD

This review is found at

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10.  Hippocrates & His Kin: A New Way to Cut Health Care Costs

Q. Is there a new code for ventilation assistance and management? I have been using 94656 and 94657.

A. If you reported 94656 or 94657 since January 1, 2007, you should have been denied payment. These codes were deleted in CPT 2007. Please review your accounts receivable. Check with insurers on how far back you can resubmit claims processed in error. These codes have been replaced by the following four codes since January 1, 2007. . .

Since the code books are as large as textbooks required in medical school, taking a full semester to learn, any physician should be able to take off a semester every other year to study and digest the new codes. When the physician pays his biller a hundred hours or two at $25 an hour, he may find the reimbursement for the new codes is actually an administrative maneuver to reduce his income.

The Medical Association, that represents 25 percent of physicians, produce the CPT codes and makes them more money than all the dues the doctors pay.

Nirvana: It looks like the answer to controlling health care costs is a new Current Procedural Terminology (CPT) book every year. Doctors won't get paid until it's too late to correct or collect.

Insurance carriers as Consulting (Controlling) Physicians

I received a notice from BC-BS stating "available claims suggest your patient has diabetes with no recent history of lipid-lowering therapy. If your patient does not have diabetes, please disregard this.

"If after evaluating the overall treatment goals for your patient . . . please consider: Adding lipid-lowering therapy. Note that lipid-lowering therapy should be accompanied by laboratory monitoring (e.g. lipid panels, creatine kinase, liver function tests) and follow-up visits.

"If necessary, please provide your patient a new prescription."

The insurance company's meddling in the private practice of medicine is very costly and does not improve the quality of health care or patient well being. This patient is of advanced age (ninth decade of life), and the lipids are only mildly abnormal and will not affect lifespan even without treatment. Furthermore, treatment with statin has certain risks and may cause myopathy and myoglobinuria, renal failure and death. Avoiding death can increase health care costs by a thousand fold if renal complication occurs. The monitoring guidelines mentioned will further increase the cost of statin therapy by two to fourfold. The inconvenience and hazards of more frequent visits to the office, laboratory and pharmacy would decrease the quality of this patient's final years of life.

As is generally the case, medical treatment guidelines and government and insurance companies interference, will increase health care costs significantly - in the range of 10 to 1000 times normal. (1000 to 100,000 percent increase). It would be fair to project that if all the various recommendations were followed, the $2 trillion annual health care costs could easily be pushed to 4 trillion and quality would not be better. 

It would be more cost effective if Congress rather than doctors and hospitals were held accountable for their actions. At least doctors have medical expertise to vary treatment based on clinical judgment, which is totally lacking in congressional or insurance carrier meddling.

To read more HHK medical vignettes, please go to

To read more HMC, go to

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


                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at and register to receive one or more of these reports. This month be sure to read the report on High Cigarette Taxes Are Fueling Organized Crime as "butt-leggers" make over $1 million on each tractor-trailer load of smuggled smokes to bypass the $9 a pack of taxes.

                      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 This month, be sure to read Ms Pipes article Actions Speak Louder than Words: A Case Study.

                      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. Join the Mercatus Center for Excellence in Government. This month be sure to read Karol Boudreaux' Book Review of Paul Collier's "The Bottom Billion".

                      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. You will want to see their proposed Healthy Access Plan for Affordable and Responsible Heath Care Reform at 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 A new study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. Review her Health Policy Matters Newsletter.

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. 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 Read more at Read Ralph Weber on HRAs.

                      The Heartland Institute,, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care? You may sign up for their health care email newsletter.

                      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. This month as schools have their commence exercises, it would be worthwhile to pause and read: The Spread of Education Before Compulsion: Britain and America in the Nineteenth Century.

                      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." This month, as consumers plan their health care options for the next work year, do your homework and read Consumer-Driven Impact Study Gets it Wrong.

                      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. This month, look at Linda's OpEd on How Colorado Fixes Roads AND Increases Health Care Costs. 

                      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 an excellent review of Tom Sowell's latest book: Economic Truths and Fallacies.

                      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. Actually, this month with the emphases on Education, you may prefer to read about your Schools Performance Report Cards.

                      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. With this month's emphasis on education, as our students are graduating, make an intelligent choice of schools since American education is in a state of crisis inasmuch as the average for primary and secondary (K-12) education is now costing parents or taxpayers $100,000.

                      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. This month, you may want to brush up on why there is a nursing shortage. You may also log on to Lew's premier free-market site 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 Save gas and read about the five best train rides in the world.

                      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 Michael Tanner's OpEd on Mandate for Health Care Disaster that appeared in the Washington Post last April.

                      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. Learn more about Charter Schools in your area.

                      The Free State Project, with a goal of Liberty in Our Lifetime,, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.] You may want to visit their Liberty Forum.

                      The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, war time allows the federal government grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in war time we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to You'll be impressed and will want to subscribe to this handy little journal for your coffee table or bedside.

                      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. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. 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 USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read America's Interests and the U.N. by John Bolton. The last ten years of Imprimis are archived.

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Del Meyer

Del Meyer, MD, Editor & Founder

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 Words of Wisdom

Integrity has no need of rules. - Albert Camus (1913-1960) Nobel Laureate in Literature 1957

The best way to escape from your problem is to solve it. - Robert Anthony

Never fear shadows. They simply mean there's light shining somewhere nearby. - Ruth E. Renkel

Some Recent Postings

Diets Don't Work  by Bob Schwartz, PhD, 1996.

Diets Still Don't Work  by Bob Schwartz, PhD, 1990.

In Memoriam

 Cardinal Alfonso López Trujillo, Vatican enforcer, died on April 19th, aged 72

From The Economist print edition, May 1st 2008

IN 1995, as head of the Pontifical Council for the Family, Cardinal Alfonso López Trujillo published a "Lexicon of Ambiguous and Debatable Terms". They included "safe sex" (no such thing, unless confined to the nuptial bed); "gender" (a construct of strident feminists) and "family planning" (code for abortion). He could also throw back a few phrases of his own: "contraceptive colonialism", "pan-sexualism", "new paganism" and, with a special lowering of those beetling black brows, "the culture of death".

People sometimes forgot, when they met the cardinal, that he had studied Marxism as well as theology at the Angelicum in Rome. He could neatly trade jargon for jargon in the propaganda wars. Or he could write books entitled "Liberation and Revolution" to undercut, from the right, the theologians and priests in his native Latin America who thought they had a monopoly on those words. His red cardinal's skullcap was as much a battle statement as the beret of Che Guevara. "Prepare your bombers", he wrote to a colleague just before the opening of the Latin American Bishops' Conference in 1979. "Get into training like a boxer going into a world fight." Every day, on every front, this was López Trujillo contra mundum.

The enemy was all around him. Legislators and governments across the first world who passed laws to ease divorce or ensure "gay rights" (though of course, to quote Aquinas, lex injusta non obligat). Fervently Catholic countries, like the Philippines, which adopted two-child policies to curb their surging populations. Scientists in white coats who committed murder in test tubes in the name of medical research. And round the fringes members of Act-Up, dressed as giant condoms, who leapt up and blasphemed him whenever he spoke.

Condoms were the first enemy. In their sly, shiny packets, they invaded the poor world as insidiously as the disease they were meant to prevent. To the cardinal, there was nothing safe about them. They merely encouraged promiscuity. To hope to stop AIDS by wearing one was like "playing Russian roulette". They were as full of tiny holes as a sieve, through which the HIV virus, "roughly 450 times smaller than the spermatozoon", as he told the BBC, would slither with no difficulty. The World Health Organisation might claim condoms were 90% effective; he had read it in the Guardian; but "they are wrong about that". And he was right.

He was always right, staunchly on the side of order, stability, hierarchy and God's law. The track of his life had been determined, from priest to bishop to archbishop to cardinal at 48, in one astonishing trajectory; and the direction of his ministry had been fixed on the day when, as a young priest in Colombia, he had been vouchsafed the "grace" of kissing the hands of Paul VI in the Bogotá nunciature. From that moment he took on the task of defending the "procreative mission": the beautiful, profound, but profoundly impracticable teaching of Paul VI's Humanae Vitae, that every human sexual act must be open to the transmission of life. Against the intrinsic disorder of the human libido he proposed to reinforce, like a fortress, the institutions of family and marriage and the virtues of fidelity and chastity. On his visits to Rome he so pleaded for a family policy, browbeating the future Pope John Paul II even as they waited in the rain for a car, that John Paul in 1990 asked him to run that pontifical office for him, not knowing it would soon become a war room.

Redefining liberation

It was not the only one. Disorder had a way of impinging on his life. From 1979 to 1991, as archbishop of Medellín, he had care of souls in what was becoming the world's most violent city, a sprawl of hillside shantytowns patrolled by young assassins on motorbikes and ruled by ruthless drug lords. One, Pablo Escobar, became an ally for a time, bringing order to the cinderblock slums just as another ally, Eduardo Frei, promised to clamp down on Marxist elements in Chile and beyond. Latin America's crop of military dictators received no condemnation at the archbishop's hands. Where there was chaos, he reminded his bishops, people needed firm government. . .

In recent years his influence had faded. The cardinals' conclave of 2005 produced little sense that he was papabile. He was tireless, but had perhaps made too much noise. He hoped that Benedict XVI would appoint him to his own former office, the Congregation for the Doctrine of the Faith, where he could define not just the terms of sex but the rules of belief itself. But the old rottweiler, by comparison as gentle as a spaniel, looked elsewhere.

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On This Date in History - May 13

On this date in 1607, Jamestown, Virginia, the first permanent English settlement in what is now the United States was founded. Pocahontas and Captain John Smith were Virginians. On this anniversary date, it is good to reflect on the seeds of a great nation, consider how far have we come, and how much off course are we since Jamestown?

On this date in 1940, Winston Churchill, speaking in the House of Commons as Great Britain's new Prime Minister, said "I have nothing to offer but blood, toil, tears and sweat." Blood, toil, tears and sweat is the human investment in our country, or any country of free people. How is our investment doing?

After Leonard and Thelma Spinrad