Volume 62, No. 10 October 2006
THE GAS-SIPHONING SOLUTION
For all the government and academic cant about "evidence-
based" medicine, reform proposals sweeping the states and hawked
by candidates are decidedly non-evidence based.
"The tax on medicine to fund medicine is like the gas
siphoning solution to the gas shortage," writes Gerald Yorioka,
M.D., of Everett, WA.
"Taxing people with insurance to subsidize other people's
insurance" as with the Massachusetts surcharge on health
plans is a prescription for an infinite cost spiral, writes
Linda Gorman of the Independence Institute.
Medicare adds such a tax in 2007, a surtax on Part B
premiums for individuals with an adjusted gross income greater
than $80,000 a little-known provision of the 2003 Medicare
Modernization Act, which also brought us Part D. By 2015, seniors
with incomes over $200,000 will be paying about $4,700 annually
for Part B, according to CMS estimates plus tax on the income
represented by the benefit.
Shortages and cost spirals result from attempts to replace
the natural regulator of free-market prices with administrative
pricing. Gorman calls it "a grand experiment on the whole
population...with no informed consent forms required." And no
heed paid to the outcome.
Although the grand scheme of the Clinton Health Security Act
was temporarily derailed, the fallback plan of piecemeal
implementation in state "laboratories of democracy" proceeds.
Model legislation designed by the Robert Wood Johnson Foundation
(RWJF) has been enacted: as in New York, New Jersey, Kentucky,
and Tennessee. "Regardless of the wreckage," writes Gorman,
Massachusetts and Maine fell back on "if at first you don't
succeed, try, try again."
Gorman thoroughly debunks the reformers' deeply held beliefs
in a Health Care Policy Center Newsletter, August 2006,
(www.i2i.org) and other
The Myth of Cost-Saving Primary or Preventive Care
It is claimed that lack of insurance leads to lack of
primary care, which results in more sickness and more use of the
emergency department. In fact, the publicly insured are over- -
represented among ED users, and having a source of primary care
does not seem to affect ED use. Insurance status also made little
difference in the percentage of recommended care acute, chronic,
or preventive received by those who made at least one visit to a
medical facility in the previous 2 years (Asch SM, et al. N
Engl J Med 2006;354:1147-1156).
Specialist care is supposed to be more expensive. Yet a
study of consumer-directed care by Aetna and Humana showed that
while consumers chose to consult more of the expensive
specialists, total costs nevertheless went down.
Although preventive care (or early detection) may well
improve longevity and quality of life, it does not save societal
resources in the long run (Shenkin H. West J Med
2001;714:85). Even if prevention costs less per person than acute
care, its cost per unit of health benefit can be as great or
greater (Russell R. Health Policy 1984;4:85-100).
Government Efficiency Myth
The savings from eliminating private insurance overhead and
profits, and from allegedly superior government efficiency is
said to be sufficient to provide high-quality, comprehensive care
to all ignoring the long history of corruption in programs such
as Medicaid. According to Christopher Rowland of the Boston
Globe, Medicaid officials used $55 million in Medicaid funds
to replace defective granite siding on a medical school building.
According to the Office of Inspector General for the U.S. Dept.
of HHS, Massachusetts Medicaid improperly billed the federal
government for $86.6 million in just 2 years. It also paid more
than $1 million between 1998 and 2001 to deceased patients whose
death certificates were on file.
Government programs do little or nothing about the
hemorrhage of funds due to use of fraudulent or stolen Social
Security numbers, services to illegal aliens miscoded to obtain
payment for noncovered items, or improper payments to politically
favored programs such as school-based clinics.
As nonremunerative Medicaid fees to private facilities have
driven them out, patients are forced into public clinics, which
must by law be reimbursed according to their costs and which do
as they please, and to mid-level providers and EDs.
Earmarks, as for "research that never ends," divert millions
to "case management," "culturally competent care," and other
projects of special interest groups, such as those that must by
law be included on the advisory committee to the Massachusetts
health care quality and cost council (list available on www.forhealthfreedom.org
Health Care uber Alles
The mandatory-insurance siphon doesn't just suck funds from
the medical economy. Health insurance comes before food,
transportation, and shelter, by Massachusetts law. Paraphrasing
Lord Keynes, Gorman notes that "in the long run, enterprising
Massachusetts businesses are all dead."
The Only Way Out
Gas lines came to an end only when price controls were
lifted. But energy supplies, like medical resources and the
economy as a whole, are still crippled by massive taxation,
regulation, and litigation. The siphoning solution of legal
plunder must be halted, and the economy must be freed, or a
sudden, catastrophic decline could result in medicine and other
areas. Banging on the pipes, as the AMA repeatedly does with
Medicare fee cuts, won't help when the fuel runs out.
Energy, the Economy, War and Health
Some say that World War III has already started. The U.S.
faces increasingly deadly threats from the Muslim Middle East,
Communist Venezuela, possibly Russia, and others. Our enemies are
buying weapons and recruiting terrorists with American
money acquired by selling us energy. Moreover, high energy costs
imperil American prosperity.
The U.S. has substantial untapped reserves of oil and an
essentially unlimited supply of coal and natural gas, both of
which can be converted into oil. Nuclear energy could supply most
of our electricity. But domestic production and refining of
hydrocarbons has been despoiled, and the nuclear industry
ravaged under the banner of environmental health.
War and the impoverishment of America are the most serious
health threats in our future. Costly false "insurance" against
minor risks; tax subsidies that siphon wealth from productive
into politically correct channels; and taxation, regulation, and
litigation are sapping our strength and our resistance not just
in medicine but throughout the economy. The blind pursuit of
"health" in the broad sense and of relief from risk and
individual responsibility could destroy American medicine and
America as a free nation.
Access to medical care not "coverage" by insurance is the
real issue. It is a subset of access to other necessities of
life, which ultimately depends on free enterprise. (See "Health
Technology," "Solar Poverty," "Energy and War," "Economic War,"
and other articles in Access to Energy,
especially March, May, June, July 2006, for key facts and
analysis on critical current issues not available in the popular
or medical press, PO Box 1250, Cave Junction, OR 97523, $35/yr,
The Empty Entitlement Pipeline
"Your Social Security Statement," which contains an estimate
of the prospective beneficiary's monthly future benefit, states
on p. 1 that "by 2040,...there will be enough money to pay only
about 74 cents for each dollar of scheduled benefits."
The federal government has a contractual obligation to the
holders of its T-bills; a default on interest would be a form of
national bankruptcy. It has no such obligation to those with
entitlements, according to the landmark 1960 U.S. Supreme Court
decision in Flemming v. Nestor.
"Today's Congress can promise future retirees a lifetime
golf pass and a free trip to the moon, but it can't bind a future
Congress" (Wall St J 8/22/06): note the new Part B
People can drop Part B. Joel Lehrer, M.D., of Teaneck, NJ,
suggests that a private market might eventually arise.
AAPS Counters Citizens Working Group
The Interim Recommendations of the Citizens Health Care
Working Group (AAPS News, July
2006) "were arrived at through a `consensus' process
involving a select few, apparently structured so as to lead to
the endorsement of predetermined conclusions," writes AAPS. "We
reject a system of top-down command and control that is implied
by a `core benefit package,' enforced use of `evidence-based best
practices,' coerced use of electronic medical records, and `pay
for performance.'" AAPS also submitted the "White Paper on Medical Financing,"
published in fall issue of our journal, as an outline for free-
market reform. Comments from organizations and individuals are
posted at www.citizenshealthcare.gov
Conflicts of Interest
Organized medicine has generally been reluctant to criticize
managed care, or to warn physicians about bad contracts.
Antitrust concerns are the usual pretext; the reason may have
more to do with its leaders.
The current speaker of the AMA House of Delegates, Dr. Nancy
H. Nielsen, has just been named chief medical officer of
Independent Health, an Amherst-based health plan, according to a
tiny article in the business section of a local newspaper. She
formerly served as associate medical director for quality and was
named interim medical officer in 2004. She is also senior
associate dean at the University of Buffalo School of Medicine
(Buffalo News 7/30/06). Her promotion comes at a time
when HMOs are seeking physician support for P4P and EMRs, notes
AAPS past president Lawrence Huntoon, M.D.
On the local level, the 2005/2006 president of the Erie
County (NY) Medical Society, Dr. Richard P. Vienne, Jr., was and
is medical director of Univera Health Care, an HMO.
The new president of the Texas Academy of Family Physicians
(TAFP), Doug Curran, M.D., regularly appears in full-page glossy
ads for BlueCross BlueShield of Texas. He is quoted as saying
that he is glad when a patient has a BCBS card because "this is a
company I can work with!" No other physicians in Texas can work
with BCBS, reports Shirley Pigott, M.D.: its policy on contracts
is "take it or leave it."
TAFP has a conflict-of-interest policy. However, Dr. Pigott
was told that Dr. Curran is not in violation because the
executive committee knows about and fully supports his position
with BCBS. Dr. Pigott demanded an investigation. Officials agreed
to meet with her but have postponed the time until all 2006
business is completed.
The TAFP Commission on Health Care Services and Managed
Care, which is appointed by Dr. Curran, recently squashed all of
Dr. Pigott's private-sector resolutions, although all had
previously received a favorable vote when the Commission was
"blitzkrieged" with them. The chairman has, on the record,
refused to hear or discuss a resolution about the relationship
between primary care and subspecialist physicians.
On British P4P
Doctors get no rewards for patient satisfaction in the NHS
version of P4P. According to Martin Roland, advisor to the U.K.
P4P program, the reason is that the British Medical Association
"thought that the notion that physicians were essentially running
a service industry where the customers' views mattered,
would be quite hard for the doctors to adjust to" (Galen
Institute, Health Policy Matters 9/8/06).
Oct 6, 2006. Dinner and presentation by Andrew
Schlafly, Rockford, IL: call Dr. Mark Kellen, (815)
Oct 10-13, 2007. 64th annual meeting, Cherry Hill, NJ.
Prosecutions of Pain Physicians
Hurwitz Conviction Overturned. In a stunning defeat to
federal prosecutors, the Fourth Circuit Court of Appeals vacated
the conviction of Dr. William Hurwitz and remanded the case for a
new trial (News
of the Day 8/24/06).
"Good faith was at the heart of Hurwitz's defense," the
Court held. By affirmatively instructing the jury that good faith
was not relevant to the drug charges, but only to the fraud
charges, "the district court effectively deprived the jury of the
opportunity to consider Hurwitz's defense."
The majority, however, rejected the instructions proposed by
Dr. Hurwitz, which defined "good faith" to mean "good intentions
in the honest exercise of best professional judgment as to a
patient's needs" and that "the doctor acted according to what
he believed to be proper medical practice." Two judges
held that an objective standard should be applied:
To permit a practitioner to substitute his or her
own views of what is good medical practice for
standards generally recognized and accepted in the
United States would be to weaken the enforcement of our
drug laws in a critical area. Vamos, 797 F.2d.
Judge Widener, concurring and dissenting, wrote: "I do not
believe good faith should be objective; the two terms are
contradictory, it seems to me."
Rottschaefer Petitions for Writ of Certiorari. Denied a
new trial by the Third Circuit, Bernard Rottschaefer, M.D., (see
J Am Phys Surg
2005;10:66 and News of the Day
1/26/06) is petitioning the U.S. Supreme Court. A family
physician who occasionally treated pain, Dr. Rottschaefer faces
78 months at an above-maximum security level in prison for
offenses charged under the Controlled Substances Act (CSA).
Key issues addressed in the AAPS amicus brief authored by
Andrew Schlafly are federalism, the inappropriate use of a civil
standard in a criminal case, and perjury.
By "indicting a physician for practicing medicine in a
manner of which the federal prosecutor disapproved," a single
executive officer turned the state medical board into a nullity.
This "disrupted the delicate federal-state balance by supplanting
the regulatory scheme of a state with an uninformed federal
jury's view of the proper standard of care."
Because there is a "bona fide dispute in the medical
community" about Dr. Rottschaefer's prescriptions, "then
reasonable doubt about criminal intent exists as a matter of
law," Schlafly argues.
To obtain a conviction, the prosecutor presented a "spiced-
up tale of sex for drugs" which was a complete lie. Despite
proof of perjury by the star witness that came to light after the
trial, the Third Circuit ruled that the evidence was
"cumulative," and that a new trial was not warranted.
The burden of proof, Schlafly contends, cannot be properly
shifted to the accused; he should not have to convince the court
that he would not have been convicted in the absence of the
Because of the current lack of a consistent standard,
"perjury runs amok," Schlafly writes. "The judicial
permissiveness toward prosecutorial perjury stands in stark
contrast to the exclusionary rule, which flatly prohibits the use
at trial of much evidence improperly seized."
The DEA, Dr. Rottschaefer observes, is attempting to deny
that physicians who provide needed pain relief are being
inappropriately targeted. On its website, the DEA states that it
is impossible to provide definitive guidelines on the meaning of
"legitimate medical purpose in the usual course of professional
practice." That is why, Dr. Rottschaefer believes, prosecutions
almost universally involve an additional alleged crime such as
inappropriate sexual contact, or fraud involving such minuscule
amounts of money that it almost certainly represents clerical
error. It is the other alleged crime that creates the CSA
violation, even if the doctor is acquitted of the other charges
as happened in Dr. Hurwitz's case.
DEA Liberalizes Prescribing Rule
The DEA has proposed a rule allowing physicians to write
three prescriptions for a 30-day supply of controlled drugs,
dated to be filled 30 days apart, at a single office visit. This
overturns a two-year-old policy that was forcing chronic pain
patients to make office monthly visits just to keep doctors out
of trouble with the DEA. The agency had received more than 600
comments on its policies on opioids, many strongly opposing its
position on limiting refills (Wash Post 9/7/06).
The DEA has begun posting information on doctors it has
prosecuted at www.dea.gov, hoping doctors will
be convinced that only "egregious" offenders are indicted.
Alberta Sued for Ban on Private Insurance
The Supreme Court of Canada having overturned Quebec's ban
on private insurance in Chaoulli, debate rages on
whether such bans violate the Canadian Charter. The question may
be answered by a class action suit challenging Alberta's law.
Last year, Premier Ralph Klein's government contemplated
allowing private insurance, but backed away from the proposal.
"If these court cases go ahead and are successful it will be
the ruin of medicare as we know it," said Ray Martin, health
critic of the New Democrat opposition party (NDP).
The case was launched by the Canadian Constitution
Federation and Calgary patient Bill Murray, who bought two
private surgeries after the government denied him state-of-the-
art hip replacements (Calgary Herald 9/8/06).
AHIC Elevates Status of Privacy Panel
In the wake of the AAPS lawsuit challenging the American
Health Information Community (AHIC) for failure to comply with
the Federal Advisory Committee Act (FACA), a privacy panel has
been declared a fifth work group. AAPS had complained that no
privacy expert had been designated.
The HIPAA Privacy Rule will probably be discussed, stated
panel member Jodi Daniel, who helped draft the first versions as
an HHS staffer in the Clinton Administration.
At least two members have spoken in favor of allowing
federal rules to preempt state privacy protection, and at least
one favors creating a unique patient identifier. This was called
for in the 1996 HIPAA law but stalled through the efforts of
Congressman Ron Paul, M.D., (R-TX) and privacy advocates. Panel
members are listed at www.modernhealthcare.com
Other events that followed the lawsuit included the abrupt
resignation of David Brailer as health IT czar, and a change in
AHIC procedures and ambitions.
Documents pertaining to the lawsuit, AAPS v. HHS,
are posted at
www.aapsonline.org/judicial/ahic.php. Litigation is
being supported by the American Health Legal Foundation (see
AAPS News, April 2006).
Is the End Nearing? The government has already shifted
the burden of paying for Medicare to the children of this country
(even as politicians talk constantly about the plight of "the
children"). And now it is shifting some of the costs into the
next fiscal year. It is simply not paying hospitals or doctors
from Sept 22 until Sept 30 with no interest or penalties. The
government's resort to such accounting tactics indicates that its
financial stress is significant. As I recall, prior to the fall
of the Soviet Union, workers were subjected to delays in
government payments, and ultimately, no payment.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
A Solution that Works. In five and a half years, my
third-party-free practice in a rural county of 65,000 has grown
to 7,000 patients. Of these, 4,000 have been uninsured and could
have chosen instead to receive care at one of the four state-
subsidized clinics located within 15 miles of my office.
Eliminating the tax exemption for health insurance would cut
the Gordian knot that has attached health insurance to employers
since World War II. This would liberate us from the oppressive
system of third-party payment for routine medical care. As Ronald
Reagan said, "Solutions are never easy. Just simple." He ignored
the contrived convolutions of policy elites and cut straight to
the core of seemingly intractable problems.
Robert S. Berry, M.D., Greeneville, TN
The Real Answer to Price Transparency. The recent
lemming-like rush to force pricing "transparency" on hospitals to
help achieve competition would strike me as dangerous even if
Senator Hillary "Health Care" Clinton hadn't jumped on the
bandwagon. Inviting government to pass judgment on what is or is
not "transparent" is an invitation to impose price controls and
business practice controls. A better approach would be to
challenge government, the real cause of the hospital pricing
problem, to publicize its Medicare pricing, including the codes.
Consumers would then have a known price to begin with when the
hospital asks them to pay an outlandish amount.
Linda Gorman, Independence Institute, Golden, CO
Squelching Competition. The enormous barriers to market
entry have created a very noncompetitive insurance industry. That
was the intention of the regulators. They wanted small-
group reform to "stabilize" the industry not to lower
prices or increase the number of insured persons. Regulators,
such as one who started out with Blue Cross/Blue Shield, wanted
to have just a few carriers so that employers wouldn't be
"confused" by having too many choices. They succeeded.
Greg Scandlen, Consumers for Health Care Choices
HSAs Give Options. A widow with three children, who runs
her own business in Fairfax, VA, found that she could get a
$3,500 deductible health plan for $4,200 compared to the $10,800
she paid in premiums for a PPO with a $2,000 deductible in 2004.
Each month, she pays $350 into her HSA plus $350 in premiums. The
total is less than before, and half the money is hers. She also
has the flexibility to decrease her HSA contribution during times
when business is slow.
Ernest J. White, Alexandria, VA
Nihil Novi Sub Sole. The list of proposals by German
socialist physician E. Simmel in 1928 (see Racial Hygiene:
Medicine Under the Nazis by Robert Proctor, p 260) to me
sounds almost identical to the curent postulates of the AMA and
the ACP: (1) Expand coverage of state-sponsored health insurance
to the entire population; (2) eliminate all institutions that can
make a profit from any form of medical treatment; and (3) make
pharmacists employees of the state. Some people never learn.
Walter Borg, M.D., New Iberia, LA
Non-Single Payer. One Big Lie of the Left is that the
U.S. is an "aberration" for expecting people to pay something for
medical care, and that in all civilized countries, free universal
health care is a right. Germany has dozens of sickness funds, and
one-third of the population is eligible to opt out of them (of
whom one-third do so). France and Germany have coinsurance.
Single-payer advocates who refer approvingly to European systems
other than the NHS generally don't understand how they work nor
do they read accounts of their failures, which are generally not
printed in English.
Sean Parnell, Heartland Institute, Chicago, IL
Perpetuating Poverty. Any time you institutionalize the
fact of being "poor," you create a "safety" net from which it is
very hard to escape. Volunteers provide the right help at the
right time, and are happy when they are no longer needed.
Government workers need to have people stay poor, in order to
justify their own jobs.
Alieta Eck, M.D., Somerset, NJ
MinuteClinics. Competition from walk-in clinics in
retailers such as Wal-Mart and CVS is pushing physicians' offices
to become more responsive to patients' needs, as by offering
speedier appointments. The American Academy of Family Physicians
is spending $8 million on consultants to advise doctors on how to
improve patient care. The AMA prefers the competition-ectomy,
recommending at its annual meeting that such clinics accept
restrictions on their scope of operations and require physician
Jeffrey Singer, M.D., Phoenix, AZ