Community For Better Health Care

Vol V, No 16, Nov 28, 2006


In This Issue:

1.      Featured Article: The Most Vitally Important Physician Organization in the U.S.A.

2.      In the News: Where Do the Bright People in America Live and Why Does That Matter?

3.      International Medicine: U.S. Lags in Several Areas of Health Care, Study Finds

4.      Medicare: America's Crisis of Confidence

5.      Medical Gluttony: FP-HMOs - the Biggest Waste of Health Care Dollars

6.      Medical Myths: Single-Payer Medicine Will Decrease Health Care Costs

7.      Overheard in the Medical Staff Lounge: Will the Election Affect Healthcare?

8.      Voices of Medicine: California Society of Anesthesiologists: Laughing Gas

9.      From the Physician/Patient Bookshelf: Redefining Health Care

10.  Hippocrates & His Kin: The Ethics of Congress: Rob Peter to Pay Paul - More Votes

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

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1.      Featured Article: Why AMGA Is the Most Vitally Important Physician Organization in the U.S.A. Today, BY FRANCIS J. CROSSON, M.D.  Executive Director, The Permanente Federation, LLC, and Chair, Board of Directors, American Medical Group Association

An Address to the AMGA's 2006 Annual Conference. March 17, 2006, San Antonio, Texas.

Why is AMGA the most critically important physician organization in the U.S.A. today?


Simply put, our nation is in a health care crisis, a crisis each of us will see evolve in the next five or so years. It is a crisis of cost, of affordability, of access, of fairness, but most importantly, a crisis of confidence.


There is a growing crisis of confidence in the land about whether our country has a workable plan to achieve rational, sustainable health care for all Americans.


It is a crisis of confidence made worse by the fact that the physician voice, the responsible voice of the profession of medicine, is often absent from or ineffective in the public debate. I believe that this void of physician leadership can and must be filled by America's proud multispecialty medical groups, by their leaders, and by their association, AMGA, if our national healthcare system is to evolve in a sound manner.


Pick up this challenge we must. Because I believe that the next five years are going to be absolutely critical for the direction of American medicine. I believe that through AMGA, the medical group community must work collectively to influence that direction, for the benefit of each of our own revered institutions, for the benefit of our patients, and for the benefit of the nation as a whole. Tip O'Neill, the former Speaker of the House of Representatives, said once that "all politics is local."


We know that all health care is local, and each of us who are at this meeting is engaged in a daily, weekly, and monthly struggle to make our medical groups the best they can be, to provide our physicians a satisfying and productive environment for the practice of medicine, and to provide responsible leadership in our communities.


But many of us know from experience that despite our best efforts, despite hard work, and despite careful planning, our medical groups, indeed our patients and our communities, can be impacted, for better or worse, by changes in the marketplace of health care - changes in the commercial marketplace, the world of employers, employer coalitions, health plans, insurance companies, and public payers such as Medicare and Medicaid - but also by changes in the marketplace of ideas.


New business concepts, heathcare financing changes, and legislative initiatives, which appear seemingly from nowhere, can change our world quickly, positively or negatively.


Medical group physicians and managers who lived through the advent and evolution of the managed care industry and the rise and dissolution of the physician practice management industry (PhyCor and MedPartners) are well aware of the impact of such changes.


Today at the midpoint of the first decade of the 21st Century, spurred by the sense of crisis in health care, the marketplace has begun to present us, the medical group community, with a new set of challenges.


First is the change underway in the financing of health care, a change driven by cash-strapped employers, away from comprehensive benefits in favor of higher coinsurance, higher deductibles, and savings accounts. Whatever value this change can have in moderating long-term cost trends, it clearly will create new financial burdens on families, perhaps higher levels of bad debt for medical groups, and the potential loss of continuity of care, as patients forego needed healthcare services for financial reasons.


A second growing challenge is a trend toward further fragmentation of care delivery. Multispecialty medical groups are organized to coordinate care among specialties for patients with multiple health conditions, and to assume longitudinal responsibility for patients and families. This is what our nation needs. So-called "focused factories" and certain single-specialty groups are not organized to manage these critical accountabilities and have come to be viewed by many purchasers and health economists as being primarily organized for financial purposes. This view, in turn, can create confusion about, and adversely impact, the reputation of our multispecialty medical group community.


Fragmentation is also manifest in the growing emergence of care delivery by ancillary providers and, on occasion, by physicians in retail commercial space, particularly drugstore chains and discount commercial retailers. It is not to say that such care is necessarily undesirable; simply that the emergence of this business model can, again, create a trend away from continuity and care coordination.


Each of us should watch or perhaps even seek to constructively guide the evolution of this trend in our communities.


Finally and most importantly, our medical group world is presented with a challenge and with an opportunity by what I think of as the three-leaf clover of performance - performance measurement, pay for performance, and the newest entry from the insurance industry, something called "high performance networks," essentially contract lists of lower cost doctors and hospitals, without regard to patient continuity of care or care coordination. It is in this triple entry from the marketplace of ideas that our medical group community has the greatest opportunity to shape our collective future for the better. I believe that there are still open questions: Who will decide in the end what quality of care really is and how it should be measured?


What does efficiency in healthcare delivery mean and how should that be assessed? And how should commercial payers or public payers, like Medicare, adjust payments to physicians and organized delivery systems in response?


Our interest clearly lies in the evolution of a system that rewards physician organizations that truly improve patient care and that foster the responsible use of healthcare resources. There is no doubt in my mind that the current concept called "high performance networks," as envisioned by some employers and particularly by some benefits consultants, has little to do with quality of care and nothing to do with the kind of organized, patient-centric delivery of health care practiced by the nation's leading healthcare organizations gathered here today. Yet this idea is proceeding unchallenged to date.


So we meet together this week in San Antonio to renew old acquaintances, to learn from some of the best medical groups in this country, and to be inspired together. But, I believe we also need to take this opportunity together to reinforce our common interests, especially our common interest in leading and shaping that marketplace of ideas that can affect us in the years to come. This is why AMGA is a critically important organization at this time - critically important to us as member groups and yes, I believe, critically important to the country.


The AMGA Board of Directors and Don Fisher and his team intend to lead that effort on our behalf. Much of it is work that has already been foreseen and planned for, and I hope you will learn more about it during the next few days of this meeting.


To read the entire address and more about the AMGA's innovative project, please go to and click on The Voice of Medical Groups in America.


To read The Group Practice Journal, go to

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2.      In the News: Where Do the Bright People in America Live and Why Does That Matter?

The Agenda: The Nation In Numbers: Where the Brains Are, The Atlantic

America's educated elite is clustering in a few cities - and leaving the rest of the country behind

By Richard Florida

America's social fabric has been regularly reshaped by great migrations - of pioneers westward, of immigrants and farmers to rising industrial cities, of African Americans from the rural South to the urban North, of families outward from cities to suburbs to exurbs.

Today, a demographic realignment that may prove just as significant is under way: the mass relocation of highly skilled, highly educated, and highly paid Americans to a relatively small number of metropolitan regions, and a corresponding exodus of the traditional lower and middle classes from these same places. Such geographic sorting of people by economic potential, on this scale, is unprecedented. I call it the "means migration." . . .

What's behind this phenomenon? Some of the reasons for it are essentially aesthetic - many of the means metros are beautiful, energizing, and fun to live in. But there is another reason, rooted in economics: increasingly, the most talented and ambitious people need to live in a means metro in order to realize their full economic value.

The physical proximity of talented, highly educated people has a powerful effect on innovation and economic growth - in fact, the Nobel Prize-winning economist Robert Lucas declared the multiplier effects that stem from talent clustering to be the primary determinant of growth. That's all the more true in a postindustrial economy dependent on creativity, intellectual property, and high-tech innovation.

Places that bring together diverse talent accelerate the local rate of economic evolution. When large numbers of entrepreneurs, financiers, engineers, designers, and other smart, creative people are constantly bumping into one another inside and outside of work, business ideas are more quickly formed, sharpened, executed, and - if successful - expanded. The more smart people, and the denser the connections between them, the faster it all goes. 

The local cultures of most, if not all, means metros have facilitated the establishment of many loose connections among people of diverse talents, lifestyles, and social circles (as opposed to a few tight connections within homogenous groups). They are socially tolerant and open to new ways of thinking. Job switching is common, as is periodic unemployment, and free agents find plenty of common spaces in which to work and meet. The soup is continuously stirred, and newcomers are assimilated easily.

But the means metros also have a larger and simpler advantage over other regions: a head start. For a variety of historical reasons - the presence of great universities is usually one - the means metros already have a high concentration of highly talented people. And as more such people are added, their multiplier effect on growth seems to keep increasing. That's true not just for economic growth in the aggregate, but for individual incomes and opportunities as well.

Yet the opportunities do not exist for everyone. In both early agricultural and industrial economies, overall population growth was the key to economic growth, and economic growth meant opportunities across the board. But in a creative, postindustrial economy, that's no longer true. Changing technology, increased trade, and the ability to outsource routine functions have made highly skilled workers less reliant on the colocation of the unskilled and moderately skilled. What matters today isn't where most people settle, but where the greatest number of the most-skilled people does. Because the return on colocation among the ablest is so high, and because high-end incomes are rising so fast, it makes sense for these workers to continue to bid up real estate and accept other costs that traditional middle-class workers and families cannot afford. As traditional middle-class households are displaced by smaller, higher-income households, population can decline even as economic growth continues. America's most successful cities may increasingly be inhabited by a core of wealthy workers leading highly privileged lives, catered to by an underclass of service workers living in far-off suburbs.

Some of today's means metros could fall back eventually as housing prices and living costs rise, and new ones could emerge. But there are powerful reasons to believe that the wealth disparity between some city-regions and others will continue to grow, and perhaps even accelerate, thanks to the snowball effect of talent attraction. "This spatial sorting," says Gyourko, "will affect the nature of America as much as the rural-urban migration of the late nineteenth century did." Accommodating that sorting will be one of the great political and cultural challenges of the next generation.

To read the entire article, please go to

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3.      International Medicine: U.S. Lags In Several Areas Of Health Care, Study Finds

Americans have a harder time than residents of several other countries getting after-hours appointments with a nurse or primary care physician without going to an emergency room, according to a study published in the journal Health Affairs.

Other findings:


Advocates say greater use of electronic records would improve patient care, reduce errors, curb unnecessary tests and cut paperwork.  About 28 percent of U.S. primary care doctors said they use such records, compared with 98 percent in the Netherlands, 92 percent in New Zealand, 89 percent in the United Kingdom, 79 percent in Australia and 42 percent in Germany. Only Canada ranked lower, at 23 percent.

Source: Christopher Lee, "U.S. Lags in Several Areas of Health Care, Study Finds," Washington Post, November 3, 2006; based upon: Cathy Schoen et al., "On The Front Lines Of Care: Primary Care Doctors' Office Systems, Experiences, And Views In Seven Countries," Health Affairs, November 2, 2006.

For study text:

For text:

For more on Health Issues:

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4.      Medicare: America's Crisis of Confidence

Survey Finds Doubts about Leaders, and Nation's Safety by Elizabeth Williamson, Washington Post Staff Writer, November 7, 2006

Here's something to think about when you cast your vote today: A new study shows that Americans have lost faith in the people who lead their federal, state and local governments, and in businesses, churches and schools. And they are afraid to fly.

"America is in trouble," reads the introduction to the 2006 National Leadership Index, sponsored by U.S. News & World Report and the Center for Public Leadership at Harvard's Kennedy School of Government. According to the report, nearly three-quarters of Americans think that the nation faces a "leadership crisis."

This is the survey's second year, and it has been downhill all the way, said Todd Pittinsky, the center's research director. "Most groups are following the general trend of having low confidence and, if anything, having that confidence slip further."

The only leaders who earn more than a smidgen of Americans' confidence, the researchers say, are those in the military and medical fields. (Confidence in the media didn't slip, but it was in the sewer already.)

"We could have asked about grandmothers," Pittinsky said. "Maybe we could have had more confidence in grandmothers."

The researchers hope the survey will "contribute to our ongoing civic dialogue -- deepening our understanding of ourselves and the pressing need for effective, responsible democratic leadership."

Sounds scary. . .

Perhaps, joked survey researcher and assistant professor Seth Rosenthal, these are people "so paralyzed they can't even tell you if they're pessimistic."

The researchers also asked: "If you flew today, how confident do you feel that you would be safe from terrorist harm on a domestic flight?" Nearly half sucked it up on this one, saying they felt confident about flying safely. But 13 percent put a potential evildoer on every plane. "That's pretty bad," Rosenthal said. "Obviously there aren't planes being dropped out of the sky every day."

Blending fears of leadership failure and flying, the study further found that "Americans who are not confident at all that government leaders in Washington will respond effectively to an emergency crisis are less confident than other Americans about their safety from a terrorist attack on a domestic flight."

Any bright spots?  . . . To read the entire article, go to

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5.      Medical Gluttony: FP-HMOs - the Biggest Waste of Health-Care Dollars

The For-Profit Health Maintenance Organizations came into being some three decades ago to compete with Kaiser Permanente. Kaiser was a staff model non-profit HMO wherein all of health care was totally integrated. Initially the hospital, doctors' offices, laboratory, x-rays were all within one complex. This was an efficiency that couldn't be duplicated in a FP-HMO, consisting of hospitals, offices, laboratories, x-ray facilities distributed over a wide geographic area, each with their own medical records. The FP-HMOs are essentially on life support while the Kaiser system has evolved into a totally integrated health plan (IHP).

The push for electronic medical records (EMR) is directed to the FP-HMOs in an effort to unify the medical records of the various disparate offices. It will still be unsuccessful. The patients that desire their own personal physician generally will not support having their records widely available among offices they don't use. Some of my patients asked me not to enter their records into my computer. However, that is where my patient records reside and I just assure them that no one has access to my computer.

This past week, the FP-HMO's gluttonous cost of health care was brought sharply into focus. Unfortunately it was not recorded as a cost by any organization that surveys costs or tries to direct health-care policy.

I wrote a simple prescription for a glucometer for a diabetic patient to monitor her glucose, which is necessary to manage her diabetic drugs. This was an HMO patient. My receptionist spent 20-30 minutes a day for four days navigating the phone lines at the HMO and MCO (Managed Care Organization) offices to help this patient. After four days, she breathed a sigh of relief thinking she had helped this patient to manage her diabetes. She then got a phone call a few days later wanting justification for the instrument. Wouldn't that be apparent without taking up the doctor's and office staff's time?

The following week, we received a call from this patient that her glucometer was no yet available. On further investigation, the HMO had changed suppliers and all the work was for naught. My medical assistant redid the above routine with the new supplier. After considerable time on the phone, she again thought everything was in order. She had barely hung up the phone when the patient called and stated the original supplier had just notified her that the glucometer was being shipped. This was the supplier that she had spent the time with the previous week that the HMO and MCO said were no longer their favorites. The current series of repeat phone calls were for nix. The harassment time was now two hours and twenty minutes.

Meanwhile, a similar event took place at Kaiser Permanente. The doctor stated that with the patient still in front of him, he accessed the electronic script program, scrolled down to glucometers, and saw a dozen or so that were listed. He saw that two were approved by this patient's level of insurance, clicked on one and sent it to the pharmacy electronically. While the pharmacy printer was still printing, the patient walked down to the pharmacy, obtained her prescriptions and her glucometer, and was home in less time than one phone call to the FP-HMO. It took less than one minute at Kaiser, an Integrated Health Plan (IHP), to accomplish the same thing that it took more than 140 minutes at an FP-HMO. Unfortunately, those 140 minutes are nowhere recorded as a health-care cost. It is a non-reimbursable physician's expense.

The For-Profit HMOs are on life support. It's time for private doctors to stop their resuscitative efforts.

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6.      Medical Myths: Single-Payer Medicine Will Decrease Health Care Costs

If that were true, why do the large government programs, such as Medicare and Medicaid, contract out to private parties to run their programs? Why should the non-profit Medicaid program become a For-Profit HMO? Can they really give the same quality of care at a reduced fee and still make a profit? Let's take a look.

Healthy Industry: In Medicaid, Private HMOs Take a Big, and Profitable, Role;

Managing Care for the Poor, They Prosper by Cutting Beleaguered States' Costs;

Dr. Polack Seeks an Antibiotic; By BARBARA MARTINEZ, WSJ, November 15, 2006;

Some 55 million poor and disabled Americans are covered by Medicaid. With an annual price tag topping $300 billion, it's among the biggest government programs around.

It's also a lucrative business for some private companies that act as middlemen between the government and patients. Instead of directly paying the bills when a Medicaid patient goes to the doctor, state governments increasingly outsource the job to private contractors. More than one in three Medicaid beneficiaries now receive care through a private insurer. . .

Four of the biggest Medicaid HMOs -- WellCare, Centene Corp., Molina Healthcare Inc. and Amerigroup Corp. -- have seen their shares surge on the New York Stock Exchange over the past few years, although prices of the latter three have been volatile. WellCare's stock price has tripled since it began trading in July 2004, bringing the value of stock and options held by its chief executive, Todd S. Farha, to $77 million.

The companies are growing fast. Centene boasts nearly 1.2 million members and posted $1.5 billion in revenue last year. That compares with 142,000 members and $200 million in revenue six years earlier.

With the growth has come criticism from some doctors and patients who accuse Medicaid HMOs of scrimping on care. Even as they restrict medical tests and use of prescription drugs, the companies spend the money they get from states on items that don't have an obvious connection to patients. Centene has funded a multimillion-dollar arts center in St. Louis and paid to put its name on stadiums in Montana and Missouri. The HMOs are also big donors to political campaigns.

Executives say their profits are justly earned and don't come at patients' expense. Traditional Medicaid is a fee-for-service program: The government pays each medical bill the patient racks up, with little or no effort to manage the costs. Medicaid HMOs, like other HMOs, seek to save money by eliminating unnecessary care and paying for preventive treatments. Centene Chief Executive Michael Neidorff says the company sometimes gives free child-safety car seats to pregnant women who attend all of their prenatal exams. "We save millions" by preventing premature births, he says.

Mr. Neidorff earned $1.85 million in salary and bonus last year and as of the end of last year held restricted stock valued at $26 million. The company also recorded $135,547 last year in compensation for Mr. Neidorff representing the value of personal trips he took on the corporate jet, a Bombardier Challenger that features an espresso machine on board, according to the lease agreement. . .

Each state runs its own Medicaid program but the majority of funding generally comes from the federal government. When states sign up HMOs to manage care, they often calculate what they would spend on Medicaid patients directly and pay the HMOs a per-patient premium below that amount. Florida, for instance, sets its HMO premium rates about 8% below what it would cost the state. WellCare, a big operator in Florida, says it saves the state $75 million a year. HMOs have an incentive to keep their costs under the premium because they keep the difference as profit . . .

States began experimenting with using managed care for Medicaid patients in the early 1980s, and the idea took off in the 1990s. Now many states are moving aggressively to put more Medicaid patients in HMOs. Last month, Ohio chose the winning bidders to provide Medicaid HMO services to 120,000 of the state's aged, blind and disabled population -- a group that traditionally hasn't been placed in HMOs. . .

Many doctors refuse to take patients in Medicaid HMOs because reimbursements are so low. (The same problem occurs in traditional Medicaid.) Noha Polack, a pediatrician in Union City, N.J., has an arrangement under which Centene pays her a fixed monthly sum per child to handle basic medical needs. Until a few months ago, that sum was $11.50 per month, equal to $138 a year -- about half of what other Medicaid insurers pay, says Dr. Polack. A child who had a few colds or scrapes during a year would quickly put her in the red.

Dr. Polack threatened to drop all her Centene patients and recently got a raise -- the amount of which is confidential, she says -- but she still stopped accepting new Centene patients.

The HMO is stingy about drugs that others approve with little question, says Dr. Polack, naming the antibiotic Ceftin as an example. "Many times we have to make treatment decisions not depending on what would be best for the patient but what the patient can afford," she says. While she could ask for an exception to use Ceftin, "they are so notorious for not getting back to you" and there's little time when a child has an infection, she says . . .

Research on the quality of care in Medicaid HMOs is thin. A study of infant health last year by researchers at the University of Illinois-Chicago and the Urban Institute found that Medicaid managed care was correlated with a slight increase in inadequate prenatal care in some women but in general showed little difference from traditional Medicaid.

While some doctors and patients complain of Centene's stinginess, the company has been generous in regions where it has offices. Centene last year was the biggest donor for a $9.5 million renovation of an arts building in St. Louis, now called the Centene Center for Arts and Education, according to a spokeswoman for the center. The company paid $200,000 last year for the naming rights of a minor-league baseball stadium in Montana, where Centene employs 100 claims processors but doesn't have Medicaid clients. Centene also pledged $400,000 this year to the school district in Clayton, Mo., where the company has its headquarters, to rename the district's stadium.

Cynthia Schultz, director of the Great Falls International Airport in Montana, says Mr. Neidorff, the Centene CEO, once walked through the airport and heard that it couldn't afford artwork. Centene then commissioned and donated a $7,000 welded-metal sculpture of an eagle with a 16-foot wingspan that now hangs prominently in the airport, she says. The company confirmed the donation. "It's a great gift from someone who doesn't even live here," says Ms. Schultz.

Mr. Schenk, the Centene spokesman, said the donations show Centene is a "responsible and publicly focused corporation" and they help make the communities better places to live. . .

--- Raymund Flandez contributed to this article.

To read the entire report, go to

Write to Barbara Martinez at

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7.      Overheard in the Medical Staff Lounge: How Do Doctor's Think the Election Will Affect Healthcare?

Dr Sam: I think the answer is in how the government cut costs in September. They refused to pay us for the last two weeks in September. It was a delaying tactic for accounting reasons. [Doesn't the government prosecute business for accounting manipulations?] Well, just as I told you, we would never see payment for those two weeks. I've been waiting two months to see the smallest blip in my Medicare income. Did I see any? Not any that I or my billing clerk would notice. In fact our income in October was less than our usual monthly income and our November income seems to be even less.

Dr Michelle: Well I think I saw a small increase in October Medicare receipts. Not much. Probably not enough to make up for the loss in September.

Dr. Yancy: Well, we surgeons took a big hit. I did 16 major operations those two weeks. We've gotten paid for three of them in October and we're waiting for the other 13. But while we're waiting, we've got every one of those operations pegged and we'll get every bloody cent from Medicare even if I have to lose money doing it.

Dr Sam: But it's easier for a surgeon to track every charge since yours are in the high three-figure or low four-figure range. But for us Internal Medicine doctors, trying to make a living on $110 office calls for which we get paid $65, a number of patients are batched to include a number of patients lumped into one.

Dr Milton: And if a patient has several charges, e.g. an office call plus an injection, the payment may be one or both or none. So it takes a lot of billing clerk's time to sort this out. So after a month or two of hassling, we just give up and never know just how much the government cheated us.

Dr Dave: When this new Congress gets in gear, we'll probably have one of those non-payments for a half month every three months?

Dr Sam: You're being too kind. We'll probably drop two weeks of income every month.

Dr Rosen: Why do doctors still trust the government? Why would any doctor want the government to be his sole payer, as in single payer? And our own California Doctors Organization supported the single-payer initiative. Why would any doctor join that group?

The R's must be devastated.

Not so. For the D's politics is their life, their vocation. Government is the be-all-and-end-all of "goodness." So being part of the government is the culmination of their lives. What in the world would Henry Waxman or John Dingell do with themselves if they weren't in Congress? That is why they were willing to abide the humiliation and frustration of 12 years in the minority. They had nowhere else to go. –HBR

An Outside Perspective From the HealthBenefitsReform

I see next to no impact at all. The Ds, even if they take the Senate, will have smaller margins than the Rs have had. And many of the new Democratic members of Congress are as conservative as the Rs have been. It will take them a while to get organized and the presidential elections start today. The one real power the Dems will have is the ability to orchestrate hearings, and they are FAR better at that than the Republicans have ever been. Pelosi will have to curb the instinct of Stark, Waxman, Dingell, et al, to make up for lost time and go overboard—and embarrass the party.

The next two years will be consumed with political posturing to set the stage for the '08 elections.


Greg Scandlen, President, Consumers for Health Care Choices
442 N Potomac Street, Hagerstown, MD 21740, 301-606-7364


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

California Society of Anesthesiologists: CSA Bulletin, Fall 2006: Laughing Gas

Gaseous Planet - Medicare Man by Harrison Chow, M.D.

It is widely known within the Washington Beltway that the real political divide in the United States is not between Democrats and Republicans, nor rich and poor, but rather between young and old. The elderly Medicare generation, represented by the American Association of Retired Persons, is purported to be the wealthiest and most powerful political force in the history of American politics.

I spoke with long-time AARP President Cunningham "Medicare Man" Grey at the AARP's corporate office off the lush 18th green of the Palm Springs Country Club about the dramatic impact that elderly Americans and the AARP are having upon American health care.

HC: Thank you for meeting with me. I'm surprised that the AARP moved its office cross-country to Palm Springs from Washington, D.C. 

CG: One of the advantages of modern technology is that we can relocate to a venue that is warm year-round and yet still stay intimately connected to the federal government.

HC: How's that? Medicare and Social Security policy is made on the East Coast, not in the sand trap of the 18th green.

CG: I have one phrase for you—"IRDs."

HC: What is an "I-R-D"?

CG: An IRD is an "improvised reminder device." As you know, terrorists use cell phone-activated "improvised explosive devices" or "IEDs" to blow up targets. We wondered: What if we had the power of the IED magnified by 60 million voting retirees? What would happen? That's how we became excited with the idea of the IRD.

HC: You threaten to blow up Senators and Congressmen? 

CG: Hardly! Our IRDs, when dialed and activated by the cell phone, only give off a 12-volt shock—just enough to make you wince.

HC: How did you get federal legislators to agree to carry this IRD device?

CG: The AARP made Washington politicians an offer that they couldn't refuse:  Get an IRD and get elected, or refuse and be voted out next term. They don't even have to worry about carrying them. They simply fly out to Palm Springs to get their IRD surgically implanted after a round of golf or a visit to a spa. 

HC: Wow, the IRD gives new meaning to how to stay "connected" to your elected—or should it be "electrified"?—representatives. The IRD should certainly spark them into action. But now I must ask, what is the AARP's position on the deepening fiscal crisis that threatens to bankrupt Medicare? 

CG: Our down home position is really very simple. We've paid our dues, and we should get medical care for free—free, nada, zip, zero, complimentary.  Comprende, amigo?

HC: Hey, I get it, but with a surging elderly population, and the advances in the medical sciences, and a resultant massive boost in medical costs, Medicare soon will be unable to meet its obligations.

CG: Now just try to understand. Medicare and America's goals are the same—to provide the elderly with the best health care available for free. Everything, and I mean everything, else is secondary. For example, this year we had the Congress eliminate the school lunch program from the federal budget to pay for the new generation of titanium pacemakers. We need titanium. You can go into an MRI with titanium.

HC: But, respectfully, you know that recent studies have shown that the average Medicare recipient's contributions in today's dollars would buy, at best, a single bottle of outdated penicillin tablets, not the latest pacemaker. 

CG: Doctor, let me remind you that my generation, the Medicare generation, defeated Hitler, Mussolini, Hirohito, Stalin and Mao, landed on the moon, invented the computer chip, the Internet—Al Gore is one of us, isn't he?—and cell phones, and created what we call "modern medicine." What has your generation done?

HC: Uh, let me think. My generation invented the iPod?

CG: What's an iPod?

HC: Someone told me that the iPod is a mysterious and magical device that allows spoiled suburban kids to listen to urban gangsta' rap at the mall. 

CG: Doesn't sound too impressive to me. Oh, please excuse me. I have to make a phone call.

The Medicare Man, while on the phone, turns on a 60-inch high definition flat screen T.V. in his office: We see on C-SPAN that Senator Ted Kennedy from Massachusetts is speaking before Congress about the need to increase Medicare taxes. It is quite obvious that Senator Kennedy is sweating profusely. 

HC: I notice that Senator Kennedy is sweating a lot; are you calling his IRD right now?

CG: Yes, but that's not why he is sweating. I've called Senator Kennedy so many times that I think he is immune to a single shock. 

HC: Well, why is he sweating so profusely? I hope that he's OK. 

CG: He's sweating because I've threatened to post his IRD's cell number up on the AARP Web Site.

Dr. Harrison Chow is a practicing anesthesiologist in San Jose, California. He also teaches regional anesthesia at Stanford when nobody is looking. You may reach him at <>. Recently, he received notification from Medicare that he will qualify for benefits when he turns 90 years of age.

To read the original, please click on Laughing Gas at

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9.      From the Physician/Patient Bookshelf: Redefining Health Care

"Redefining Health Care," by Michael Porter and Elizabeth Olmsted Teisberg is a must read for anyone interested in health policy.  The authors have identified the single most important problem in health care and it is a problem health economists tend to routinely ignore.  To wit: We don't bundle and price health services the way we would if the medical marketplace even remotely resembled an efficient, competitive market.  

Take diabetes, for example:

The authors produce a rich smorgasbord of other examples of failures to bundle and price in sensible ways, and they argue persuasively that costs are higher and quality is lower as a result.  But as good as they are in analyzing problems, they are weak on showing us how to get solutions, says John C. Goodman, president of the National Center for Policy Analysis.

Where they go wrong is in thinking that many of these problems could be solved if only we had more entrepreneurship on the provider side, explains Goodman:

Entrepreneurship will eventually find a way around our bureaucratic third-party payment system.  The more dollars that are controlled by patients, the faster that change will come, says Goodman.

Source: John C. Goodman, "Review of Porter/Teisberg Book," National Center for Policy Analysis, November 6, 2006; based upon: Michael Porter and Elizabeth Olmsted Teisberg, "Redefining Health Care," Harvard Business School Press, May 25, 2006.

For more on Health Issues:

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10.  Hippocrates & His Kin: The Ethics of Congress: Rob Peter to Pay Paul - More Votes

Headlines in the papers after the US elections indicated that Rep Nancy Pelosi and her city, San Francisco, rose to the top of the congressional political heap this week. Pelosi's impending elevation by her fellow Democrats to the post of House speaker . . . that will become official in January, already is generating national and international attention for the city. It might also mean more federal dollars from congressional appropriators who inevitably look favorably on projects from the speaker's home district, even if he or she doesn't overtly push for them.

Isn't there something unethical in the very concept of Congress being able to forcibly take money away from some citizens and give it to others? If you or I or any citizen did what Congress does and brags about it, wouldn't that be called theft, or burglary or a gun-point hold up?

Isn't this another reason why health care should never be part of this arena? In Oregon, murder by doctors in the hospital setting against the weakest is already sanctioned as legal. If murder is allowed, couldn't just about any crime be made legal with the right combinations of lawmakers in Washington, DC or any statehouse? We must do everything in our power to keep lawmakers out of the practice of medicine.

Medical Costs of HIV

Life expectance of a symptomless person infected with HIV has increased from less than seven years in 1993 to 24 years at an average annual cost of $25,200. Our thanks go to a vigorous pharmaceutical industry that has been able to develop and market about two dozen HIV-fighting anti-retroviral drugs that has changed a disease that once was considered a death sentence. The average life time cost of an HIV patient is calculated at $618,000 which is equivalent to the lifetime medical care cost for heart disease and some other chronic conditions in women, who incur more costs than men because they live longer. A 2003 study concluded that 55 percent of HIV patients were on drugs.

What do the Medicaid FP-HMOs spend the money they get from states on? See Section 6 above.

Centene has funded a multimillion-dollar arts center in St. Louis and paid to put its name on stadiums in Montana and Missouri. The HMOs are also big donors to political campaigns. . .

While some doctors and patients complain of Centene's stinginess, the company has been generous in regions where it has offices. Centene last year was the biggest donor for a $9.5 million renovation of an arts building in St. Louis, now called the Centene Center for Arts and Education, according to a spokeswoman for the center. The company paid $200,000 last year for the naming rights of a minor-league baseball stadium in Montana, where Centene employs 100 claims processors but doesn't have Medicaid clients. Centene also pledged $400,000 this year to the school district in Clayton, Mo., where the company has its headquarters, to rename the district's stadium. . .

Cynthia Schultz, director of the Great Falls International Airport in Montana, says Mr. Neidorff, the Centene CEO, once walked through the airport and heard that it couldn't afford artwork. Centene then commissioned and donated a $7,000 welded-metal sculpture of an eagle with a 16-foot wingspan that now hangs prominently in the airport, she says. The company confirmed the donation. "It's a great gift from someone who doesn't even live here," says Ms. Schultz. Mr. Schenk, the Centene spokesman, said the donations show Centene is a "responsible and publicly focused corporation" and they help make the communities better places to live. . .

Isn't there an ethics issue involved when people who get tax money to provide health care to the poor spend it so arrogantly on their own aggrandizement? Can any public dole be spent ethically?

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11.  Physicians 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 For the latest on their Antigua Project, please go to You may be interested in a Medical Timeshare in a resort.


                      PATMOS EmergiClinic where Robert Berry, MD, an emergency physician and internist practices. To read his story and the back ground 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 his the various topics at his website above.

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

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

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

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

                      Dr. Nimish Gosrani has set up a blend between concierge medicine and a cash-only practice. "Patients can pay $600 a year, plus $10 per visit, to see him as many times in a year as they want. He offers a financing plan through a financing company for those unable to plop down $600 all at once." Patients may also see him on a simple fee-for-service basis, with fees ranging from $70 for a simple office visit to $300 for a comprehensive physical. Dr. Gosrani reports that he saves two hours per day that he used to spend dealing with insurance company paperwork. To read more, go to

·                     Dr. Elizabeth Vaughan is another Greensboro physician who has developed some fame for not accepting any insurance payments, including Medicare and Medicaid. She simply charges by the hour like other professionals do. Dr. Vaughan's web site is at, where you can see her march in a miniskirt for Breast Health without a Bra. Careful or you may change your habits if you read her entire page.

                      Madeleine Pelner Cosman, JD, PhD, Esq, who has made important efforts in restoring accountability in health care, has died (1937-2006). Her obituary is at She will be remembered for her important work, Who Owns Your Body, which is reviewed at Please go to to view some of her articles that highlight the government's efforts in criminalizing medicine. For other OpEd articles that are important to the practice of medicine and health care in general, click on her name at

                      David J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the free Medical MarketPlace in speeches and writings. His series of articles in Sacramento Medicine can be found at To read his "Lessons from the Past," go to For additional articles, such as the cost of Single Payer, go to; for Health Care Inflation, go to To read his latest column, Politicians Cannot Manage a Health Care System, 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, write an informative Medicine Men column at NewsMax. Please log on to review the last five weeks' topics or click on archives to see the last two years' topics at This week's column is on Abortion Hurts Mothers Too.

                      The Association of American Physicians & Surgeons (, The Voice for Private Physicians since 1943, representing physicians in their struggles against bureaucratic medicine, loss of medical privacy, and intrusion by the government into the personal and confidential relationship between patients and their physicians.  Be sure to scroll down on the left to departments and click on News of the Day in Perspective: "Canada's social system expected to collapse soon" or go directly to it at Don't miss the "AAPS News," written by Jane Orient, MD, and archived on this site which provides valuable information on a monthly basis. This month, be sure to understand what Government means by Quality Health Care at  Scroll further to the official organ, the Journal of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a neurologist in New York, as the Editor-in-Chief. There are a number of important articles that can be accessed from the Table of Contents page of the current issue. Don't miss the excellent articles on EMR, Mental Health Screening or the extensive book review section which covers four great books this month.


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Words of Wisdom

Today we have the highest material standard of living in history. Advances in medicine, science, and technology give even the poorest among us benefits that the richest and greatest men of history never had. Still, we are preoccupied with what we don't have and are always wanting more.  Robert VanHoose, retired entrepreneur and Arabian horse breeder.

Edward Langley, Artist 1928-1995: What this country needs are more unemployed politicians.


Some Recent Postings

How to Lose Weight Without Dieting or How I lost My 30 Pounds: to Lose Weight Without Dieting
How to Lower Your Cholesterol Without Drugs:


In Memoriam

Ralph Harris, The Economist, Nov 2nd 2006

Lord Harris of High Cross, economist and freedom-fighter, died on October 19th, aged 81

ON NATIONAL No-Smoking Day, March 8th 2000, two suspicious figures were seen loitering outside the Houses of Parliament. One, in a loud red coat and louder lipstick, was Baroness Trumpington, with a clay pipe. The other, straight, thin and moustachioed, in a trilby and exotic waistcoat, was Lord Harris of High Cross, with a Meerschaum.

Ralph Harris loved smoking. He kept two more pipes in his pockets, in case one sputtered out. But as the years passed he loved smoking less for the tang of the tobacco, or its stimulus to thought, than for its defiance of the nanny-hand of the state. As smokers were increasingly repressed and made outcasts by the "authoritarian itch" of governments, so he all the more fiercely took their side.

He too had been out in the cold, like them. When he became general director of the Institute of Economic Affairs ("my little institute", as he fondly thought of it), in 1957, he was pushing ideas that were deeply out of fashion in the Keynesian post-war years. The IEA, set up by Antony Fisher in 1955, promoted deregulation, privatisation, tax cuts, trade-union reform and the free market. It attacked the welfare state, incomes policies and—Mr Harris's particular bęte noire—high public spending that unleashed inflation. These opinions were so outside the bounds that Mr Harris compared the IEA in those years to a band of 30-year-old boys fooling with fireworks. Or, perhaps, lighting up in a non-smoking carriage; for when he went to give talks in universities in the 1960s, most of the audience would walk out.

To critics, the ideas of the IEA were all the worse for being "German". Their source was Friedrich Hayek, in fact an Austrian. Mr Harris, fresh down from Cambridge in 1947, had fallen under the spell of Hayek's "The Road to Serfdom". Serfdom was all around him then: ration books, travel restrictions, the persistent shadow of wartime central planning, and most of all the depressing disposition of people to do what they were told and to suppose that this was modern life. He never believed it. The way to freedom was to unleash the millions of individual actions that made up a working economy, and never to seek to control them.

Slowly, these ideas caught on. Arthur Seldon, his chief collaborator, made the IEA's papers readable, while Mr Harris proselytised among movers and shakers and, most usefully, raised money. The IEA stayed aloof from party politics—essential, Mr Harris believed, to avoid embroilment in "vote-getting, lying and cheating"—but sought to change the intellectual climate in which politicians had to operate. Geoffrey Howe and Keith Joseph, the chief brains of the Conservative Party, deeply inhaled the new air; and Joseph passed the IEA's papers to his favourite pupil, saying, "Here, Margaret, read this."

The moral science

Mrs Thatcher adored Mr Harris's ideas. He admired her, and was amazed at the vigour with which she took on the unions and defended the free market through the 1980s. He did Thatcherite things, such as chairing the Bruges Group that opposed the European Union (though on grounds of interventionism, not the single market) and founding in 1985 a fan-club called No Turning Back. . .

He sometimes regretted he had not lived in Smith's time. To him, economics—or at least his variety, the economics of freedom—was a religious belief, the "moral science" that Smith had taught. The law of supply and demand, he once wrote, was the nearest social science approached to the laws that governed the universe. The modern conception of economics was much too small a canvas for him.

Nonetheless, he could use the jargon for all it was worth. Speaking in the House of Lords in July 2005, he railed against "statistical jiggery-pokery", "selective surveys" and "spurious precision to two decimal places". The numbers he was pulling apart, this time, were not government predictions for economic growth or industrial output—nonsense, he always thought, implying the sort of comprehensive knowledge humans simply didn't have—but figures for deaths by passive smoking, which he refused to credit. He suspected that untruths were being peddled to curb liberty, and he was having none of it. . .

To read the entire Obit, please go to

On This Date in History – November 28

On this date in 1520, Ferdinand Magellan reached the Pacific Ocean from the Atlantic. The Straits, which bear his name, was discovered by Magellan's as he was trying to find a way to get to the Moluccan Islands in the Pacific.

On this date in 1929, Commander Richard E Byrd took off with Bernt Balchen from their base in Little America to try to fly over the South Pole. They succeeded the following day.

On this date in 1967, The United Nations turned down Red China's request for admission for the 18th time.  Almost sounds like Ancient History in view of China's standing in the world in several spheres.