Hippocrates & His Kin by Del Meyer, MD
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Roaming About Moscone
The continuing saga of the "biomedical rape" of women at UCIs fertility clinic continues to get more complicated. Some of these eggs have been implanted without donors or recipients consent and have produced children with biologic parentage in doubt. A second doctor is out of the country developing a huge practice in Chile. However, the three doctors on "suspension" continue to get their salaries (about $100K each) deposited to their bank accounts because they are tenured, and they can still access these funds. UCI is a California tax-supported institution with research funded by federal grants. It appears that both sides of this fiasco are paid for by state or federal taxpayers.
Doctors incomes continue to fall. The current estimate is that after paying over $180,000 in expenses, we make about $150,000 for our 3000 hour year which is about $50 an hour. About the same as the "handy man" that fixed the skylight and ceiling in my office. Except we had to have an extra 12 years of higher, professional, and post doctoral education to allow us to make this humongous hourly wage.
Sixth-grader to his father who just finished explaining to his mother that with all the new contract reductions and with increasing overhead, he thought he was losing about $2.50 a patient: "Daddy, if you saw ten less patients every day, you'd save $25, and you could buy me a CD ROM every day, come home when I get out of school, and we could play it on the computer. Wouldn't that me more fun than losing money at the office?"
Just as we were convinced that all government projections missed their mark by only 200-400%, we came across the failed health plan. The 12 member President's Task Force on Health Care Reform, which Hillary Rodham Clinton oversaw, had an original charter in March 1993 stating that the planning cost was "expected to be below $100,000." In testimony before Congress in 1994, White House aide Patsy Thomasson revised that estimate, placing the planning cost closer to $211,000. (A 111% error, not bad.) The associated press found advisers with political connections who were getting as much as $100,000 each. The General Accounting Office then did an audit and found that the White House spent over $662,000 of its funds and over $13 million in funds from other federal agencies. Included was $433,966 to unsuccessfully fight a law suit against a doctors' group wanting to make the task force documents public. A sixty five fold increase on top of the second projection is another 6500% error in a government projection for a total of 13,000% error over initial cost projections. That was just for planning the health plan which was discarded by congress in a few months. What if it would have passed and the half trillion dollars were a few hundred percent off? Can we try NOT to top that?
The government recently ran out of funds. Actually this happened decades ago but there is a renegade crowd in D.C. that is calling a spade a shovel. When the government shut down by calling off 800,000 nonessential workers, David Lettermen commented that maybe we have found the cause of our national problem... Jackie Mason, on CNN, stated that it was obvious that the 40% put on furlough should not be rehired. Since the other 60% didn't seem to be exerting themselves to get additional work done, he suggested that another 10% or half of the 2 million federal workers should be furloughed ...Debra Saunders in the SFChronicle, commenting on this showdown, stated that the $66 per year Medicare premium increase is reasonable since retirees are getting $126,700 more in lifetime benefits than they paid into the system... The national debt monitor near Times Square froze at $4.9 trillion... Did we balance the budget for a few days? Can we just balance it forever now that we know how: Just freeze spending until it equals income. Like the rest of us have to do... Six days later, all the nonessential workers were rehired and given back pay for not working. Rewarded with an extra week of vacation with pay. The government then announced that it actually cost more money to stop spending than was saved.
Jon Carroll reports in the SFChronicle that "Some of the for-profit HMOs in California make the Mafia look like a model of...compassion."
Piraro in a cartoon suggests a Miranda type statement to be read to all patients when admitted to a hospital: "..Everything here is grossly overpriced...not every doctor is fully qualified...some of our nurses couldn't care less about you...this is an excellent place to catch a weird disease...we're not above ripping your insurance company off..we're only in it for the money...
The SF based Pew Health Professions Commission, a private foundation of 21 experts from universities, the health care and health insurance industries, and other private and public organizations, predicts that in 2005 there will be a surplus of at least 100,000 doctors, 200,000 nurses and 40,000 pharmacists. They recommend closing one-fifth of the medical schools and dramatically reducing the FMG's in US residencies. They attribute the surplus in medical professionals to the government subsidies in the 1960s and 1970s, which encouraged the excessive construction of medical schools, and to managed care... But without the government push to increase medical school enrollment and residency programs, neither the mass importing of FMGs or managed care would have occurred. Nearly all our current ills are caused by government planning. Unfortunately much of government planning is done by physicians in the bureaucracy. The challenge is how can we keep from hurting ourselves?
Von Gordon Sauter, CEO of KVIE Channel 6 spoke at a recent meeting of the Comstock Club. As you know some people inside of public radio and TV are bemoaning shrinking government money. Sauter replied, "Once the government gives you money, you accept the government concept on how you will proceed. Government money does not help..."
And with that, we wish everyone a professionally satisfying 1996.
The Grimmer Side of Medicine
Atrocities against women continue. Egypt has done another reversal on female circumcision. After CNN aired footage of an amateur cutting away the clitoris of a screaming 10-year-old girl in September 1994, the government again allowed hospitals to do the "procedure" stating that the ban implemented in 1959 had not changed practice. This practice was continued by midwives and surgical barbers at home with dull knives, without anesthetics. However as of December 1995, this mutilating procedure has again been banned from hospitals for fear of losing US Aid... Since these "amateur surgical barbers" know little about female anatomy, the more accurate term is "female genital mutilation." The AMA Council on Scientific Affairs recommend that we join forces with WHO & WMA and other major health care organizations in opposing all forms of medically unnecessary surgical modification of the female genitalia. (JAMA 1995; 274: 1714-16)
In Uganda, doctors are paid about $3 per day or $1000 per year. When pay becomes poor, ethics frequently are abandoned. So doctors sometimes don't show up for work because they can make a days wages in 10 minutes doing illegal abortions, sell drugs on the open market (by skimming a portion of each patients medications), squeezing bribes out of the sick, selling plastic syringes... Uganda has one medical school, graduating 60 doctors a year, but a quarter leave for better pay elsewhere. There are fewer than 800 doctors for 17 million people. This provides about one doctor for all services to over 20,000 people. The number of bodies in the hospital's morgue each morning is dependent upon the number of medical personnel who didn't show up for work or were on strike the previous day. This is the ultimate on capitation.
Although National Public Radio, on "All Things Considered," aired an apology for the remarks of Andrei Codrescu on the Christian Coalition ("The evaporation of the 4 million who believe in this crap would leave the world a better place."), the Coalition will intensify lobbying for Congress to discontinue funding public radio. NPR also airs disparaging remarks about physicians and organized medicine. Should we join the Coalitions effort to eliminate the $200 million NPR receives from us taxpayers?
Doctors and other professionals are joining the ranks of secretaries and nurses as "temp" employees. An outplacement firm in Chicago estimates that 250,000 professionals lost their jobs in 1995. Some doctors who are completing their residencies are also doing "temporary" work until they are able to see what's going to be happening in health care and whether it's worthwhile to start a practice. "Temping" has clearly climbed from the secretarial pool to the executive suite, according to the New York Times.
RN at the nursing station after spending several minutes on the phone trying to obtain a physician in one of these new groups with elaborate phone systems: "For a minute I thought that if I punched another key or two, the electronic voice would proceed to answer all my questions and I would not even need to talk to a doctor."
MDs Woolhandler & Himmelstein have a short article, "Extreme Risk--the New Corporate Proposition for Physicians," in the NEJM (Dec 21, 1995) cautioning us not to end up like tobacco company executives who, repenting their sins, find that their contracts forbid confessing them.
Scientist at Cornell University have shown that very low calorie diets have extended the outer limit of life span and slowed the aging process in a large number of species from single-cell protozoans to worms, fruit flies, fish, and mammals. Basic research in the cellular mechanisms is going on in a number of laboratories and the research is being extended to primates, the final step before full study in humans. Richard Weindruch, PhD, reporting in Scientific American, states that even if caloric austerity turns out to be a fountain of youth for humans, it might never catch on due to our poor record of adhering to severe diets... A New York marketing research firm estimates that 75 percent of men and 60 percent of women in America are overweight, but only 20 percent are even trying to lose weight.
Medicine and the Tax Code
The nurse was confused. The patient was confused. And the family became confused when they read their father's death certificate: The doctor in frustration had entered as the cause of death: Confusion.
Philip K. Howard, author of The Death of Common Sense, states "Humans may be flawed, but at least they can think and act on the facts before them. No 'system' of regulatory rules can ever do that." ...There was a time, not so long ago, that doctors could at least think and act on the facts that patients laid before them, something which a rules-regulating fiscal intermediary can never do.
Robert L Bartley, editor of the Wall Street Journal, reviews the Kemp Commission report, which is not merely proposing to debate the arithmetic of taxation; it is starting to reassess the morality of taxation. Rather than get involved in a specific tax plan, rates, flat vs graduated, deductions, and so on, their report is trying to lay to rest the ghost of Henry C. Simons. Mr Simons, a University of Chicago economist from 1927 until his death in 1946. Although a stalwart proponent of laissez-faire, for which his school is known, Simons was, at that time, the godfather of the notion that the tax system should be used to redistribute income. He was insidiously responsible for the operational definition of what income should be taxed, which, according to Bartley, has caused all anti-growth anomalies in tax systems here and abroad. For instance, if you make an extra $1000, you get to keep $720. If you spend this going to Disneyland, according to the report, you incur no further taxes no matter how many times you ride Space Mountain. However if you save or invest this $720 (e.g., towards your future economic security), you incur a whole stream of additional taxes--the corporate tax, the dividend tax, capital gains tax, and estate tax. The Commission has accepted the challenge of how to tax income only once.
Reader's Digest commissioned a poll to find out what Americans really think of fairness in taxation. They found an amazing consistency; almost everyone thought that a 25% tax burden was fair and should include all forms of taxes, whether federal, state, or local. They found that this 25% did not vary significantly between rich or poor, males or females, white or black, Republicans or Democrats, conservatives or moderates or liberals, the old or the young. More than 68% of Americans felt their taxes were too high. The average tax in this country is 39% when all taxes are added. Everette Ladd, a professor of political science and director of the Roper Center for Public Opinion Research, called this consensus the single most extraordinary finding in the history of domestic-policy polling in the United States.
Dan Lungren, California Attorney General, gave his Fifth Annual State of Public Safety address to the Comstock Club, cited instances of judges, whose pro-inmate stance has turned some federal courtrooms into a prisoners playground. One judge, noting that the prisoner was still seated at the table after her ruling, tried to explain to the felon that she thought she had given him a fair hearing. The prisoner laughed and said "That's OK. I had a really great time..." (Another play ground is the escorted trip to a private doctors office.) Only 23-25% of the worst felons ever go to prison... Lungren said the "three strikes, you're out" law is working. Repeat offenders are asking, "Is it really possible to go through life without going to jail?" Felons are finally waking up to the fact that one has to do something bad to go to prison... Eliminating the felons playground of endless appeals and reducing crime will reduce costs to the taxpayer.
Ross Perot also gave an address to the Comstock Club the morning after the State of the Union Address, which he called "theater... a three act play with makeup and dress rehearsals." He felt sorry for Newt, who looked like he dropped by after a day's work...why didn't someone tell him and Dole to have makeup artists?... Highlights of Perot's talk: The $5 trillion US debt is just the tip of the iceberg. The government has guaranteed $17 trillion in liabilities which exceeds its assets. The recent S & L bailout is only one of its numerous guarantees... During the past decade, the standard of living has decreased as the federal debt has increased another 320%. With 35 years of free candy, it's hard to give up sweets... In 1965, Medicare was projected to increase to $9 billion by 1990 and in fact has increased to $106 billion. Medicaid was projected to increase to $1 billion by 1990, but in fact increased to 91 billion. The way to save Medicare is to fix it...Medicare is frozen in time... we don't have one social program that is working... The entitlements (Medicare, Medicaid, Social Security) alone will have a deficit of $4 trillion by 2030... We have the largest trade deficit in the worldmore than $200 billion. And we still have people that want to increase our minimum wage, causing even more goods to be produced overseas at 25 cents an hour, further worsening our deficit in trade...I came to Sacramento to build a new screwdriver. This is certainly a simple tool. But it is impossible to design one screwdriver that fits every screw. If we can't build a screwdriver to fit every screw, how do politicians think they can design a complicated health care system that fits people throughout the country?" Perot deplored the fact that "legislators are no longer writing the laws; lobbyists are no longer in the halls; lobbyists are at the desks writing the laws." And finally, "Tax money doesn't come out of the sky. It comes off the sweat of the brow. Tax money should be used as sparingly as water in the desert."
Debra Saunders of the San Francisco Chronicle commented on the biggest "BUT" of all. Clinton offered $1000 college scholarship to the students in the top 5% of their high school class and up to $10,000 tuition tax credits. The top 5% are generally in the higher socioeconomic level students, and would go to college anyway because they know that college grads make almost twice as much as high school grads ($32,600 vs $18,700). She says Clinton treats tax money as "mad money," and is really saying, "The era of Big Government is over, BUT: Ask not what you can do for yourself. Ask what your country can do for you."
Arianna Huffington summarized her evaluation of the state of the union address in the Wall Street Journal as "The president continues to believe that nothing really important can happen in this country unless government either makes it happen or is the star of the "team."
James Glassman of the Washington Post reports on men and women who are in college and entering the work force. In 1950, this group, in about a 2:1 ratio, was far left politically. In the 1990's, this has totally reversed. This group thinks that if government wants to provide opportunity, it should get out of the way so that the private sector can work its opportunity-making will...
We seem to be getting the government more involved, not only in our professional lives, but also in the lives of those we serve. The Kemp Commission will be unable to make a major change in our tax structure. The ghost of Henry Simons will not go away. Taxes will continue to be used to encourage whatever society feels is important for our generation. Health care seems to be at the forefront. We can extend responsibility to patients for their health care by placing it in the individual tax code like the mortgage deduction. By making health insurance a tax deduction to employees rather than employers, with a patient responsibility requirements at all levels to make it deductible, patients will reduce their costs significantly. Why don't we join the next generation by insisting that opportunity requires getting the government out of the way? If we get this obstacle out of the way and only allow it to facilitate personal responsibility through the tax code, we will improve our patients' physical health and our own mental health.
Congratulations to Doctor William Au, the new Chief of Staff of Sutter who took a firm leadership position at his first meeting. He wants to strive for collegiality amongst the staff members. What a refreshing breeze. Nothing could stop us if we treated each other as colleagues.
The Orange County REGISTER reports that the lady who had her eggs removed at the now infamous UCI fertility clinic (and were implanted without permission), is suing the birth couple for custody of the resultant twins who are now seven years old... Dr Ricardo Asch, who has not worked for this clinic in over two years and lives out of the country, is suing to have his $95,000 UCI salary restored plus payment of all legal costs.
The "Ask a Nurse" program may not be a professional organization after all. An RN who works for them admitted to me last year that her directives had changed in recent years from getting patients into the hospital emergency rooms to getting patients in to see their own physicians the next morning, a much lower cost center by a ratio of 10 to 1. This month an RN who had works for "Ask a Nurse program, which is now nationwide, said their stock was doing well on the NASDAQ exchange. When asked if they were still directing patients to the low-cost centers, she replied it all depended on where the patient's call originated from. "We're a national organization now. If a patient called from Georgia, where the hospitals are paying our fee, I would send patients to the hospitals. If the call was from Pennsylvania, where managed care is paying my salary, I would direct patients to low-cost centers or give advice until the patients could see their own physicians the following day..." When doctors and nurses become bureaucrats, they will act like bureaucrats and do what's best for the corporation--not necessarily what is best for the patient.
Anthony Edwards, after receiving the Best Actor award from the Screen Actors Guild for his part in playing a doctor on ER, dedicated it to the hard-working doctors and nurses everywhere who are just doing their jobs every day.
Debra Saunders, in her SFChronicle column, points out that when the government placed all nonessential workers on furlough, it lacked all sense of compassion and timing. Donna Shalala (Secy HHS) and Dan Glickman (Secy Agriculture) released new dietary guidelines during the partial shutdown. She states Washington wunderkinds decided not to differentiate between men and women, placing far more women into the normal range. She feels that even Big Brother in Washington should have figured out that men and women have different bodies.
Received a copy of Cost & Quality to entice me to subscribe for $200 a year. Articles were on cost-effectiveness of CME; need for full-time, around-the-clock in house hospital coverage, just like university hospital with housestaff. This slick publication at $50 an issue or nearly $2 a page, gave less meaningful data than the New England Journal of Medicine at $2 an issue or 2 cents a page, or the Western Journal, which is free.
A recent Medical Economics article asked the chilling question, "Are jurors competent enough to judge doctors?" The discussions had little to do with medical facts; most jurors fell for the smooth hired-gun testimony. The author felt so badly about being railroaded into voting the doctor guilty that she tried to get a reversal of the verdict after the jury was discharged.
Attorney General Lundgren recently spoke to the Comstock Club. After several references to the OJ disaster, one businessman asked what can business people do to improve the quality of juries: He answered, "If your firm can afford it, please pay your employees while they sit on juries."
Scientific American questions the doctor glut discussed in JAMA when they run ads for doctors with $500K+ income. They quote some HMO stats that some doctors are responsible for up to 800 patients. To get them all seen, appts may be 7 minutes apart. They conclude that these statements make HMO stats problematic... Not to mention that any doctor seeing a patient every 7 minutes for an interim history, exam, review of lab data, writing requisitions and prescriptions, and recording everything that was done would have approximately 100% of his records deficient on any outside review, which would make him subject to peer review sanctions, reportable to the Medical Board and to the National Data Registry. He would be Professionally Dead. However, on internal review saving all those costs, he may be a hero and get a bonus.
Herb Caen in his SFChronicle column reports that a woman had a grand mal seizure in a Muni bus directly in front of UCSF on Parnassus. UCSF, rather than administering care directly, advised calling 911. Herb Caen responded, "O' Ma Gawd!"
According to a recent conference report, the invasion of our privacy by computers tracking our activities, contributions, and nearly every purchase, in these days of desperate HMO practices, may result in the purchaser of Preparation H getting a phone call from a starving proctologist.
World Wide Medicine
A patient mentioned that he had escaped Canadian Medicine. While living in Canada, he would take his wife to a 10AM doctor's appointment by dropping her off at 9 AM. It was frequently 5 PM when he was called to pick her up. He states there were usually 50 people waiting and patients went through at a rapid clip. One time he accompanied his wife and timed how long she had with her doctor. It came to 45 seconds... He feels so fortunate that in this country he sometimes has to wait less than one hour for a 15 minute appointment here.
The world wide organ market has been highlighted in the current issue of Scientific American. Some three decades ago, science-fiction writer Larry envisioned a world in which organ transplants were common. To ensure a continuing supply of organs for the public at large, he suggested draconian laws mandating capital punishment for a host of offenses, and shadowy "organ-leggers" plucking victims off the street to extend the lives of the rich and remorseless... Human rights organizations estimate that China executes somewhere between 3,000 and 20,000 prisoners every year and harvests organs from at least 2,000. They also allege that prison officials allegedly "botch" executions so that prisoners die slowly, giving transplant teams more time to get their organs. Although government officials claim the prisoners agree to the harvesting, critics argue that meaningful consent is impossible under conditions preceding an execution. (The US forbids such transplants.) India, known as the spare-parts repository for richer nations, where $30,000 could buy a new kidney from doctors who paid a living donor less than $1,000, last year banned organ sales. Scientific American showed photographs of Indian villagers with large diagonal flank scars consistent with the harvesting of kidneys without consent.
The University of Arizona has developed a systems approach to medical education in North America for International Health. This program for senior medical students and residents was made possible through the International Health Medical Education Consortium. The focus is on relationships between health care careers internationally and among our own domestic underserved population.
Once while returning from an overseas meeting, a man on a stretcher was in line to board the plane ahead of us. He had a patch on one eye and stated that he had a detached retina. He was flying directly home to see his ophthalmologist. He stated that any loss in vision by delaying treatment could not be worse than his brief encounter with international medicine.
A lady from England commented on her sister who had a colon polyp removed. The sister was told to call back in two years for a follow-up colonoscopy. When she did, she was given an appointment 18 months later. That was the best they could do. She developed a recurrence waiting for that 18 month appointment.
Rhone-Poulenc Rorer, Inc introduced a new drug (Rilutek for ALS) over the Internet. It was the first time that cyber "chat-rooms" were used by the drug industry to publicize a new product. Although RPR had planned a Manhattan introduction, bad weather cancelled the meeting and a cyber-press conference was organized by America's House Call Network (AHCN). It was promoted via the Business Wire and PR Newswire as well as e-mail to key reporters. There were 14,000 inquiries (multinational) at the Website <http://www.housecall.com> in the first two hours. The market for on-demand health care information is expected to grow from $20 million to $500 million by the end of this year when 18 million people will spend $10 per month to access online services to find health related information. Medical experts say that about 80% of most healthcare problems can be handled at home, without the assistance of a physician (see "Selfcare,"Sacramento Medicine, April 1993, p 18).
Received an E-mail from a science editor I met at the medical writers conference in Monterey. Of 171 scientific papers reviewed, only 19 had adequate statistically valid techniques and 11 had minimal deviation. The other 141 were not thought to have a valid basis for the conclusions rendered. There were similar discrepancies in Australian and European research with as high as 88% of scientific papers having no scientific value.
Medical Staff Meetings
Sacramento has a new cover lady. Congratulation to Sister Bridget McCarthy, Sacramento's Business Woman of the year.
The recent staff meeting of Mercy General Hospital at the Hyatt regency was an honest attempt at dialogue among the various management groups, whose talk about how fine a job they were doing with the lives they were responsible for made me think of that old caution: When you see a restaurant that advertises "fine food," it might be best to avoid it. The Sisters of Mercy are to be commended for having paid for this major effort of intergroup and community dialogue.
The new Smith Kline Beecham Androderm patch, a testosterone transdermal system, can be applied to the trunk or extremities. It appears the Alza's Testoderm patch, the original Testosterone Transdermal System, which had to be applied to the scrotum, "just wasn't catching on."
The State supreme court ruled that the custodial parent can move out of State and take the children away from the noncustodial parent, essentially severing the latter relationship in an already fractured family. This was heralded as a win for mothers with custody. The supreme court forgot to mention this was a loss for the other two legs of the fractured triangle, namely, the children and their noncustodial parent. And perhaps society. Isn't it better to try to reduce and place the pieces of a fracture in reasonable, although painful, apposition rather than sever or amputate them? As physicians interested in the mental health of our patients, we should highlight the tragedy of that ruling in the court of public opinion. We certainly wouldn't want to make it worse with another law.
Mike Yellen, analyst at Global Health Care Fund said the industry of physician practices under acquisition has been "over-hyped." "It's a hot area in terms of the valuation these stocks have," he said, "but it's really a new industry in the sense that nobody really organized doctors on a large basis before. So, they're really concept stocks." Critics of the industry say investors are taking an overly simplistic view. Acquiring physician practices alone may not translate into long-term growth, he said. Acquisitions have major risks. Integrating new doctor practices is not always simple, and competition is fierce.
Merrill Matthews of the Center for Health Policy Studies in Dallas states, "Managed care can succeed in lowering health-care costs only to the extent that it succeeds in preventing patients from obtaining all the services it is in the patients' self-interest to obtain..." Managed-care supporters, however, say that traditional fee-for-service insurance has encouraged so much waste and inefficiency that simply cutting that out allows tremendous savings. Both statements are obviously true. The challenge is how to mesh the two problems.
Texas passed a law that requires doctors to see their HMO patients at least twice a year. The Texas physician who told me this at a recent medical meeting said this was to prevent HMOs from influencing doctors to do too much care by phone. That could jeopardize a lot of doctors who, through no fault of their own, may see patients only once a year. Looks like the Texas Medical Association supported bad law and bad medicine. Why do we keep trying to practice law rather than medicine? It always places us in someone else's court when we've spent 12 years learning how to play in the medicine court, the only court in which we can win.
A final thought of the MGH meeting. The majority of the attendees left before the six speakers finished their presentation within the 90 minutes promised in the flyer, in effect voting with their feet about the management groups present despite the very large amount of health care funds spent on a three-course dinner, unlimited libations and parking at a premier hotel.
New Orleans (N'awlins)
The American Thoracic Society and its International conference continues to enlarge. Of 15,000 registrants, there were 12,000 professionals including 3,000 international physicians who made the trek to New Orleans this year. It was a pleasure to be sharing ideas with colleagues from three continents over breakfast and en route to conferences. Valentine Poppa, a member of SEDMS and of Sacramento Medicine editorial committee, was the chair of the session, "Pulmonary Manifestations of Immunoglobulin Deficiency" and presented a paper entitled "Pulmonary Manifestations of IgG, IgA and IgM Deficiency." Congratulations, Val.
Arthur Gelb, MD, who once considered Sacramento as a possible practice location, gave a renegade session at an off-site hotel concerning lung reduction surgery. There were also a number of "legitimate" seminars and symposia on this subject. One Chief of Thoracic Surgery who gave a "Meet the Professor" session, pointed out that surgeons were using RBRVS codes for bullectomy or pleurodesis as the closest thing to "lung reduction surgery." He said surgeons were upset that medicare recipients had a good deal with cheap charges. A medicare reviewer has advised the professor that using the wrong RBRVS code, even though the charge is less, is considered MEDICARE FRAUD... We, of course, understand medicare fraud in Sacramento since one of our members is sitting in jail for using what he thought was the closest RBRVS code for what he was doing.
The president's lecture was given by Bernard Lo, MD, Professor of Medicine and Director of the Program in Medical Ethics at UCSF. He suggested that managed care is needed to control costs, because physicians aren't doing it. HMOs cover 29% of all insured persons, PPOs (Preferred Provider Organization) 29%, POSs (Point of Service Plans) 14%, and FFS (Fee For Service) are at 29% and shrinking. He stated that HMOs are no longer growing as fast as expected. Dr Lo said that typical monthly premiums for a family of four at UCSF are $361, $388, $387, and $990, respectively. (The latter was called "the Mercedes" of the plans--does that make the cheap HMO the "Geo Metro" plan?) He mentioned that he had opted for the lowest plan, reducing his premium from $388 to $361, a $27 savings. Do you suppose he drives a GEO Metro or Mercedes? It always interests me to see if people are more particular about their mechanized fossil fuel burning vehicles than their own complex biochemical physiology. As physicians shouldn't we challenge the public's willingness to spend more on their cars than their bodies?
After enjoying Pete Fountain's superb clarinet at his club inside the Riverside Hilton, our city tour guide in New Orleans said we should visit Bourbon Street one night, even if only for 10 minutes. "N'awlings", as the natives say, is the birthplace of Dixieland Jazz. Al Hirt wasn't playing the evening we walked through Bourbon Street, which is closed off to traffic at 8PM each night to allow people to wander from clubs on one side of the street to those on the other side. Stages of some of the clubs could be seen from the street, giving impetus to public nudity, and inviting orgies. The Doctors that stayed in the French Quarter complained that the noise was so loud until 2 AM that they couldn't sleep. The commotion resumed at 5:30 AM when trucks came to wash down the streets. Many of the revelers emptied their bladders and stomachs all over the streets and sidewalks. No wonder the streets had to be hosed down every morning before the work day started. Humans must be the only mammals that mistreat their bodies in this fashion and call it fun.
We got home just in time to welcome friends from London who make an annual trek to our own Dixieland Jazz festival as well as festivals in Europe and Australia. We enjoyed discovering Bodo Bucar's Green Town Jazz Band from Slovenia, Bob Pelland's Grand Dominion Jazz Band from Vancouver, Nobby Baldwin's Merseysippi Jazz Band from Liverpool, and Hamish McGregor's Fat Sam Jazz Band from Scotland. Two weeks of contact with international friends who are willing to share their global point of view was truly engaging.
FP-HMOs (For Profit - HMOs
Patient: Id like this prescription filled. Druggist: That will be ninety eight dollars. Patient: How much is the placebo? (After Parker)
A recent FP-HMO (For Profit Health Maintenance Organization) merger netted nearly $1 billion for one individual. The profit from health care dollars for this one individual would have covered the health care overhead for two employees of every physician in the United States of America. Or to put it more succinctly, it would have provided a basic entry level HMO policy for one million poor people for an entire year. Isnt converting health care dollars into personal fortunes racketeering? Or at least fraud? Isnt that what they said doctors were doing who ran efficient labs in their offices at half the price of the competition? Looks like despite all the encumbrances, Health Care should move forward to a position it once had in the Non Profit Insurance and Non Profit HMO world.
Kudos to the Kaiser Foundation Health Plan of Northern California for placing third in the nation in Newsweeks recent report ranking Americas 43 largest HMOs.
Overheard in the Staff Lounge when physician job security was being discussed: Why should doctors have more job security than John & Jane Q with an ordinary job?... Are we comparing ourselves and our investment of hundreds of thousands of dollars into our 6-10 years of post college professional education and training with the average John & Jane Q, who may even have a union protecting them? In a free society with the freedom to practice the best medicine for our patients, the doctor providing the best care received the rewards including recognition. As we become a third party controlled profession, it no longer is what we know, but who we know and our willingness to compromise to maintain that favor.
Wells Fargo announced that they cant close branches fast enough to save money, even with the closing of three-fourths of the First Interstate Branches they just bought. They are now considering opening up drug stores in some of their branches... St Joseph Health Center in Kansas City, MO decided rather than make deep cuts in spending, they would look for new revenue sources. So they built a shopping mall-style food court that generates a profit... A Chicago hospital put in a full physical fitness center... Maybe our hospitals should consider a similar conversion of facilities. How about a banking center next to the gift shop?
The Wall Street Journal showed a cartoon in which the FP-HMO told a patient that they had approved the requested surgery. However, if he would be willing to decline the operation, they would give him 5 nights and 6 days in Barbados... How about a travel agency between the gift shop and the ATM right next to the business office?
A recent study on the value of autopsies indicated that they are being used less frequently. With modern sophisticated testing, accurate diagnosis are achieved in over 80% of patients and, therefore, the need for post mortem examination is decreasing. In fact, in those 20% that uncovered additional diagnoses, including cancer, nearly all of them are basically of academic interest only... Perhaps hospitals could use some of their excess space, such as the old autopsy/morgue area, for a mortuary. Hospitals would then truly give bassinet to crematorium total care... Like the autopsy, the crematorium may not a covered HMO service.
An East coast HMO organization related to me that they are now selling "Major Medical Insurance" in addition to their basic HMO plans. Canadians are their largest market. He stated that with government medicine in Canada, patients are having to wait 6 to 18 month for major surgery, such as coronary bypass, hip replacements, and transplants. They are willing to pay a significant premium for a one to three thousand dollars deductible policy which gives them the option of obtaining the operation in the USA.
Politics & Health
Doctor Paul Striker, a New York plastic surgeon, estimates that one in five members of Congress has undergone some form of plastic surgery. We always knew that politicians try to make themselves look better than they really are, but did we ever suspect that they would go to this extent?
Herb Caen recently reported that the homeless are upwardly mobile. A local transient was assaulted in the K-Mart parking lot, pulled out his cellular phone and called the police... In a related story, a Sacramento insurance agent reported that he traveled to San Francisco to pay $300,000 to the family of a recently deceased "homeless" victim. He had been sleeping under a car when the driver got in and pulled away from the curb, fatally wounding him. Following his demise, it was ascertained that he did have a home. The agent stated it was cheaper to pay the maximum on the policy than to fight the case in court. Evidently there is more risk in exceeding 1,000 hours of attorneys services at $300 per hour than in just paying $300,000. It seems that legal remedies are now affordable only for the very wealthy and the very poor if the defendant is wealthy... Caen also reports that across the Bay the wedding guests were informed to keep the gates locked or the "outdoorsmen" would attend the wedding. He then determined that was Berserkleyese for their "homeless."
Many of Americas richest law firms got richer last year. Profits per partner--the key measure of law-firm wealth--averaged a record $446,000 in 1995 according to American Lawyers annual ranking of the nations 100 top grossing firms. The top five firms on this list racked up over a million dollars profit per partner. Lynn Mestel, a law-firm headhunter in New York, states that non-productive partners, bloated administrative staffs, and high overhead, continue to hurt the bottom line...
Although drivers side steering wheel airbags save lives, the governments requirement of extending airbags to the passenger side by 1999 in the cause of safety, has proven quite hazardous to children. Of the 23 people killed by passenger side airbags, 22 were children. The lone adult was a frail woman. For years federal regulators and safety advocates ignored industry warnings, first predicted by General Motors in 1969, that passenger air bags could kill kids. Now the government is in the awkward position of fumbling for ways to minimize the danger of a government required safety device which has been called a "lethal dashboard bomb."
Felons in Congress (convicted of mail fraud, bribery, false financial statements, tax evasion, etc) continue to receive their pensions of nearly one million to $2.4 million at taxpayers expense, even while in jail. We should trust this "House of Thieves" to rewrite Medicare, Medicaid, and be serious about the betterment of humankind?
Overheard in the patient lounge: "Why dont doctors send a sympathy card to the family when one of their patients dies?" Now that would indeed show a genuine interest in the patient as a person rather than a case. Better get a box of cards ready at the office.
Joel D Wallach, DVM, MD, nominee for the Nobel prize in Medicine in 1991, mentioned in an address that hundreds of thousands of patients lose their lives unnecessarily in hospitals. He then stated that we have two "opportunities" to give our lives for our country--once on the battlefield and once in a [government] VA hospital.
Consumers Reports gave an HMO a 61% satisfaction index. The HMOs, according to George Anders in the Wall Street Journal, have become very sophisticated in their own polls. They found that telephone polls give higher satisfaction indices than written polls. Also the season is important. It has been shown that ratings are higher during the sign up quarter than the last quarter. Thus their privately financed pseudoscientific polls will give satisfaction indices up to 50% higher.
Deja Vu: Phil Alper, MD, reports that in France, the "Order of Physicians" (initially created by the Vichy Government during the Nazi occupation) was instructed to create a cookbook listing "appropriate" guidelines for ordering...tests and medication. It leans heavily on office-based physicians and spares the more politically powerful hospital sector, even though the latter consumes 60% of the health francs. The French doctors are terrified. Computers have made mathematical criminals of doctors without any awareness of wrongdoing. In the first two months of the program, dozens of doctors have been fined thousands of dollars.
Well, how can you tell if a politician is lying? Just by observing if the lips are moving.
Political Side Notes
"When they call the roll in the Senate, the senators do not know whether to answer 'Present or 'Not guilty." Theodore Roosevelt
Many large corporations, which are forbidden by law to donate to political parties, donated rather large sums of moneys to the political conventions. The corporations did not want media exposure which might alienate members of either party. To play it safe, many contributed to both parties. The Democratic convention sold sponsorships for $100,000 to 75 companies. The Republicans to 40, with some sponsorships to $500K. Scanning the media as the political conventions were playing proved rather amusing. Comments from those allegedly contributing over $100K, and some others:
B of A: We didnt know how else to get the three Democratic women on the Senate Banking Committee in the same room.
United Airlines: We look at the convention parties as more social in nature than political.
Ameritech when asked about the $1.2 million they spent stringing thousands of telephone lines, fiber and copper cables into the convention center: Its really not about politics but about pride in our city.
Phillip Morris: Clinton could have gone after us a lot sooner...Id like to think its because we were giving all these years.
Allstate: Its just the cost of doing business.
Anheuser-Busch: If they can declare war on tobacco to win re-election, why not liquor? Drinking causes costly health problems that taxpayers can get stuck with.
Dont laugh, BIG MAC: After theyve done away with cigarettes and alcohol, cholesterol will be next.
United Airlines: I have no regrets. Theres been a lot of pressure for tough safety regulations, and so far the administration hasnt caved...money for the conventions is a bargain compared with what it would cost to put smoke hoods in all our planes.
Lockheed-Martin: Take the long view. My company is getting $1.6 billion from the Pentagon... $100K is chump change...gravy... and tax deductible.
Anheuser-Busch: Phil, I think I need a beer. Want to join me?
Phillip Morris: Sure. I need a smoke, Bud. Do you mind? There ought to be at least one smoke filled room in a convention.
Prez: I pledge, when elected, ... to build a bridge to a future that is free from the curse of dental caries. I am appropriating $5.3 million from emergency funds for an educational campaign urging every American to floss after every meal. (After Hoppe)
Senator (after 6 terms of 6 years minus a few months to run for higher office): I pledge, if elected, to implement term limits for senators. We need outsiders running for president, not career politicians (or was it the other way around?).
ADM: I feel a special simpatico to the party in Chicago. Read the platform. It unabashedly touts corporate welfare. See: government investment in technology, government investment in jet aircraft; a permanent research and development tax credit... I look at this $100K as a tip.
Debra Saunders: Theres opportunity to be found with this party. Look at it this way: Big business, big government, no dif.
The Federal Medical Dictionary to help you traverse the "treat yourself quagmire"
Barium: What you do when the patient dies
Cat Scan: When the Secret Service looks for Socks
Cauterize: Made eye contact with her
Coronary: Domestic yellow bird
D & C: Where Washington is
Dilate: To live a long time
Fibrillate: To tell a small lie
Humerus: To tell us what we want to hear
Paradox: Two Doctors
Penis: Someone who plays the piano
Rectum: Dang near killed him
Seizure: Roman Emperor
Doctor: I thought you are innocent until proven guilty. Attorney: No you are guilty until proven innocent. Legislator: No, as a doctor you are guilty until proven guilty. FP-HMO: Doctor, you are guilty and we dont have to prove a thing.
When I started this column over three years ago, Eugene D Robin, MD, Professor Emeritus of Medicine and Physiology at Stanford gave me some insight concerning the Hippocratic Oath. I had known Dr Robin as one of the foremost investigators after reading some of his hundreds of research articles over the years. As I met more of is pulmonary fellows he had trained, I became aware that he also excelled in all three legs of medicine--clinical practice, and teaching in addition to research. His books have had a high moral perspective long before the discipline of ethics was as well developed as today. In 1984, he challenged the consciousness of physicians with the idea that some procedures may not only be unnecessary, but actually do harm. His book that year was titled MATTERS OF LIFE & DEATH: Risks vs. Benefits of Medical Care. In the NEJM the same year an article appeared stating that the physicians "need to know" more about the patients illness than is necessary for treatment, would eventually exhaust medicines economics resources. In April 1985 Dr Robin wrote an article for California Physician with the subtitle of "At least try to do more good than harm." In 1986, Dr Robins book was reissued in a popular format by Harper & Roe as MEDICAL CARE CAN BE DANGEROUS TO YOUR HEALTH. If at that time we had listened to him we may not have needed managed care today to conserve resources. It was then that I first became aware of Dr Robins research into the history of the Hippocratic Oath. In an article in THE LANCET on June 3, 1995 he summarized the background of the Hippocratic Oath. He recently sent me the latest revision of that oath which may have out lived its usefulness after 24 centuries. We publish this latest revision as a "Code of Conduct" for physicians to live by as we enter the 21st century.
The New Oath for Physicians
In the name of suffering humanity, with humility, compassion, and dedication to the welfare of the sick according to the best of my ability and judgment, I will keep this oath and stipulations:
I will be honest with my patients in all medical matters. When this honesty reveals bad news, I will deliver it with understanding and sympathy and tact.
I will provide my patients with acceptable alternatives for various forms of diagnosis and medical and surgical treatment, explaining the risks and benefits as best I know them.
I will allow my patients make the ultimate decision about their own care. In circumstances where my patients are incapable of making decisions, I will accept the decision of family members or loved ones, encouraging them to decide as they believe the patient would have decided.
I will not sit in moral judgment on any patient, but will treat their illness to the best of my ability whatever the circumstances.
I will be empathetic to patients with illnesses caused by substances such as alcohol or drugs, or other forms of self-abuse usually believed to be under voluntary control.
Knowing my own inadequacies and those of medicine generally, I will strive to cure when possible but to comfort always.
I shall perform medical tests only if I believe there Is a reasonable chance that the results will improve the outcome.
I will not perform any tests or procedures or surgery solely to make money. I will freely refer my patients to other physicians If I am convinced that they are better able than I to provide treatment.
I will freely furnish copies of medical records to patients or their families upon request.
I will do unto patients and their families only what I would want done unto me or my family. I will not experiment on patients unless the patients give truly informed consent. I will strive to instruct patients fully so their informed consent is possible.
I will remain a student all my professional life, attempting to learn not only from formal medical sources but from my patients as well.
I will attempt to function as a teacher for my patients so that I can care for them more effectively and can apply the lessons they provide to the care of other patients.
I will provide care to all patients seeking it, regardless of sex, race, colour, creed, sexual preference, lifestyle, or economic status. In particular, I will volunteer some of my time to providing free care to the poor, the homeless, the disadvantaged, the dispossessed, and the helpless.
I will turn away no patient, even though with dreaded contagious diseases.
I will encourage my patients to seek medical opinions other than my own before agreeing to accept my opinion.
I will treat my professional colleagues with respect and honour, but I will not hesitate to testify openly about physicians and medical institutions that are guilty of malpractice, malfeasance, cupidity, or fraud.
I will defend with equal fervour colleagues who are unjustly accused of malpractice,
cupidity, or fraud.
Contact Del Meyer, MD
Phone: (916) 488-5864