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Immoral Medicine

Immoral Medicine
by Dr. Lee Hieb

The magician distracts the audience by doing meaningless but fascinating
things with his right hand, while his left hand is doing the really
meaningful activity unnoticed by the crowd. The bigger the trick, the
bigger the distraction required.

Democrats and President Obama should make David Copperfield proud. With one
hand they are distracting the American people with a nonstop barrage of
bills and discussion: What will happen to the budget? How many are really
uninsured? Is the Congressional Budget Office to be believed?

And for the ultimate distraction, Mr. Obama paraded a group of “doctors” in
borrowed white coats for a great visual effect wholly devoid of substance.
For all we knew, these guys could have been a group of actuaries at a DC
convention bussed in as props for the day. (More likely they were doctors of
the government paid variety, like Rahm Emanuels’s physician brother Ezekiel,
sheltered in research institutions and teaching hospitals where they don’t
have to run their own small businesses.)

While this diversion is going on, the real issues are hidden from the public
-- the consequences of government funding of medical care on individual
liberty and our moral compass.

Government pay medicine -- under any name you give it -- is immoral for
patients/citizens, and for physicians. No citizen would consider it moral
to put a gun to his neighbor’s head and demand that he pay for his mother’s
medical care -- no matter how much she may need it. It is no more moral
when people use the government as intermediary. For the physician, it is
impossible to practice moral medicine in a government system, because
ultimately at some level a physician will have to choose between doing the
best for his patient or acquiescing to the requirements of the state.

The worst moral examples of course were the German doctors who were forced
to cooperate in death camp selections. At the other end of the spectrum the
moral tightrope has already started here with Medicare. Federal practice
guidelines have slowly become mandates. If you do not do what the
government has deemed the optimum pathway for care, the hospital will not
get paid. In my case, for the most part, the guidelines can be followed,
but the day is coming when I will have to choose.

There is no question that the risk of DVT -- deep venous thrombosis, and PE
(pulmonary embolism) goes up after some hip fractures. So, usually,
Orthopaedic Surgeons prescribe a form of blood thinner to prevent this
complication. But thinning someone’s blood comes with its own risks of
death and morbidity, and there are certainly people for whom the risk of
anticoagulation is greater than the risk of thrombosis after the fracture.
Without federal “guidelines” physicians used clinical judgment to cull out
those people who would do well without the risk of anticoagulation, e.g.
those who have a non-displaced fracture, who undergo minimally invasive
pinning, and who are mobilized within hours of the fracture. This is not
uncommon in small hospitals where these patients can be treated promptly.

But the government is telling us we must anticoagulate all patients -- as if
all patients and all circumstances were the same. Although there are
recognized exceptions to the blood thinning protocol, judgment of relative
risk by the surgeon is not one the government accepts. So surgeons are in
the position of doing what is best for their patient, or what is prescribed
by the state wielding a financial mallet.

In between these two extremes is the Canadian physician who must prioritize
patients in a system with too little resources. Dr. Leo Kurisko is a
radiologist who left Canada to practice in the US (as have 11% of practicing
Canadian doctors). At a recent medical meeting, he related the moral
problem of practicing radiology in Canada. Because the system is
chronically short of functioning CT scanners, at his regional hospital there
was a three month waiting list for a CT. Dr. Kurisko would review the
requests for testing, and would then triage which patients went to the front
and which to the back of the queue. After the scans were finally completed,
he reviewed the studies and began to recognize patients with life
threatening tumors whom he had prioritized to the back of the line. Faced
with this Canadian version of “death camp selection” he quit. He has
documented the evils of government medicine in a new book, Health Reform:
The End of the American Revolution?

Consider the Netherlands, where the number one reason for the death of
children under the age of ten is murder by their doctor. Oh, of course they
do not call it that, but it is what it is. Because the Netherlands pays for
medical care, they choose whom to support. And severely disabled children
and the infirm elderly are not high on their priorities.

The Dutch doctors practicing thus are the children and grandchildren of
physicians who went to the death camps themselves rather than participate in
the Nazi killing machine. So how did this happen? It happened through the
moral incrementalism of becoming state doctors--of putting the good of the
state above the good of the individual patient.

Medicare has been an assault on freedom since its inception. Americans who
turn 65, may think they are still free but they are not. You are not free
to opt out unless you are willing to forgo your social security payment.
Even people who see Social Security as part of the problem are not willing
to give up an entitlement they have paid into all their lives. And once
enrolled in Medicare, you cannot pay for services outside the system unless
these services are not offered at all by Medicare, or unless you find that
rare physician who runs a cash practice totally off the grid.

Physicians who see any Medicare patients at all are not free to bill outside
the Medicare system for services which they cannot afford to offer at
Medicare rates. For example, if an active 65 year old patient wants to have
a special high tech knee implant that was designed for the more active
younger patient, he cannot pay the difference between the regular implant
and the latest development. If Medicare offers “the service” at any level
you cannot buy the service on the free market.

In this way, rationing by diminishing the supply of specialists has already
started by diminishing the options open to Medicare recipients. Physicians
are not that different from Starbucks -- they are not going to pay you for
the privilege of serving you.

Although, for a while, Oncologists did just that. In the last few years, as
Medicare cut the reimbursement for some newer types of chemotherapy,
Oncologists would suck up the cost because they wanted to do the best for
their patients. But now, as Medicare has ratcheted back payment even more,
they have reverted to older drugs. And because there is no free market, the
patient cannot simply pay the difference to get the latest scientific
breakthrough.

So ignoring the smoke and magic mirror tricks, government payment for
medicine must be rejected, not on practical financial grounds, but by people
who value their freedom and their moral lives. As recognized by our
founders, but ignored by the current crop of politicos, the most unhealthy
immoral force in human history has been overly powerful central
governments. Charley Reese put it best when he said, “It is an eternal
shame to give up one’s freedom for a filled bowl of oatmeal and the promise
of security from liars”.

-----------
Read more articles like this at HUMAN EVENTS ONLINE!
http://www.humanevents.com/

--
Dr. M.

Immoral Medicine

Need more beer to keep going!
But at least I can quit by agreeing with you. I got to spend some time away
from Duke med school in Oxford. Very different expectation from that
population. "Good" was good enough. Did not have to have the latest/greatest
of everything. I think the perception is that the med/mal risk is less if the
doc has the latest greatest equip so that he can have a slight edge over that
famous "standard of care" thing... Reminds me of the Judge in Tx who delivered
a mega-million dollar judgment against Ford pickup trucks because of the
side-saddle gasoline tanks - those were safer than the lighter pickup trucks
by far , but were "below average" for the full sized class. The judge stated
as he handed down a huge judgment that his court was not going to tolerate
"below average performance from anyone".

John Edwards never sued a doc because he did a c-section too soon. (Remember,
that slime ball had 40% of ALL med/mal judgments in the state of North
Carolina for 1 or two years partly because he was very good at "channeling"
fetal thoughts for the jury...
-Graham

-----Original Message-----
From: Chip Hart [mailto:hidden@email-address]
Sent: Thursday, November 19, 2009 11:53 PM
To: Graham Barden
Cc: hidden@email-address
Subject: Re: [PedTalk] Immoral Medicine

I'm getting too tired to keep up, but my comments about defensive medicine
(which are, of course, insupportable) were related to my position that greater
than defensive medicine is the American demand for the best/latest/most
expensive/thorough treatments and services. We'd ASK for every lab under the
sun if they weren't already offered and we don't have to pay for them
(directly).

Graham Barden wrote:
> My impression of Ca medicaid was that the payment was terrible and
> fewer pediatric practices accepted Medicaid there. I don't know of any
> in NC that don't accept Medicaid. 90% that I do know are not capped in
medicaid numbers.
> You certainly are in a better position than I to comment about
> Medical, but I thought the E&M payments were way low.
> (and I think you are wrong about defensive medicine - that cost is
> HUGE - 20-30% would be a conservative guess for me. I don't care much
> about the malpractice insurance expense. I care about the malpractice
> risk) -graham
>
> -----Original Message-----
> From: Chip Hart [mailto:hidden@email-address]
> Sent: Thursday, November 19, 2009 11:36 PM
> To: Graham Barden
> Cc: hidden@email-address
> Subject: Re: [PedTalk] Immoral Medicine
>
>
>> I agree it is not necessarily tied to a party, but the inability to
>> get meaningful tort reform is sure tied to a particularly
>> lawyer-owned political party...
>
> Well, now you're changing the subject. Important as it is, we could
> eliminate lawsuits and we'd have all the same problems, just with
> lower premiums and slightly less defensive medicine.
>
>> As far as having the highest health ranking in the country, Vermont
>> and NH might also have the LEAST diversity. Maybe there is a
>> correlation
> there....
>
> There's no question that our lack of diversity, size, etc., play a part.
> But that doesn't explain why places like MA, CT, HI fare so well and
> LA, TX, TN, etc., do not.
>
>> While you are looking at Red/Blue states, look at their debt and
>> solvency as well. The country is a mess!
>
> It is, no argument. But last I checked, the money has flowed strongly
> from Blue -> Red states for some time, even with all the massive
> oil/mineral receipts from the most Red of states (TX, WY, AK).
>
>> NC has pretty good Medicaid - way better than California - but that
>> was developed while we vote R for Presidents (except this year) and D
>> for local politicians. So what color are we?
>
> Why is NC's Medicaid way better than CAs? I don't doubt it, but I
> wonder why you say that.
>
> --
> Chip Hart - Pediatric Solutions * Physician's Computer Company
> chip @ pcc.com * 1 Main St. #7, Winooski, VT 05404
> 800-722-7708 * http://pedsource.com/chipsblog
>
>

Immoral Medicine

I stopped taking California medicaid years ago after two experiences.

Spent an entire lunch hour with a pretty sick kid. Billed medicaid
99215 which was downcoded to 99213 (medicaid never, ever paid a 99215
and rarely a 99214) and was reimbursed less than $15.00.

Worse was an entire afternoon spent working up a child for suspected
sexual abuse. Knowing I'd be with this family for at least a couple of
hours we canceled as many patients as we could and everyone else
waited. Medicaid actually only downcoded the 99215 to 99214 (prolonged
service codes paid? Don't think they're even in the medicaid database)
and was reimbursed almost $30.00 for almost a whole afternoon's worth of
work. Gave more than that in courtesy discounts to the patients who
were kept waiting.

I didn't have a whole lot of medicaid patients anyway so that's when I
tendered my resignation and just saw the patients who remained in my
practice at no charge.

I once calculated that if I saw no private patients and only medicaid
patients then reimbursement would be so much less than my overhead I'd
have to close my office.

I don't know how docs with a high medicaid patient population stay in
business in California.

Michael Sachs, M.D.
General Pediatrician

Graham Barden wrote:
> My impression of Ca medicaid was that the payment was terrible and fewer
> pediatric practices accepted Medicaid there. I don't know of any in NC that
> don't accept Medicaid. 90% that I do know are not capped in medicaid numbers.
> You certainly are in a better position than I to comment about Medical, but I
> thought the E&M payments were way low.
> (and I think you are wrong about defensive medicine - that cost is HUGE -
> 20-30% would be a conservative guess for me. I don't care much about the
> malpractice insurance expense. I care about the malpractice risk)
> -graham
>
> -----Original Message-----
> From: Chip Hart [mailto:hidden@email-address]
> Sent: Thursday, November 19, 2009 11:36 PM
> To: Graham Barden
> Cc: hidden@email-address
> Subject: Re: [PedTalk] Immoral Medicine
>
>
>
>> I agree it is not necessarily tied to a party, but the inability to
>> get meaningful tort reform is sure tied to a particularly lawyer-owned
>> political party...
>>
>
> Well, now you're changing the subject. Important as it is, we could eliminate
> lawsuits and we'd have all the same problems, just with lower premiums and
> slightly less defensive medicine.
>
>
>> As far as having the highest health ranking in the country, Vermont
>> and NH might also have the LEAST diversity. Maybe there is a correlation
>>
> there....
>
> There's no question that our lack of diversity, size, etc., play a part.
> But that doesn't explain why places like MA, CT, HI fare so well and LA, TX,
> TN, etc., do not.
>
>
>> While you are looking at Red/Blue states, look at their debt and
>> solvency as well. The country is a mess!
>>
>
> It is, no argument. But last I checked, the money has flowed strongly from
> Blue -> Red states for some time, even with all the massive oil/mineral
> receipts from the most Red of states (TX, WY, AK).
>
>
>> NC has pretty good Medicaid - way better than California - but that
>> was developed while we vote R for Presidents (except this year) and D
>> for local politicians. So what color are we?
>>
>
> Why is NC's Medicaid way better than CAs? I don't doubt it, but I wonder why
> you say that.
>
> --
> Chip Hart - Pediatric Solutions * Physician's Computer Company
> chip @ pcc.com * 1 Main St. #7, Winooski, VT 05404
> 800-722-7708 * http://pedsource.com/chipsblog
>
>

Immoral Medicine

" ..they found no evidence that restrictions on tort liability reduce medical
spending." Having been named twice in such suits, I can immediately relate to
the concept of protecting oneself against future experiences of this nature.
But do the facts support my fears? "

Whether or not physician's fears of being sued are justified does not matter -
it is whether or not they act on the fears that matters!
We have done defensive medicine for so long - 30 years or more - that our
"standard of care" has now become "defensive medicine". Look at the recent
recommendations for less mammograms. 3 weeks ago my 43yo sister in law was
dx'd with bad stage three 18 node breast CA found on a routine mammogram.
The recommendation said we don't need to do them because it would only save 1
in 2,000 patients and create a lot of needless anxiety. If the one in 2,000
number has the Gov Seal of Approval, should we be dismissed from med/mal
"mis-diagnosis" cases if we show it the rare event we did not find occurs less
than 1:2000? At some point there needs to be a "rarity" defense. Might help
now with patients who can - rarely - have fatal H1N1 disease within 48 hrs
despite minimal sx, yet the physician is sued because he did not prescribe
Tamiflu.
-graham

-----Original Message-----
From: Wegehaupt, Dr. Paul [mailto:hidden@email-address]
Sent: Friday, November 20, 2009 6:20 PM
To: 'Graham Barden'; hidden@email-address
Subject: RE: [PedTalk] Immoral Medicine

No one doubts that there is truth to the concept of increased cost due to
"defensive medicine." Whether or not it is "HUGE" is a matter of debate.
There is surprisingly little research on this topic, with most high estimates
citing the article by Kessler and McClellan from California (Stanford)in 1996.
Several other studies, however, failed to find anywhere near such costs. Both
the GAO and the CBO now question the conclusions of this study. According to
FactCheck.org, "when the CBO attempted to duplicate the Stanford economist's
methods...they found no evidence that restrictions on tort liability reduce
medical spending." Having been named twice in such suits, I can immediately
relate to the concept of protecting oneself against future experiences of this
nature. But do the facts support my fears? Evidently not. According to the
IOM as many as 98,000 deaths occur annually from medical "misadventures."
Fewer than 2% of those injured by medical error actually file a law suit. Of
those cases that go to a jury (and are not settled out of court), 80% are
found in favor of the defendant. When "guidelines" are published based on
consensus agreement of experts, only 40-50% compliance with these guidelines
can be documented. When the government or HMOs attempt to strong arm
physicians to follow these guidelines, there is whining about government
mandates, government intrusiveness, cook book medicine, "death squads,"
rationing of care, etc. When I send one of my patients to a tertiary care
facility, no expense is spared in the work up of these patients. I doubt the
driving force is fear of getting sued. We (at least we doctors) also define
"quality" in terms of our skills and technology. Lets face it, we think we
are superior to Canada because we have CT and MRI scanners in every podunk
hospital in every community scanning every kid with bellyache for acute
appendicitis. When it's conventient for us we are critical of Canada (and
other countries) for limiting this technology, but when we actually
overutilize it, or when Canada misses a case of appendicitis, we use this as a
hammer to argue agains "socialized" medicine, and complain "the devil made me
do it" (because we are afraid of being sued).

Oh, by the way, shouldn't someone mention that if a state like California
votes against every tax increase that comes along, they shouldn't be surprised
if they get into financial trouble and pay low rates for medicare? Remember
that arguments against "redistribution of wealth" go both ways. We now have
about the same distribution of wealth as we had during the "robber-baron"
years of the industrial revolution. Graduated income tax changed that to what
some consider the birth of the middle class. Now the middle class seems to be
disappearing. Personally, I think Free Market principles apply very well to
electronics and most businesses, but not to health care. Competition does not
occur in the same way, and the result of consumer misjudgement is more severe,
and lastly, the public is not educated to make decisions based on competition.

Back to my beer which is now getting warm.

PKW
Rhinelander, WI

-----Original Message-----
From: hidden@email-address [mailto:hidden@email-address] On
Behalf Of Graham Barden
Sent: Thursday, November 19, 2009 10:47 PM
To: hidden@email-address
Subject: Re: [PedTalk] Immoral Medicine

My impression of Ca medicaid was that the payment was terrible and fewer
pediatric practices accepted Medicaid there. I don't know of any in NC that
don't accept Medicaid. 90% that I do know are not capped in medicaid numbers.
You certainly are in a better position than I to comment about Medical, but I
thought the E&M payments were way low.
(and I think you are wrong about defensive medicine - that cost is HUGE -
20-30% would be a conservative guess for me. I don't care much about the
malpractice insurance expense. I care about the malpractice risk) -graham

-----Original Message-----
From: Chip Hart [mailto:hidden@email-address]
Sent: Thursday, November 19, 2009 11:36 PM
To: Graham Barden
Cc: hidden@email-address
Subject: Re: [PedTalk] Immoral Medicine

> I agree it is not necessarily tied to a party, but the inability to
> get meaningful tort reform is sure tied to a particularly lawyer-owned
> political party...

Well, now you're changing the subject. Important as it is, we could eliminate
lawsuits and we'd have all the same problems, just with lower premiums and
slightly less defensive medicine.

> As far as having the highest health ranking in the country, Vermont
> and NH might also have the LEAST diversity. Maybe there is a
> correlation
there....

There's no question that our lack of diversity, size, etc., play a part.
But that doesn't explain why places like MA, CT, HI fare so well and LA, TX,
TN, etc., do not.

> While you are looking at Red/Blue states, look at their debt and
> solvency as well. The country is a mess!

It is, no argument. But last I checked, the money has flowed strongly from
Blue -> Red states for some time, even with all the massive oil/mineral
receipts from the most Red of states (TX, WY, AK).

> NC has pretty good Medicaid - way better than California - but that
> was developed while we vote R for Presidents (except this year) and D
> for local politicians. So what color are we?

Why is NC's Medicaid way better than CAs? I don't doubt it, but I wonder why
you say that.

--
Chip Hart - Pediatric Solutions * Physician's Computer Company
chip @ pcc.com * 1 Main St. #7, Winooski, VT 05404
800-722-7708 * http://pedsource.com/chipsblog

Immoral Medicine

On Thu, Nov 19, 2009 at 11:18 PM, Chip Hart wrote:

>
> Chip lives in Howard Dean country . . . lot's of strange things up there.
>>
>
> Yeah, like having the highest ranked health in the country, as of just
> today:
>
> http://www.burlingtonfreepress.com/article/20091118/NEWS02/911180309/Ver...
>

Also found in the above glowing press report:

High rank doesn't mean Vermont can't improve. The report identifies a high
> prevalence of binge drinking and only a moderate rate of immunization of
> children ages 19 to 35 months.

(I had the binge drinking and Howard Dean's cat calls more in mind with my
initial Vermont reference. In any case, the immunization report certainly
appears contrary to the other glowing report quoted below.)

Also from the press reference quoted above:

Another just-released report paints an ugly picture of escalating hunger in
> Vermont. The U.S. Department of Agriculture's food security report suggests
> that severe hunger was a problem in one in 20 households.
>

Geesh, hungry Vermonters. That would explain the lower rate of obesity which
helps give Vermont the "healthy state" ranking found in the first reference.
I guess those taxes to pay for the public health care wouldn't have any
impact on that?

>
> Or 99% of the kids covered by insurance.
> Or one of the highest vaccination rates.
> Or being the best place in the country to raise kids:
>
> http://www.childrenshealthmag.com/parents/The-best-and-worst-places-to-r...
>
>
"Severe hunger" in one in 20 households vs. 99% of kids covered by
insurance.Looks like VT is about average in the hunger department. The
northern plain states below average. <
http://www.ers.usda.gov/Briefing/FoodSecurity/map_2008.jpg> Must be the way
they cling to all those guns they use to hunt their dinner.

>
> That IS weird, you're right. Weird how all this stuff seems to happen
> in such a socialist state!

Hunger in a socialist state . . . happens all the time as far as I can tell.

> Last I remember, Boogy Man Dean was known
> for his balanced budgets and tight fiscal policy. But if you're only
> watching the national news, especially from that one station who
> played the (deliberately distorted) Dean Scream 1000 times in the
> first 24 hours, you wouldn't know that. He's from the wrong team, of
> course, so there's nothing at all we could possibly learn from him.
>

Like his acknowledgment that the public option may be the Democrats' undoing
in 2010? <
http://www.usnews.com/articles/news/politics/2009/10/07/dean-public-option-will-hurt-democrats-in-2010-elections.html>
I tend to agree with him.

>
> You know what's also funny? Given that you've (again) tied this issue
> into a particular party line, look at the rankings of any of these
> measurements (try americashealthrankings.org) and try to tell me you don't
> see the correlation between Red/Blue states and children in poverty, teen
> pregnancy, immunization rates, prenatal care, lack of insurance, obesity,
> even primary care physician count. It's not one-to-one, of course, but
> it's pretty obvious. Even Blue States like NY and CA, who are worthy of
> being their own countries with their range of challenges, fare better than
> their Red State peers.
>
> Why do you think that is? Is the (supposed) tight-fisted fiscal
> policy of those righteous Red States really paying off?
>

Let's correlate health of population once the deficit spending in NY & CA
cannot be sustained. (Recall what happened in the USSR after it collapsed.)
The people who pay the taxes are leaving NY in droves and I believe the same
is true in CA. Since the states do not possess the power of the printing
press (yet), something's got to give soon.

Of course, now that our attorney general is sending more terrorists to NYC,
I imagine all the new snipers and bomb sniffers that will be employed for
the next few years will be a big boost to our local economy and tax base.
Amen--finally a jobs program that will create real jobs.

>
> Stop making this about the Democrats being the problem. Their solution
> is full of flaws, no question, but holding them up against the Republicans
> makes them look 10x better than they deserve.
>

I agree that both parties have been negligent, derelict and guilty of
malfeasance. Do you? I don't think the Democrats hold a special place in the
pantheon of righteous, well meaning politicians when it comes to
straightening out health care.

I had the opportunity to hear Stuart Altman yesterday speak on the current
state of health reform in the US. Dr. Altman was in charge of reforming
health care during the Nixon administration when health care consumed 7% of
GDP. At the age of 32 and very wet behind the ears, he was told that if
health care hit 8% of GDP, the US would collapse. In retrospect, he readily
acknowledged that he knew nothing about fixing the problem. Health care
spending hit 8% and he was fired by Haldeman & Ehrlichman.

He was one of the Clinton advisers for health care and when they met in
Little Rock after the election, he made the point to Bill and Hillary that
their "public plan" would never get passed. Bill put his arm around him,
told him thanks and he was off the team.

He's a BHO health care adviser as well. He is the first to acknowledge that
what began as a health reform plan has now morphed into a health insurance
reform plan. Their goal, which he supports, is to get everyone covered. (I
was disappointed that he didn't acknowledge that the current group of 32
year-olds are no better schooled in health care than he was 30 some years
ago.)

Altman admits there is no cost containment in either House or Senate bill
and that it won't get passed now if there is. He admits costs will explode.
He says then, there will be no choice but to cut costs. His plan for
spending less . . . is to spend less. (I stole that line from him.)

Simply put, I do not trust the government to do the cost cutting. When have
they ever cut health care costs? And if they do really cut costs, do you
trust them not to enact a "death-plan" equivalent to do it? I really haven't
reviewed the just released mammogram/breast cancer screening recommendations
yet, but I think such recommendations when released in the context of the
government needing to drastically cut costs will be tainted by a very strong
perception (whether real or imagined doesn't make a diffference) of such
death-panel images. Seriously, do you think the Congress at that point won't
simply override any such cost cutting recommendations just like they
override the SGR Medicare cuts?

>
> The patient - doctor
>> relationship needs to be rebalanced by eliminating the middle man from
>> each
>> and every transaction.
>>
>
> This, I agree with! We should move back to indemnity insurance. It
> makes no sense whatsoever to have preventive care covered by
> insurance. What, exactly, is the justification for covering well
> visits? That's just paying the inscos to manage cash flow - which
> means they make your money.
>
> Well, nice to know that on the bottom line, we do agree. Kumbaya!

--
Dr. M.

Immoral Medicine

> High rank doesn't mean Vermont can't improve. The report identifies a high
>> prevalence of binge drinking and only a moderate rate of immunization of
>> children ages 19 to 35 months.

Oh My God! We're not perfect! [One of the things I detest about this
debate is that everyone tends to use a single example of imperfect as
"proof" that an entire system won't work. "Some people die early, so
private insurance is bad! There is fraud in Medicare, so it's
awful!"]

> (I had the binge drinking and Howard Dean's cat calls more in mind with my
> initial Vermont reference. In any case, the immunization report certainly
> appears contrary to the other glowing report quoted below.)

Hmmmm:

http://governor.vermont.gov/tools/index.php?topic=GovPressReleases&id=41...

"At age 2, 81.1 percent of Vermont children are fully immunized against
most vaccine preventable diseases. This includes protection against
diphtheria, pertussis, tetanus, polio, hepatitis B, Haemophilus influenza
type B (Hib), measles, mumps and rubella.

The national average is 77.4 percent. According to the CDC survey,
only Rhode Island has a higher percentage of 2-year-olds vaccinated at
81.3 percent."

That's what I had in mind when I mentioned the imms rates. Vermont
won a CDC award, even.

Frankly, I'm proud of my binge drinking capabilities. I plan to use
them this weekend at my brother's 40th birthday.

> Geesh, hungry Vermonters. That would explain the lower rate of obesity which
> helps give Vermont the "healthy state" ranking found in the first reference.

Yeah, you're right - we starve them here. Of course, you failed to
mention that our apparently poor food record still puts in a better
position than many Red States. But I Vermont's not perfect. Only
BETTER ON AVERAGE.

> "Severe hunger" in one in 20 households vs. 99% of kids covered by
> insurance.Looks like VT is about average in the hunger department. The
> northern plain states below average. <
> http://www.ers.usda.gov/Briefing/FoodSecurity/map_2008.jpg> Must be the way
> they cling to all those guns they use to hunt their dinner.

Do you really believe in your own arguments? Vermont is average at
something, so that negates it's entire success elsewhere? A poor score
in one metric can somehow be traded off for another?

I don't understand your gun comment, either. You know that Vermont
has arguably the most lax gun laws in the country, right?

> Hunger in a socialist state . . . happens all the time as far as I can tell.

Hmmmm, what about those *other states who had worse scores for
hunger?* Forget those?
http://www.ocpp.org/cgi-bin/display.cgi?page=iss080116hunger

Alabama
Alaska
Arizona
Arkansas
Colorado
Whoops, not CT, DE.
Georgia
Idaho
Kentucky
Louisiana
Mississippi
etc.

Vermont is far from perfect. Far from it. But cmon.

> Like his acknowledgment that the public option may be the Democrats' undoing
> in 2010? <

What does that have to do with this discussion? That maybe he can be
right about something?

> Let's correlate health of population once the deficit spending in NY & CA
> cannot be sustained. (Recall what happened in the USSR after it collapsed.)

Tell me again exactly how the Federal tax dollars flow in and out to
the various states. Last I recall, and correct me if I'm wrong, CA
and NY paid faaaaaaaaar more into the federal coffers than they got
back. How, exactly, do states like LA and MS sustain themselves
again? I bet NY would love to get some of their money back and stop
paying for health care in all those OTHER states.

> The people who pay the taxes are leaving NY in droves

To go where - the soon to be bankrupt states of AZ and FL?
[Personally, I think NY's supply of freshwater will keep it healthier
than many for a long time.]

BTW, they aren't "leaving NY in droves." NY's population continues to
climb. Maybe it's growing more slowly than other states, but I think
only poor Michigan has actually shrunk.

> I don't think the Democrats hold a special place in the
> pantheon of righteous, well meaning politicians when it comes to
> straightening out health care.

No, I don't. But holding them up to the Republican flame lets them
cast a bigger shadow.

> Simply put, I do not trust the government to do the cost cutting. When have
> they ever cut health care costs? And if they do really cut costs, do you
> trust them not to enact a "death-plan" equivalent to do it?

I'm with you up to here. Do you _really_ think the Feds could
actually institute something REMOTELY like this? Even the countries
you rail against (like, most of Europe, Japan) have plenty of room for
private medicine. Why do people assume that public option means no
private option? I believe I'll ALWAYS be able to get a doctor if I
have money. Always. [OMG, visions of back alley well checks.]

> I really haven't
> reviewed the just released mammogram/breast cancer screening recommendations
> yet, but I think such recommendations when released in the context of the
> government needing to drastically cut costs will be tainted by a very strong
> perception (whether real or imagined doesn't make a diffference) of such
> death-panel images.

Hmmmm. Recommendation says - correct me if I'm wrong - that doing
mammograms *for people who aren't covered by Medicare anyway* isn't
cost effective. But no one even implies that you couldn't do it
ON YOUR OWN DIME.

Hey, if you're going to spend less money, how DO you do it without
demanding more services, exactly? Yes, it certainly might suck for
your wife or daughter, but if mammograms don't make sense financially,
why aren't you saying, "Finally, common sense!"

> Seriously, do you think the Congress at that point won't
> simply override any such cost cutting recommendations just like they
> override the SGR Medicare cuts?

I think they'd all act like sheep.

>> This, I agree with! We should move back to indemnity insurance. It
>> makes no sense whatsoever to have preventive care covered by
>> insurance. What, exactly, is the justification for covering well
>> visits? That's just paying the inscos to manage cash flow - which
>> means they make your money.
>>
>> Well, nice to know that on the bottom line, we do agree. Kumbaya!

This is why I continue these debates :-)

--
Chip Hart - Pediatric Solutions * Physician's Computer Company
chip @ pcc.com * 1 Main St. #7, Winooski, VT 05404
800-722-7708 * http://pedsource.com/chipsblog

Immoral Medicine

Chip Hart wrote:
>> Well, nice to know that on the bottom line, we do agree. Kumbaya!

This is why I continue these debates :-)

Not to mention the binge drinking!

--
Gary M. on LI
Sent from my Palm Prē

State Immunization ratings

"At age 2, 81.1 percent of Vermont children are fully immunized against most
vaccine preventable diseases. This includes protection against diphtheria,
pertussis, tetanus, polio, hepatitis B, Haemophilus influenza type B (Hib),
measles, mumps and rubella. The national average is 77.4 percent. According to
the CDC survey, only Rhode Island has a higher percentage of 2-year-olds
vaccinated at 81.3 percent."

I recently received a letter from the state (NC) saying the immunization rate
of our patients was 28%. Turns out the analysis did not include the lack of
hib - having given 3 dosages and not the forth during the period of shortage.
And, since we see a lot of Tricare infants until they are 1 or 2 months old
and then send them back to the base, we were dinged for LOTs of babies who
only received their 1 or 2m shots...
Stats often lie.
-graham

-----Original Message-----
From: hidden@email-address [mailto:hidden@email-address] On
Behalf Of Chip Hart
Sent: Friday, November 20, 2009 1:08 AM
To: Gary Mirkin
Cc: hidden@email-address
Subject: Re: [PedTalk] Immoral Medicine

> High rank doesn't mean Vermont can't improve. The report identifies a
> high
>> prevalence of binge drinking and only a moderate rate of immunization
>> of children ages 19 to 35 months.

Oh My God! We're not perfect! [One of the things I detest about this debate
is that everyone tends to use a single example of imperfect as "proof" that an
entire system won't work. "Some people die early, so private insurance is
bad! There is fraud in Medicare, so it's awful!"]

> (I had the binge drinking and Howard Dean's cat calls more in mind
> with my initial Vermont reference. In any case, the immunization
> report certainly appears contrary to the other glowing report quoted
> below.)

Hmmmm:

http://governor.vermont.gov/tools/index.php?topic=GovPressReleases&id=41...
ticle

"At age 2, 81.1 percent of Vermont children are fully immunized against most
vaccine preventable diseases. This includes protection against diphtheria,
pertussis, tetanus, polio, hepatitis B, Haemophilus influenza type B (Hib),
measles, mumps and rubella.

The national average is 77.4 percent. According to the CDC survey, only Rhode
Island has a higher percentage of 2-year-olds vaccinated at
81.3 percent."

That's what I had in mind when I mentioned the imms rates. Vermont won a CDC
award, even.

Frankly, I'm proud of my binge drinking capabilities. I plan to use them this
weekend at my brother's 40th birthday.

> Geesh, hungry Vermonters. That would explain the lower rate of obesity
> which helps give Vermont the "healthy state" ranking found in the first
reference.

Yeah, you're right - we starve them here. Of course, you failed to mention
that our apparently poor food record still puts in a better position than many
Red States. But I Vermont's not perfect. Only BETTER ON AVERAGE.

> "Severe hunger" in one in 20 households vs. 99% of kids covered by
> insurance.Looks like VT is about average in the hunger department. The
> northern plain states below average. <
> http://www.ers.usda.gov/Briefing/FoodSecurity/map_2008.jpg> Must be
> the way they cling to all those guns they use to hunt their dinner.

Do you really believe in your own arguments? Vermont is average at something,
so that negates it's entire success elsewhere? A poor score in one metric can
somehow be traded off for another?

I don't understand your gun comment, either. You know that Vermont has
arguably the most lax gun laws in the country, right?

> Hunger in a socialist state . . . happens all the time as far as I can tell.

Hmmmm, what about those *other states who had worse scores for
hunger?* Forget those?
http://www.ocpp.org/cgi-bin/display.cgi?page=iss080116hunger

Alabama
Alaska
Arizona
Arkansas
Colorado
Whoops, not CT, DE.
Georgia
Idaho
Kentucky
Louisiana
Mississippi
etc.

Vermont is far from perfect. Far from it. But cmon.

> Like his acknowledgment that the public option may be the Democrats'
> undoing in 2010? <

What does that have to do with this discussion? That maybe he can be right
about something?

> Let's correlate health of population once the deficit spending in NY &
> CA cannot be sustained. (Recall what happened in the USSR after it
> collapsed.)

Tell me again exactly how the Federal tax dollars flow in and out to the
various states. Last I recall, and correct me if I'm wrong, CA and NY paid
faaaaaaaaar more into the federal coffers than they got back. How, exactly,
do states like LA and MS sustain themselves again? I bet NY would love to get
some of their money back and stop paying for health care in all those OTHER
states.

> The people who pay the taxes are leaving NY in droves

To go where - the soon to be bankrupt states of AZ and FL?
[Personally, I think NY's supply of freshwater will keep it healthier than
many for a long time.]

BTW, they aren't "leaving NY in droves." NY's population continues to climb.
Maybe it's growing more slowly than other states, but I think only poor
Michigan has actually shrunk.

> I don't think the Democrats hold a special place in the pantheon of
> righteous, well meaning politicians when it comes to straightening out
> health care.

No, I don't. But holding them up to the Republican flame lets them cast a
bigger shadow.

> Simply put, I do not trust the government to do the cost cutting. When
> have they ever cut health care costs? And if they do really cut costs,
> do you trust them not to enact a "death-plan" equivalent to do it?

I'm with you up to here. Do you _really_ think the Feds could actually
institute something REMOTELY like this? Even the countries you rail against
(like, most of Europe, Japan) have plenty of room for private medicine. Why
do people assume that public option means no private option? I believe I'll
ALWAYS be able to get a doctor if I have money. Always. [OMG, visions of
back alley well checks.]

> I really haven't
> reviewed the just released mammogram/breast cancer screening
> recommendations yet, but I think such recommendations when released in
> the context of the government needing to drastically cut costs will be
> tainted by a very strong perception (whether real or imagined doesn't
> make a diffference) of such death-panel images.

Hmmmm. Recommendation says - correct me if I'm wrong - that doing mammograms
*for people who aren't covered by Medicare anyway* isn't cost effective. But
no one even implies that you couldn't do it ON YOUR OWN DIME.

Hey, if you're going to spend less money, how DO you do it without demanding
more services, exactly? Yes, it certainly might suck for your wife or
daughter, but if mammograms don't make sense financially, why aren't you
saying, "Finally, common sense!"

> Seriously, do you think the Congress at that point won't simply
> override any such cost cutting recommendations just like they override
> the SGR Medicare cuts?

I think they'd all act like sheep.

>> This, I agree with! We should move back to indemnity insurance. It
>> makes no sense whatsoever to have preventive care covered by
>> insurance. What, exactly, is the justification for covering well
>> visits? That's just paying the inscos to manage cash flow - which
>> means they make your money.
>>
>> Well, nice to know that on the bottom line, we do agree. Kumbaya!

This is why I continue these debates :-)

--
Chip Hart - Pediatric Solutions * Physician's Computer Company
chip @ pcc.com * 1 Main St. #7, Winooski, VT 05404
800-722-7708 * http://pedsource.com/chipsblog

Immoral Medicine

but it is sooooo cold up there :)

Lynn

Lynn Cramer RN-BC
Practice Administrator
Eden Park Pediatrics
Lancaster, PA

On Thu, 19 Nov 2009, Chip Hart wrote:

>
>> Chip lives in Howard Dean country . . . lot's of strange things up there.
>
> Yeah, like having the highest ranked health in the country, as of just
> today:
> http://www.burlingtonfreepress.com/article/20091118/NEWS02/911180309/Ver...
>
> Or 99% of the kids covered by insurance.
> Or one of the highest vaccination rates.
> Or being the best place in the country to raise kids:
> http://www.childrenshealthmag.com/parents/The-best-and-worst-places-to-r...
>
> etc.
>
> That IS weird, you're right. Weird how all this stuff seems to happen
> in such a socialist state! Last I remember, Boogy Man Dean was known
> for his balanced budgets and tight fiscal policy. But if you're only
> watching the national news, especially from that one station who
> played the (deliberately distorted) Dean Scream 1000 times in the
> first 24 hours, you wouldn't know that. He's from the wrong team, of
> course, so there's nothing at all we could possibly learn from him.
>
> You know what's also funny? Given that you've (again) tied this issue
> into a particular party line, look at the rankings of any of these
> measurements (try americashealthrankings.org) and try to tell me you don't
> see the correlation between Red/Blue states and children in poverty, teen
> pregnancy, immunization rates, prenatal care, lack of insurance, obesity,
> even primary care physician count. It's not one-to-one, of course, but
> it's pretty obvious. Even Blue States like NY and CA, who are worthy of
> being their own countries with their range of challenges, fare better than
> their Red State peers.
>
> Why do you think that is? Is the (supposed) tight-fisted fiscal
> policy of those righteous Red States really paying off?
>
> Stop making this about the Democrats being the problem. Their solution
> is full of flaws, no question, but holding them up against the Republicans
> makes them look 10x better than they deserve.
>
>> The patient - doctor
>> relationship needs to be rebalanced by eliminating the middle man from each
>> and every transaction.
>
> This, I agree with! We should move back to indemnity insurance. It
> makes no sense whatsoever to have preventive care covered by
> insurance. What, exactly, is the justification for covering well
> visits? That's just paying the inscos to manage cash flow - which
> means they make your money.
>
>
>

--

Immoral Medicine

The behavior of individual adult humans does tend to be consistent over time (hence the difficulty of incorporating new methods in existing practice), but unless the variations in behavior across a population are taken into account, any conclusion about the effect of social institutions will be a flawed simplification.

There is interesting research being done about the correlation between human biology and social behaviors. The expression of traits with biological correlates vary across a population. Not surprisingly, certain traits are expressed more fully in the context of certain social institutions.

Neither nature nor nurture are deterministic...which is not to say that certain social institutions may evolve because they allow a better expression of a common - but not ubiquitous - human behavior with roots in biology. Religious belief and religion, for instance.

http://www.sciencedaily.com/releases/2008/12/081217124156.htm

G -

PS. I'm wondering about the

"> Human behavior is fairly consistent across any area, therefore the economic

> construct is critical.">

-----Original Message-----
From: Gary Mirkin
To: Ped Talk
Sent: Thu, Nov 19, 2009 8:39 pm
Subject: Re: [PedTalk] Immoral Medicine

On Thu, Nov 19, 2009 at 12:46 PM, Kenneth Hayashida wrote:

> Chip,

> You are seeing a different medical economy that what I am seeing in

> Southern California.

Chip lives in Howard Dean country . . . lot's of strange things up there.

> Human behavior is fairly consistent across any area, therefore the economic

> construct is

> critical.

>

100% correct. This is the most critical part of the failing of our current

system as well Medicare, Medicaid and the rest of our medical market place.

The socialist nation expects to get service but without compensating the

> provider of those services directly. The result is a nation which is

> orchestrating the whole sale theft of resources, time, and energy from

> those who trained 20 years to provide those services. Correlation of

> compensation with the service provided is essential. Such correlation

> can not occur when money is being paid to NOT see patients (capitation).

>

Amen. I also believe that the only way to cut the spending is to cut the

spending. Unlike most Democrats, I don't believe that government or

insurance companies can do this. Definitely not gov't--that's why Medicare

and the rest of the gov't programs are going bankrupt. Insurance companies

can cut, but they can't do it effectively or logically and certainly not

without encountering a lot of blow back from irate customers.

It's the patients that are going to have to cut the spending. They need to

realize that the money, or at least for first big chunk of a respectable

deductible, is going to come out of their pocket. The patient - doctor

relationship needs to be rebalanced by eliminating the middle man from each

and every transaction.

--

Dr. M.

Immoral Medicine

Kenneth Hayashida wrote:
> You are seeing a different medical economy that what I am seeing in
> Southern California.

I think it's safe to say that the entire rest of the country and
southern California differ in many ways, don't you?

My remarks weren't about _my_ view, but the view of people who are
actually *measuring the numbers*.

> So, the doctors in the area end up afraid to say
> anything, perform with mediocre results, and cover up the problems so
> they are not judged to be "trouble-makers".

The way you describe it, southern CA is a veritable WASTELAND for
physicians with no one but the meek and poor to provide the
services...yet somehow SOME of those MDs and DOs are still bringing
home plenty of money and seeing plenty of patients. I know bunch!

> The socialist nation expects to get service but without compensating the
> provider of those services directly.

Well, wait a second. Although you may be right, I think it's
difficult to blame a socialist construct for the failure of a string of
medical office parks, each of whom, one presumes, was constructed with
private money. Those aren't gov't funded medical parks, right?

--
Chip Hart - Pediatric Solutions * Physician's Computer Company
chip @ pcc.com * 1 Main St. #7, Winooski, VT 05404
800-722-7708 * http://pedsource.com/chipsblog