Community For Better Health Care

Vol X, No 16, Nov 22, 2011


In This Issue:

1.                  Featured Article: The Greek Tragedy – A Lesson in Government Health and Entitlements

2.                  In the News: Doctor’s Revolt Shakes the Social Security Disability Program

3.                  International Medicine: Spreading prosperity and growth

4.                  Medicare: Can Medicare make three-quad-trillion decisions a year? 3,000,000,000,000,000?

5.                  Medical Gluttony: Pharmacy Gluttony

6.                  Medical Myths: Electronic Medical Records are efficient savers of time.

7.                  Overheard in the Medical Staff Lounge: Electronic Medical Records—Current Status

8.                  Voices of Medicine: Polypharmacy Among Our Patients

9.                  The Bookshelf: Taking Back Healthcare for Future Generations

10.              Hippocrates & His Kin: Sex and STD in Sacramento;  

11.              Related Organizations: Restoring Accountability in Medical Practice and Society

Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

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Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people’s welfare.

Thus we must also remember that ObamaCare has nothing to do with appropriate healthcare; it was similarly projected to gain loyalty by making American citizens dependent on the government and eliminating their choice and chance in improving their welfare or quality of healthcare. Socialists know that once people are enslaved, freedom seems too risky to pursue.

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1.      Featured Article: The Greek Tragedy – A Lesson in Government Health Care and Entitlements

Greece is broke, and so is Democracy

By Michael Walker

The Globe and Mail

It is often the role of the economist to point at the impending doom with which reality confronts our fondest wishes. For that reason Thomas Carlisle referred to economics as the dismal science. It is made the more dismal for the economist when the fondest wishes are held and extolled by ones friends and those whom one admires.

I find myself in this predicament with the pronunciations of two such people on the issue of the Greeks and their political reactions to the gifts borne to them by Germany in the guise of the European Union. In assessing the gift of monetary rescue wrapped in the sack-clothe of fiscal austerity, then-Greek Prime Minister Papandreou unexpectedly proposed that there should be a referendum. This gesture caused pandemonium in markets and after stern ultimatums from the EU, the Greeks found that they could accept the lifeline without waiting four months for a referendum . . .  Read more . . .

The problem with these assessments of the Greek tragedy is that they ignore the fact that in Greece and an increasing number of countries, democracy itself is in deficit. It is in deficit in the sense that a majority of the Greek electorate has been bribed with payments from government for which nobody in Greece is having to pay in taxes. Corrupted at its very foundation, Greek democracy no longer speaks for the public interest and cannot be relied upon to solve the problem. In effect, that is why the European Union is involved in the lives of Greeks in the first place.

Democracy rests on a delicate balance of economic interests. Citizens both pay taxes to, and receive benefits from, government which is controlled by the democratic process. Rhetoric notwithstanding, the normal pattern in Western democracies is that lower income families are net beneficiaries and higher income families are net payers. The crucial balance point for democracy is where the crossover in the weight of the electorate occurs.

The normal circumstance is that fewer families are net overall beneficiaries than are net payers. The ongoing process of democracy is persuading those who pay more than they receive to support the social infrastructure because it does provide some benefit to them and to the society in general. Fiscal democracy works in this context as long as the attempt to spend more is met by resistance from those who must pay – resistance of a kind that it might take the creation of a Reform party to effect

The problem with deficit financing, which unfortunately is being forgotten, is that it makes possible the delivery of current benefits to the population for which nobody pays – or at least nobody who is voting at the moment. Deficits shift the burden of spending forward onto the shoulders of children not yet old enough to vote and those not yet born. And in the case of the Greeks, owing to the system of transfer payments imbedded in the European Union, at least part of the cost of their spending could be shifted to the voters not yet born in other countries of the union.

The demonstrations in the streets of Athens were not the manifestation of democracy at work. They were the vanguard of the clear majority of citizens who are disconsolate at the prospect of losing their ability to continue to feast at the expense of their children. As past Greek and other experience has demonstrated, the only way that democratic frenzy comes to a halt is when the country hits the wall and can no longer borrow the money to carry on.

The fondest wish of the creators of the European Union was that the fiscal discipline which has historically eluded some European countries would somehow emerge from the great EU democratic coming together. Regrettably, that wish took no account of the delicate balance of interests which is the crucial underpinning of all successful democracies and which in the case of Greece, is simply broken.

Read the entire report at the Fraser. . .

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2.      In the News: Doctor’s Revolt Shakes the Social Security Disability Program


Earlier this year, senior managers at the Social Security Administration in Baltimore, frustrated by a growing backlog of applications for federal disability benefits, called meetings with 140 of the agency's doctors.

The message was blunt: The number of people seeking benefits had soared. Doctors had to work faster to move cases. Instead of earning $90 an hour, as they had previously, they would receive about $80 per case—a pay cut for many cases which can take 60 to 90 minutes to review—unless the doctors worked faster. Most notably, it no longer mattered if doctors strayed far from their areas of expertise when taking a case. Read more . . .

“The implication there was that you really didn’t have to be that careful and study the whole thing,” said Rodrigo Toro, a neurologist who analyzed cases for the SSA for more than 10 years. Some doctors, including Dr. Toro quit following the changes. Others were fired. In all, 45 of the 140 left within months, the agency said.

The upheaval, described by current and former doctors and agency officials, is the latest strain on a cash-strapped program struggling to deal with a giant influx of applications.

In targeting the doctors, the SSA says it is seeking to over hall a part of the disability-review program that can be both expensive and slow. . .

“People who shouldn’t be getting [disability] are getting it, and people who should be getting it aren’t getting it,’ said Neil Novin, former chief of surgery at Baltimore’s Harbor Hospital, who worked for Social Security part time for about 10 years.  In August, Dr. Novin said, he was pressured by a supervisor to change his medical opinion and award benefits to someone he didn’t believe had disabilities that would prevent the person form working.

Read the entire story in the WSJ – subscription required . . .
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3.      International Medicine: Spreading prosperity and growth

Economic Freedom

Economic freedom is one of the main drivers of prosperity, resulting in improved wealth, health, and education as individuals and families take charge of their own future.

Economic freedom is the extent to which you can pursue economic activity without interference from government, as long as your actions don't violate the identical rights of others.

The Fraser Institute has several programs that examine the effects of economic freedom in countries around the world: Read more…

o    The Economic Freedom of the World Index
Find out how your country rates in economic freedom. This index is the most objective and accurate measure of economic freedom published by any organization. It was developed by a research team led by Nobel Laureate Milton Friedman and former Fraser Institute Executive Director Michael Walker.

o             North American Economic Freedom Index
Find out how your state, province, or territory compares to other jurisdictions across North America. This index measures differences in economic freedom within Canada and the US.

o             Economic Freedom of the Arab World Report
Find out how Arab countries rate in economic freedom. This report rates 22 Arab League Nations.

o             Economic Freedom Network
The Economic Freedom Network is a joint venture involving research institutes from more than 80 countries. The Economic Freedom Network focuses on encouraging public discussion and awareness about the benefits of economic freedom and is committed to increasing economic freedom and growth around the world.

Visit the official website for more info.

Economic freedom in health care would solve the world’s HealthCare Dilemmas

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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

However, such restriction of freedom in healthcare, only restricts health care, and lowers quality.

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4.      Medicare: Can Medicare make three-quad-trillion decisions a year? 3,000,000,000,000,000?

A Better Way to Approach Medicare's Impossible Task

Commentary by John C Goodman | Co-author Thomas Saving

As the “Super Committee” faces mounting pressure to rein in Medicare spending, two sides seem to be squaring off. The don’t-touch-a-thing-other-than-squeezing-provider-fees position seems to appeal to mainly Democrats, while eat-your-spinach reforms, including more cost sharing and higher premiums, seem to appeal mainly to Republicans. Neither position is very appealing to voters, however, nor should they be.

Is there a third way? Is there a way to get the job done and appeal to voters — young and old — at the same time? We think there is. Tom Saving and I suggested a different approach in a recent post at the Health Affairs blog. Read more . . .

To see how it might work, we first have to understand that what Medicare is currently trying to do is virtually impossible. Consider that Medicare has a list of about 7,500 separate tasks that it pays physicians to perform. For each task there is a price that varies by location and other factors. Of the 800,000 practicing physicians in this country, not all are in Medicare and no doctor will be a candidate to perform every task on Medicare’s list.

Still, Medicare is potentially setting about 6 billion prices at any one time all over the United States of America, as well as in Guam, Puerto Rico, the Mariana Islands, American Samoa and the Virgin Islands.

Each price Medicare pays is tied to a patient with a condition. And of the 7,500 things doctors could possibly do to treat a condition, Medicare has to be just as diligent in not paying for inappropriate care as it is paying for procedures that should be done. Medicare isn’t just setting prices. It is regulating whole transactions.

Let’s say that the 50 million or so Medicare enrollees average about 10 doctor visits per year and let’s conservatively assume that each visit gives rise to only one procedure. Then considering all of the ways a procedure can be correctly and incorrectly coded, Medicare is regulating 3 quadrillion potential transactions over the course of a year! (A quadrillion is a 1 followed by 15 zeroes.)

Is there any chance that Medicare can make the right decisions for all these transactions? Not likely.

What does it mean when Medicare makes the wrong decisions? It often means that doctors face perverse incentives to provide care that is too costly, too risky and less appropriate than the care they should be providing. It also means that the skill set of our entire supply of doctors will become misallocated, as medical students and even practicing doctors respond to the fact that Medicare is over-paying for some skills and under-paying for others.

A more sensible approach is to quit asking for the impossible. Instead, let’s begin the process of allowing medical fees to be determined the way prices are determined everywhere else in our economy — in the marketplace.

We believe there are at least nine important policy changes that can circumvent these two problems and free the marketplace in the process. . .

To read the suggested policies changes, please proceed to NCPA . . .
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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: Pharmacy Gluttony

Phone calls are one item that pharmacies have not understood in terms of lean health care. Time spent that does not improve health care and only adds to the cost and is an inefficient waste of time. Time that does not produce what patients want or need is wasted time and only adds to health care costs and decreases the quality of health care. Anything that adds to time or costs without improving efficiency or reducing costs is called MUDDA by the Japanese. Read more . . .

At the end of each office visit or consultation, the plans are made for F/U care. Lab or x-rays to be done are requisitioned. An agreement as when the next appointment should be made is discussed and made. The patient is then given his prescriptions with refills to last until the next office visit, plus one month to give adequate time for the appointment to occur. We felt there would never be a need for a phone call from the pharmacist to request a refill.

The only reasonable time to plan the treatment schedule including the pharmaceutical treatment was when the patient was there with his chart in front of you. With an average of nearly a thousand patients per physician, to plan a prescription refill without the patient in front of you and chart present for review would be a source of error. It could also be a source for malpractice action should error be made in one’s memory recall. The patient always had an extra month’s supply if he/she couldn’t get in on schedule. This, we felt, should eliminate all refill requests and improve the quality of care. It didn’t.

Some physicians didn’t understand this concept and even went overboard in adding a prescription phone line just for refills and staffing it with an RN. We estimated this personnel cost to be between $40,000 and $50,000 per year. This added to the pharmacy’s concept that phone-in prescription requests were appropriate. This is pure MUDDA. This gross inefficiency and cost in any economy should be rather obvious. It’s also a haven for medical errors, which is the forerunner of medical malpractice. But apparently it wasn’t understood in many practices.

Many pharmacists bragged about their automated prescription program. When the last refill is given, we are deluged with refill requests by fax. We must receive between 10 and 20 such faxes a day. This is not only a waste of paper, but a gross waist of valuable staff time. At an insurance meeting with pharmacy program distributors present, I presented the above. After many tries, I was unable to convince the administrators of the cost in health care or the jeopardy in health care by filling prescriptions without the patient’s chart. They were totally convinced they were saving doctors' time with their efficiencies and automated programs, which I tried to point out caused me to waste time. I had to respond to each fax stating that it was time for that patient to come in and review his medical program and decide which prescriptions needed to be filled and which should be changed.

I now have an electronic prescription service and all prescriptions are neatly typed up, the sig is always readable, the refills usually are for a full year.

And guess what? The refill requests are now also electronic. But I don’t have to waste my time. I can just ignore them. When I wrote the prescription for my last patient, I noticed there were 184 electronic requests for refills. I reviewed a number of them and saw they were just like the faxes of yesterday—refill requests before the next appointment. And so I just closed the window and returned to the practice of medicine.

I wish pharmacists would stop their faxes and return to the practice of pharmacy.

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Medical Gluttony thrives in Government and Health Insurance Programs.

Gluttony Disappears with Appropriate Deductibles and Co-payments on Every Service.

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6.      Medical Myths: Electronic Medical Records are efficient savers of time.

Medicare is forcing the issue of acquiring electronic medical records under the guise of improving health care. While waiting for the hard data of that to become available, let’s look at some observations by the medical community. Anecdotal data is very important during the transition. It may become more important as time continues. In fact, it may even replace current accepted data. Read more . . .

My own physician has spent considerable time and expense converting to EMR this past year. I see him about every six months. Each time he tells me of the difficulty and expense he has incurred during the transition. After 18 months, he’s still not convinced he’s ahead in efficiency, accuracy, improved patient care, or rapport with patients.

We hear the same stories from our other colleagues, most of whom are members of an Independent Practice Association (IPA) that either provide an EMR or will require its use.

So we called a consultant to see if we should be concerned about the future Medicare requirement and fines. His final opinion was that Medicare’s fines of one percent would be inconsequential to the cost of going electronic and wouldn’t save us money for at least the next five or ten years. By that time there may be a new administration, new rules, different rules, or even no rules concerning EMRs. It could be catastrophic for us to purchase an expensive EMR program at this time. Furthermore, EMR are still in an evolving status. With few exceptions,  tomorrow’s EMRs may not be able to interface even with today’s EMRs.

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Medical Myths Originate When Someone Else Pays The Medical Bills.

Myths Disappear When Patients Pay Appropriate Deductibles and Co-Payments on Every Service.

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7.      Overheard in the Medical Staff Lounge: Electronic Medical Records—Current Status

Dr. Rosen:      We’ve been pushed to obtain EMRs by several years of the Bush Administration and now three years by the Obama Administration. Why this big push by non-medical politicians to force us to use EMRs? Is there a similar push to force other professions to do things electronically? Shouldn’t there be a bigger push to have Lawyers use Electronic Legal Records? Seeing the number of attorneys rush from one case to the next in a court room and “hem & haw” trying to figure out the issue of the hour should be a far greater need for attorneys to have all their records electronic. Read more . . .

Dr. Dave:        I agree totally. My records are concise, complete, and typed up on the office computer, which basically gives me an EMR without the finery. But it’s all the peripheral stuff that doesn’t run smoothly. What you do Rosen, I think most of us do? Nobody types on a typewriter any more. We all type everything directly into the computer. It’s faster, more accurate, and efficient. For your patients' annual exams, you can copy and paste and then proceed to make the yearly changes: date, patient’s age, and new complaints. Include necessary revisions in the rest of the history and physical. Add the laboratory and x-ray data, update the diagnosis and sign.

Dr. Ruth:        Now with separate pharmacy programs, we can order prescription on-line, whether to the local pharmacies or to the mail-order pharmacies.

Dr. Milton:      Actually these free standing pharmacy programs are more flexible than the Kaiser Permanente programs that can only send to their own pharmacies. For both local and mail order pharmacies, we had to print out the prescription for the patient to take to their local pharmacies or mail to their mail order pharmacies.

Dr. Michelle:   Don’t we have a Medicare Mandate to have EMR by next year?

Dr. Milton:      I think we do. The penalty is one percent as I recall. That’s peanuts compared to the 30 to 40 percent write downs we already take on Medicare that doctors never understood as a penalty for dealing with Medicare patients.

Dr. Edwards:  Why doesn’t Medicare or the Government understand?

Dr. Dave:        The government and/or Medicare still feel that they carry the bigger stick and that we will “cow-tow” to them. They think they can beat us into shape. But if none of us will bow down and kneel, how long could Medicare last without any doctors to care for their patients?

Dr. Edwards: I see you have that right. We now refer to “our” patients as their patients. They think they have taken over control.

Dr. Dave:        I think they have. I don’t see many doctors giving them resistance. Organized medicine has acquiesced.

Dr. Rosen:      That is true for the standard medical associations. The Association of American Physicians and Surgeons is the only medical organization that unequivocally supports private medicine. They use to be very large in the pre-Medicare days. But as physicians lost their battle with government, and Medicare controlled their patients, many rejoined the standard Medical Societies and have become more socialistic with time.

Dr. Michelle:   So you think the state of medicine is hopeless?

Dr. Edwards:  Not at all. All socialistic endeavors go belly up with time. Human greed has no limits. It’s unsustainable.            

Dr. Paul:         I beg to disagree. There are no limits. Health care for all is so just and fair.

Dr. Edwards:  I would think that those of us in the trenches would begin to understand human nature. More is never enough. It just makes you hunger and thirst for even more.

Dr. Rosen:       Just look at Greece and Europe. They can’t even agree as they go belly up.

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The Staff Lounge Is Where Unfiltered Medical Opinions Are Heard.

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8.      Voices of Medicine: A Review of Local and Regional Medical Journals and Articles

Polypharmacy Among Our Patients

By Stephen Sheerin, MD

Sonoma Medicine | Fall 2011

Maria (not her real name) is in her late 40s and was placed on amiodarone by her cardiologist to control her new onset atrial fibrillation. Unbeknownst to that physician, Maria had a remote past history of Hashitoxicosis (transient hyperthyroidism). Within two months of starting the amiodarone, she began having symptoms suggestive of hyperthyroid, subsequently confirmed by labs. She was then placed on an antithyroid medication (methimazole) and eventually became hypothyroid, despite stopping her methimazole. Her roller-coaster ride finally ended when all her doctors were convinced to stop the amiodarone. She was stranded in the middle of good intentions, poor outcomes, and lack of communication and data-sharing. Read more . . .

We physicians see patients like Maria almost daily in this era of polypharmacy, where medicine offers a pill for practically every condition. Patients like medications and often ask for them. Doctors oblige by writing prescriptions, a sign that we are providing a welcome service. The time has come, however, for us to step back and reassess our role in this pharmaco-epidemic.

Most of the polypharmacy dilemma resides with our elderly population. According to a recent survey, 44% of the men and 57% of the women over 65 years old are taking five or more medications per week. Taking all these drugs leads to adverse drugs reactions, which account for about 10% of ER visits and 10-17% of hospital admissions.

Adverse drug reactions have two main causes. The first is the side effect of the individual drug, and the second is the potential for drug-drug interactions (DDI). There is a linear relation between the number of medications and the risk of DDI: taking two meds entails a 13% chance of DDI, whereas taking more than six meds entails an 82% chance.

For the geriatric population, the risk of falling is greatly increased when they are taking five or more medications daily. This group is especially sensitive to benzodiazepines, anticholinergics and sedating psychotropics (one-third of nursing-home patients are prescribed three or more psychotropics).

DDIs should be well known to physicians, both because of what we can remember and because we get constant reminders through our electronic medical records (when we email a prescription), pharmacies, and insurance and home-care agencies. Some reminders are clinically irrelevant and bothersome, but some may be life-saving.

I know certain patients need Plavix and aspirin, or they may be on Coumadin and aspirin, but the red alert flashes each time they are renewed. However, we need to be vigilant with other often-used medications. We frequently prescribe cholinesterase inhibitors to patients with early dementia (to increase cerebral acetylcholine) and yet they may be taking OTC anticholinergic meds to sleep, so each med blocks the effect of the other. We give proton pump inhibitors to nearly everyone with dyspepsia, but PPIs can increase hip fractures, and by raising the gastric pH can decrease the absorption of various medications. Effective absorption of levothyroxine is decreased when the drug is taken with calcium or iron, and its efficacy is affected by methadone, phenytoin and others. Cardioprotective doses of aspirin for patients with coronary artery disease can be blocked by NSAIDs if both meds are taken at the same time. Vitamin D deficiency is almost guaranteed with patients on anticonvulsants.

Antibiotic use is especially bothersome. Though patients are on these for brief periods, some affect everything from INRs for patients on Coumadin, to QTc interval prolongation with fluoroquinolones, to peripheral neuropathy, pancytopenia and pulmonary fibrosis in patients taking Macrobid with a cr clearance under 60ml/min. I tell patients who want to clear their fungal nail infections with an azole (such as Sporanox or Lamisil) that they should probably stop taking all other medications.

Here’s a classic polypharmacy scenario. An elderly patient with nocturia gets up in the dark to urinate. He has an unsteady gait and is taking an anticholinergic, an alpha blocker for prostatic hypertrophy, a PPI and a glitazone that increase the risk of fractures, along with other blood-pressure meds that cause orthostasis. In this case, we can just anticipate a fall and fracture. Data from 2003 show that fall prevention is most dramatically decreased (by 39%) with discontinuing psychotropic meds—more than balance/strength training (14-27% reduction) or reducing home hazards (19%).

We must be aware of OTC and herbal remedies. St John’s wort plus an SSRI can cause the serotonin syndrome. Lupine beans and jimson weed are anticholinergic plants. Ginkgo biloba has been shown to decrease platelet aggregation and can influence the use of aspirin, Lovenox, heparin, warfarin and others. In the elderly, iron (ferrous sulfate) has been shown to increase side effects (constipation) without increasing the absorption when over 325 mg are taken daily.

Patient compliance is always a challenge. If patients cannot afford the prescription they won’t fill it. Several pharmacies (including Costco, Target and Walmart) have a $4 prescription program for some generic drugs. We also know that the more times a pill is supposed to be taken daily, the less likely it will be taken. Moreover, many medications taken for long-term use (except for analgesics) are probably taken for far less time than prescribed.

So what can we do in this environment of multiple meds, multiple docs, and an aging population? Patients often have a primary care physician and several specialists. All these doctors must be in communication regarding new medications prescribed. This dialogue is perhaps improved by electronic medical records, but I have found that it is much easier to add meds than to subtract them.

Medication reconciliation is critical and should be done with the prescription and OTC bottles lined up for the doctor during each visit. Such reconciliation is ultimately the responsibility of the primary care physician. Remember to consider the drug-drug interactions and try to hone down the number of medications. If possible, that number should be under five daily, which decreases the risk of falling.

Dr. Sheerin, an internist at Santa Rosa Community Health Centers, is medical director of the House Calls program and of Friends House adult day services.

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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about.

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9.      Book Review: Taking Back Healthcare for Future Generations

A CALL TO ACTION –Taking Back Healthcare for Future Generations, by Hank McKinnell, McGraw-Hill, New York, Chicago, San Francisco © 2005, ISBN: 0-07-144808-X, 218 pp, $27.95.

Hank McKinnel, Chairman & CEO, Pfizer, opens the preface with the question, “Is our healthcare system really in crisis?” He finds the question difficulty to answer because it makes a presumption he doesn’t accept. The phrase with which he has trouble is “healthcare system.” He agrees there’s a crisis, but it isn’t in “healthcare”- it’s in “sick-care.”  Read more . . .

He quotes Mohandas Gandhi who had similar difficulty in 1932. He had led a campaign of non-violent disobedience to help colonial India win independence from Britain. After being named Time magazine’s “Man of the Year,” Gandhi visited London for the first time. The entire world was curious, the press swarmed wherever he went, when one reporter’s hastily called-out question became a defining moment, both for him and for the nation, he was trying to set free.

“What do you think of Western civilization?” yelled the reporter.

“I think it would be a good idea,” replied Gandhi.

That’s what McKinnell thinks about our healthcare system: It would be a good idea.

He maintains we’ve never had a healthcare system in America. As far as he can tell, neither has any other nation. What we’ve had—and continue to have—is a system focused on sickness and its diagnosis, treatment, and management. It’s a system that is good at delivering procedures and interventions. It’s also a system focused on containing costs, avoiding costs, and, failing all else, shifting costs to someone, anyone else. In fact, discussions about better health now take a back seat to arguments about costs. In the United States, a nation already spending nearly $2,000,000,000,000 a year on sick care, tens of millions of people do not have adequate access to the system. In other developed nations, rationing and price controls undermine the patient-physician relationship, degrade the quality of care, and add to the anxiety of individuals struggling with health issues. An aging population around the world clamors for relief from chronic diseases and the cumulative effects of heredity and lifestyle behaviors. Some of these we cannot as yet prevent. Others, such as smoking, we can.

Today, in healthcare, we have it entirely backwards. We’re like a community that builds the best fire-fighting capability in the world but stops inspecting buildings or teaching kids abut fire prevention. Fighting fires is sometimes necessary, and we must be prepared to do that with the most modern technology available. But firefighters around the world will tell you that they’d rather prevent fires than fight them.

To put it simply, McKinnell feels that our fixation on the costs of healthcare—instead of the costs of disease—has been a catastrophe for both the health and wealth of nations. By defining the problem strictly as the cost of healthcare, we limit the palette of solutions to those old stand-bys—rationing and cost controls. What if we reframe the debate and consider healthcare not as a cost, but rather an investment at the very heart of a process focused on health? Then other solutions suddenly appear out of the fog.

That’s why this book was titled A Call to Action. It represents McKinnell’s conviction that the debate on the world’s healthcare systems is on the wrong track. Unless we correct our course, we will not be able to make the same promises to our children and grandchildren that our parents and grandparents delivered to us: that you will receive from us a better world than we received from our forebears. He feels that the basic bio-medical research conducted by his company is doing just that. But he’s concerned that his and other research-based pharmaceutical companies might lose the capacity to advance the science that can change the lives of our children and grandchildren for the better, just as polio vaccines and cardiovascular medicines and other therapies changed out lives.

McKinnell doesn’t believe in surprise endings. Although he loves a good mystery, this book was not meant to be one. The first phase of his book sets up its basic theme—that when our most cherished support systems are at risk, we are called to rethink our most well-accepted assumptions. Everywhere in the developed world, people are dissatisfied with the healthcare their families are receiving. The near universal experience is that healthcare is increasingly unaffordable, fragmented, and impersonal. Thus, the first third of the book details the proposition that the current system is profoundly misfocused in three ways. It is preoccupied with the cost of healthcare, it defines the provider as the center of the system, and it regards acute interventions as its primary reason for existence. . . .

A Call to Action distills more than three decades of experience—both joyous and painful—that has brought McKinnell to this special vantage point. He offered these thoughts, plans, and calls to action to give our descendants all the benefits of healthcare that we have enjoyed. But we cannot do so under the liabilities and constraints that today weighs down the world’s healthcare systems. These systems promise healthcare but actually swindle people out of both their health and wealth. He concludes that you and I, our children—indeed, our entire human family—most certainly deserve better.

The three decades of thought and experience shows throughout the entire treatise. There is little to disagree with. Every physician, nurse, administrator and healthcare executive should read this volume and keep it as a handy and useful reference—someplace within reach, preferably on your desk. This refocus is crucial to our understanding and to healthcare reform.

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10.  Hippocrates & His Kin:  Sex and STD in Sacramento;  Long Term Care Insurance

STDs rise for young women
Clinicians diagnosed Sacramento County teen girls and young women with more sexually transmitted diseases, or STDs, last year than ever. At the same time, the county's teen birthrate dropped to a historic low. Read more . . .

STD specialists worry that the seeming contradiction between rising STD rates and declining teen pregnancies may have a troubling explanation: that girls are using hormonal contraceptives like the pill, but young couples aren't using condoms. . .

More than four of every 100 women in Sacramento County between ages 15 and 24 were diagnosed with chlamydia or gonorrhea in 2010, according to new data from the California Department of Public Health.

That's a 12 percent jump from the year before – a spike that one local women's health care specialist called "a silent epidemic."

Though easily treatable with antibiotics, chlamydia and gonorrhea sometimes exhibit few symptoms and, if left undetected and untreated, can cause serious problems, including infertility.

Read more:

Long Term Care Insurance
In California, the average cost of a one-year stay in a nursing home is $91,250 and increasing about $5,000 annually. Most of us have homeowners insurance but only 1 out of 1000 home owners will ever have a serious fire. Consider that 700 out of 1000 of us over the age of 65 will need some type of long-term care. (CDHCS). . . The cost of spending the last week of our lives in a hospital in preparation for dying is also about $91,000. Many of us now save this $91,000 by choosing to die at home. Have you read the obituaries lately to see how many now die at home with their loved ones around them instead of tripping over ventilator tubes, IV infusion lines, heart monitor cables and sustaining a fractured hip trying to give their loved ones a final kiss? Americans are very smart and will soon figure out that spending the last year of your life in a nursing home is very inhumane and cruel as your buns (buttocks) turn into huge infected pus draining bedsores.

Now is the time to furnish the guest room for mom or dad for their final year and save $91,000.

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Hippocrates and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow

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11.  Professionals Restoring Accountability in Medical Practice, 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

                      Medi-Share Medi-Share is based on the biblical principles of caring for and sharing in one another's burdens (as outlined in Galatians 6:2). And as such, adhering to biblical principles of health and lifestyle are important requirements for membership in Medi-Share. This is not insurance. Read more . . .

                      PATMOS EmergiClinic - where Robert Berry, MD, an emergency physician and internist, practices. To read his story and the background for naming his clinic PATMOS EmergiClinic - the island where John was exiled and an acronym for "payment at time of service," go to To read more on Dr Berry, please click on the various topics at his website. To review: How to Start a Third-Party Free Medical Practice . . .

                      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. 

                      FIRM: Freedom and Individual Rights in Medicine, Lin Zinser, JD, Founder,, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance. Read Lin Zinser’s view on today’s health care problem:  In today’s proposals for sweeping changes in the field of medicine, the term “socialized medicine” is never used. Instead we hear demands for “universal,” “mandatory,” “singlepayer,” and/or “comprehensive” systems. These demands aim to force one healthcare plan (sometimes with options) onto all Americans; it is a plan under which all medical services are paid for, and thus controlled, by government agencies. Sometimes, proponents call this “nationalized financing” or “nationalized health insurance.” In a more honest day, it was called socialized medicine.

                      To read the rest of this section, please go to

                      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."

                      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.  

                      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

                      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, 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, who wrote an informative Medicine Men column at NewsMax, have now retired. Please log on to review the archives. He now has a new column with Richard Dolinar, MD, worth reading 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 read News of the Day in Perspective. Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. Browse the archives of their 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.  You may want to check how to opt out of Medicare:

The AAPS California Chapter is an unincorporated association made up of members. The Goal of the AAPS California Chapter is to carry on the activities of the Association of American Physicians and Surgeons (AAPS) on a statewide basis. This is accomplished by having meetings and providing communications that support the medical professional needs and interests of independent physicians in private practice. To join the AAPS California Chapter, all you need to do is join national AAPS and be a physician licensed to practice in the State of California. There is no additional cost or fee to be a member of the AAPS California State Chapter.
Go to California Chapter Web Page . . .

Bottom line: "We are the best deal Physicians can get from a statewide physician based organization!"

 PA-AAPS is the Pennsylvania Chapter of the Association of American Physicians and Surgeons (AAPS), a non-partisan professional association of physicians in all types of practices and specialties across the country. Since 1943, AAPS has been dedicated to the highest ethical standards of the Oath of Hippocrates and to preserving the sanctity of the patient-physician relationship and the practice of private medicine. We welcome all physicians (M.D. and D.O.) as members. Podiatrists, dentists, chiropractors and other medical professionals are welcome to join as professional associate members. Staff members and the public are welcome as associate members. Medical students are welcome to join free of charge.

Our motto, "omnia pro aegroto" means "all for the patient."

Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

Words of Wisdom

"Each person has this magical thing called Soul Purpose within them. The difference between surviving

and thriving has to do with whether we see it or not." — Garrett Gunderson: an entrepreneur and author

Some Recent Postings

In The November 8th Issue:

1.                  Featured Article: How does a woman say goodbye to her breasts?

2.                  In the News: OLIVES: UCD Rising Industry

3.                  International Medicine: Health Welfare and Corporate Welfare are Lawmaker Diseases

4.                  Medicare: : Bundled Payment Experiment

5.                  Medical Gluttony: Corporate Practice of Medicine

6.                  Medical Myths: The National Practitioner Data Bank is Confidential

7.                  Overheard in the Medical Staff Lounge: Will GOP choose between two flawed candidates?

8.                  Voices of Medicine:  Krauthammer: Two very flawed front-runners

9.                  The Bookshelf: Robin Cook, MD and Tess Gerritsen, MD

10.              Hippocrates & His Kin: Washington thinks it can do it better. 

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

In Memoriam

George Daniels, master watchmaker, died on October 21st, aged 85

From the Economist | print edition | November 26, 2011

A SCHOOLBOY once asked George Daniels what he had at the end of the chain that led to his pocket. A silly question, really. But it was worth asking, because what Mr Daniels pulled out, carefully, was what he called his Space Traveller’s Watch. It gave mean solar time, mean sidereal time, equation of time, and could chart the phases of the moon. Mr Daniels liked to say it would be useful for trips to Mars. He had surmised almost the same when, at five or six, he had first prised open with a fairly blunt breadknife the back of an old watch he had found at home, and seen “the centre of the universe” inside. Read more . . .

He had never imagined then that he would make the universe by hand. But he did. Every component of his Space Traveller’s Watch—as of the 36 other watches he made, each unique, over his 42 working years—was produced from scratch. He made the screws, the springs and the levers, the pallets and gears, the hands and the plain, often numberless dials. He also made the tools that made them, except for the lathes and turning engines. No one else had ever learned the dozens of necessary skills. But after years of teaching himself horology from clocks bought for a bob or two at jumble sales, or comrades’ broken watches in the army, or the wonderful Breguet and old English timepieces he went on to restore for collectors, he had begun to think, why not?

Hour after hour, for it wasn’t the sort of work you could just do a little of and leave again, he would cut and shape, file and polish, temper and hammer. The work flowed from the tools almost unconsciously. He learned from a craftsman in Clerkenwell how to make cases, usually of gold with a silver back and bezels. His first watch was sold to a collector friend, Sam Clutton, in 1970 for £1,900; when sold in 2002, it fetched more than £200,000.

Tick, tock

A hard, poor childhood in north London had given him a nose for a deal and a sharp sense of the value of everything. But his pieces were private experiments, not commissions. He wanted to build watches that kept better time than any in the 500 years before. The general public was happy, from the late 1960s, with quartz models that lost, on average, two or three seconds a month. But Mr Daniels was determined to show that a mechanical watch could beat them. In the mid-1970s he made a double-escapement watch for Mr Clutton which, over 32 days, lost less than a second. His happiness at beating quartz came close to his boyhood joy when a wall-clock he had mended magnificently exploded, springs and glass everywhere, as the family ate their bread and jam at the supper table.

Now he had to improve on the lever escapement, which had been invented in 1754 by the English horologist Thomas Mudge and used in most watches since. It worked by friction, as the teeth of the gears slid over the pallet; but this arrangement needed lubrication, and as the oil degraded the watch lost time. Mr Daniels became obsessed with the tick, tock of clocks (a sound that filled his various homes, together with silvery chimes), and how to get an impulse on both the tick and the tock that would not be affected by humidity, temperature, oil sludge or agitation. His solution, invented in 1976, was the co-axial escapement, an arrangement in which two wheels, placed one above the other, transmitted to the pallet a radial impulse that needed no lubrication and so (if wound) would never stop.

That achievement earned him many honours for services to horology, but it was only the beginning of a long slog to get his idea accepted. The world of clocks and watches was a closed one. He knew it himself, because his boyhood watch studies from library books were a private realm only he could understand, and the 18th-century English masters—Mudge, Arnold, Earnshaw—the only real friends he had. Watchmakers kept the secrets they learned in their lonely working hours. Even later, when he had put himself in the millionaires’ bracket and had to move to the Isle of Man for tax reasons, his friends were in the motoring clubs where he shared his other passion, for vintage Bentleys and racing cars. He had no watchmaker friends at all.

So it was no surprise to him, though keenly disappointing, that the Swiss watchmaking industry was neither eager to look at the co-axial escapement, nor able to understand it. He did the rounds of the factories for more than 20 years. After four years with Patek Philippe, he could not persuade them to make it. Omega began to produce it in limited editions in 2006, after seven years of “development” that Mr Daniels dismissed as unnecessary. Large-scale production would have been too expensive. But Mr Daniels also suspected sheer dislike of outsiders.

While restoring the timepieces made by his idol Breguet in the 19th century, he had made two clocks in the same style, just to prove he could beat the master. They were so fine that the company insisted on putting the Breguet secret signatures on them. Mr Daniels went along with it. He had a secret cipher of his own, though, a dove with an olive branch. It meant peace to his rivals, French or Swiss; but if the most ingenious invention in watchmaking for 250 years was too tricky for them, why, he would just pick it up, snap it shut and put it back in his pocket.

 Read the entire obituary in the Economist – Subscription required . . .

On This Date in History – November 22

On this date in 1963, President John F. Kennedy was assassinated. This will always be remembered, by everyone who lived through it, as the day when a young President was struck down in an assassination. So much of what transpired thereafter was seen on the television screen, that the event is vividly engraved on the memories of millions of people. Questions about it have persisted ever since. It was the nature of John F. Kennedy to stand back and look at himself, and sometimes be amused at what he saw in himself. John Kennedy said, in the year that he died, “. . . if we cannot end now our differences, at least we can make the world safe for diversity.”

On this date in 1906, SOS, spelled out in wireless code, was adopted as the international distress signal. We may not have much luck in the world as different peoples attempt to talk in order to convey happy news to each other, the letters SOS is the one phrase that everybody understands and conveys bad distressing news.

After Leonard and Thelma Spinrad

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