Community For Better Health Care

Vol VIII, No 11, Sept 8, 2009


In This Issue:

1.                  Featured Article: Competition in Medicine

2.                  In the News: Looking back

3.                  International Medicine: The Private Sector’s role in Canadian healthcare is expanding

4.                  Medicare: What is this Life vs Death Debate?

5.                  Medical Gluttony:  Mega Gluttony: $5000 an hour!

6.                  Medical Myths: Comparative Effectiveness Research will control cost and improve quality

7.                  Overheard in the Medical Staff Lounge: What’s In This Year, What’s Out This Year?

8.                  Voices of Medicine: Biomedicines need new regulatory approaches.

9.                  The Bookshelf:  Health Policies - Health Politics by Daniel L. Fox

10.              Hippocrates & His Kin: Consumer-Driven Plans now exceed that of HMOs

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

Words of Wisdom, Recent Postings, In Memoriam . . .

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Go to and click on Newsletter to sign up for our sister Newsletter which is now separate from MedicalTuesday and focuses more on health care and reform rather than practice issues.

The Annual World Health Care Congress, a market of ideas, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. The third year it was about half, indicating open forums such as these are critically important. The 4th Annual World Health Congress was held April 22-24, 2007, in Washington, D.C. That year many of the world leaders in healthcare concluded that top down reforming of health care, whether by government or insurance carrier, is not and will not work. We have to get the physicians out of the trenches because reform will require physician involvement. The 5th Annual World Health Care Congress was held April 21-23, 2008, in Washington, D.C. Physicians werse present on almost all the platforms and panels. However, it was the industry leaders that gave the most innovated mechanisms to bring health care spending under control. The 6th Annual World Health Care Congress was held April 14-16, 2009, in Washington, D.C. The solution to our health care problems is emerging at this ambitious Congress.  The 5th Annual World Health Care Congress – Europe 2009, met in Brussels, May 23-15, 2009. The 7th Annual World Health Care Congress will be held April 12-14, 2010 in Washington D.C. For more information, visit The future is occurring NOW.  You should become involved.

To read our reports of the 2008 Congress, please go to the archives at and click on June 10, 2008 and July 15, 2008 Newsletters.

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1.      Featured Article: Competition And Cost-Conscious Buyers Will Save Medicine

Competition Would Save Medicine, Too By John StosselThe FreemanSeptember 2009

Competition so regularly brings us better stuff—cars, phones, shoes, medicine—that we’ve come to expect it. We complain on the rare occasion the supermarket doesn’t carry a particular ice-cream flavor. We just assume the store will have 30,000 items, that it will be open 24/7, and that the food will be fresh and cheap.

I take it for granted that I can go to a foreign country, hand a piece of plastic to a total stranger who doesn’t speak English . . . and he’ll rent me a car for a week. Later, Visa or MasterCard will have the accounting correct to the penny.

Compare: Governments can’t even count votes accurately—or deliver the mail efficiently.

Yet now, somehow, government will run auto companies and guarantee us health care better than private firms? And the public seems eager for that!

If you think it’s mainly the political class and mainstream media that are clueless, listen to the doctors. Dr. Atul Gawande, in an otherwise interesting New Yorker article on health-care costs, disparages medical savings accounts and high-deductible insurance. . .

The doctors then dismiss the idea with a sneer.

“We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? . . . ‘Who comes up with this stuff?’

I do. Adam Smith did. Market competition is what’s brought us most of what’s made life better and longer.

The Free-Rider Benefit

But the doctors have mastered the anti-free-market sneer: Markets are good for crass consumer goods like washing machines and computers, but health care is too complicated for people to understand.

That’s nonsense. When you buy a car, must you be an expert on automotive engineering? No. And yet the worst you can buy in America is much better than the best that the Soviet bloc’s central planners could produce. Remember the Trabant? The Yugo? They disappeared along with the Berlin Wall because governments never serve consumers as well as market competitors do.

Maybe 2 percent of customers understand complex products like cars, but they guide the market and the rest of us free-ride on their effort. When government stays out, good companies grow. Bad ones atrophy. Competition and cost-conscious buyers who spend their own money assure that all the popular cars, computers, etc. are pretty good.

The same would go for medicine—if only more of us were spending our own money for health care. We see quality rise and prices fall in the few areas where consumers are in control, like cosmetic and Lasik eye surgery. Doctors constantly make improvements because they must please their customers. They even give out their cell numbers.

Drs. Dyer and Gawande don’t understand markets. Dyer’s elderly woman wouldn’t have to haggle over price before surgery. The decisions would be made by thousands of 60-, 40-, and 20-year-olds, the minority who pay closest attention.

Word about where the best values were would quickly get around. Even in nursing homes, it would soon be common knowledge that hospital X is a ripoff and that Y and Z give better treatment for less.

People assume someone needs to be “in charge” for a medical-care market to work. But no one needs to be in charge. What philosopher F. A. Hayek called “spontaneous order” and Adam Smith called “the invisible hand” would make it happen, just as they make it happen with food and clothing—if only we got over the foolish belief that health care is something that must be paid for by someone else.

Feedback . . .

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2.      In the News: Looking Back at how lucky President Clinton was to have a Republican Congress.

Looking back, what a lucky man President Clinton was to have—to help bring about after his own health-care fiasco—a Congress controlled by the opposite party. What a great and historic team Mr. Clinton and Newt Gingrich were, a popular Democratic president and a determined GOP leader with a solid majority.

Welfare reform, a balanced budget, and a sense the public could have that not much crazy would happen and some serious progress might be made. If Mr. Clinton pressed too hard, Mr. Gingrich would push back. If Mr. Gingrich pressed too hard Mr. Clinton pushed back. Two gifted, often perplexing and always controversial boomers who didn't even like each other, and yet you look back now and realize: Good things happened there.

Right now Mr. Obama's gift is his curse, a Congress dominated by his party. While the country worries about the economy and two wars, the Democrats of Congress are preoccupied with the idea that this is their moment, now is their time, health care now, "Never let a good crisis go to waste," the only blazingly memorable phrase to be uttered in the new era.

It's not especially pleasurable to see history held hostage to ideological vanity, but it's not the first time. And if they keep it up, they'll help solve the president's problem. He'll have a Republican congress soon,0,1595856.story

--Peggy Noonan in Pull the Plug on ObamaCare, WSJ

Feedback . . .

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3.      International Medicine: The Private Sector’s role in Canadian healthcare is expanding

Ms Holmes appeared on US television recently to explain why she mortgaged her house on the outskirts of Toronto to pay to have a brain tumour treated at the Mayo Clinic across the border in Minnesota.

She has received “terrific support” for her view that Americans would be ill-advised to look north of the border for a solution to their healthcare problems.

But she says her views have also drawn a torrent of criticism, even a death threat, from fellow Canadians. However fed up Canadians are with long waits for tests and surgery, a shortage of family physicians and the other shortcomings of their taxpayer-funded system most recoil at the thought of a US-type, profit-based model.

According to an Angus Reid Strategies poll this month, two-thirds of respondents said they were happy with their healthcare system. An overwhelming 79 per cent disapproved of the US model.

David Caplan, Ontario’s health minister, responded to the furore over Ms Holmes’ statements by asserting that “we have a strong, publicly funded healthcare system that every Ontarian can be proud of. I’m committed to ensuring that Ontarians get access to healthcare based on their needs, not on their ability to pay.”

The trouble is that neither Ms Holmes’ criticisms nor Canadian politicians’ rhetoric matches reality.

Even as American conservatives decry their neighbour’s system of “socialised medicine”, the private sector’s role in Canadian healthcare is expanding as governments seek to curb runaway costs while meeting voters’ high expectations.

The provinces, which administer the system, have diluted the Canada Health Act’s bedrock principles of universal access and a single public-sector insurer by curtailing the list of services covered by public health insurance. . .

Over the past five years, Ontario has removed eye tests, physiotherapy and chiropractic treatments from health coverage. Dental work is also typically excluded.

Private insurers have stepped in to provide cover for these benefits, thus planting the seeds of a “two-tier” system – one for the rich, another for the poor – that Canadians are keen to avoid.

The provinces have also quietly opened the door to more private-sector involvement as suppliers.

The Canada Health Act allows workers’ compensation boards, the police and prison authorities to bypass the public system for speedy treatment. Burgeoning demand from these “third parties” has spawned an array of privately owned clinics.

These clinics have not only taken over a variety of treatments from hard-pressed public hospitals, but are being allowed to serve the public, especially in British Columbia and Alberta.

The services available at Vancouver’s privately owned Cambie Surgery Centre include mastectomies, hernia repairs and cornea and cataract surgery. Treatment is still covered by the provincial health plan.

Public-private partnerships have also proliferated. British Columbia is considering proposals from three groups – including one led by UK-based Health Care Projects – to build, finance and maintain a large cancer-care centre for northern communities, among other projects.

The authorities have placated trade unions by excluding some services, such as housekeeping, laundry and catering, from contracts.

The provinces also use the very system that so many of their residents decry. Ontario paid for almost 9,500 people to receive specialised care in the US last year.

Feedback . . .

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

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

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4.      Medicare: What is this Life vs Death Debate?

What's Going on Out There? By Greg Scandlen

Last week, I wrote an op-ed defending Sarah Palin's concern about "death panels." Certainly her expression was shocking and designed to get attention. It succeeded extremely well in that regard.  The case I tried to make was that, if we follow the British model, we will indeed end up with a federal agency that makes life and death decisions for all of us based on a cost effectiveness standard.
I got some amazing responses to the op-ed. Almost everyone who contacted me agreed and thanked me for saying it, but most interesting was the intense hostility from academics and policy wonks. You would think I had kidnapped their baby or something. I have never seen such a visceral reaction to any issue in health care . . .

How can this be, they wonder. We have big majorities in the House and Senate. We have a smooth talker in the White House. We have bought off the special interests. We have learned from the Clinton mistakes. We have done everything right. How can we be losing again?
There are two big reasons.
First, they believed their own propaganda. For years, these folks have cherry picked the data and exaggerated the problems to make it seem like there is a BIG CRISIS! They did this to justify changing American health care from top to bottom and gain more power for themselves. That is fine as a tactic. It's a way to stampede less informed people, especially the media, into echoing your talking points. But if these folks actually believed it, they are bigger fools than I realized. People have been talking about a CRISIS in health care since the 1960s.
In a remarkably candid interview in 2001, Brandeis economics professor Stuart Altman said, "When I was 32 years old, I became the chief regulator in this country for health care. At that point, we were spending about 7.5 percent of our GDP on health care. The prevailing wisdom was that we were spending too much, and that if we hit 8 percent, our system would collapse."
Obviously the system did not collapse, even though the share of GDP now exceeds 15 percent, and the fear mongers were proven to be blowing smoke. But that didn't stop the exact same people from pitching the exact same line every year since.  .  .

The advocates have convinced themselves that Clinton was defeated by a small cabal of Washington special interests who spent a lot of money opposing the plan. They figured if these special interests could be neutralized, it would be clear sailing. Plus they figured Clinton's big mistake was in writing a massive bill in secret with little Congressional participation, so if they let Congress write it, everything would be okay.
They were wrong on both counts. In fact in 1993 - 1994, there was the same kind of grass roots fervor there is today. People in Washington didn't notice it. They only noticed what the special interests were doing, and assumed that any grassroots concerns were orchestrated by these special interests. Not true then, and not true today.
On the second point, the issue isn't who wrote the massive bill in secret. The issue was that it was then, and is today, that a massive bill was written in secret at all. The folks don't care is it is written by a Congressional elite or a White House elite. The simple fact that any elite group is massively changing everything about their personal health care with the sweep of a pen is enough to raise alarms.
Every time over the past 100 years that Washington has tried to enact massive health reforms affecting every man, woman, and child among us, it has been defeated. Not by the insurance companies and not by the doctors, but by the people of America. It is, quite plainly, not how we want change to be done.
Yes, we may want change to happen, but we want it to be gradual, so it can be revised and amended as we go along. Why is that so hard to understand?

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

- Ronald Reagan

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5.      Medical Gluttony: Mega Gluttony - $5,000 an hour!

Today I saw a 42-year-old man in consultation, who also mentioned that he had Gastro Esophageal Reflux Disease. He’d recently missed his Omeprazole and had severe substernal pain. His wife insisted he go to the emergency room. He said the magic word at the registration desk (Chest Pain) and was ushered immediately into the private ER ward and the full cardiac workup was given.

He told the nurse that he had GERD but never this severe. Instead of giving him his acid reducer and acid neutralizer, he was taken directly to the cardiac catheterization laboratory. He mentioned several times his GERD was really bothering him but it was too late. The focus was on his heart. He was given a right heart catheterization, then a left heart catheterization and then a coronary angiogram. All of his coronaries were wide open and no heart disease was found. His left ventricular ejection fraction, which measures the effectiveness of his heart action, was totally normal.

The cardiologist paused trying to figure out what could be causing such severe angina. The nurse said he had GERD. Doesn’t that mimic angina? He would like something for it. We forgot to give him some antacids down stairs. He was immediately given a chug of antacids. Within a few minutes he was feeling much better and sat up. He asked for another chug and by that time was feeling really good. He left the ER about 10 hours after arrival. The cost? $58,000 or $5,000 per hour.

Medicare, ObamaCare, Medicaid, Hillary Care, Blue Cross, HMOs are all totally ineffective in stopping this mega gluttony. The only remedy to force the doctor and the patient to at least have a 30-second talk on the patients history would be a percentage co-payment on every item of care. The patient’s wife would have stopped at the registration desk and remember that her husband hadn’t taken his acid reducers and acid neutralizers as soon as she heard the minimal charge would be $5000 and their 20% co-payment of $100 was due at the window—now.

Hospitals would have to find another revenue generator or stop building palaces.

Feedback . . .

Medical Gluttony thrives in Government and Health Insurance Programs.

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

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6.      Medical Myths: Comparative Effectiveness Research will control cost and improve quality

Myth 5. Cost control and quality will emerge from comparative effectiveness research.

Congress appropriated $1.1 billion—the total worth of 1,100 millionaires—to “comparative effectiveness research” (CER). It promised that CER would not turn out to be “cost-effectiveness research”—and the rationale for treatment rationing and denial—although it defeated a proposed amendment that would have codified that promise into law.

In his talk to the AMA, Obama said, “[We]…need to do…figure out what works, and encourage rapid implementation of what works into your practices. That’s why we are making a major investment in research to identify the best treatments for a variety of ailments and conditions.” He wants a system “where…doctors can pull up on a computer all the medical information and latest research they’d ever want to meet that patient’s needs.”

Unlike other research funded by the $30 billion spent annually by the National Institutes of Health (NIH), or by pharmaceutical companies, universities, and others, CER has nothing to do with discovering better treatments or achieving a better understanding of disease. CER is simply supposed to rank existing treatment methods.

The Institute of Medicine (IOM) has winnowed down some 1,300 topics suggested by “stakeholders.” Of the IOM’s 293 recommended primary and secondary research priorities, 50 (by far the largest number) pertain to “health care delivery systems”; 29, to racial and ethnic disparities; and 22, to functional limitations and disabilities (John K. Iglehart, N Engl J Med, posted 6/30/09).

Half the recommended primary research priorities for delivery systems concern how or where services are provided, rather than which services are provided.

An IOM committee also recommends “determining the most effective dissemination methods to ensure translation of CER results into best practices”—i.e. enforcement.

The goal of CER is indistinguishable from that of managed care: “delivering the right care to the right patient in the right place at the right time.”

Cancer is the focus of only six primary CER topics, of which one is related to congressional concern about increased use of advanced imaging.

The $1.1 billion is only a down payment. A new nonprofit corporation is expected to carry on, financed by a $1 annual “contribution” from each Medicare beneficiary and each privately covered life (ibid.).

CER, by proponents’ own admission, achieves nothing in itself. It merely “represents a significant investment in one of the translational steps toward improving the quality of health care for all” (Patrick H. Conway and Carolyn Clancy, N Engl J Med 2009; posted 6/30/09).

Operationally, CER means setting up a bureaucracy and dividing the funding among stakeholders. The content for the materials and methods section of a standard research report—consent, an institutional review board, control groups, validated data collection tools, defined endpoints, statistical procedures—appears to be absent.

There is no evidence that CER will decrease costs, improve quality—or produce any scientifically meaningful data. But for its proponents, there is no danger that the reformed system will be proved inferior, as there is no “usual care” arm to the protocol.

For example: determining patients’ needs—by talking to patients. Determining the comparative effectiveness of various treatments in individuals—by interviewing and examining patients. Determining the cost and value of differing options—by permitting prices to equilibrate in a direct-payment model.

AAPS Mythbusters:

Additional information:

·         “Organization on High: Expanding Use of Physician Examination Scores,” by Hilton P. Terrell, M.D., Ph.D., J Am Phys Surg, Spring 2009.

·         “What Does the Stimulus Bill Mean for Medicine?” AAPS News of the Day 2/24/09.

·         “Medical Information and Bureaucracy: F.A. Hayek and the Use of Medical Knowledge,” by Hilton P. Terrell, M.D., Ph.D., and Timothy D. Terrell, Ph.D., J Am Phys Surg, Fall 2005.

Tags: comparative effectiveness research

Feedback . . .

Medical Myths originate when someone else pays the medical bills.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service.

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7.      Overheard in the Medical Staff Lounge: What’s In This Year, What’s Out This Year?

Dr. Rosen: The HMOs have been very diligent in persuading doctors not to have patients come in every month or two, getting us not to order GI consults, colonoscopies, lipid panels, or even cardiology consults. Now it seems there’s been a dramatic change.

Dr. Edwards: Now they’re telling us to start doing colonoscopies at age 50, cholesterol checks every six months, diabetic screening every three to six months.

Dr. Sam: I just try to read the expected protocol and order them. What the HMOs accept as the best practices may not actually be so. But I follow their demands. So my profile has gone up dramatically.

Dr. Edwards: Doesn’t that bother you?

Dr. Sam: No. My quarterly bonus seems to be increasing, also. Having a clean record and making money (even though it may be what I believe is inferior medicine) is a win-win situation.

Dr. Edwards: So you’re admitting you practice inferior medicine and that’s increasing your income?

Dr. Sam: It’s far better than being eliminated by the HMO for not following protocol. They always think they know best. And this isn’t a two-way street—it’s a one-way street and it’s their way.

Dr. Edwards: So diabetes and cholesterol are in this year?

Dr. Sam: Remember heart and hypertension were in last year.

Dr. Edwards: So at no time will every disease be in?

Dr. Sam: That’s correct. Remember medical bureaucrats are medically illiterate. There is no argument you can win with an illiterate.

Dr. Edwards: What about these young doctors coming into the field? Are they being hoodwinked? Aren’t they idealistic still?

Dr. Sam: You’re thinking about our day. The evidence clearly shows today’s students are more sophisticated than we were. They psych out the professors on day one and regurgitate back exactly what he wants and don’t vary from it to try to learn more. And this has boiled over into medical schools. After all, they went through college and learned the system.

Dr. Rosen: It doesn’t stop with the HMO fiasco. This lack of idealism carries over into practice.

Dr. Edwards: How so?

Dr. Rosen: These laidback students would never have the drive to go into private practice. That’s why so many of them are socialists from the get-go.

Dr. Ruth: You really think it has changed all that much?

Dr. Rosen: Yes I do. My physical diagnosis students don’t seem to be as interested in private practice like they were twenty years ago.

Dr. Milton: They’re so used to following the professor’s protocol they expect to follow anyone’s protocol in practice, whether it’s the government or their specialty society. They are not about to make waves.

Dr. Rosen: They will milk the system. So it’s not who is the best doctor any more. It’s who is the shrewdest to take advantage of the system and make more money.

Dr. Milton: They see nothing wrong with seeing six patients an hour if they make more money.

Dr. Rosen: But the patients notice the difference and they will be increasingly unhappy and complain to their Congressman who will rain retribution on all of us.

Dr. Sam: And I will survive any retribution from any Congressmen. With their average IQ, I’d be ashamed if any could outwit me.

Dr. Edwards: Now that is a very shameful attitude for a professional man.

Dr. Sam: No it’s a winning attitude in a government environment that is hostile to Doctors. Otherwise, you’ll lose with the losers. If you lose with the losers, there’s no hope for you in medicine or in any other profession. There’s no other way to win with losers.

Dr. Rosen: So what’s in this year is whatever Congress and the Government and the Bureaucrats say. Everything else is out—at least for now.

Feedback . . .

The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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

VIEWPOINT: New types of medicines need new regulatory approaches
Dr. Robert J. Cihak and Dr. Richard Dolinar

As physicians, we are excited by new medical advances undreamed of only a few decades ago.

Scientists are now creating advanced and truly individualized medicines that work with a person’s unique set of bodily components, such as DNA. Many of these new medicines – “biologic” drugs – are much more complicated than previous generations of medicines.

Biologics are large, complex molecules, produced by genetic engineering techniques and manufactured by living cells. The everyday drugs that we are all familiar with, such as aspirin, are small in molecular weight and made by chemical reactions. Mixing the same chemicals in the same way always gives the same predictable outcome.

In comparison, biologics are not the result of a chemical reaction but are “grown” in cells biologically engineered for this purpose.

As a result, biologic drugs grown using different cell lines or different manufacturing processes are not identical. They are variants of the original drug, each containing different contaminants produced by the living cells used in the production process.

These unavoidable contaminants can cause different allergic (immune) responses. On average, biologic drugs cost more than $1 billion and often take more than 10 years to be created and tested before they are available for patient use.

Now that some patents on some older biologic drugs are expiring, generic pharmaceutical companies are looking to enter the market with variant products, similar to the original, innovative drug. These new drug versions would open the market to competition and cost savings.

But because the replicated variant drugs – called “follow-on biologic” or “biosimilar” drugs – aren’t identical to the original drug, they are not true generic or “bioidentical” drugs.

In reality, these drugs should be called “biodifferent” because it is the differences and not the similarities that concern us.

In response to this new class of drugs, Congress is considering ways to appropriately create new Food and Drug Administration approval pathways for follow-on biologics.

Rep. Henry Waxman, D-Calif., has introduced HR 1427; Washington Congressman Jay Inslee, D-Bainbridge Island, is one of the sponsors of HR 1548.

Both bills recognize the difference between older and simpler generic drugs and the newer, much more complicated biologics. But they take significantly different approaches to testing drug risks and to providing incentives for future innovation and intellectual property protection.

The Waxman approach essentially acknowledges that a follow-on biologic is not identical to the innovator drug. But it considers a follow-on drug to be “close enough” to the innovator drug and, therefore, would allow for an abbreviated, less thorough drug-approval process than used with the original medicine. The intent would be to save money and speed introduction of the new drug.

In contrast, HR 1548’s approach would require more clinical testing and monitoring of the risks and efficacy of the follow-on biologics, a process that has been successfully adopted by the European Union.

The approval process is important because seemingly small differences in drugs can cause very significant adverse events in the body. Because biologics are hugely complex entities, predicting the risks and effectiveness of follow-on biologics is impossible.

For example, a biologic form of erythropoietin (a hormone stimulating production of red blood cells) is available in the United States and Europe. Despite the complete cooperation of the two companies producing the medicine, the products aren’t identical. Slight differences caused different and sometimes devastating immune responses in the European version.

Every moment of a physician’s working day is devoted to helping patients live healthier lives and to treating their ailments more safely and effectively. What is “close enough” for government work in Waxman’s bill might not be close enough for our patients. Because of the greater diversity of possible treatments, biologics require more highly individualized care. The physician and the patient are partners in the appropriate use of these new medicines.

Government agencies can’t predict the future any better than anybody else and, by definition, can’t predict innovation. The FDA is therefore often behind the times in dealing with any new class of drugs.

We believe the Inslee bill would better enhance development of these innovative drugs; Congress should act quickly to enact it. It’s the better approach to helping patients access these promising medical treatments.

Robert J. Cihak, M.D., of Brier in Snohomish County, is a senior fellow in medicine at the Discovery Institute. Richard Dolinar, M.D., is a private practice clinical endocrinologist in Phoenix, Ariz., and a senior fellow in health care policy at The Heartland Institute.

Originally published: August 6th, 2009 12:15 AM (PDT)

Feedback . . .

VOM Is Where Doctors' Thinking is Crystallized in Writing.

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9.      Book Review: Health Policies - Health Politics by Daniel L. Fox

Health Policies - Health Politics, The British and American Experience 1911-1965  by Daniel L. Fox, Princeton University Press, Princeton, N.J., 1986

In his introduction, Fox summarizes three assumptions that became the basis of health policy in Britain, the USA, and most industrialized countries in the twentieth century.  1) The causes of cures for most diseases are usually discovered in the laboratories of teaching hospitals and medical schools.  2) These discoveries are then disseminated down hierarchies of investigators, institutions, and practitioners that serve particular geographic areas.  3) Health policy should stimulate the creation of hierarchies in regions that lack them and make existing ones operate more efficiently.

Most authors feel that health policy should encourage people to seek medical care by providing an adequate and efficiently organized supply of services – doctors, health workers, and hospital – and removing or reducing the burden on individuals to pay for them.  Most American students of health policy have assumed that their central task is to explain the failure to achieve compulsory national health insurance.

Fox feels that’s an invalid assumption and writes the history of health policy from a different point of view.  He tries to remain neutral about the worth of particular policies and of the people who advocated or attacked them.  He is critical of the concept that history teaches.  Instead, he tries to explain why particular policies were adopted in American and Britain.  Unlike other historians of health policy, Fox does not believe that the progress of medicine has made a particular policy inevitable or desirable.  In his view, medicine changes and advances technologically; but it does not progress.  Neither medicine nor the human condition progresses – changes for the best – over time.  The purpose, content, and social valuation of medicine are, he believes, in constant flux.  A century ago, many people in America and Britain began to believe that, for the first time in history, scientists were discovering wholly new kinds of truths about nature that would, eventually, make it possible for doctors to reduce the suffering and death caused by the most threatening diseases. 

By the 1920s, medical care and health policy had become synonymous for most people.  For the next half-century, health policy was usually made on the assumption that increasing the supply of medical services and helping people to pay for them was the best way to reduce morbidity and mortality and help individuals lead more satisfying lives.  The priority of public health policy in each nation changed from regulating or improving the environment to providing direct services to individuals.  Doctors’ decisions about what to order for their patients distributed most of the resources allocated by health policy.  Moreover, priority within health policy was accorded to the services provided by specialized doctors in hospitals.

Fox takes us on a fascinating journey that I believe provides insight as to how the US may do something significant in health care and in public health.  As he states in his final paragraph, both in a practical and philosophical sense, there is no past – no correct description of any earlier time.  There is only evidence, which historians must reinterpret continuously.  Neither is there a future – no way to predict what will happen.  There is only a succession of presents, each with enormous possibilities for thought and action.  The study of history is a source of experience, not of justifications for policy. . . . My four grandparents left Europe just before the government intrusions of the 1880s occurred to go to a country of freedom from those restrictions of individual initiative.  This book may give us the rationale why their reasoning was valid then and may still be logical.  The real question may be, “Can we preserve their vision for another generation, our children and grandchildren?”

Feedback . . .

This book review is found at. . .  

To read more book reviews . . . 

To read book reviews topically . . .

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10.  Hippocrates & His Kin: Consumer-Driven Plans now exceed that of HMOs

A new survey by United Benefits Advisors finds that enrollment in consumer-driven plans now exceeds that of HMOs. The survey included over 12,000 employers and discovered that 15.4% of all employees are now in CD Plans, compared to 13.6% in HMOs. PPOs remain the Big Daddy with a 63.9% market share.

With the defeat of ObamaCare, America’s Health Care will continue to be the Envy of the World

Administrative costs consume half of pledged US aid says Islamabad

Half of the planned assistance pledged by the US to Pakistan is likely to be wastefully spent on administrative costs, Islamabad's top finance official said. Shaukat Tarin, Pakistan's finance minister, has urged the US to channel its assistance through Pakistani agencies instead to save on high intermediation costs incurred by US counterparts.

It would make more sense to cut foreign aid in half and eliminate the half that’s bureaucratic expense rather than endorse the Obama goal to finance a $ trillion dollar health plan by cutting the inefficiencies of Medicare.

Government inefficiency doesn’t change whether abroad or at home.

The Impact on Your Patients

Bulletin:  Five reactors located in Canada, Belgium, France, the Netherlands and South Africa produce the global supply of radioactive molybdenum (99Mo), which is used to create the tracer, technetium (99mTc).

In May 2009, the Canadian reactor was shut down due to a leak. This event, paired with scheduled and unscheduled maintenance required on the other reactors, is causing a national shortage of 99mTc that is likely to last several months, if not years.

Nuclear exams affected by the Shortage include the following: Thyroid, Bone, Lung, Heart, Liver, Gallbladder, and Renal Scans, as well as Gastric Emptying Studies and Myocardial Perfusion Imaging.

Why can’t the United States keep up with South Africa in building reactors?

Feedback . . .

To read more HHK, go to

To read more HMC, go to

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

                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at and register to receive one or more of these reports. This month, read Replacing a private monopoly with a public monopoly won't do much good . . .

                      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 signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. Be sure to read Sally Pipes: An ounce of prevention is no cost-saving cure . . .

                      The Mercatus Center at George Mason University ( is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This month, treat yourself to an article on Financial Crisis 2007 - 2012.

                      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.

                      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 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. This month, you might focus on An Era Ends.

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Greg has joined the Heartland Institute, where current newsletters can be found.

                      The Heartland Institute,, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?. This month, be sure to read Obama Health Plan: Rationing, Higher Taxes, and Lower Quality Care.

                      The Foundation for Economic Education,, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, 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. Be sure to read the current lesson on Economic Education that Preventive Care Won’t Save Enough Money.

                      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."

                      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. Read her latest newsletter: Obama Care Means High Price Tag for Coloradans.

                      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 Seven State Regulations That Made The Crisis Possible.

                      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.

                      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. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, they have lost site of their mission and we will no longer feature them as a freedom loving institution.

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at to obtain the foundation's daily reports. This month read The 19th-Century Bernanke. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

                      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, articles and books 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, wartime allows the federal government to 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 wartime, 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

                      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, The Constitution and American Sovereignty at The last ten years of Imprimis are archived.

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Words of Wisdom

Washington is not the place that great change is going to occur in America. It will occur in the laboratory of innovation called the states. I want to be a part of that. –Rick Perry, Governor of Texas.

All mankind's inner feelings eventually manifest themselves as an outer reality."— Stuart Wilde: Author and lecturer on consciousness and awareness

Some Recent Postings for January 2009 . . . for April 2009 . . . for July 2009 . . .

HealthPlanUSA is now a separate Newsletter devoted to the rapidly evolving field of health plans being promoted throughout the USA. These are dangerous times. Stay tuned to the current issues, which we bring quarterly and will increase as staffing permits. Why not sign up now at

In Memoriam

The Reagans and the Kennedys: How they forged a friendship


This is what Ronald Reagan said of John F. Kennedy, on a warm dark night in the floodlit garden of Ted Kennedy's home in McLean, Va.:

"It always seemed to me that he was a man of the most interesting contradictions, very American contradictions. We know from his many friends and colleagues, we know in part from the testimony available at the library, that he was both self-deprecating and proud, ironic and easily moved, highly literate yet utterly at home with the common speech of the working man. He was a writer who could expound with ease on the moral forces that shaped John Calhoun's political philosophy; on the other hand, he betrayed a most delicate and refined appreciation for Boston's political wards and the characters who inhabited them. He could cuss a blue streak—but then, he'd been a sailor.

"He loved history and approached it as both romantic and realist. He could quote Stephen Vincent Benét on Gen. Lee's army—'The aide de camp knew certain lines of Greek / and other things quite fitting for peace but not so suitable for war . . .' And he could sum up a current 'statesman' with an earthy epithet that would leave his audience weak with laughter. One sensed that he loved mankind as it was, in spite of itself, and that he had little patience with those who would perfect what was not meant to be perfect.

"As a leader, as a president, he seemed to have a good, hard, unillusioned understanding of man and his political choices. He had written a book as a very young man about why the world slept as Hitler marched on, and he understood the tension between good and evil in the history of man—understood, indeed, that much of the history of man can be seen in the constant working out of that tension.

"He was a patriot who summoned patriotism from the heart of a sated country. It is a matter of pride to me that so many young men and women who were inspired by his bracing vision and moved by his call to 'Ask not' serve now in the White House doing the business of government.

"Which is not to say I supported John Kennedy when he ran for president, because I didn't. I was for the other fellow. But you know, it's true: When the battle's over and the ground is cooled, well, it's then that you see the opposing general's valor.

"He would have understood. He was fiercely, happily partisan, and his political fights were tough, no quarter asked and none given. But he gave as good as he got, and you could see that he loved the battle.

"Everything we saw him do seemed to show a huge enjoyment of life; he seemed to grasp from the beginning that life is one fast-moving train, and you have to jump aboard and hold on to your hat and relish the sweep of the wind as it rushes by. You have to enjoy the journey, it's unthankful not to. I think that's how his country remembers him, in his joy.

"And when he died, when that comet disappeared over the continent, a whole nation grieved and would not forget. A tailor in New York put a sign on the door: 'Closed due to a death in the family.' The sadness was not confined to us. 'They cried the rain down that night,' said a journalist in Europe. They put his picture up in huts in Brazil and tents in the Congo, in offices in Dublin and Danzig. That was one of the things he did for his country, for when they honored him they were honoring someone essentially, quintessentially, completely American. . .

"And sometimes I want to say to those who are still in school, and who sometimes think that history is a dry thing that lives in a book, that nothing is ever lost in that house. Some music plays on.

"I have been told that late at night when the clouds are still and the moon is high, you can just about hear the sound of certain memories brushing by. . . Walk softly now and you're drawn to the soft notes of a piano and a brilliant gathering in the East Room, where a crowd surrounds a bright young president who is full of hope and laughter.

"I don't know if this is true, but it's a story I've been told, and it's not a bad one because it reminds us that history is a living thing that never dies. . . . History is not only made by people, it is people. And so history is, as young John Kennedy demonstrated, as heroic as you want it to be, as heroic as you are."

Read the introduction, the entire speech and epithet along with Peggy Noonan’s final attribute to Ted:

On This Date in History - September 8

On this date in 1157, King Richard the Lion-Hearted was born in Oxford, England. Richard spent most of his time outside England, and did not quite have the glittering record to go with his reputation in history.  

On this date in 1565, the First permanent European settlement in North America took place in St. Augustine, Florida. This first settlement was Spanish.

On this date in 1951, the Japanese Peace Treaty was signed. Although Japan surrendered in 1945, ending the Second World War, it took another six years before the matter was settled on paper in San Francisco, California, by the United States, Japan, and forty-seven other nations.

After Leonard and Thelma Spinrad


Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements is the former publisher of "American Venture" magazine who made news in 2005 for a property rights project against eminent domain called the "Lost Liberty Hotel."
For more information visit or email