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1. Hi Eric, Are groceries a right? Is transportation a right? Here are my thoughts: Your input/feedback is appreciated and desired. — Dr. Shelley
   A New Wellness Paradigm
   How to Fix the United States Health Care System
   We Must Do It Ourselves
   “Problems cannot be solved at the same level of awareness that created them.”
   –Albert Einstein
   Identify the Components: Ones That Work and Ones That Don’t
   The first step to solving any seemingly daunting problems is to break it down into component parts, identify what works about the existing status; and what doesn’t. It’s crucial to learn from the past.
   As a physician and owner of a solo practice (small business) I’ve experienced the health care system from all sides. I’m intimately familiar with how Medicaid, Medicare, and for-profit insurance companies such as Blue Cross, United Healthcare, Aetna, and others work. I am also a consumer of health care services. I’ve had babies, knee surgeries, and other personal interactions with the American medical system. I have witnessed first-hand the extent to which non-citizens are receiving benefits paid for by working Americans. I am a small business owner so I’ve had to decide whether and how to offer health insurance to my employees. I, and others like me, am among the most qualified people in America to help fix the health care system because we have experienced health care from all angles: health care providers, patients, business owners, and tax payers.
   In this chapter we’ll explore what works and what does not work about the existing U.S. health care system. We’ll also address how to fix what doesn’t work and improve upon what does work.
   What Does Not Work
   Big Government Entitlement Programs
   Big Government does not work. Entitlement programs such as Medicare and Medicaid have spiraled out of control, increased our debt, and are a huge burden to existing and as-yet unborn taxpayers. Many people have figured out how to “game” the system and receive benefits they don’t deserve.
   In my county the office that determines Medicaid benefits is populated by some former illegal migrants who are now citizens. Through knowing people who work in that office and are dismayed by current practices, I am aware some staff members are dispensing Medicaid benefits to those who don’t deserve them. We all pay for this. I don’t want my children bearing the cost of the ballooning U.S. entitlement programs, as it will impact their and their children’s standard of living.
   Medicaid “Emergency Services Only” is a perfect of example of an entitlement program gone woefully wrong. Don’t misunderstand me – some of the recipients of this entitlement program truly deserve it. However, this benefit is dispensed to some citizens and non-citizens alike who drive brand new large SUV’s, and reside in single family homes – I’ve literally seen them deliver a baby at the taxpayer’s expense and drive away in a shiny brand new Cadillac SUV. They pay through these luxuries with cash earned “under the table,” not subject to income tax.
   The Medicare Part D prescription drug program is another example of an entitlement program which benefits pharmaceutical companies and wealthy Americans at the expense of middle class and younger Americans. Most beneficiaries of Part D are retired older Americans who did not pay enough into the system to cover this benefit during their working years. As a consequence working Americans and future working Americans as yet unborn will pay for this program. Pharmaceutical companies are guaranteed a “permanent” revenue stream through Part D unless the system is revoked or revamped. As drug costs increase, which they inevitably will, Part D will balloon out of control as has the rest of Medicare and Medicaid and be another source of national debt and excess tax burden.
   Big government does not work because it’s too costly to administer and it is too easy to take advantage of.
   For the first time in U.S. history we are seeing new generations’ standard of living decline compared to the generations that preceded them. This should be a wake-up call to all of us. If you live in the moment and have the attitude, “It won’t affect me,” think again. Your children or your friends’ children, or mother Earth will bear the brunt of our existing behaviors. Examine your motives. Be honest. Do you feel like you need more money or more stuff? Do you really need these things? Or do you need a healthy earth in which you and your children can live sustainably? Now that you’re making a baby it’s up to you to create the best world possible for them.
   Inequities in Wealth Distribution Harm Everyone
   As a species we have not solved the problems engendered by unequal distribution of wealth. The rich getting richer and the poor getting poorer is not simply an economic problem. It’s an environmental and moral one: It’s hard to care about the pollution you create as an individual when you’re worried about how you’re going to feed your family from day-to-day.
   Ostentatious displays of wealth accentuate inequities and engender jealousy. This sentiment leads to the emotion of rage and ultimately to behaviors of radical and violent extremism, terrorism being just one example.
   Dramatic inequity in wealth distribution is a moral problem that engenders social ills such as thievery, violence, and mistaken beliefs.
   National Health Care Administered by the Government is a Bad Idea
   Several countries already have national health care systems in Canada and Europe. This approach has resulted in a two tiered system: A “private” system in which the wealthy can receive any and all healthcare when they desire it; and a “public” system in which the average person must sit on a waiting list for a year or more to have their knee replacement or their heart surgery. Many of these countries have high income taxes on the order of eighty percent to pay for their entitlement programs. The government decides how the individual citizen’s money is spent. Do you think the U.S. Federal Government has proven it is the best entity to determine how your health care dollar is spent? That is the inevitable outcome of a “National Healthcare System”.
   A national health care system already exists in the United States. It’s called Medicare and Medicaid. These programs have failed miserably in several aspects: Lack of coverage: The number of uninsured citizens keeps rising despite the ever increasing money spent on Medicaid and Medicare. Those who are on Medicaid and Medicare are under-insured because these systems reimburse physicians at a rate of roughly twenty cents on the dollar. Most primary care physician practices’ overhead averages forty to fifty or more percent. Thus, physicians lose thirty cents on the dollar for every Medicaid and Medicare patient they see. This necessitates physicians to either refuse to accept Medicaid and Medicare; or to be forced to go out of business through lack of financial viability.
   Entitlement programs charge working Americans twice, and in some cases three times, for the benefits they provide their recipients: through taxes, through cost-shifting of high insurance premiums; and through obligating physicians and hospitals to provide free care to anyone who walks through the door, be they tax-paying citizens or not.
   Just so you’re under no illusions this is a small problem, look at the 2006 statistics published in the American College of Obstetricians and Gynecologists’ newsletter: Seven percent of obstetricians quit delivering babies altogether and another twelve percent curtailed services to accept only low risk clients. The reasons cited for this were declining reimbursement for deliveries and increase financial and emotional cost of malpractice insurance. A large portion of obstetric patients are illegal immigrants who are either uninsured or covered by Medicaid “Emergency Services Only” which pays dismally. This twenty percent reduction in obstetric services in a single year is truly astounding.
   The main reason reimbursement by Medicare and Medicaid is insufficient is because there is a tremendous disconnect between the consumers of these benefits and those paying for these benefits. The payers are middle class working Americans. The consumers are retirees, people below the poverty level, and people who are illegal migrants. There is a complete disconnect between those who pay for the system (middle class Americans) and those who receive the benefits.
   Disconnect between payer and recipient results in over-utilization of expensive services. If you don’t have to pay for something why hesitate to use it? Many people on Medicaid use the nation’s emergency departments like clinics because they don’t have to foot the several thousand dollar bill for an emergency department visit. If people are insulated from the cost of their prescription medications they are likely to use expensive heavily marketed drugs even if they have no proven benefit over older generic drugs.
   Solving the health care crisis in this country requires increasing the connection between the payers and recipients and dispensers (health care providers and organizations) of health care services.
   Profit Incentives…well…raise profits (and cost)
   Why should commercial insurance companies and pharmaceutical companies make billions in profits when there are 46 million uninsured Americans? It just does not make sense. That is the multi-million dollar question. How can, for example the CEO of United Healthcare justify taking home a multi-million dollar annual compensation package when there are children and adults in this country who go without basic health care needs such as vaccinations and access to medical providers?
   Commercial Insurance Companies:
   Increasing Transparency and Evaluating “Managed Care”
   Increasing Transparency
   How do you know you’re getting the health care benefits for which you’ve paid? Do you understand your EOB (Explanation of Benefits) you receive in the mail after you’ve visited a health care provider or pharmacy? Have you checked to see if the insurance company has paid the correct percentage (accounting for deductibles and co-pays) according to your written policy? Have you read your insurance policy?
   The average person (including me) has not read her insurance policy word for word. It’s usually a dense 50 or 60 page document written in legalese. The fine print within this document can contain many exceptions to the summary of the policy, of which you are unaware.
   Does your insurance company pay for “out-of-network” providers in strict accordance with the written policy?
   If you don’t know the answers to all these questions you may not be (probably aren’t) receiving the full benefits for which you are paying. Ask your insurance policy to account proportionally for every dollar of your premium – write to their CEO or CFO. They should at least send you an “annual report” – the company summary they mail yearly to investors. If you can’t get the information by asking, state you’re interested in investing in the company and can they send you an annual report? Money talks and information is power. We can’t do anything about rising health care premiums until we understand where each dollar goes. Once we understand where the dollars go, we can work to control the components eating those dollars.
   Part of how insurance companies have made away with so much of our money is because we don’t demand the information. If we sit passively and complain it accomplishes nothing. Do something! Start by demanding an accounting of where your money goes. You have a right to know.
   If we curtail existing entitlement programs we decrease the administrative burden of the Federal Government. There is a National body, the Joint Commission on Accreditation of Hospital Organizations (JCAHO), whose job is to regularly visit every hospital in the United States to see if they are living up to standards of safety and hygiene. Why not demand a Federal body that does for commercial insurance companies what JCAHO does for hospitals? Given that the largest portion of our national gross domestic product goes to health care it’s only appropriate the insurance companies be held accountable for responsible use of those dollars.
   Evaluating Managed Care
   Managed Care is a model that originated in the 1980’s to attempt to control heath care costs. The original intention behind it was to link quality to cost and use the scientific method to evaluate the merit of various medical treatments. It has undergone much iteration over the past three decades. However, managed care has failed to control cost. Indeed costs have risen hundreds of percentiles over the past three decades.
   Original versions of managed care involved a “gatekeeper” system in which insurance companies dictated patients must see a primary care physician before obtaining a referral to a specialist. Patients also had to jump through hoops to get basic services or tests ordered by the doctor covered. These factors caused great dissatisfaction among consumers of healthcare.
   The present version of managed care involves “Preferred Provider Organizations” (PPO’s): establishing “in-network” and “out-of-network” benefits paid at different levels. The idea behind this is an insurance company negotiates “discounted rates” with a group of physicians or hospitals then drives consumers to use those physicians or hospitals. The advent of PPO’s has also failed to result in controlling health care costs.
   Some of the greatest reductions in health care costs have come from hospitals and physicians themselves. Many physician groups and hospitals have taken the initiative to develop “Disease State Management Protocols” and “Clinical Pathways”. These are tools used to standardize care for common illnesses using evidence-based medicine and proven methods to control the cost of in-patient hospital care. These and similar efforts have produced the most dramatic control of health care costs, while actually improving and standardizing the quality of medical care delivered.
   Pharmaceuticals
   The FDA incentivizes pharmaceutical companies to develop and market “new and better” drugs because patents on drugs expire after ten years and the drugs can then be produced as generics. Pharmaceutical companies are under minimal obligation to prove their “new and better” drug really is more effective than older, cheaper generic drugs. Pharmaceutical companies aggressively market new expensive drugs direct to consumers on television and to physicians without being required to prove they are more effective than their predecessors. Why? They should at least be required to disclose data about efficacy, just as they’re required to disclose side effects of their drugs.
   Often new drugs are simply old drugs that have been “tweaked” by adding a minor chemical appendage so as to technically make them into new chemical compounds, although they don’t act any differently than their older predecessors. Some examples are “new” birth control pills touted to improve premenstrual syndrome and acne, which are variations on older generic birth control pills. Newer birth control pills sell for about $50 to $60 per month; whereas generic pills sell for about $7 to $10 per month. Both types of pills improve acne and premenstrual syndrome.
   Another example is newer anti-depressants such as Lexapro and Celexa. These drugs are off-shoots of the old stand-by, Prozac (fluoxetine). Prozac is now generic (fluoxetine) and cheap whereas these newer drugs are not. They are touted to have fewer side effects; and they may indeed have fewer side effects. But they have not been required by the FDA to prove it in head-to-head randomized double-blinded, placebo-controlled trials. Are they required to disclose this fact in direct-to-consumer advertising? Why not? Moreover, there are new concerns about all the anti-depressants and increased risk of suicidal or violent behavior.
   What is the logic insurance companies use to determine what they will and will not cover? For example, some insurance companies cover drugs to treat erectile dysfunction but they don’t offer maternity coverage, or coverage for contraception. Or they offer these benefits for additional premium. Why?
   We certainly don’t want to discourage development of new drugs by removing the profit incentive. However, companies should be required to disclose efficacy data in marketing to consumers and physicians. Drug development must become more transparent to consumers so they can make the best choices for their physical well-being and the well-being of their wallets.
   Malpractice Risk Drives Up Cost Via Defensive Medicine
   You’ve all heard the politicians and the media bemoan the fact that malpractice risk increases costs for everyone so I don’t want to tire you with repetition of this other than to summarize. The high cost of malpractice insurance and the emotional toll of malpractice suits cause physicians and hospitals to engage in “defensive medicine”. Defensive medicine is ordering unnecessary tests in order to prove the patient doesn’t have a serious illness and thereby avoid a malpractice suits. There is no evidence that defensive medicine results in better medical care or reduces malpractice suit. The only reliable conclusion drawn by studies of defensive medicine is that it increases the overall cost of health care.
   Malpractice suits have become something of a “lottery” – consumers looking for the multi-million dollar payoff. Defendants (physicians or hospitals) “win” eighty percent of malpractice suits that go to trial – usually after an expensive, drawn out, draining battle. The only people who truly win in these cases are the trial lawyers. Even the malpractice insurance companies take a hit but at least they can pass their cost onto the physician. Guess who the physician passes the cost onto?
   However, if physicians passed on the entire cost of rising malpractice premiums to patients, no one would be able to afford to visit the doctor. Therefore, they only pass on a portion of the increased cost and they absorb the remainder. As malpractice insurance premiums rise, guess what happens to the business bottom line? This is a large contributor to the exodus of physicians from obstetrics: rising malpractice cost and declining reimbursement. If it actually costs you money to get up at 3 a.m. and go deliver someone’s baby, why do it? It makes no sense.
   Money Spent on Extremes of Life
   Ninety percent of the health care dollar is spent on the last six months of life. This often involves intensive care for people afflicted with terminal illnesses who are on life support. They
   may require a tube to breathe, medication to keep their heart rate going and blood pressure normal, a tube for feeding in the stomach, or intravenous nutrition. We often die in hospitals hooked up to machines and being pumped full of drugs. We may not even be conscious. Is this how you want to die?
   Just because we possess the technology does not mean it is best for us to use it. In the past we died with dignity in our homes, surrounded by family members. You should consider how you want to die at a time when you have full mental faculties and can make an advance directive. An advance directive is a document specifying what measures you want taken to extend your life should you not be able to decide for yourself. Don’t leave it up to your family members to make the decision because no one wants the responsibility of “pulling the plug”.
   These extreme measures often consume the final dollars of a family’s savings and are a large component of Medicare expenses. This is money that could go to your children and grandchildren. It could pay for someone to go to college or someone to have a place to live. We have to decide for ourselves how much is enough and how much is too much?
   Okay, so I’ve identified this, that and the other thing that are wrong with our health care system. What is right with it? Well we have access to advanced technology, well-trained physicians and nurses, antibiotics, and the best science money can offer. Too bad such a huge number of people struggle to get basic health care needs met. How do we get out of this mess?
   Addressing the Big Four will “Fix” the United States Health Care System
   In summary there are four big offenders in producing out-of-control health care costs:
   Addressing each of these will decrease the cost of health care while preserving the advantages of technology and science, and increase access for everyone to basic health care services.
   The silent underpinning of many of these problems is risk. So how we manage risk determines the cost of our health care.
   Connecting the Payer with the Recipient
   It is crucial to connect the recipient of health care directly with the payer. The consumer needs to bear the risk of his health care decisions. The consumer of health care needs to directly feel the impact of system utilization in their wallet.
   Eliminating or reducing the scope of entitlement programs would go a long way toward reducing the burden of health care costs for the middle class. Recipients of Medicaid should be required to prove they are U.S. citizens. Non-citizens should not be eligible to receive benefits for free. They should have to pay for their health care just like the rest of us.
   If we do issue driver’s licenses or identification cards to non-citizens, it should be tied to proof of health insurance, proof of auto insurance, and proof of paying taxes.
   We need to decrease the influence of the middle man and limit the role of private health care insurers and the government. One approach to this would be for groups of people to participate in pooled risk plans in which premiums and benefits are determined impartially by an actuarial company. This could be self-directed, for example, by employees of large companies or other pooled risk groups. Alternatively the existing insurance company framework could be restructured so as to decrease the “fat” in the system. This would require government or some outside agency regulating insurance profitability. What justification is there for the CEO of an insurance company making millions of dollars while many Americans go without basic services? Insurance companies would certainly balk at government regulation.
   Consumers must demand greater transparency from commercial insurance companies regarding how their health care premium dollars are spent. Only when we understand where the money goes can we solve the problem of high cost.
   Exert Your Own Cost Control
   You have the power to control your individual health care costs. If everyone reduces her individual costs, the collective cost of health care will decline. Examine your utilization. The most expensive healthcare services are emergency room care, intensive care units (ICU’s), surgery, and advanced imaging studies such as MRI’s and CT scans.
   Examine your utilization of the system. First, if you are ill after regular business hours, decide if you’re sick enough to need to go to the Emergency Room at a cost of thousands per visit; or can your condition wait until your doctor is available during regular business hours for a fraction of the cost?
   Of course for emergencies like chest pain or hemorrhage you should proceed to the emergency room. But if you have chronic pelvic pain and have developed a worsening of pelvic pain the emergency department is not the best place to receive care for this problem. Childhood runny noses and rashes also don’t need to be seen in the Emergency department unless you’re concerned your child may be seriously ill (e.g. have a high fever, or is unable to keep food and water down).
   If your doctor recommends a test, ask why? What is the doctor trying to learn with the test? What are the benefits, risks, and costs of the test? Will this test lead to further testing or surgery? Are you asking for the test because you want to know a certain result? Is the test going provide the information you desire? Will the test give you any useful clinical information to better understand your health? You should know the answers to all these questions before submitting to tests.
   A perfect example of useless tests is “hormone levels”. Women ask me every day to check their hormone levels. If I can’t talk them out of it I usually oblige to satisfy them. However, female hormone tests do not tell us anything your own body can’t tell. For example, if you are having regular monthly periods your hormones will be “in the normal range”. The “normal range” is determined by measuring hormones of millions of “average” people to establish normal values. If you are over thirty, skipping periods, having night sweats, or have stopped having periods, your hormones will be in the “menopausal range” because these values are established by measuring hormone levels of millions of menopausal women. If you are skipping periods before age thirty, you probably have “polycystic ovary syndrome” caused by irregular ovulation. I can test your hormone levels to confirm, but this is usually a diagnosis that can be made by asking questions and doing a physical exam.
   If you are having raging premenstrual syndrome (PMS) I can test your hormone levels. They will most likely be “in the normal range” because hormone levels vary depending on time of cycle, age, and other factors. I can be of much more help by addressing your symptoms and developing a plan to manage them than I can by testing your hormone levels.
   Knowing your actual hormone levels does not help us treat hormonal disorders most of the time because treatment is based on symptoms, not on a number from a lab.
   If you have excess acne or hair growth it is likely your testosterone is high. I can measure it to be sure, but your body is telling me, by producing excess hair and acne that your testosterone level is high. Now if you have these symptoms a hormone level would be useful to exclude a testosterone-producing ovarian tumor. However, testosterone-producing ovarian tumors are exceedingly rare (<1/100,000). I will still recommend the test if I think it’s necessary based on your symptoms and physical findings.
   Be careful of independent labs that offer “saliva tests” for hormones. These are expensive and can be misleading. Saliva levels of hormones can be quite variable from time of cycle and time of day.
   Develop an advance directive while you’re at an age when you have full mental capacity and you can consider these decisions in a thoughtful manner. Write it down. You don’t need an attorney to create an advance directive. Simply writing it down in one page or one paragraph is sufficient. If you want it to be “official” have it notarized. Make sure it answers crucial questions in a clear fashion for your relatives to understand. Advise your relatives you have an advance directive; review it with them; and make sure they know its location. At the end of life do you want to be kept alive with a breathing tube, intravenous feedings, or drugs? To what extent and expense do you want your body to be preserved, possibly with your mind in a vegetative state? Do you want to be resuscitated (brought back to life) if your heart or breathing stops? What would be the criteria you would want established for any of these measures to be taken?
   Require Insurance Companies and Pharmaceutical Companies to Increase Disclosure, Transparency, and Accountability
   We must hold big business accountable for making the most of the dollars we pay them. Insurance companies should be required to present policies in clear, consistent, standardized language to make it easy for the consumer to compare policies. An objective oversight body similar to the Joint Commission for Accreditation of Hospital Organizations (JCAHO) should be established to assess insurance companies and pharmaceutical companies to determine if they hold up to their promises.
   Pharmaceutical companies or an outside agency (don’t we pay the FDA to do this?) should be required to conduct studies of efficacy of new drugs in an objective manner and disclose these results to the public along with the rest of their direct-to-consumer advertising.
   The free market system works: competition encourages innovation and fosters incentives for cost control. We want to preserve the elements of the free market system that function well, while not sacrificing accountability and quality control.
   Doctors Can Impact Cost by Using Evidence Based Medicine and Resisting the Temptation to Practice Defensive Medicine
   Doctors, nurses, and other healthcare providers can dramatically impact the cost of health care by resisting pressures to practice defensive medicine. One would not want to deny access to a necessary diagnostic test or treatment based on price. However, so many tests and treatments are ordered as “cya” measures.
   Often patients request tests that are unnecessary. Usually one can explain the rationale behind testing or not testing and advise the patient to make an informed decision. However, some people are set on the idea that they need this or that test to understand their health. In this instance it is usually counter-productive to try to “talk” the patient out of it, and just go ahead and order the test.
   In order for health care professionals to reduce the habit of defensive medicine, they need relief from the pressures to do so. A revamping of the “malpractice” system in the United States is long overdue.
   Eighty percent of “malpractice” suits are won by the doctor or hospital being sued. This means in most cases that go to trial, evidence of malpractice cannot be found. The stress and cost of malpractice suits is discouraging good people from entering the field of medicine; and causing many to leave medicine or limit their practice to “low risk” disease conditions.
   It has been suggested by consumer groups, physician groups, politicians, and government agencies that it is time to move to institutionalizing compensation for bad medical outcomes. The extent of damage and amount of compensation could be determined by an arbitration group. Funds for this should come from a number of sources: insurance premiums, lawyers, physicians, and consumers. Everyone should have to bear the cost of bad medical outcomes in order to curtail frivolous law suits and keep overall health care costs down over the long term.
   It is much more effective to use a carrot to get people to do the right thing, than to beat them with a stick. For the most part doctors are smart, conscientious – often perfectionist – people who strive to do their best; and if you prove to them certain disease management protocols improve care and reduce cost, they will use these disease protocols. Doctors have studied long and hard to become physicians and it is a life-long learning process that involves accumulating “continuing medical education credits” throughout one’s career.
   Evaluate How We Manage Extremes of Life
   You can maximize your chances of having a healthy term baby by following the advice in this book. You have more control than you may realize. Overall, though, ninety percent of the health care dollar is spent on the last six months of life. Premature babies are expensive and we should strive to reduce prematurity.
   This phenomenon has occurred because advances in technology have outpaced the study of ethics and responsibilities of a society to its members to provide the greatest good to the most number of people.
   We need to decide as a society: How do we want to enter and exit life? Do we want to die hooked up to machines in a vegetative state? Is this the best use of our precious resources? Do we want to risk leaving a legacy of health care debt to our heirs?
   You actually have complete control over this. By writing your advance directive, you remove the burden of your life’s decisions from others and take the initiative. I encourage you to write an advance directive and make your friends and family aware it exists. It doesn’t have to be long – a page or a paragraph. It doesn’t need to be written by a lawyer or notarized. However, if you take the trouble to have it notarized it may increase the likelihood it is taken very seriously.
   You must consider all the possibilities: What if you’re completely paralyzed or brain damaged in an accident? Or rendered into a coma? What type of medical interventions do you want to take place? I urge you to think about these things and write them down: Your family’s lives depend upon it.
   Only by tackling the four major factors increasing health care cost in this country can we obtain a safe, logical, cost-effective health care system. I encourage you to do your part.

2. Do we count the exclusive privileges granted to specialists who staff hospitals as compensation? What about the massive public subsidy that is medical education?
   Docs used to be able to make a great living staffing ER centers. That’s not necessarily the case anymore, but if the argument is to allow the “free market” to work then there is also a discussion that needs to be had about a nunber of other policies (corporate practice of medicine, joint negotiation, licensure, role of medical socieities, paying the full cost of medical education, tort reforms that have benefitted physicians- to name a few). I think docs have legitimate complaints with the system as it is, but it is not a one-way street where they have been abused.
   Oh, and please indenture me.
   http://www.cnn.com/2007/US/Careers/02/12/cb.big.bucks/index.html

3. Hi , a little off topic but i was wondering what you view is on psychotropic drugs such as Paxil? , I have a blog documenting the paxil medical scandal (seroxat in the uk) …
   I ws wondering could you highlight it? …
   thanks
   http://truthman30.wordpress.com/

4. Regarding our noble brother the attorney who may be forced by a judge to accept the case of the indigent defendent: Unlike the physician that is dicatated a set fee, that same attorney is FREE to charge $200, $300, $500 an hour – or more, plus incidental expenses to the remainder of his or her clients.
   And same attorney, has every incentive, without remorse, suing a brother internal medicine physician (real case in Illinois)on the behalf of grieving relatives, for “not doing enough” to convince said relative to lose more weight.
   Regarding “defensive medicine”:
   Short of locking someone in a room, suspend them from the ceiling and having them chained to a treadmill, with motivational messages & subliminal commands, and periodic nutritional supplements … what constitutes “enough”?
   ‘Tis not a true or fair comparison, my friend.

5. Sorry for the rant folks !!! Just had a visit from the local taxing authority who indicated that I will be assessed taxes on the FREE pharmaceutical samples that I give for FREE to my patients, of special benefit to those who are elderly or indigent.
   No good deed goes unpunished. Guess the government wants me to stop helping people…perhaps they think my elderly and indigent patients would be better off without medication…
   I know the answer: I should pay for the privilege!

6. Indentured servitude is a proper terminology for the role of physician in american society today. Last time I checked, the United States of America was a free society with a free market economy… except in healthcare. Over the last 20 years healthcare in the US has devolved into a morass of rules and penalties that dictate your clinical decisions and your compensation in an ever downward spiral.
   Sorry ladies and gentlement, you are no longer considered professionals, but technicians whose judgements are not to be trusted, and whose services are not valued.
   The mere fact that you may profit from your labors is evidently abhorrant from some who envisions 2 jaguars in every garage… clearly equating ‘for profit’ with greedy profiteering and taking advantage of the poor public…. simultaneously blessing ‘non profit’ entities with noble virtue… and maintaining a fantasy that healthcare has no associated costs and therefore, should be free…
   NEWSFLASH: Non profit entities must be ‘profitable’ or they go into the red and DIE – unless, of course they get a government subsidy to sustain them. Since non profits don’t pay any taxes, that means a parasitic government has to squeeze those evil profit makers to do their civil responsibility… till the life is squeezed out of them…. then there is NO HEALTHCARE FOR ANYBODY.
   As for the virtue of “taking federal money”… QUIT.
   ============
   PHYSICIANS, one and all, let us stop taking Medicare and Medicaid money. This ‘privilege’ is too heavy a burden.
   What’s the ramification? Seniors would have to pay more for the medical care they receive in the clinic, would risk financial ruin for surgical and recurrent, chronic care, and a significant number of hospitals and nursing homes would close across the nation.
   According to some, you should be made to see them anyway, for free, for the privilege of being a licensed physician and disparage your professionalism for wanting to be paid for your services.
   I don’t know how to stretch a $28 nursing home visit or a $50 clinical visit any more than I can. Perhaps my receptionist will work for me for free. My nurse has a license, surely she will be professional enough to work for free – although she will probably lose her house and she and her son will have to live in a homeless shelter…
   HMMMM…. nurses, receptionists, and billing staff have to be paid, office rent have to be paid, supplies and medications have to be paid for, the ever popular malpractice policies have to be current …. or I shut my doors…
   I am so fortunate to be “for profit”.
   Maybe Matt is right!
   It would be smarter to quit and do nothing – and collect a government check – paid for by those idiotic for profit people…
   If I got tired of doing nothing, I could get me a good government job! I hear they have good healthcare benefits…
   That’s the answer!! EVERYBODY WORK FOR THE GOVERNMENT
   Hmmm… sounds like the former Soviet Union. If I remember correctly, it suffered an economic collapse …
   Wake up folks! Something for Nothing Healthcare does not work.

7. To Spike; You have a point about docs in other countries. I often thought it would be easiest and let us docs get back to what we do best, just to put everyone on salary. However, there are significant issues with that system too – one being productivity of someone on a salary. Ergo long wait times in the U.K. Also, docs in Germany recently went on strike to protest incomes and practice conditions. Not to mention a host of other issues.
   To Matt; Since you like to split hairs, you split one the wrong way. The federal money is taken by the HOSPITALS, not the docs who have to cover the ER at 3 a.m. And often the patient who is there at 3 a.m. is a self-pay patient (if not a Kaiser patient) from whom the doc will never see a dime. It used to be that the concept of hospital “privileges” accorded to a doc were the exchange of leadership services, ER call, and many other free services from the docs to the hospital, in return for the hospital making available its facility and equipment for the doc to treat his patient. With the advent of outpatient surgery centers and drastically reduced lengths of stay, many docs rarely come to the hospital anymore. Hence the dissent over all these free services to the hospital (which is getting the federal $$)
   The last paragraph of your April Fool’s day comment to me is so out there I won’t even bother to address it. “Reverence”, “respect”??!! In our dreams!

8. “So professional athletes are not professionals? Interestingly though, waiters are.”
   No, neither are, not in the way described above. There are no standards of conduct for which a board can revoke your license to perform either of those.

9. It’s so weird how there are still doctors in other countries. And they’re competent, too! With all the doomsday scenarios from profit-driven doctors like Eric Novack, you’d think that the only thing keeping doctors around is the promise of lucre. But somehow, Britain still has doctors. Very strange.
   And to get that money, American doctors propagate a system they hate and compromise their professionalism, because they’re afraid that if they change the status quo and move to a fairer, more efficient system, they might have to give back one of their jags.

10. Matt- while I disagree with much of what you wrote— I do believe that, yes, doctors (me included) ought to ‘just say no’ to the money that binds us to the system.

11. “I’m quite objective”
    Just ask him. He’ll tell ya.
    “I think this definition of a “profession” is a good one: “An activity that involves a responsibility to serve the public, has a complex body of knowledge, has standards for admission, and has a need for public confidence.”
    “involves”??? “serve the public”??
    So professional athletes are not professionals? Interestingly though, waiters are.

12. Eric, it’s a privilege in both the literal and more meaningful sense of the world. It’s a privilege in the sense that you cannot do it without a license from the state, and it is, or at least ought to be, in the sense that you are granted authority to assist people’s lives in a very meaningful way.
    The public is the consumer. As for that bureaucrat, if you don’t want to deal with him, you don’t have to. But when you choose to take money from certain sources, that’s part of the deal. If you don’t want that money, you don’t deal with him.
    Your comparisons to slavery or indentured servitude are overwrought and add nothing to the discussion. Again, if you don’t want to be subject to certain federal regulations, don’t take federal money. YOU make the choice.

13. Matt- “practicing medicine is a privilege”
    A privilege provided by whom? For whose betterment? For whose need? Who is “the public”? Any person who should choose to show up in an emergency room at 3am because it is convenient?
    Define who “the public” is: nameless, faceless bureaucrats who like wielding power? Any person who ‘needs’ a doctor– regardless of the reason or his or her ability to actually pay for services?
    You see, Matt, that the problem of placing physicians (or other groups) abilities and intellectual property at the mercy of some unnamed person’s need can be called indentured servitude– or possibly even slavery.

14. I’m quite objective, and don’t misunderstand me. A “profession”, as it were, carries a greater responsibility to the public. Lawyers can be ordered by a judge to take indigent cases, for example.
    I am not discounting their work or its value, I’m merely suggesting that comparisons to 95% of other jobs is an imperfect comparison. I’m not just talking about “licensure” by the state, nor am I suggesting that we shouldn’t license. However, practicing medicine, or law for example, is a privilege. If you don’t feel it is, perhaps you should find other employment.
    Your disputes with health insurers, while interesting, are not really relevant, because that’s a contractual dispute between two private parties. And, if a hospital doesn’t want the law to apply to them (I presume you’re referring to EMTALA), then it doesn’t have to take federal money. That’s a choice it makes in entering into that contract.
    I think this definition of a “profession” is a good one: “An activity that involves a responsibility to serve the public, has a complex body of knowledge, has standards for admission, and has a need for public confidence.” If you don’t want the practice of medicine to be treated with reverence, reduce your standards for that of admission to those of hairdressers. However, if you want the respect, income, and ability to punish those without the license, that being given a license to practice medicine entails, then be prepared for additional demands from the public that grants you this authority.

15. You know Matt, sometimes I wonder how objective you really are about health care. Are you suggesting that the practice of medicine should be opened up to competition to anyone who claims to have the knowledge and training to perform it? That doctors are somehow “privileged” to be the only ones to practice medicine, despite having probably the longest training program of any profession in the world? So we should provide services in the middle of the night free. Get real.
    Many years ago I was on the executive committee of a hospital where Kaiser sent patients. Kaiser sent patients to our emergency room, but refused to provide its own specialists after hours to see them. However, if a non-Kaiser physician got up in the middle of the night to treat the Kaiser patient, the patient was taken away from them by Kaiser the next day and they were not reimbursed. When our exec committee invited a Kaiser representative to meet and discuss this situation, she specifically stated that the doctors were required by law to see these patients in the emergency room, and Kaiser had no plans to change anything about the situation. Here was a perfect example of deliberate manipulation of the system for economic advantage. And you wonder why today’s doctors seem resentful of people like you. I suggest you spend a week following physicians around in a hospital (yes, and in the ER at 2 a.m.) and see what it’s really like, instead of using this forum to skew other people’s views.

16. “If, however, a group receives what is in effect a sanction from the government to limit those who can perform health care services”
    What exactly can doctors limit? The only thing that is limited is surgery. Everything else can be done and IS DONE by nurses. The notion that only doctors can provide healthcare is a myth. So your entire premise is flawed.

17. “If, however, a group receives what is in effect a sanction from the government to limit those who can perform health care services, shouldn’t that group be required to go above and beyond other types of employment?”
    Mind explaining that?
    A few questions your comment raises – at least to me:
    1. The government directly limits the practice of medicine thru licensure. In your opinion, should the government be doing this? If yes, then because of its role limiting practitioners, does the government comprise a group that should be required to go above and beyond?
    2. Can you name any group of state-licensed individuals who obtained their licenses on account of their membership in a group?
    3. Are you suggesting that e.g., hairdressers or auto mechanics or anyone else who is licensed by a state also has a responsibility to go above and beyond?
    4. What does above and beyond mean? How do you know when you’re not seeing it?

18. If, however, a group receives what is in effect a sanction from the government to limit those who can perform health care services, shouldn’t that group be required to go above and beyond other types of employment?
    After all, that group enjoys the benefits of the protection of law for performing their services. Practice medicine without a license and the government will fine and even jail you.
    I’m not arguing that physicians should have to work for free at all times, however, they should have increased responsibility to the public as opposed to say, a Sears clerk.

19. Great point, Dr. Novak.
    If healthcare is a right (and I am not saying it is) the obvious question is “Against whose liberty is this right claimed?” Short run, its really cheap to answer “Against the provider’s liberty.” But as you point out, short-run might be shorter than anyone imagines. If you say “Against ‘societial liberty'” you run into serious agency problems. The short-run can be made longer by imposing more and more requirements on licensees, but at a certain point nobody will want the license anymore.
    If immediate availability is considered essential, then “Pay for Call” seems to be required on grounds of justice. Rates would vary considerably by specialty and hospital geography. I can think of a few arrangements:
    1) An hourly rate, and services are not seperately reimbursed. This amounts to a salary during call.
    2) An hourly “retainer” rate, and services are billed seperately. This amounts to a “concierge” approach to call.
    3) A blend, wherein the first case of the call shift, whatever it may be, is covered by the retainer, but subsequent cases are billed seperately.
    This last arrangement seems best to me. What barriers are there to its implementation?
    And I have another question. I can see how younger, less experienced docs might want to take call under this arrangement. But Emergency Medicine sometimes (often?) requires truly superior skills. What happens when the on-call guy needs help?
    t