Volume 64, No. 12 December 2008

THE MORNING AFTER

Euphoria about "change" explodes across the television screens and front pages and at least the coastal and heavily urbanized parts of the land. Huge crowds hitherto a feature of Third-World but not American politics applaud and cheer. The most lavish inaugural ball in history is planned.

But the morning after will dawn, when one asks, "Was it really love?" Is it now This Perfect Day of Ira Levin, with perfect central planning and ever-present "advisors," quick to prescribe an extra drug treatment should a disruptive thought or selfish impulse intrude? Have we perhaps spawned Levin's Rosemary's Baby, a monster that will destroy its mother?

The seeds of the destruction of the Republic have been gestating for a long time, long before the current campaign. Will one final push to burst the fetters of the Constitution ("what the government can't do to you," as Barack Obama put it) succeed? Will we all be "citizens of the [One] world," required to perform "national service," "spread the wealth around," and assure that every woman immediately gets her "choice" if the choice is an abortion? Or will Obama, as some media sages predict, instead "govern from the center," continuing the bipartisan incrementalism of recent years?

Have we reached the point at which the frog will either get cooked, or jump out of the pot before the lid clamps down?

Has the Titanic already hit the iceberg? And are we now planning to drill some holes to let the water out?

What It Means for Medicine

Obama promises, in an October article with his byline (NEJM 2008;359:1537-1541), that: "Under my plan, if patients like the insurance they have, they keep it and nothing changes, except the costs are lowered." That assumes that the plan is still permitted to exist, with requirements for guaranteed issue, community rating, "meaningful coverage," etc. He opposes health savings accounts because "the freedom to choose magnifies the uneven risks and rewards of today's winner-takes- all economy" (Cato Briefing Papers #104, 7/29/08).

Also promised: a children's mandate; $10 billion/yr for health information technology; and funds for care coordination, exercise, vaccination, anti-smoking, and anti-obesity programs.

His answer to malpractice: preventing medical errors. "I will also support legislation dictating that if you practice care in line with your medical society's recommendations, you cannot be sued" (NEJM, op. cit.).

Obama might adopt the plan being readied by the dying Sen. Ted Kennedy: mandated purchase, employer payment, HIT, case management, etc., with a new national Health Insurance Exchange as the sole source of coverage. In sum, massive government control over the entire insurance and medical care system. "If you liked Fannie Mae, you will love this system," writes Greg Scandlen (Consumer Power Rprt 152).

What about the Money?

The cost of the $700 billion bailout has reached $5 trillion, say some analysts (infowars.net 10/15/08), and the government will borrow a record $550 billion in the current quarter (SFGate.com 11/3/08). Private investors have lost trillions. Where will Congress find the money to enact new programs, even with grossly understated costs?

Scandlen suggests that federal expenditures would be limited at first as the infrastructure is set up, with physicians and hospitals bearing the entire brunt of "cost-containment."

Could the hidden agenda be drastic cuts in medical spending through rationing? "Waste, we know you are out there," writes Henry J. Aaron, Ph.D., of Brookings (NEJM 2008;359:1865- 1867). If spending limits cause withholding of services, uninsurance would be terrifying, and societal revulsion toward inequities would threaten the cost-control effort, he states. Hence the need for compulsory universal care.

Part of the answer to rising costs is something like Britain's National Institute for Health and Clinical Excellence (NICE), writes Victor Fuchs (NEJM 2008;359:1749-1751). Obama, who in the 1990s was a forthright proponent of single- payer health care, has promised to spend billions on a NICE- inspired institute, writes David Gratzer (City-Journal 11/2/08).

NICE doesn't try to be cruel. "We are trying to look after everybody," states chairman Michael Rawlins (NEJM 2008;359: 1977-1981). Patient advocates suggest that up to 36,000 Britons went blind from macular degeneration waiting for NICE to approve Lucentis in the name of "fairness" (Gratzer, op. cit.).

Is There Hope?

Scandlen notes that imposing a Massachusetts-style system on the whole country is more daunting than putting a man on the moon, and the whole enterprise could collapse.

Sen. Schumer and Ben Bernanke could be right: paying almost all bills through credit is the "lifeblood of the economy" of nonproductive Masters of the Universe. Likewise, funneling almost all medical bills through third-party payers feeds government and insurance bureaucracies.

What if doctors stopped collaborating with the destruction of medicine? How about some bypass surgery?

Paper money and vapor money are in trouble the prices are wrong. But, "as serious as this economic crisis is," writes Henry Maybury, "I have not heard of one instance of real wealth disappearing. The factories, railroads, skyscrapers, telephone poles, and lug nuts are still there" (EWR 11-12/08).

X-ray machines, surgical instruments, and libraries are still there too. In liberty, the love of the art can be rekindled.

"People will never surrender themselves for a point of utility," writes Fr. Sirico of Acton Inst. But for deeds of moral courage on behalf of liberty, a vast army can be summoned.

Economics in Literature

In a 1944 novel by Agatha Christie, Death Comes as the End, set in Thebes, 2000 B.C., the scribe Hori and a daughter of the estate have this conversation:

Hori said, "At present a few scribes are all that are needed on a large estate, but the day will come, I fancy, when there will be armies of scribes all over Egypt. We are living at the beginning of great times."

"That will be a good thing," said Renisenb.

Hori said slowly: "I am not so sure."

"Why are you not so sure?"

"Because, Renisenb, it is so easy and it costs so little labor to write down 10 bushels of barley, or 100 head of cattle, or 10 fields of spelt and the thing that is written will come to seem like the real thing, and so the...scribe will come to despise the man who ploughs the fields and...raises the cattle but all the same the fields and the...cattle are real they are not just marks of ink on papyrus. And when all the records on all the papyrus rolls are destroyed and the scribes are scattered, the men who toil and reap will go on, and Egypt will still live."

Renisenb looked at him attentively. She said slowly: "Yes, I see what you mean. Only the things that you can see and touch and eat are real . To write down I have 240 bushels of barley means nothing unless you have the barley. One could write down lies."

Recovery

"We've lived with government interference so long that we've forgotten how fast an unfettered economy can get back on its feet," writes Richard Maybury (op. cit.). "In World War II, Germany may have suffered more economic damage than any other country in modern times except Russia. Whole cities were leveled.... Much of the population was starving, living barely above the stone age." Ten years later, Germany was one of the world's leading economies. The Marshall Plan got the credit, but Germany received only $1.45 billion, compared with $3.3 billion to Britain which went socialist after the war and did not fully recover until the Thatcher era in the 1980s.

Doctors Defect in Washington State

According to a straw poll taken by the Washington State Medical Association, 31% of the state's physicians either see no Medicare patients or take no new Medicare patients (Puget Sound Business J 10/242/08). AAPS member Smiley Thakur, M.D., however, accepts Medicare-eligible patients gladly he just turns down government money.

"It's sad to lose patients you've taken care of for years," he said, as many patients abandoned him. Dr. Thakur is the first U.S. nephrologist to opt out of Medicare.

Dr. Thakur's article, "Whether to Opt Out of Medicare: How to Make a Titanic Decision" appears in the winter 2008 issue of the Journal of American Physicians and Surgeons.

"There is a profound ethical reason why an economy governed by free...markets...implies health and plenty, while the socialist economy means sickness, disorder, and lower productivity. The liberal economic system releases and utilizes the extraordinary forces inherent in individual self-assertion, where as the socialist system suppresses and wears itself out opposing them."
Wilhelm Ropke, A Humane Economy, 1960

Political Blackmail

Politicians call bills designed to extract large campaign contributions from industry "milker bills" or "fetcher bills." The Clintons' proposal to impose price controls on pharmaceutical and other medical enterprises brought in unprecedented levels of contributions. The most egregious example of regulatory blackmail was the Community Reinvestment Act (CRA), featured during Clinton's 1999 "Poverty Tour." Before granting NationsBank permission to merge, it had to promise $150 million in low- interest loans in areas chosen by the Administration, probably corresponding to areas where votes were most needed (Thomas DiLorenzo, mises.org 9/16/99).

IT at a Standstill in NHS

Rollout of the flagship 12 billion Pound information technology system has been halted by the British National Health Service.

"This huge centralised project has been a shambles from the start," said Liberal Democrat health spokesman Norman Lamb (Daily Telegraph 10/28/08). Conservative shadow health spokesman Stephen O'Brien said that the "hugely expensive" program was "desperately behind schedule"; that suppliers were "deserting in droves"; and that "frontline professionals" were "voting with their feet and insisting on local solutions" (E- Health Insider 10/28/08).

WWW I in E-Stonia?

Estonia is one of the most web-dependent places on earth; its parliament considers Internet access to be a "fundamental human right." For 3 weeks in the spring of 2007, its commu- nications infrastructure was crippled by what has been called "Web War I," "Cyberwar I," or a "cyber-riot." It is thought that the attack was launched by Russian nationalists unhappy about the relocation of a Soviet-era war memorial.

While "cyberwar doesn't make you bleed, it can destroy everything," said Ene Ergma, speaker of the Estonian parliament. Estonian President Toomas Hendrik Ilves warned that the attack might be a test run for something much worse, like the 1936 tests of German Stuka bombers in Spain.

The U.S. considers cyberwar a threat to national security. The Pentagon was forced to disable a system serving the Dept. of Defense after the Chinese military hacked into it. A Cyberspace Command is being set up, and the U.S. Air Force is working with industry to develop weapons for disrupting an adversary's information system (Fraser Forum, September 2008). Will the Dept. of Homeland Security's "information highway patrol" keep our electronic medical records safe?

AAPS Calendar

Feb 6-7, 2009. Workshop, board meeting, Dallas, TX.

Sep 30-Oct 3, 2009. 66th annual meeting, Nashville, TN.

Medicare Patients Sue to Opt Out

Three seniors who want to provide their own hospital insurance and avoid Medicare's rationing, loss of privacy, and stifling rules are suing for the right to refuse Medicare Part A without losing their Social Security benefits, or to disenroll without having to repay all the benefits they have already received. Brian Hall et al. v. Michael Leavitt, et al., was filed Oct 9 in the U.S. District Court for the District of Columbia.

Hall, a retired federal worker who contributed to a health savings account throughout his career, also complains that if he is required to take Medicare, he will no longer be allowed to make contributions to that account (WSJ 10/27/08).

The relevant policies were implemented by the Clinton and continued by the Bush Administration. Plaintiffs ask the Court to void POMS HI 00801.002, POMS HI 00801.034, and POMS GN 00206.020 because they violate the U.S. Constitution, and because their implementation without required notice and comment violated the Administrative Procedure Act.

If just 1% of seniors turned down Part A, taxpayers would save $1.5 billion/yr immediately and $3.4 billion/yr by 2017.

Rep. Sam Johnson (R-TX) has introduced the Medicare Beneficiary Freedom to Choose Act, which would allow seniors to forgo Medicare Part A without penalty, and contribute tax-free dollars into a Health Savings Account.

"It's sad that people who want to make their own health care decisions feel like they have no other option than to sue the federal government," Johnson said (Daily News 10/22/08).

Social Security is tied to Medicare for the same reason that the 1990s Congress barred seniors from supplementing their government care: to avoid a "two-tier" system. "Equity trumps freedom even if it means poorer care" (WSJ, op. cit.).

Opting Out of TRICARE

In response to a recent member's question, Dr. Lawrence Huntoon sent a Jul 22, 2005, letter from Karen Marlowe, TRICARE Provider Data Management, of HealthNet:

"This is to acknowledge your recent request to no longer be an Authorized TRICARE Provider. We have changed the status of your record in our database to Inactive effective...the date your request was received by this department. Please be aware and advise your staff of the following:

"1. By electing to be an inactive provider (Non- Authorized), you may not provide services to a TRICARE beneficiary.

"2. A sign must be posted in your office that indicates that you are not a TRICARE Authorized Provider. The sign must specifically state Non-Authorized rather than Non-Participating.

"3. If you have a TRICARE beneficiary that you elect to treat by mutual agreement anyway, prior to treatment, you must specifically advise the beneficiary that you are not an Authorized Provider. You must have the patient sign a statement that they were informed of this, that they will be solely responsible for the bill and that neither the beneficiary nor the provider will submit a claim for the services to TRICARE. Thus, the beneficiary is exempting the provider from the Balance Billing rules for the specific treatment episode of care.

"4. We suggest that you have ALL patients sign the mutual agreement, so you are protected from a beneficiary who fails to inform you of their TRICARE eligibility and submits a claim.

"5. If you treat a TRICARE beneficiary without the mutual agreement, you are bound by the Balance Billing Act, even if you choose not to accept assignment. And your status would again be updated to Active in our Provider database. Failure to comply with the Balance Billing rules would subject you to being sanctioned by all Federal government programs."

AAPS Supports Freedom of Conscience

Together with Family Research Council and others, AAPS filed comments in response to a proposed rule, "Provider Conscience Regulation" 73 Fed. Reg. 50,274 (Aug 26, 2008), that would deny federal funding to institutions that punished medical professionals for refusing to participate in abortions.

The right to obtain a certain service does not impose an obligation on others to provide, promote, or pay for it, AAPS argues. The freedom from discrimination on the basis of one's moral beliefs is at least as important as the protection of other civil rights. "If HHS [Dept. of Health and Human Services] had not taken up the cause of the conscientious-objector Ob/Gyn community, those physicians would face daunting economic pressure to conform their conduct to quasi-official coercion."

Comments are posted at www.aapsonline.org .

The Un-Choice

Although the incoming administration is strongly committed to removing all limitations on the one choice, there is substantial evidence that abortion is often not a free choice. A former abortion clinic security guard testified before the Massachusetts legislature that women were routinely threatened and abused by men outside the clinic to be sure they kept their abortion appointment. A survey showed that 64% felt pressured by others, and 84% felt they were not given enough information to make an informed choice. There have been no federally funded studies of abortion's impact on women. The rate of immediate, potentially life-threatening complications, according to some sources, is startling: 10%. The all-cause death rate for women was 3.5 times higher after abortion than after giving birth (see www.unfairchoice.info/Coerced.htm).

2009 OIG Work Plan: "A Return to Hard Ball"

Already scores of providers have had their Medicare licenses suspended, data mining is rampant, and there is a discernable increase in search warrants. Agents knocking at your door could represent the FBI, Postal Service, BATF, and the IRS. Medicare Compliance Alert offers 18 tips on how to handle a search, including making your own inventory of the items seized instead of signing the agent's. If you don't cooperate, agents have axes to break open locked files. Usually they arrive early in the morning, secure all entrances and exits, cut off the phones, and attempt to interview employees on their way to work (MCA 11/3/08). Advice not given by MCA: Quit. Now. Other reasons: Recovery Audit Contractors (RACs) "will get you every time for technical errors." You could have 3 employees working full time to copy thousands of documents. "There is no data point that will exonerate someone." Some contractors, though they have little understanding of Medicare rules, commonly find provider error rates of 100%. The government makes billions of dollars from bounty-hunting contractors (MCA 10/6/08).

Correspondence

Viciousness Escalates. I recently heard from a neurosurgery resident who had a loaded gun held to his head (and to his sister's head) by a medical school security guard as they sat in his sister's car on a public street. Although he was unarmed and had threatened no one, he was treated like an armed terrorist. The security guard had been ordered to pick him up and bring him in. With five other neurosurgery residents from the same academic institution, he was sent to a "retraining center" for "disruptive physicians." He was terminated from the program and is without income. He is living in a room provided by another physician whom we have assisted.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY

History Lesson. The Soviet Union was founded on liberal principles. The world was going to be remade, and they were going to lead the way. The problem was that there was no room for disagreement. Anyone who disagreed was, by definition, an evil person. When coercion did not work, capital punishment, which was initially banned, was brought back.

Liberals who move to totalitarian means do so out of frustration with people who block their better world. Before he was Stalin, Josef Vissarionovich used "Koba" the name of the Georgian Robin Hood, as his Communist nickname.

My wife, who grew up in the USSR, says: "We were willing to try for 70 years and shoot 22 million people to prove socialism doesn't work, so why is the U.S. intent on trying it?"
Edward Dee Hinds, C.L.U., Paso Robles, CA

Soviet Story. The Latvian film maker for this grisly film which I hear has played in the European parliament but not here takes the position that Hitler learned the technically difficult task of disposing of millions of dead bodies from Stalin. He was reportedly burned in effigy in Russia.

It is remarkable how people think that socialism is benign, and that something is wrong with people who warn about it.

Speaking of which, when I hear the "seat at the table" line, I think of Molotov and Ribbentropp at the table, carving up Poland. Alas, our profession has more than a few docs who consider themselves so clever as to move the line a few miles one way or the other, so they keep their view property while millions are sent to the gas chambers.
Russell W. Faria, D.O., Kent, WA

The Plan. Funny how the U.S. government thinks in terms of five-year plans like Mao's "Great Leap Forward." U.S. politi- cians are generally out of office before the 5 years are up, and they don't have to deal with consequences.
Greg Scandlen, Heartland Institute

Effects of SCHIP. Since SCHIP pays at the Medicaid rate (less than cost), shifting kids from private to state coverage increases financial stress on physicians and hospitals and reduces access to care. This may explain why the director of Indiana Family and Social Services said, in a letter to Health Affairs, that his conviction about SCHIP is almost religious. There is no, that is no, as in NO data showing that the program produces actual benefits for children. Also note that the SCHIP reauthorization does not require real ID for enrollment. At the time real ID went into effect, Medicaid caseloads started falling. Finally, what sense does it make to tax a poor family more heavily so that a family with an income up to $80,000 can have the government provide insurance for its children?
Linda Gorman, Ph.D., Independence Institute, Golden, CO

Insurance: No. I'm a child and adolescent psychiatrist. I've never participated with insurers since finishing training in 1988. I agree that the concept and function of insurance is beneficial. However, "health insurance" as we know it today...is a parasite ...holding little value for the [medical] industry or the common citizen. At this point, I don't think the health insurance identity can change its identity and be tamed. It is both too entrenched and too enmeshed with political leaders. The campaign managers of both Bush and Gore campaigns were top health insurance financial executives....
Scott Hagaman, M.D., past president, MedChi

Addiction Cure. Society is addicted to entitlements. The government is the dealer, and the payment is the vote. As long as the addict is willing to buy, the dealer is willing to provide. The only real cure is when the dealer no longer has any product to provide.
Frank Timmins, Dallas, TX

Indentures. Canada tells doctors they are in private practice only so the government doesn't have to pay their overhead. The Physicians Master Agreement between the Queen and the British Columbia Medical Association (www.health.gov.bc.ca) shows what doctors can not do. Once they pass the daily allowed total, fees are discounted 100%! American doctors have no clue how bad it is working in socialized medicine. They see the bright side one place to bill, less worry about malpractice. What frustrates Canadian doctors most is lack of tools to heal.

In Canada, the best medical minds are veterinarians. Who wants to work in a system so restrictive you can't even use stents! Some Canadians who can't get medical care resort to seeing veterinarians and paying under the table. Still, people accept the high taxes and poor service there's nothing they can do about it anyway and think Americans are evil.
Ralph Weber, C.L.U., Paso Robles, CA