Community For Better Health Care

Vol VI, No 15, Nov 13, 2007


In This Issue:

1.                  Featured Article: Ethical and Moral Issues Are Inseparable from Health Care

2.                  In the News: Waiting Lists and Superbugs Push 70,000 Brits to Foreign Clinics

3.                  International Medicine: Trebled Patient Loads; Actual Case Reports; Pay For Performance in the UK - Lessons for American Doctors

4.                  Medicare: Medicaid's Soaring Cost: Time to Step on the Brakes

5.                  Medical Gluttony: Is Frequently Misinterpreted As Superb Health Care

6.                  Medical Myths:  Medical Care Should Be Evidence Based Objective Practice

7.                  Overheard in the Medical Staff Lounge: Medicare Subterfuge

8.                  Voices of Medicine: Please Google Me, By Sanjay Dhar, MD, Sonoma Medicine

9.                  Book/Movie Review: Michael Clayton: Just Pretend This Isn't Madness

10.              Hippocrates & His Kin: Evading Do Not Call Lists, P4P, Wealth Improves Health

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. This year it was 50 percent, indicating open forums such as these are critically important. The 5th Annual World Health Congress has been scheduled for April 21-23, 2008, also in Washington, D.C. The early registration discounts expire on November 30, 2007. So HURRY. The World Health Care Congress - Asia will be held in Singapore on May 21-23, 2008.  The 4th Annual World Health Congress – Europe will meet in Berlin on March 10-12, 2008. For more information, visit 

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1.      Featured Article: Ethical and Moral Issues Are Inseparable from Health Care                      

Patients' Freedom of Conscience: The Case for Values-Driven Health Plans by Robert E. Moffit, Ph.D., Jennifer A. Marshall, and Grace V. Smith, Heritage Foundation, Executive Summary #1933

Ethical and moral issues are inseparable from health care and are usually addressed by employers' health insurance plans, government agencies, and national and state lawmakers. Through the delibera­tions of their elected representatives, Americans will define and refine the laws concerning abortion, medical care at the end of life, and such other com­plex and difficult topics as the use of genetic infor­mation, embryonic stem cell research, the use of fetal tissue, and the legitimacy of physician-assisted sui­cide. Public debate on biomedical ethical issues is necessary and should not be confined to experts. Every American has a stake in these issues, which involve tax dollars as well as private dollars for health insurance and medical care.

Primacy of Conscience. Regardless of how health policy issues are resolved legally, Americans must retain their individual right not only to dis­sent from existing public policies, but also to make personal health care decisions - including how money is spent for health benefits, medical treat­ments, and procedures - according to the dictates of their consciences. This is why, regardless of their differing views on many controversial health issues, all Americans should work together to protect patients' freedom of conscience in health care. Recent debates on the rights of conscience have focused on providers, not patients, but freedom of conscience for every person should be the rule in health care, which is emerging as the central arena of new and profoundly serious scientific and ethi­cal issues. Americans should have the option to control their health care dollars and to participate in plans that respect their values and deliver medi­cal benefits that are consistent with those values.

But most Americans, as a practical matter, do not have that kind of control. Third-party payers - administrators of government and private health insurance plans - generally set the rules for cover­age: which plans are offered, what benefits are included, and how they are funded. Many Ameri­cans are rightly concerned that they are progres­sively losing control over the key decisions that affect their health care.

Biomedical Advances. The fruits of biomedical research will be incorporated rapidly into advanced medical treatments and procedures. Once a proce­dure is covered by a health insurance plan, its financing is spread among all participants in the plan. In the case of publicly funded insurance, that includes all taxpayers.

Because many emerging treatments and proce­dures will have serious ethical ramifications, poli­cymakers should enact major reforms that would allow health care in America to function more as a genuine consumer-driven and values-driven mar­ket functions. Freedom of conscience is merely an abstraction unless individuals and families can act on it, especially when spending their own money on insurance premiums, medical providers, and medical procedures. In this way, individuals and families could "vote with their feet," freely choosing which health benefit plans, packages, and medical procedures they wish to support.

Emerging Ethical Challenges. Abortion and related issues are flashpoints at the busy intersec­tion of health care policy, medical ethics, and per­sonal morality. Meanwhile, embryonic stem cell research, therapeutic cloning, pre-birth genetic screening to identify "unwanted" children, thera­pies or treatments for genetic enhancement, and growing social acceptance of physician-assisted suicide will create new ethical challenges. Individ­uals and families cannot assume that employers, third-party administrators, or government officials will resolve these sensitive issues in a manner con­sistent with their personal beliefs.

Creating a New Environment for Personal Freedom. Most individuals and families have little control over the terms or conditions of their health insurance contracts or the payment of premiums to doctors and other providers. Most Americans get what they are given and pay what they are told to pay. Personal choice is limited, and this limitation on personal freedom is a central defect of America's health care system. Policymakers can correct this deficiency by returning control to individuals and families in four major ways:

Allow all Americans to choose their own health plans. In addition to conventional and employer-sponsored health plans, Americans should be allowed to choose plans sponsored by professional associations, employee organi­zations, unions, and faith-based and religious groups. Individuals and families could then secure coverage through health plans that are compatible with their ethical and moral values.

Eliminate discrimination in the tax code. To make personal choice a reality, the federal and state tax codes should treat all types of plans equally. The best way to accomplish this is to give every person a refundable, individual health care tax credit to purchase the plan of his or her choosing, regardless of place of work. This change could foster the development of new kinds of plans, including plans sponsored by religious organizations and church consortia.

Open up health insurance markets. Health insurance is governed by state law and, to a lesser extent, federal law. State officials could open up current markets by replacing the bal­kanized, highly regulated state health insurance markets with a single statewide market, or insurance exchange. Through the exchange, employers could contribute a defined amount to the health plans designated by their employ­ees, and plans would compete directly with each other for consumers' dollars. Congress could allow Americans to purchase health insurance across state lines, just as they buy many other goods and services, including other types of insurance.

Allow values-driven health plans to partici­pate in public programs. Health plans spon­sored by religious and other organizations should be allowed to participate in Medicare, Medicaid, and the State Children's Health Insur­ance Program, just as they already do in the Fed­eral Employees Health Benefits Program.

Conclusion. Individuals and families should be free to control the flow of dollars in their health care plans and to make the decisions that will affect their medical treatment and health care coverage, including ethical decisions.

Robert E. Moffit, Ph.D., is Director of the Center for Health Policy Studies, Jennifer A. Marshall is Direc­tor of Domestic Policy Studies, and Grace V. Smith is a Research Assistant in Domestic Policy Studies at The Heritage Foundation.

To read the entire paper, go to

Our thanks to Gretchen Longcore, AMWA, Senior Medical Writer for MacroGenics, Inc, Rockville, MD.

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2.      In the News: Record Numbers Go Abroad for Health, The Sunday Telegraph

Record numbers go abroad for health, By Laura Donnelly and Patrick Sawer, 29/10/2007

Record numbers of Britons are flying abroad for medical treatment to escape NHS waiting lists and the rising threat of hospital superbugs.

Thousands of "health tourists" are going as far as India, Malaysia and South Africa for major operations – such is their despair over the quality of health services.

The first survey of Britons opting for treatment overseas shows that fears of hospital infections and frustration with NHS waiting lists are fuelling the increasing trend.

More than 70,000 Britons will have treatment abroad this year - a figure that is forecast to rise to almost 200,000 by the end of the decade. Patients needing major heart surgery, hip operations and cataracts are using the internet to book operations to be carried out thousands of miles away.

India is the most popular destination for surgery, followed by Hungary, Turkey, Germany, Malaysia, Poland and Spain. But dozens more countries are attracting custom. Research by the Treatment Abroad website shows that Britons have travelled to 112 foreign hospitals, based in 48 countries, to find safe, affordable treatment.

Almost all of those who had received treatment abroad said they would do the same again, with patients pointing out that some hospitals in India had screening policies for the superbug MRSA that have yet to be introduced in this country.

Andrew Lansley, the shadow health secretary, said the figures were a "terrible indictment" of government policies that were undermining the efforts of NHS staff to provide quality services.

The findings come amid further revelations about the Government's mishandling of NHS policies, and ahead of official statistics that will embarrass ministers:

• On Wednesday, figures are expected to show rising numbers of hospital infections. Cases of the superbug Clostridium difficile, which have risen five-fold in the past decade, are expected to increase beyond the 55,000 cases reported last year.

• On the same day, statistics will show that vast sums have been spent on pay, with GPs' earnings rising by more than 50 per cent in three years to an average of more than £110,000.

• New research shows that growing NHS bureaucracy has left nurses with little time to see patients – most spending long periods dealing with paperwork.

Katherine Murphy, of the Patients' Association, said the health tourism figures reflected shrinking public faith in the Government's handling of the NHS.

"The confidence that the public has in NHS hospitals has been shattered by the growth of hospital infections and this Government's failure to make a real commitment to tackling it," she said. "People are simply frightened of going to NHS hospitals, so I am not surprised the numbers going abroad are increasing so rapidly. My fear is that most people can't afford to have private treatment - whether in this country or abroad."

Some foreign hospitals touting for business on the internet offer consultations in hotels in Britain. But other patients are happy to rely on email to discuss their treatment with doctors thousands of miles away. Low prices in India, where flights, hotels and a heart bypass cost less than half the price charged by British private hospitals, explain its top ranking in the survey by Treatment Abroad, a British website providing information on hospitals overseas.

Hungary's popularity rests on a boom in dentistry, thanks to a shortage of NHS dentists in Britain.

Mr Lansley said: "Healthcare is an area where Britain could be a world beater because we have some of the best research and best clinicians. If people don't trust the health service, then that is a terrible indictment of this Government, which has turned the NHS into a nationalised bureaucracy, instead of something able to focus on what patients want."

The British Medical Association advised people to be careful when considering treatment abroad, highlighting the dangers of flying soon after surgery, which can cause complications.

A spokesman said: "Travelling can place a great deal of stress on the body. Patients travelling abroad for surgery should consider their fitness to fly and get an understanding of an appropriate convalescence period before attempting to return home."

A Department of Health official said the number of patients seeking treatment abroad was a tiny fraction of the 13 million treated on the NHS each year. Waiting times had fallen. Almost half of patients were treated within 18 weeks of seeing a GP. Most people who had hospital care did not contract infections.

Our thanks to Julie Meyer, CEO of AriadneCapital, our correspondent in London.

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3.      International Medicine: Trebled Patient Loads; Actual Case Reports; Pay For Performance in the UK - Lessons for American Doctors

Hundreds of GPs forced to take extra patients may retire early, By Lorna Duckworth Health Correspondent, The Independent, 24 September 2002

Hundreds of over-stretched family doctors are considering early retirement because of a massive increase in the number of patients being imposed on their practices.

The problem stems from a shortage of newly qualified GPs, which has left many practices, including those in affluent areas, unable to fill staff vacancies.

Many doctors have closed their lists because of the pressure of work. But health officials have to ensure that everyone has a GP so they have forced some doctors to accept extra patients.

In the past year, the number of "compulsory allocations" in some areas has trebled. In Liverpool, allocations rose from 1,563 in 2000 to 3,817 in 2001 and are likely to exceed 5,000 this year. . .

"Doctors feel their workload is so great that if it increases any further, they won't be able to provide a safe service for patients. Many GPs are already working 11, 12 or 13 hours a day.". . .

"For many GPs it will be more cost-effective to resign from the partnership of a practice and go to work as a locum. The patients are innocent victims. They have been told to expect a Rolls-Royce service that we are having to deliver out of the back of a Mini."

Dr Laurence Buckman: A Doctor writes: My profession is being vilified for doing what was asked, The Independent Sunday, 01 November 2007

-- Family doctors are now being penalised for rising to the challenge of performance-related-pay by delivering the quality care
-- The only pay rise that GPs got from the 2003 awards was for performance.
-- GP pay since then has been completely static but our expenses have risen, so it is - in effect - a pay cut.
-- If you don't make the patient in front of you better, then you don't get the extra pay.

Doctor, doctor: How can you justify a 10% pay increase? By Jeremy Laurance, Health Editor, The Independent, Sunday, 01 November 2007

. . . Official figures published yesterday show GPs' pay soared to an average of £110,000 a year in 2005-06, a rise of almost 10 per cent on the previous year and 35 per cent in the two years since their new contract was introduced in 2004.

British GPs are now among the highest earning family doctors in the world. They have enjoyed a bonanza at a time when the NHS was struggling to balance its books by closing wards and cutting services. A poll last week found they were the happiest in Europe with their pay which has increased from £100,170 in 2004-05 and £81,556 in 2003-04.

Part of that rise, it turns out, has come because they have chosen to pay themselves more. GPs are self-employed and are paid a gross sum (£245,020 in 2005-06) out of which they are expected to hire staff and buy equipment to run their practices. What is left is their "profit" or income for the year.

Not content with six-figure incomes, the report from the NHS Information Centre published yesterday reveals that, during 2005-06, they spent less on their practices and kept a larger profit for themselves - for the second year running. Over the two years, the extra they have pocketed amounts to £10,000 per doctor. . .

British health case studies

To read a series of health case reports, go to

The NHS does not give timely access to healthcare, it only gives access to a waiting list.

Our thanks to Bob Speth, MBA, MIS, for forwarding these articles to MedicalTuesday.

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4.      Medicare: Medicaid's Soaring Cost: Time to Step on the Brakes by Jagadeesh Gokhale

Jagadeesh Gokhale is a senior fellow at the Cato Institute and the coauthor of Fiscal and Generational Imbalances: New Budget Measures for New Budget Priorities.

Executive Summary

Current trends and policies imply unsustainable growth in federal Medicaid outlays. In the year 2006, federal Medicaid spending was 11.9 percent of federal general revenues and 1.5 percent of GDP. Making conservative assumptions about future growth in Medicaid enrollment and spending per beneficiary, this paper estimates that the present value of federal Medicaid outlays over the next 100 years will take up 24 percent of the present value of federal general revenues and 3.7 percent of the present value of GDP calculated over the same period.

By the end of the next 100 years, that is, in the year 2106, Medicaid's share of federal general revenues will be 48 percent - four times larger than its 11.9 percent share in 2006. In the year 2106, federal Medicaid spending as a share of GDP is estimated to be 7.4 percent - a fivefold increase from its current share of 1.5 percent. If the federal government continues to match state Medicaid outlays at the current rate, Medicaid's share of GDP in the year 2106 will become 13 percent - or one-eighth of GDP in 2106.

If current policies and trends are maintained, federal Medicaid outlays will take up 36 percent of lifetime federal general revenue taxes for males born in 2025 and 69 percent for females born in that year. For females born after 2050, almost all of their lifetime federal nonpayroll taxes will be consumed by their lifetime Medicaid benefits.

Higher tax rates cannot plausibly cover this growing spending commitment. On average, today's 35–year–old males are projected to have 15 percent of their lifetime federal general revenues returned in the form of Medicaid benefits. Maintaining that ratio for today's newborn males would require a 78 percent increase in their lifetime nonpayroll taxes. Limiting Medicaid spending growth is, thus, an essential component of putting the federal budget on a sustainable course without imposing crushing tax burdens on younger and future generations, thereby harming the prospects for future economic growth.

Full Text of Policy Analysis no. 597

(PDF, 510 KB | HTML)

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

- Ronald Reagan

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5.      Medical Gluttony:  Is Frequently Misinterpreted As Superb Health Care

Barber Don's wife turned 65, obtained Medicare and enrolled in an HMO. She developed benign positional vertigo and her doctor wanted an MRI. The HMO denied it and her doctor had a fit of rage that someone would question his judgment. The MRI was accomplished. The test was negative. (One of my patients last week had to pay $968 for a scan.) She was then given an anti-vertigo drug and was discharged from the hospital.

The barber expounded on the great care his wife obtained. However, vertigo is something that every practitioner sees frequently, if not weekly. The usual treatment with anti-vertiginous drugs or decongestants will, in most instances, alleviate the problem.

Some thoughts on this sequence of medical events: A doctor that won't listen to alternative treatments should be treated with suspect. There are usually several ways to treat many medical conditions. Second, there is only one easy way to change this excessive utilization of health care costs. Higher copay is not one of them. After paying a $50 or $100 copay, the sky is still the limit. Only if the patient has to pay a percentage of every item of health care will the patient be his or her own reviewer of medical necessity. A copay of 10 or 20 percent would result in the patient querying the doctor about the medical necessity. Many patients are getting very sophisticated medically with the advent of Web Medicine and Patient Directed Health Care. They will have a good idea of the seriousness or lack thereof for vertigo if they have a stake in the costs.

Actuaries have estimated a 30 to 40 percent reduction in health care costs with consumer or patient involvement. As evidence is accumulating, it appears that health care costs in this country can almost be cut in half with Patient Directed Health Care - any system in which the patient is partially liable for every item of health care.

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6.      Medical Myths: Medical Care Should Be Evidence Based Objective Practice

In 2002, two women in their 80s had abnormal mammograms. Both saw their doctors with their daughters. Both were alert and lucid in their thinking. Both had the usual diseases that come in the ninth decade of life - arthritis, atherosclerosis, mild non-limiting heart disease and mild easily treated hypertension.

Mrs. Crystal had a small one-centimeter lesion in the lower inner quadrant of her right breast. On speaking with the daughter in front of the patient, they decided to go the entire route and an ultrasound was obtained suggesting a solid non-cystic lesion, very like a carcinoma. The family history was negative for cancer. The daughter stated that she wanted everything done and wanted a surgeon for her mother. A biopsy was accomplished and it was positive. She wanted to proceed to mastectomy and have her mother cured. The patient was reticent but concurred. Her doctor pointed out that in the ninth decade of life she could outlive her cancer even if nothing were done. Nevertheless, a mastectomy was done on her right breast. The diagnosis was reconfirmed and she received radiation therapy. She was also given chemotherapy.

The patient had a fairly miserable year and then seemed to do well. After two years, she developed metastases to her ribs and was in severe pain for the next year. She then developed metastases to her brain. Her daughter wanted to continue with all modes of diagnosis and treatment. As she was being prepared for radiation therapy to the brain lesion and as the black marks were placed on her shaved scalp by the radiation oncologist, the patient reeled in horror at her reflection in the mirror. She asked them to remove the ink markings so that she could be sociable with her friends during the final months of her life. However, she had difficulty being part of the "girls" and no longer could play bridge. She would retreat to her room at the senior citizen's abode, sometimes in tears. She was getting more depressed. She told her daughter that she did not want anything else done. In fact, she wasn't sure that life was worth living anymore. She is prepared to say goodbye to her daughter and her friends. The daughter is a basket case. She tells her mother, "How can you do this to me after all I did for you?"

Mrs. Berry had a small one-centimeter lesion in the lower inner quadrant of her left breast. The daughter took her doctor aside and asked about the prognosis. Could she live for several years in relative comfort and not have surgery? The answer was a "probable yes." She said that she had her mother's power-of-attorney and did not want anything done to cause suffering or interfere with her mother's social contacts. She would prefer to see her mother active, enjoying her friends, and live in comfort, even if for only one or two years, rather than go for a radical cure. Her doctor said that he would be happy to obtain a repeat mammogram in six months and every year thereafter and follow the lesion expectantly. She stated that she would like that. However, she wound up declining the follow-up mammograms since she had already determined that removal of her mother's breast was not acceptable. Each year she quietly asked the doctor to examine the breast manually to check for any significant growth. After five years, it still was barely palpable. The patient was enjoying life, playing bridge, and active in her senior citizen's environment.

Two similar cases are never really alike. But these two cases reveal a basic difference in how people react to the same medical problems, which never really are the same. However, the first patient had medical costs that exceeded $100,000 including the hospitalizations, surgery, expensive radiation therapy, and expensive chemotherapy. Despite these major costs to health care, she had a miserable first year, and a miserable 4th and 5th year before dying. She had two years of relative wellness.

The second case had five years of relative wellness, enjoyed life to the fullest and had essentially no significant health care costs except the mammogram, five yearly office evaluations, at a total cost of less than $1000, and is still alive and well.

What are the issues? If the patients had physicians that followed evidence-based medicine, the costs would have been considerably more for the second. The first with one hundred times the costs probably would not have changed. If the government were directing the health care, the second doctor might have been Peer Reviewed as giving inappropriate care and reported to the State Medical Board, which may have resulted in his Medical License being revoked. He then would have been reported to the National Data Bank as a bad doctor and would never have been able to practice again. His bankruptcy would result in the lost of home and family, since he no longer could support them.

Costs would have increased astronomically with any government infringement, despite the fact that government medicine always goes bankrupt, and controls and delays are placed in the system. Thus, the public does not perceive bankruptcy. We will see patient-sensitive doctors frightened away from practicing clinical medicine, adding unnecessary costs to save their license. Government medicine has numerous hidden and conflicting agendas and will never deliver what patients need. They work under the pretext that they have polled the patients and found what patients want but are unable, with their lack of medical sophistication, to understand the problem or the issue at hand. And costs will increase astronomically, ending up with bankruptcy. However, the public will never perceive it as such because it is constantly bailed out with increased taxation, as in the case of Medicare.

If you think health care is expensive now, wait until you see what it costs when it's free.     

               - P. J. O'Rourke

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7.      Overheard in the Medical Staff Lounge: Medicare Subterfuge

Dr. Rosen: Well what's the latest on the St George Remodeling Medicare fiasco?

Dr. Sam: I'm without Medicare payment for going on six months now, and still no word from Medicare.

Dr. Milton: Does any one have any word on when this Medicare fiasco is going to be resolved?

Dr. Dave: I'm redirecting my practice so I'm less dependent on government medicine.

Dr. Rosen: We have one person from Stanford who reports that he waited nine months after his change of address notice before he got paid. He got his congressman and Senator involved hoping they could speed up the payment.

Dr. Milton: Looks like that slowed the payment process even more.

Dr. Rosen: Doesn't that mean that Medicare thinks they are above the law?

Dr. Edwards: Isn't that an interesting and sad paradox. Congress is pushing for their control over health care. But they will have to lateral it over to CMS [Center for Medicare/Medicaid Services] who control Medicare and Medicaid for implementation. CMS has such utter disregard for Congress they thumb their noses at them when they call.

Dr. Rosen: So when Congress through CMS tries to run a national health care plan, we will immediately have warring factions. What a way to provide a sensitive personalized service. And many in the public fail to understand that neither faction cares a wit about them. They just want power and control. They could care less about the public's health.

Dr. Yancy: I've decided that I'm no longer accepting new Medicare patients. Then over time, I will leave Medicare totally and have a completely private practice. Either first class insurance payment or cash. No alternatives.

Dr. Michelle: Aren't you going to see poor people, Yancy?

Dr. Yancy: I operate every day on poor people for one-fourth the standard fee, which is what Medicaid pays me. It doesn't cover my overhead. So, it's mostly charity. We don't have an underclass in this country. All poor people have Medicaid insurance, which beats the national health insurance found around the world.

Dr. Rosen: What do you think is the reason for Medicare nonpayment?

Dr. Sam: The government is in a financial bind and this is simply a way to delay payment for six months or longer. Saves them a lot of money at no interest. The doctors and the hospitals are losing money and paying interest on the money they are borrowing to pay bills.

Dr. Edwards: I think the government is angry at doctors and this is one way of retaliating.

Dr. Sam: I have to agree with that also. The government, which includes Medicare, Medicaid, Congress and Senate, want to control us.

Dr. Rosen: I've done some work in Social Service for Disability evaluations. There was always an undercurrent of hostility towards doctors. Many times one could walk into a room and it would become immediately silent; you knew they were talking about doctors. Many were openly hostile.

Dr. Edwards: This hostility towards doctors is pervasive. I once walked into a room in this very hospital where everyone was laughing and as I opened up the door, I heard one person laughingly say, "And the doctors believed us!" as if we were all ignoramuses.

Dr. Milton: That's why hospitals walk all over doctors also. They blunt that perception by hiring administrative doctors half time. As they get their half-time salaries with the hospital's administrator's signature, they really fall in line.

Dr. Sam: Sort of makes them hospital whores, doesn't it?

Dr. Ruth: Wouldn't prostitutes be a better term? After all, aren't they getting paid?

Dr. Sam: That's a good point, Ruth.

Dr. Dave: And did you know that Medicare cuts fees in half when there is an associated psychiatric diagnosis such as anxiety disorder?

Dr. Edwards: Can you see anyone bailing a patient out of heart failure and that patient not be anxious? And the doctor has to work twice as hard and long with a life-threatening problem and sees his pay cut in half. Medicare has the cruelty of reducing the well-earned fee in half?

Dr. Dave: And the other paradox is that Medicare doesn't pay on many diagnoses but on symptoms. Today my bookkeeper told me that if she doesn't change the diagnosis of asthma to wheezing, we don't get paid for a pulmonary function test?

Dr. Rosen: If a patient is actively wheezing, one shouldn't even get a PFT. One should wait until the patient stabilizes and get a base line. That shows the medical illiteracy of Medicare regulations.

Dr. Dave: Can't you wait until all these Medical Illiterates run health care?

Dr. Rosen: So we all agree that this Medicare Fiasco of not paying doctors for any picayunish reason such as a simple change of address notice is abusive, hostile, retributive, vindictive harassing subterfuge against a perceived privileged group known as physicians? 

Dr. Sam: Just wait until these Medical Illiterates take over and the backlash against the health care fiasco develops with a hundred million unhappy Americans ready to March on Congress.

Dr. Ruth: I think if I were in Washington then, I'd leave town.

Dr. Sam: But Congress will blame the doctors and try to prosecute us.

Dr. Rosen: Better start thinking about cross-training now.

Dr. Sam: A retired physician told me the other day that if he had to do it all over again, he would become a forensic pathologist, the one field that government doesn't yet control.

Dr. Rosen: Who is he kidding? Bureaucrats want control, they don't care about fiscal responsibility. Or even who's on the autopsy table.

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

SONOMA MEDICINE, the Magazine of the Sonoma County Medical Association

Outside the Office: Please Google Me, By Sanjay Dhar, MD

I recently came back home after a long weekend, only to find that names like Paris Hilton and Lindsay Lohan have taken over the airwaves, electronic media, and television stations. I can't find real news anymore, anywhere. I now depend upon what is presented to me by people who decide what is important and what they think I should know or care to know. Do I really care if Britney Spears shaves her head?

I am not opposed to television or the Internet, but as time goes on I am bombarded by more and more advertisements, each one more colorful than the other, each one enticing me to buy or use their product. I want to tell the advertisers, the television stations, the radio stations, the people who send me tons of junk mail, and the spammers who blast me with e-mails: "Please know more about me, please Google me."

I am secure in my current financial situation, and I don't want to be told repeatedly that my mortgage needs to change hands because someone has a better "no-interest" deal. I know that my relatives are all doing well, and that I have no rich uncle in Nigeria who has just passed away, leaving behind millions.

I am physically in good shape and don't need medications to boost everything in my body. I don't want pop-up advertisements on my computer screen every time I log on - so much so that I can't even see the page I logged onto.

I am a married man with two children. I don't want to see Victoria's Secret lingerie commercials while watching American Idol with my daughter, and I don't want to watch commercials for Mortal Kombat while watching Sponge Bob with my son.

Now that you have an idea about what I don't want to know, maybe you should be aware of what I do want to know. . .

To read what Dr. Dhar wants to know, go to

Dr. Dhar is a Santa Rosa cardiologist.

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9.      Movie Review: Michael Clayton

Michael Clayton: Just Pretend This Isn't Madness By James J. Murtagh, M.D.

I am Shiva, God of Death

Spoiler alert- Consider seeing the movie before reading this Op Ed

Corporate crime films- from Silkwood, to Serpico, the Insider, and SiCKO- focus on the victims, and underdogs overcoming corruption. They are David versus Goliath films. But whoever tells the inside story of the Goliaths?

Surely, Goliath didn't think of himself as a monster. He saw himself as a tragic soldier, serving his own god, and his family, unfairly defeated by a tiny man with a slingshot. What makes the giant "scurvy spiders" of industry tick? How do good people go bad and sink to corporate crime? In George Clooney's new film, Michael Clayton we see a giant company's lawyers close up under siege.

In an inverse of Erin Brockovich, U/North, the film's corporate Goliath, is caught red-handed in multi-billion dollar environmental catastrophe, killing hundreds of persons. As events spin out of control, lawyers and officers of U/North sweat bullets, and unblinkingly, this film shows the people behind the disaster. They are just people, with mortgages and families, and must overcome their circumstances to rise above the evil they have slipped into.

"I am Shiva, God of Death," declares a key defense lawyer as he cracks under the stress and guilt, going manic. So, U/North calls in groups of fixers; some semi-legitimate, such as Michael Clayton; but other a strictly black ops paramilitary team. Every move, every phone call, is being monitored by the black ops team that will do whatever it takes. Clayton declares he is a janitor, and that "The truth can be adjusted," updating Orwell's doublethink, the power of holding two contradictory beliefs in one's mind simultaneously. Clayton apparently believed at the film's beginning that "Ignorance is Bliss," and "Freedom is Slavery."

"Will someone rid me of this meddlesome priest?" Most wrenching and fascinating is the U/North top legal ace cryptically ordering the death of the manic lawyer-turned-whistleblower. But the silk-stocking legal ace can't bring herself to say the actual words needed to order the killing. Through her desperation, she manages to convey that she wants the killers to "proceed."

The U/North counsel never has a moment of peace after. Like a corporate Lady MacBeth, she is never able to wash off the damned spot. The murder leads to more murder attempts, and events spiral out of control until the end. Her moment of redemption is impossible, it appears, until she is finally caught.

The suffering of tyrants has been the subject of great tragedy from Sophocles to Shakespeare. How do corporate tyrants live with their guilty consciences? In this film, guilt leads one lawyer to a madness that was greater than the truth. Guilt leads other lawyers to murder and cover-up. Guilt led Michael Clayton initially to complicity, to gambling, to other vice, but finally led him to do the right thing and expose the corporate culture of cover-up and murder.

"Corruption is why we win" declared a character in George Clooney's related film, Syriana. Some officers relish in wrongdoing. Others simply accept the banality of evil as a fact of corporate life. Most characters just appear to slip into it. Few want to accept any responsibility.

Corporate legal aces are the cream of our society. Top lawyers have the finest educations, finest backgrounds, and finest things that can be had in life. What leads to their downfall? What leads some to become Tom Hagen and some to be Matlock? Why did Goliath become Goliath? We need our best and brightest to work to end global warming instead of working for Enron. We need our best reporters to live up to the ideals of Edward R. Murrow, as portrayed in Clooney's Good Night, Good Luck. We must reject double think.

Indeed, corporations, not government, may be Big Brother. Beyond dispute, lawyers have been at the center of the great scandals and cover-ups of our times. Understanding the descent of great legal minds into morass is one of our society's great tasks.

Shiva, the ancient double-faced Hindu deity, is both destroyer and life-giver, is a perfect symbol of the two sides of corporate crime.

James J. Murtagh Jr., MD, Atlanta GA 30329

(James Murtagh spent 20 years as an Intensive Care Unit physician. Dr. Murtagh is a member of Semmelweis Society International, and has hosted several Congressional forums on the Healthcare Integrity Project.)

To read other movie reviews, please go to

To read more book reviews, please go to

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10.  Hippocrates & His Kin: Evading Do Not Call Lists, P4P, Wealth Improves Health

Older Americans around the country are getting duped by a seemingly innocuous tactic that can expose them to hard-sell pitches from the insurance industry.

The technique is centered on a marketing tool called the lead card, and it became popular after the federal government created its Do Not Call Registry in 2003 to shield consumers from unwanted solicitors. Sent through the mail, the lead card invites the recipient to mail off an enclosed reply for free information about, say, estate planning.

But the cards fail to warn that by sending off replies, recipients are giving up their right to avoid telephone solicitations from the sender -- even if their phone numbers are on the Do Not Call list.

Another unnecessary law with loopholes and consequences that our not-so-bright Congress could not see. With modern technology and caller ID, any person can monitor all incoming calls, which includes the phone number and the person calling. Hence, any senior would be foolish to pick up the receiver if it wasn't a friend or family. The whole Do Not Call list is an unnecessary intrusion and expense that should never had been implemented. We all could have done better and kept government out of the picture as it is now mushrooming into an even larger taxpayer expense. Does anyone have any idea how we can give Congress a ten year moratorium on passing new laws? That would decrease the cost of government by at least, shall we estimate, 10 percent annually? Newt, where are you when we need you?

Performance is all the rampage now for doctors, nurses and hospitals. We should extend performance to lawyers, senators and representatives. Any senator that doesn't perform constitutionally will forfeit his/her pay and be sent to the National Data Bank so that he or she can never run for office again in another state.

That should be an equalizer.

Doctors are being prosecuted for sending patients to their own laboratories and imaging facilities even if they provide superior services at less cost.

We propose that any lawmaker that accepts any bribe (contribution from any citizen or group that benefits from any previous or proposed legislation) should be prosecuted for bribery and fraud and be immediately registered in the National Data Bank so that he or she can never run for office again in any state.

That should be tit for tat.

Did you know that property values are the best predictor of obesity? According to a new study in Tuft's Health & Nutrition Letter, each $100,000 increase in value was associated with a 2% decline in obesity prevalence.

Hasn't it always been known that wealth improves health?

Meanwhile, the government always emphasizes poverty. Ever since President Johnson tried to define poverty, we have all kinds of benefits for every level of being poor: health care, food stamps, Medicaid, subsidies, and now even some Medicare benefits are contingent on being poor. We see patients maneuver daily on hiding assets or transferring them to friends or children to become as poor as possible to obtain the maximum amount of stolen goods from taxpayers.

At no time in history has there been such a constant emphasis of becoming poor, which decreases health and worsens disease.

To read more vignettes, please 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. Be sure to read the report: Despite universal health care models, Great Britain and Canada are not ideal places to get sick, say observers... at

                      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 access their health page at Be sure to read John Graham: Will the Last Gambler Pay the Last Smoker's Medical Bills? Or Vice-Versa?

                      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. Mercatus Center research seeks to understand the consequences - both intended and unintended - of social policy decisions and improve the state of knowledge to which these decisions refer, thereby fostering solutions that promote a freer, more prosperous, and civil society. Continue at

                      The National Association of Health Underwriters, The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business. Be sure to review the current articles listed on their table of contents at To read my latest column, Can the Health Insurance Industry Survive?, you may go directly 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. Grace-Marie Turner gave the keynote address at the Utah Association of Health Underwriters' Education Conference on November 8, 2007: Assessing Proposals for Health Reform.

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to To join, go to Be sure to read Prescription for change:  Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn at Read Greg's current report: Five years into the experiment with Consumer Driven Health Care, the data shows they are "working as intended." All of the empirical evidence shows they are changing patient behavior, which is lowering costs and improving care, and resulting in a sizzling rate of adoption in the market at

                      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 at Read the current report on Interpreting Health Studies: Science Panel Offers Tips for Journalists.

                      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 and keep a copy of The Freeman in my reception room. Dr. Ebeling spoke at the recent meeting of the AAPS in Philadelphia about the disastrous effects of regulation and what our country would be like if we could just push one button and eliminate all regulations. To that end we will give our efforts. This month, be sure to read President Ebeling's message: The American Spirit of Enterprise.

                      The Council for Affordable Health Insurance,, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse." Be sure to read The 2008 Presidential Candidates on Health Care Reform.

                      The Independence Institute,, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter at Read her latest, Government health insurance not worth paper it is printed on.

                      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 THE EMPEROR'S DERRIÈRE.

                      The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at for an overview of the extensive research articles that are available. You may want to go directly to their health research section at This month, log on to read For years, Canadians have been leaving the country for medically necessary treatment. But exactly how many people do so each year?

                      The Heritage Foundation,, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. This month, you might get up to speed on The Crisis in Hospital Emergency Departments: Overcoming the Burden of Federal Regulation.

                      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. Read the current excellent report on the Manichean President: Iran is a rational state actor, which, like most other countries in the world - including American allies - will eagerly cooperate with the United States when their interests coincide with ours…. To know that a country and its leaders act rationally is to take a huge and critical step toward realizing that that country - no matter how internally repressive it might be - cannot and will not be a threat to the U.S. Go to You may also log on to Lew's premier free-market site at to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see; or to find out why anyone would want to be an MD today, see

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

                      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.

                      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.]

                      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 This month, Editor Angus MacDonald writes about Global Warming, Thomas Martin on The Universal Health Care System, and Robert Woodson, Sr on Reducing Poverty: The Joseph Principle.

                      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, have A Conversation with Justice Clarence Thomas. The last ten years of Imprimis are archived

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Del Meyer

Del Meyer, MD, Editor & Founder

6945 Fair Oaks Blvd, Ste A-2, Carmichael, CA 95608

Words of Tragedy

Perspective: Americans spend more money on potato chips than they do on political campaigns.

Truly Appalling says the Cato Institute: Art Torres, President of the Democratic Party in California, stated that his party is working closely with the Republicans to ensure that all incumbents in the state were protected [from losing their seats in an election].

The ultimate paradox: The left criticizes the Religious Right while creating its own Religious Left, a political religion of a reflexive, nonthinking adherence to certain "truths:" America is a racist society, corporations are evil, speech codes on campus are good, global warming is indisputably damaging the earth, the "rich" should pay more taxes, school choice is bad, personal Social Security accounts are too risky (No access to pillage of taxpayers.). One can't even debate those issues with the Left because they are taken to be matters of faith. It's their religion.

Some Recent Postings

Michael Clayton: Just Pretend This Isn't Madness by Jim Murtagh,

David Gibson, MD: Physicians Make Lousy Advocates

In Memoriam

Today is the 105th anniversary of the birth of my Mother, Anna Marie Luethje Meyer. Thank you for being a great mother to our family and giving us a faith that is unshakeable. May you rest in Heavenly Peace. Give us 30 years, at least, and we'll join you.

On This Date in History - November 13

On this date in 1927, the Holland Tunnel under the Hudson River between New York and New Jersey opened. Why was the tunnel built before the bridge? Some say that's because politicians go right for the deep water rather than try to stay above it.

On this date in 1969, the Vietnam Moratorium demonstrations occurred over three days. Despite fears of violence, the demonstrations were peaceful, and hence far more impressive. Peaceful persuasion is more to the American taste.

After Leonard and Thelma Spinrad