Qualify for government subsidy: become a(n involuntary) unionized government employee

 Next up: doctors, section 8 housing owners, ????? Grocery stores, drug stores???

A year ago in December, Ms. Berry and more than 40,000 other home-based day care providers statewide were suddenly informed they were members of Child Care Providers Together Michigan—a union created in 2006 by the United Auto Workers and the American Federation of State, County and Municipal Employees. The union had won a certification election conducted by mail under the auspices of the Michigan Employment Relations Commission. In that election only 6,000 day-care providers voted. The pro-labor vote turned out.

Many of the state's other 34,000 day-care providers never even realized what was going on. Ms. Berry tells us she was "shocked" to find out she was suddenly in a union. The real dirty work, however, had been done when the state created an "employer" for the union to "organize" against.
Of course, Michigan's independent day-care providers don't work for anybody except the parents who were their customers. Nevertheless, because some of these parents qualified for public subsidies, the Child Care Providers "union" claimed the providers were "public employees."
Michigan's Department of Human Services then teamed with Flint-based Mott Community College to sign an "interlocal agreement" in 2006 establishing a separate government agency called the Michigan Home Based Child Care Council. This council was directed to recommend good child-care practices—and not coincidentally, to serve as a "public employer." Although the council had almost no staff, no control over the state subsidies and no supervision of the providers' daily activities, it became the shell corporation against which the union could organize.
Thus the state created an ersatz employer and an ersatz "bargaining unit" against which what was essentially an ersatz union could organize.
Today the Department of Human Services siphons about $3.7 million in annual dues to the union—from the child-care subsidies. The money should be going to home-based day-care providers—themselves not on the high end of the income scale. Ms. Berry now sees money once paid to her go to a union that does little for her. She says she is "self employed and wants nothing to do with the union."

Open Letter to AMA: I quit

Emailed to the AMA Board:
I paid my Texas Medical Association dues for 2010 but will not renew my American Medical Association membership. I do not want to be counted as an AMA member.

I dropped my membership once before due to political moves by the leadership of the AMA. I rejoined hoping to work within the House of Medicine to influence policies of the AMA. I became more active in my TMA, the Texas Academy of Family Physicians, national meetings of the AMA and the American Academy of Family Physicians and accepted the Chairmanship of the Family Medicine Section of the Christian Medical Association.

This weekend, AMA President-Elect Wilson announced support for the Reid substitute and manager’s amendment, which dropped the effort to correct the “Sustainable Growth Rate” and does not even mention (much less achieve) tort reform. Instead, current language provides billions of dollars in special deals for Democrat Senators, support for payment for elective interventional abortion in healthy mothers and on healthy babies, and an expansion of Medicaid that threatens to bankrupt my State of Texas.

The AMA leadership have told us that they hoped to protect our patients and the practice of medicine in the final legislation, just as I had hoped to influence AMA policies by lending my name and paying my dues to them. I will no longer give the AMA my name or my money, since neither of us has achieved our goal.

Beverly B. Nuckols, MD
New Braunfels, Texas

Open Letter to AMA

No Connection - Hasting Center Essays Miss the Mark

The Hasting Center has published an online collection of essays called"The Values and Health Care Reform Connection" allowing the public to comment on health care and "American Values." You have to admire the awareness of the academics - not only have they noticed that the conservative, pro-life, religious “American” is concerned with values, but they are trying very, very hard to appeal to those of us with a Judeo-Christian background. I’ve only skimmed a couple of the essays so farm but I have found a glaring inability to stay on task or a basic lack of understanding of the world view of the intended target, uh, audience.

For example, in “Stewardship: What Kind of Society Do We Want?,” Len M. Nichols misses the mark in spite of peppering the essay with terms like “stewardship,” “abundant life” and “covenant” and appeals to the writings of John Locke and Thomas Jefferson.

 (Skip over the use of a faulty, biased 2009 Institute of Medicine report on the consequences of lack of universal health care insurance in the U.S., already thoroughly debunked by Steven Malloy’s “Junk Science” blog.)

In his appeal to “American Values,” Nichols attempts to define “stewardship” to include a “covenant” as a duty of property owners to ensure that the poor have food to eat. He refers to the book of Leviticus and Jewish Law that land owners leave “the corners” of their fields for the poor to glean, rather than going back to harvest all that is there.  While noting that the rule was propagated the “other books that Moses wrote,” Nichols explains that only adult males could own land "in ancient Palestine." He would have been better off referring to the “Torah” or “the Law,” which was given by G_d, not Moses, and to the Nation of Israel, since there was no “Palestine” at that time.

Nichols almost persuades me that he “gets it” in his discussion of the basis for rights: the belief that humans are created in the image of G_d. However, he asks what good is the right to life or the pursuit of happiness without access to essential health care and quotes Jefferson’s comparison of liberty with health. He does not seem to understand that both Locke and Jefferson described these as negative rights: the right not to be killed, and the right not to be enslaved or have ‘the fruit of one’s labor” forcibly taken. In other words, no one has the right to cause another to be sick, but there is no right to medicine or medical care.

Nichols does not resort to the usual call for Christians to remember the Good Samaritan. In fact, he turns to an argument that might be more appealing to Libertarians, whom he calls “a tiny group of argumentative people.” His discussion of rights and stewardship by is converted to support for the rationing of health care, noting that Leviticus does not require the landowner to bring the poor person home and cook him a meal. In this, too, he demonstrates his lack of understanding of the Judeo-Christian world view. The covenant to care for the sick and poor is between individual believers and G_d. Government hasn’t proven itself to be trustworthy enough for me to assign my duty to G_d over to its stewardship.

LifeEthics quoted about Doctors for America posts

I've been a little distracted, getting my house ready for the New Braunfels Republican Women's Christmas Tour of Homes, but I should be blogging more in the future.

Found a post at "RBO," (RealBarackObama) that quoted my reports (here and here) on the conference call with "Doctors for America," back in September. I like being known as someone capable of "serious sleuthing."

?No self breast exams?

The recommendation *not* to teach exams throws the whole report into question for me. If we are changing the frequency of mammograms, should we also change the recommendation to do self exams? Won't the first change the effectiveness of the second?


In the news, the report by the Agency for Health Care Research and Quality. The "conventional wisdom" about breast cancer screening was turned on its head - or, at least tweaked, this week.

I think we might have been over doing the mammograms ("MMG"), but the old recommendation to do a "baseline" MMG between 35 and 40, with self exams each month and MMG each 2 years from 40 to 55 and then one a year or each 2 years according to risk, made sense to me.

What I absolutely don't get is the recommendation to stop teaching self exams. Teaching self breast exams received a "Grade D" recommendation - meaning there's no empirical evidence that the procedure is "effective." In other words, it has "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." The practice would be "discouraged" -- considered bad medicine, and actually put the doctor at risk for criticism. It most certainly won't be paid for.

There's a reason to find masses: it will change what we do, we have treatment that we can and should do for positive changes. Any mass that's fast growing and lasts over a month is highly suspicious and any mass we can feel should be biopsied. Even though the sensitivity may be low (compared to MMG), patients who do regular exams have been proven to be more likely to find masses earlier and smaller than the doc would at an annual exam, and it's non-invasive, cheap, and accessible. Teaching the self exam gives me something to talk about while I'm doing my own exam of the patient and is an opportunity to explain what I've written, above.

It looks like the fuss over the recommendation will be the first test of the realities of "Comparative Effectiveness Panels" which was funded by $1 Billion allocated in the 2009 "Stimulus Package."  Emotions and reactions are high, with Health and Human Services Secretary Sebelius,  Medicare and most insurance companies already reporting that their policies (paying for annual MMG and recommending teaching at doctors' exams) won't change. The Mayo Clinic has absolutely renounced the recommendations.

For more information on the policies of other nations, see this article.

AMA opposes marriage and "Don't Ask, Don't Tell"

November 10, 2009, delegates to the AMA interim session approved resolutions recommending that the AMA oppose same sex marriage bans, urge redefinition of marriage under federal and state laws. They also recommend the ending of the "Don't Ask, Don't Tell" policy in the military.

"Report 1" - "REPORT 1 OF THE COUNCIL ON SCIENCE AND PUBLIC HEALTH (I-09), Health Care Disparities in Same-Sex Households," is only published in the "members only" access, in advance of publication in a "peer reviewed journal." There is a specific request *not* to publish the report. However, for those of you who would like to review the report, let me know and I'll forward the pdf.

Report 1 tells us that, according to census data, approximately one third of people living in same sex relationships are uninsured, while also noting that slightly less than 1% of the US population lives in same sex households. The Reference Committee report states that "Adoption of this report further strengthens AMA policy in support of issues impacting same-sex households."

The AMA currently recommends that members be aware of and work to prevent possible health care disparities among men and women who live in same sex partnerships. However, by adopting this report, the delegates have now apparently voted to encourage a wide-spread untried and potentially unhealthy social experimentation by calling for the redefinition of marriage on behalf of 0.33% of our population in order to "support measures providing same-sex households with the same rights and privileges to health care, health insurance, and survivor benefits, as afforded opposite-sex households."

Surely, the same goal can be achieved without demanding that all States and the Federal Government change their definition of marriage.  It appears that even the State of Washington, which just voted to afford the same rights of marriage to same-sex couples, did not go far enough to make the radicals happy.



The resolution concerning "Don't Ask, Don't Tell" originally asked that the AMA oppose using any disclosure to a health care professional for dismissal. However, the reference committee recommended and the HOD approved, a substitute resolution that goes far beyond support for patient confidentiality in health care:
"HOD ACTION: Substitute Resolution 917 adopted.
"REPEAL OF “DON’T ASK, DON’T TELL”
"RESOLVED, That our American Medical Association advocate for repeal of “Don't Ask, Don't Tell,” the common term for the policy regarding gay and lesbian individuals serving openly in the U.S. military as mandated by federal law Pub.L. 103-160 and codified at 10 U.S.C. § 654, the title of which is "Policy concerning homosexuality in the armed forces.""

It's getting harder and harder to tell myself that I must continue my AMA membership in order to make a difference with in the organization. I'm beginning to be afraid that by adding to their numbers, I'm part of the problem, rather than a help.

Judge denies lawsuit to stop embryo destruction

Citing other legal rulings that embryos aren't "persons" under the law, a Federal judge (report, here ) denied the right of others to sue on their behalf or to sue to save them from being destroyed under new rules at the National Institutes of Health.

I've said it before: "law" does not a person make. "Person" is an artificial designation, made up by people who want to decrease the numbers of humans who have the right to live and by lawyers who want to control which entities (such as corporations) have "rights" bequeathed by law. Females are not "persons" in Arab nations like Saudi Arabia.

HPV vaccine adverse reports (prep for further posts)

Hwang convicted of fraud in cloning ruse

A South Korean court has convicted the perpetrator of the 2005 cloning fraud. Information here. 

Doctors pressured by scheduled Medicare pay cut

Here's confirmation from The Hill.com that planned cuts in Medicare payments to doctors are being used by Senate and White House leaders to secure support for the current health care reform bills, without tort reform.

The White House and Democratic leaders are offering doctors a deal: They’ll freeze cuts in Medicare payments to doctors in exchange for doctors’ support of healthcare reform.
At a meeting on Capitol Hill last week with nearly a dozen doctors groups, Senate Majority Leader Harry Reid (D-Nev.) said the Senate would take up separate legislation to halt scheduled Medicare cuts in doctor payments over the next 10 years. In return, Reid made it clear that he expected their support for the broader healthcare bill, according to four sources in the meeting.

and,

Reid also asked that doctors ease up on demands for medical malpractice reform during the upcoming healthcare debate. Democrats have traditionally resisted calls for tort reform, which trial attorneys — a reliable base group — staunchly oppose.

The problem with fines (mandatory health insurance)

 The Washington Post notes that manufacturers of medical devices are being accused - they haven't offered "to give something back" to pay for health care insurance for all. Because they won't play the game that President Obama's been playing with the pharmaceutical industry and hospitals, their devices will be taxed like luxuries -- and the Administration will be able to say they've saved $40 Billion dollars.

Again, how much can they save by allowing Medicare docs' 21% cut to go through at the beginning of the year? (and they'll blame the Republicans for writing the original law in 1997)

Sarah Palin writes on the problem with mandatory health insurance at her Facebook page, here.

Americans want health care reform because we want affordable health care. We don’t need subsidies or a public option. We don’t need a nationalized health care industry. We need to reduce health care costs. But the Senate Finance plan will dramatically increase those costs, all the while ignoring common sense cost-saving measures like tort reform. Though a Congressional Budget Office report confirmed that reforming medical malpractice and liability laws could save as much as $54 billion over the next ten years, tort reform is nowhere to be found in the Senate Finance bill. [17]

Here’s a novel idea. Instead of working contrary to the free market, let’s embrace the free market. Instead of going to war with certain private sector companies, let’s embrace real private-sector competition and allow consumers to purchase plans across state lines. Instead of taxing the so-called “Cadillac” plans that people get through their employers, let’s give individuals who purchase their own health care the same tax benefits we currently give employer-provided health care recipients. Instead of crippling Medicare, let’s reform it by providing recipients with vouchers so that they can purchase their own coverage. 

Aristotle ethics, RFK, and health care reform

The Wall Street Journal's daily newsletter by James Taranto, The Best of the Web Today, debunks a quote floating around the Internet to support the "right" to health care paid for by government. The blurb has been attributed to a translation from the writings of Aristotle, a translation from the original Greek by Robert F. Kennedy.

Unfortunately, the first reference to the quote is from 10 years after Senator Kennedy died, is credited to someone else, and the original cannot be found in the existing works of Aristotle.

From an article by Edmond Pellegrino, the last chairman of President Bush's President's Bioethics Council, written in 2008:

In attempts to establish the provenance of the text in question we have conducted an extensive search for its source and original wording. We have not been able to locate it. Our initial curiosity was aroused by several things, including that rights language did not seem to have the Aristotelian context, and health care, as such, was not included in Aristotle's works. We searched Nicomachean Ethics and Eudemian Ethics, and the Magna Moralia without successfully locating the quote. Nor could we find it in other of works of Aristotle: On Length and Shortness of Life, De Anima, Economics or the Fragments. "Rights" language certainly would stick out in Aristotle's virtue-based ethics.

That article by Dr. Pellegrino is available in pdf, here, thanks to the WSJ and Georgetown Bioethics.

Intentionally Skewed Cancer Survival Rates

 From Ann Coulter's latest report on Health Care Reform Myths:

European women are only 55.8 percent likely to live five years after contracting any kind of cancer, compared to 62.9 percent for American women.
In five cancers -- breast, prostate, thyroid, testicular and skin melanoma -- American survival rates are higher than 90 percent. Europeans hit a 90 percent survival rate for only one of those -- testicular cancer.
Most disturbingly, many cancers in Europe are discovered only upon the victim's death -- twice as many as in the U.S. Consequently, the European study simply excluded cancers that were first noted on the death certificate, so as not to give the U.S. too great an advantage.

I didn't know about that last manipulation of the cancer survival rates. 

Don't laugh: Nanoparticle rub for impotence

The next addiction? The next big scare? Most definitely the next big joke.

What about the man's sperm? And what about the female partner? How much of a dose will she and her DNA receive.

What are nano particles, anyway? (Don't answer that, I know the text-book answer.)

There is a report of a new topical cream that delivers medication by using nanoparticles to deliver the drug - such as nitrous oxide, in the case of impotence - through the skin.

Just think about the marketing technology: beauty, sex and the latest nanomedicine.  And it doesn't hurt (that we know of).


Get ready to mute your TV if the kids are in the room. The jokes will be risque,' to say the least.

Science Knowledge Quiz

The Pew Research Center for the People and the Press has a 12 question quiz on general science knowledge.

Take the test, here, and tell me how you did.

(I got them all right.)

(Did I mention that doctors are current or former nerds who "aced" every class - at least until med school? In med school, a few of us took an ego hit. I learned to study that first fall.) (And, now, I'm learning to deal with not being a "swift" as I used to be: ADHD mind in a 50-something body.)

Politics bites science

For a clear outline as to why you shouldn't believe that 45,000 people die each year because they don't have insurance, read the blog entry by John Milloy, publisher of "Junk Science" on last week's report in the American Journal of Public Health.

Forget that the authors are blatantly biased members of the "Physicians for a National Health Plan."

All you need to know is:
# Among the many problems with the study, here are four of the most glaring; all of which will likely be missed by the media:

* The researchers assumed that study subjects lacking health insurance at the time of the interviews did not subsequently gain or regain insurance coverage. In fact, a study subject could have received health coverage the very next day after the interview and this would not have been considered by the researchers.
* The researchers essentially assume that lack of health insurance at the time of interview is the causal factor in the deaths that occurred. No data was gathered to back up this assumption.
* None of the data collected during the interviews, including insurance status, was validated by the researchers.
* The study result is statistically weak. Combined with the peculiar date-of-death cutoff (the year 2000 as opposed to any other year), it raises questions as to whether the study result was produced by “data dredging” – essentially cherry-picking data that provides the desired result.

Obamacare-Point and Counterpoint

One of the best reviews of "Obamacare" I've seen.

Obamacare-Point and Counterpoint

Shared via AddThis

Follow up from Doctors for America

Received this message a few minutes ago.

The only people who kept bringing up "what physicians can be doing now to ensure that Congress pushes forward to create meaningful health reform" were the same guys who made sure that the rest of us were on "listen-in" mode only.

Still no mention about the close connections with Senator Max Baucus, the Obama election and transition teams, the Center for American Progress and John Podesta, or (specifically) Dr. Murthy's own role on the transition team.

If y'all would like to send your comments on to the WH Office of Public Engagement or D4A, here's the information:

-------- Original Message --------
Subject: Follow up on last night's White House call
Date: Fri, 18 Sep 2009 16:19:57 -0400
From: Vivek Murthy MD MBA, Doctors for America
To: hocndoc@flash.net

Dear Beverly,

Thank you for participating in last night's White House Physician's call. In particular we want to thank you for all of the thoughtful and substantive questions that you brought us. We hope those of you who didn't get an opportunity to ask a question during the call will still do so.

For those who didn't catch it last night, the e-mail given for the speakers on the call is: public@who.eop.gov

In recognition of the fact that the White House may not be able to reply to all e-mails expeditiously, we welcome you to cc us as well, and we will do our best to get you up-to-date information.

One of the topics that came up a few times last night is what physicians can be doing now to ensure that Congress pushes forward to create meaningful health reform. At Doctors for America, direct involvement of physicians is exactly what we do. If you haven't done so already, we welcome you to become more involved by filling out our volunteer form.

Sign up to volunteer: www.drsforamerica.org/volunteer.php.

In addition, we've created a video on our Action Center to highlight some of the things that you can do today to help ensure we take critical steps towards a better health system this year.

Watch the video to learn what you can do: www.drsforamerica.org/action_center.php.

Thank you again, for your participation and for your ongoing commitment to health reform.

Sincerely,

Vivek Murthy, MD MBA
Doctors for America

Playing doctor with the White House

Who’s playing doctor with the White House: Another example of the lack of openness in the dealings of the Obama Administration

(Informed consent blurb: Organizing for America, etc., along with all the White House websites, are collecting data including email and other information from everyone who visits or contacts their sites. I got a couple of those emails from David Axelrod last month.

Don't worry - they already have my data. I used to email President Bill Clinton at least once a month and ask him to resign for the sake of our daughters – they are about the same age - because he'd set the women's movement back 50 years. He never answered. However, it occurs to me now that maybe that's why I was named to the Bush Administration's National Advisory Committee on Violence Against Women.)

On Thursday, September 17, 2009, I was web-surfing and searching Google news hits on the September 12th March on Washington and health care reform when I found information about a conference call between "Doctors for America," the White House "Office of Public Engagement" and doctors like me who somehow found out about the conference call.

I called in, but wasn't called on to ask my questions, so I re-wrote them as an essay (see below) and emailed it to info@drsforamerica.org I'm also sending the essay to the White House OPE.

When I started writing up my notes from the call, it finally occurred to me that – even though there was no attempt at disclosure - there might be a connection between "Drs for America," "Organizing for America" (whose website address is still "http://www.barackobama.com/ ," the same url once used by - and the remains of - “Obama for America,” the Barack Obama campaign machine.

I was slow to catch on, but I was right: The leadership at Doctors for America is made up of nearly the same roster of men and women who, in 2008, were the leadership of “Doctors for Obama” in 2008. Common names are Vivek Murthy, MD MBA, Mandy Krauthamer, MD MPH, Nikhil Wagle, MD, Alex Blum, MD, and Jay Bhatt, DO MPH

And, I was wrong: there’s a disclaimer at the bottom of the “Doctors for Obama” leadership page that says “Not affiliated with Obama for America.” (Yeah, right.)

In fact, former Obama Administration transition chief John Podesta's “Center for American Progress” funds the group :

May 04, 2009
'Doctors for America' launches

This may not wind up being decisive in the health care fight, but the organizing gap between the two sides continues to widen.
Sen. Max Baucus and the Center for American Progress Action Fund are announcing a new group on a conference call later this morning: Doctors for America, which is a reincarnation of Doctors for Obama, an arm of the Obama campaign that boasted more than 10,000 members.
The question of patients' relationships with their doctors is always a flashpoint in debating changes to the health care system, so doctors are often particularly credible messengers.
Today they'll "release new reports detailing the depth and breadth of America's health care crisis and announce a new effort to amplify physicians' voices in support of health care reform," according to the advisory.
By Ben Smith 11:07 AM

Here's the bio on the President and Co-founder, Vivek Murthy, MD MBA, at the Center for American Progress website:

Vivek Murthy is an internal medicine physician at Brigham and Women’s Hospital and an Instructor at Harvard Medical School. He received his undergraduate degree in Biochemical Sciences from Harvard University, his MD from the Yale School of Medicine, and his MBA from the Yale School of Management. He completed his residency training in Internal Medicine at Brigham and Women’s Hospital. Vivek is the co-founder of VISIONS and the Swasthya Project, international health non-profit organizations focused on HIV/AIDS education and women’s health, respectively. He is also the co-founder and chairman of Epernicus, LLC a web-based professional networking service for individual researchers and scientific institutions. Vivek’s past research has focused on the participation of women and minorities in cancer clinical trials; his current research interests include physician satisfaction and burnout. During the 2008 presidential campaign, Vivek served as a member of the Obama Health Policy Advisory Committee and the Obama New England Steering Committee.

Notes on the Conference Call

I couldn't catch all the names and I am not very good at telling who was speaking, but did try to take some notes from the opening statements. The quotations are the actual words of the speakers, the rest is my own interpretation and from memory.

The moderators talked about the "public option" as though it's a done deal and strongly pitched it as just a way to provide health care for people who have lost their insurance.

We were told that everyone will be required to have insurance, and that businesses will be asked to "chip in their part."

The White House has a plan to fix the SGR that has been pushed off over and over. In fact, there are plans for a “complete reform of the physician payment system.” without incentives for doing more procedures.

The President has given instructions to begin the medical liability demonstration projects to find a way to decrease defensive medicine while "mitigating risks to patients."

We were told that we are closer than we've ever been to health care reform this year.

The moderators were surprised by the second doctor who said he was from the former Soviet Union and that the public option would soon become the only option. They were adamant that the public option is not a pathway to single payer. (And besides, we all know that being paid by and regulated to the teeth by the government is not at all like working for the government.)

Later, one of the docs who called in asked specifically about the news stories that the public option was finished and the White House representative reminded us that the legislation is not written, yet. He was adamant that we shouldn't rule the public option out and that we should advocate with our patients and fellow doctors for that option.

One doctor asked about the effect on doctors with concierge or boutique practices and the other doctors who "opted out." The answer from one of the men was that these practices were just a reaction to cash pay patients who couldn't afford insurance.

There was a lot of excitement about one doctor's suggestion that doctors be required to give two years to a sort of National Healthcare Workforce. And huffy about the shortage of doctors that a Massachusetts doc reminded them that they'd have if all the uninsured were suddenly looking for primary care.

The woman naturopath was reassured that naturopathic primary care doctors would be evaluated by the same evidence based medicine that the traditional docs were judged by.

My letter to Doctors for America and the White House Office for Public Engagement

I’m Beverly B Nuckols, MD, the National chair of the Family Medicine Section of the Christian Medical Association as well as a member of the AMA, the Texas Medical Association and the American Academy of Family Physicians. I'm not officially representing the above, but I believe that my opinions are shared by a large number of doctors.

Many of my colleagues and I see the Patient Centered Medical Home plans, the protocols at Mayo and other medical centers that have been praised are attempts to model a bureaucratic form of practice for large practices so that they can do what the family doctor does every day.

My experience is that government bureaucracy is not only more restrictive and punitive than private insurers, the clout of the Federal government results in undesired UNINTENDED consequences all across the board. Doctors used to be the good guys, but now we feel as though we are assumed to be guilty of abuse of the system, largely due to Federal legislation and regulation.

These result in time and money spent on our futile attempt to keep up with Medicare regulations in order to avoid charges of fraud, abuse and waste. For instance: HIPPA, National Provider Identification numbers, bullet points and check boxes, E & M’s, procedure and diagnosis codes and qualifiers that change each year, and a whole alphabet soup of regulators.

In addition, government cost control attempts in the '90's actually limited the numbers of graduate medical slots, while encouraging sub specialty growth in relation to numbers of primary care doctors.

Making it all worse is the fact that under current Medicare payment schemes, Family Doctors who provide the same services as sub-specialists are paid less by Medicare.

Like the laws and regulations in the past, this year's “reform bills” and proposals are overly complicated and try to guarantee too much: school based clinics, nutrition data on menus and buffet lines, an overhaul of the federal income tax code, new lists of “enhanced penalties,” taxes, fines and the mixing of all of the above abuses with an overhaul of the Federal Income Tax.

Today’s announcement about the study of liability makes me worry that our Texas laws concerning tort reform will be over come by Federal inertia and interference.

1. Why not just look at Texas’ experience with tort reform rather than wasting time and money on new studies?

2. Is it possible to make the legislation smaller in scope so that it is focused on providing help for those patients and families who cannot afford or access medical care?

3. What plans are there to ensure training and sufficient payment for family physicians and other primary care doctors who are in the best position to coordinate care for our patients in the "Medical Home?"

Edit: added this 4th question that I believe I sent to Doctors for America:

4. Could the fines and mandates be replaced with tax incentives, removal of restrictions on Health Savings accounts, return of the major medical plans and the removal of the barriers preventing patients from owning their own health care insurance?

Comments on President's 9-9-9 speech

You can read the speech, here.

As of 8:30 AM on September 10, there's not much comment from the AMA or other powerful, interested observers. I wonder if, like me, they're waiting to see the actions that result from the speech?

Here are my own(Beverly Nuckols) thoughts after the speech:

Quality, timely, or cheap medicine: Pick two. If you think you can have all three, please, tell Walmart how to do it.

The President is still talking about mandating that everyone buy insurance. He still ties it to employers and there is no mention of tax breaks for individuals who buy their own insurance. (Will companies still be forced to ensure dependents, and will "children" include adults to the age of 26?)

Instead, we hear about fines and new taxes, and more negative comments about profit-seeking companies and "the wealthiest Americans."

First, show me the wording in the actual proposed Bill, give me time to read and understand it and reassure me that you’ve read it. Will that wording be clear on the various promises?

Second, let’s get this straight: tax cuts don’t cost the government, taxes cost the taxpayers. If the government wants more money, give incentives to those who earn money that you tax. Don’t punish them by taxing them at higher rates! If the government has less, the government should do what the rest of us do: cut what you spend!

It seems illogical to me to tax insurance companies for offering "the most expensive plans." These are plans that people decide to buy for themselves. The only result of such a tax would be to kill the "expensive plans."

If the government mandates well care for everyone, there will not be enough manpower or other resources for sick care. If you mandate the addition of both numbers of people and services to the health care that is paid for not only by private funds but public funds, you will increase costs and demand.

Show me the “patient safety trials” that will decrease defensive medicine. As to the tort reform and "trials" to allow doctors to practice with less concern about lawsuits, I suggest that the President simply look at Texas since our own tort reform passed in 2005.

President Obama promised that abortion will not be funded by federal funds and that the current conscience laws will remain in place. Does this mean that no mandates for private insurance to cover abortion will be allowed? Does this mean that he will enforce the conscience laws that exist?

We must remember that the President signed an Executive Order in his first week to fund organizations that pay for abortions and referral for abortion overseas and who overturned the last Administration’s ruling to affirm the enforcement of conscience laws. What will he do in the face of the House’s passage of a Bill that will fund abortions in Washington, DC?


Cross-posted at Comal GOP blog.

Global Warming Ate the Science

The next time you hear about anthropogenic global warming or global climate change, demand to see the data. It no longer exists.

I've been a skeptic all along, because I remember the warnings about the "coming ice age," that I read in my "Weekly Reader," back in grade school. (In the dark ages of the 60's and 70's.)

This is not science, people. The proper scientific method involves the reporting of detailed, open, and reproducible modes of collecting data. Little black boxes - in which numbers are cooked without access to the raw data by colleagues and even rivals - are not allowed.

The United Nations organization that oversees climate change or global warming is the UN's Intergovernmental Panel on Climate Change (IPCC). The IPCC uses data (if you can call it that) from the Climate Research Unit, or CRU. In fact, the CRU apparently only releases numbers that have been collated and "adjusted."

After years of refusing to turn over the raw data and releasing only modified numbers, Phil Jones of the CRU reports that the organization has lost all the old data that was used to prove global warming.

From the UK's Register, "Global Warming Ate My Data":

The world's source for global temperature record admits it's lost or destroyed all the original data that would allow a third party to construct a global temperature record. The destruction (or loss) of the data comes at a convenient time for the Climatic Research Unit (CRU) in East Anglia - permitting it to snub FoIA requests to see the data.

The CRU has refused to release the raw weather station data and its processing methods for inspection - except to hand-picked academics - for several years. Instead, it releases a processed version, in gridded form. NASA maintains its own (GISSTEMP), but the CRU Global Climate Dataset, is the most cited surface temperature record by the UN IPCC. So any errors in CRU cascade around the world, and become part of "the science".

Professor Phil Jones, the activist-scientist who maintains the data set, has cited various reasons for refusing to release the raw data.

Forget conscience - go straight to mandate

Human Events has an editorial from Christian Medical And Dental Association's Jonathan Imbody.

Here's an excerpt:

A national poll showed that Americans favored the “conscience clause” regulation and the civil rights laws it enforced by a two-to-one margin. During a 30-day public comment period, an astounding 340,000 comments and petitions poured in favoring the regulation.

The White House and Congress ignored public opposition, and instead moved even more aggressively to evolve abortion from a choice into a mandate.

Besides the House bill opening the door to mandated abortion coverage in all health insurance plans, the House of Representatives in July voted to force taxpayers to fund abortions in the District of Columbia. The Senate is now eyeing publicly funded abortions under the eight million-member Federal Employee Health Benefits Program.

In each of these actions, the President and Congress tacitly assert that abortion ideology trumps the conscience rights of taxpayers, patients and health professionals like Katrina Belova.

"I became very concerned when I learned about President Obama’s plan to rescind the conscience clause," Katrina said. "It made me uneasy to think that my adopted country, which was always proud of its democratic heritage, had begun to remind me of a communist country my family fled ten years ago.

"If the conscience rule is rescinded and I am obligated to choose between performing an abortion or losing my job, I will choose the latter. And then where will I flee next?"[vii]

Former Senator Explains Consequences of Bill Language

Former Senator from Tennessee, Fred Thompson, explains the consequences of the language concerning end of life care that is included in the current version of House Bill 3200.

I do read the language as making the counseling mandatory, although not necessarily a demand that doctors (or nurses, if they are the "primary care providers") tell a patient that they must refuse or be willing to withdraw medical intervention at the end of life.

Of course, there's the pesky problem that no one has written the approved counseling language or produced the approved documents, yet. That will be done by "the Secretary," if and when the Bill passes with this provision still in place.

Here's what I think happened: the Committee or staffer who wrote that section thought that offering payment for what was mandated in the "Stimulus bill" earlier this year would be a politically advantageous move.

However, since no one knows what will actually be required by the Secretary of Health and Human Services, and there is no note as to which doctors will be responsible to counsel patients, I forsee a repeat of the confidentiality snafus and stumbling blocks that happened after the "HIPAA" became law. Remember when every single doctor and pharmacy had each patient sign a disclaimer, no one knew who could talk to whom, and a whole lot of money, time and energy was wasted making sure that you knew that the provider knew that the government wanted us to keep your medical information private - at least from everyone except the government agencies who demanded documentation, ICD-9 and CPT codes and qualifiers?

Here's Senator Thompson's essay:

FRED THOMPSON: Phantom pains at The Post

Fred D. Thompson

A Page One article in Saturday's Washington Post blaring the headline "Talk Radio Campaign Frightening Seniors" states, "A campaign on conservative talk radio ... has sparked fear among senior citizens that the health care bill moving through Congress will lead to end-of-life 'rationing' and even 'euthanasia,' " and that the bill has been described as "guiding you in how to die."

The story's continuation inside -- under the headline "Conservatives Have Seniors Fearing 'Euthanasia' as Part of Reform" says that, like arguments about abortion coverage, this has become a distraction to the president's broader health care agenda.

The reader looking for examples of this "talk show" campaign will be disappointed. Not one talk-radio host is quoted, and no specific radio show is mentioned (though The Post does quote an interview done on my radio show, without telling the reader the interview was done on a radio show). However, the article does make use of information supplied by off-the-record "Democratic strategists." One is free to conclude for oneself who has launched a "campaign."

It does seem that the words attributed to unnamed conservative culprits are fairly mild compared to the hysteria coming out of left-wing Web sites and blogs. My favorite is the one found on the Huffington Post, where Republicans are accused of saying that granny would be shot in her wheelchair under a provision in the Obama-Pelosi-Waxman health care bill.

Let's discuss whether these deranged seniors are being misled by people who actually may have read the bill. (Presumably this offense cannot be laid at the feet of their representatives of Congress.) Although I have never said anything like the things attributed to radio talk hosts, the article states that "the attacks on talk radio began when Betsy McCaughey ... told former senator Fred D. Thompson (R-Tenn.) that mandatory counseling sessions with Medicare beneficiaries would 'tell them how to end their life sooner' and would teach the elderly 'how to decline nutrition -- and cut your life short.' "

The basic position of the bill's proponents seems to be that these consultations are totally voluntary, that seniors should have the benefit of such end-of-life consultations and that the consultation provision is nothing more than to get doctors reimbursed when a consultation occurs at the patient's request. The "let's get the doctor paid" rationale was swallowed whole by The Post's writer, Ceci Connolly.

Those concerned by this provision believe it to be mandatory and wonder why the government is involving itself in the doctor-patient relationship and with end-of-life decisions.

Section 1233 of the bill, having to do with Medicare, describes the "advanced care planning consultation" as between the individual (a spouse and next of kin are not mentioned) and a "practitioner," described as a physician, a nurse practitioner or a physician's assistant. (It does not appear that it is a requirement that the physician in question be the patient's physician of record.)

In legislation, an issue as to whether an action is mandatory or not can be resolved quickly by a glance at the statute, which will state that (in this case) the consultation either "shall" be taken or "may" be taken. Remarkably, neither phrase is used in the statute in question.

Rather, the statute just describes what a consultation is and then strictly prescribes in mandatory language what must be included in the consultation as well as what may be included. For example, in Paragraph 4, a consultation "may include the formulation of an order regarding life-sustaining treatment" and may include an order for "the use of artificially administered nutrition and hydration."

The drafters of the provision were either sloppy, befitting a situation in which a complicated, 1,000-plus-page bill, controlling one-sixth of the economy, is rushed through the legislative process. Or it might be that the drafters desired an intentionally vague statute, knowing administration officials would be drafting regulations for the implementation of the bill after it passed.

As it stands, there is more than ample reason to believe the provision was meant to be mandatory with regard to the practitioners. Otherwise, why have the provision in the bill at all? If getting the doctors paid for a voluntary consultation really was the provision's intent, an amendment of two or three lines would have fixed it. As it is, it is two lines in a five-page provision full of specific instructions about what doctors, nurses or doctor's aides must explain to the patients.

Seniors are reminded daily by the media that Medicare is going broke, that the country must cut Medicare costs and that the last days of life are by far the most expensive. Now they are being told by the administration -- one that has been less than transparent on this bill and a host of other issues -- that this bill will cut Medicare costs. They are learning that they are "coincidentally" being asked about end-of-life issues at the government's behest, perhaps by a stranger who is receiving Medicare reimbursement payments. How long do you think it will take a Medicare patient to figure out which decisions will cost the government money and which will save the government money?

This is no reflection on medical professionals. They clearly are being put in a position they neither have asked for nor are completely qualified for. However, I am gratified that a president who can matter-of-factly accuse doctors of routinely removing a child's tonsils solely for financial gain has newfound trust in a doctor's or some hospital employee's ability to consult and even help draw up legal documents regarding end-of-life issues.

If this is all just a misunderstanding about whether this provision is mandatory or not, it can be resolved readily. Let's see if the supporters of the provision are willing to add language to the bill making it clear that there is no requirement that these consultations take place. Better still, they should drop this provision from the bill and let patients discuss these matters with their families, their clergy, lawyers who have expertise in living wills and powers of attorney, or whomever else they desire.

So is this a conspiracy to kill off granny? No. Will seniors be forced to make decisions they don't want to make? No. But will "practitioners" be encouraged to have end-of-life discussions that include when it might be best for patients to allow their life to end earlier than it has to? Of course. And seniors have a right to be satisfied that there is not, at the heart of this process, undo consideration given to cost-cutting.

In the end, it depends on how comfortable one is with having the government in the middle of this process. That is what this discussion is really all about.

Fred D. Thompson, a former Tennessee Republican senator, hosts a nationally syndicated radio show (www.fredthompsonshow.com).

Robin Alta Charo named FDA advisor

The University of Wisconsin at Madison has announced that Robin Alta Charo has been named senior adviser to the Commissioner of the Food and Drug Administration.

You'll remember lawyer/ethicist-for-sale Charo. She's the one who sees no problem with sex-selection abortion and who called President Bush's Council on Ethics the "endarkenment." She protests anyone following their consciences, especially religious physicians.

Page 425 (end of life counseling)

I received several emails over the last few days concerning page 425 of the House Bill on Health Reform, HR 3200, which outlines mandatory end of life "options" counseling.

Technically, it appears on the surface to allow doctors (and other "providers") to charge for the counseling. But, yes, it's mandated counseling and in the wrong hands, it might encourage withholding of care more than some of us would like -- and certainly more that others might like.

Can you imagine a more personal and private subject? The subject should be broached by your family doctor. But it appears that every doctor who sees Medicare patients will be responsible. I can imagine the emotional undertones of different doctors as they recite the standardized language and present the forms to be signed! And then, the counseling will be reported to the Center for Medicare and Medicaid Services, with the appropriate modifying code.

I object to the mandated repeat counseling when someone gets sick, the inclusion in the "Medicare and Me" handbook with language to be formalized by the Secretary and forms for the counseling. I've mentioned before how "hot" an issue this could be, even with my limited exposure to the debate.

I hope that someone with sensitivity is in the Secretary's office, assisting with decisions on the literature and forms.

ABC explains the Obama Administration

ABC News Senior White House Correspondent Jake Tapper has written an article, "When Academic Words Become Political Ammunition," that gives an anonymous "White House official's" rebuttal to the many concerns expressed about President Obama's choices for advisers and "czars" who will affect the shape of health care policies. He attempts to debunk criticisms of the philosophies of Ezekial Emanuel, MD (a bioethicist who is heading the push for control of health care finance and delivery in order to provide universal insurance) and John Holdren, director of the White House's Office of Science and Technology Policy.

The problem is that with Medicare and Medicaid, about half of medical care in this country is already paid for using tax dollars, and we are currently considering expanding tax dollar payment for nearly all health care in the Nation. I disagree with Ezekial Emanuel's position, referenced in the Hastings journal article, "Where Civic Republicanism and Deliberative Democracy Meet," which is linked (in pdf) at Tapper's essay:

Americans fear that if society guarantees certain services as "basic," the range of services guaranteed will expand to include all - or almost all - available services (except for cosmetic surgery and therapies not yet proven effective or proven ineffective). So rather than risk the bankruptcy of having nearly every medical service socially guaranteed to all citizens, Americans have been willing to tolerate a system in which the well insured receive a wide range of medical services with some apparently basic services un- covered; Medicare beneficiaries receive fewer services with some discretionary services covered and some services that intuitively seem basic uncovered; Medicaid beneficiaries and uninsured persons receive far fewer services.

In fact, while we are concerned about the amount of taxes that will be imposed, the Tapper essay points out that we are very much afraid that government interference in health care will result in more limitations, so that none of us will be allowed, much less "guaranteed," to seek medical care that will prolong our lives and make us feel better, unless we are seen as members of a group that is more valuable than others. The examples that Dr. Emanuel gives and our observation of the government pre-paid medical care schemes around the world lead us to believe that, the more health care is financed by tax dollars, the more expensive and rationed it becomes.

Academic mind experiments that do not draw a line between what is acceptable and what is condemned by the authors understandably will be interpreted by others as at best, neutral, at worst, in support of condemnable acts.

Congressman Henry Cuellar on Planned Parenthood

Went to this morning’s McQueeney, Texas meeting where Henry Cuellar was met with an overwhelming group of constituents upset over what's happening in Washington, DC.

Rep. Cuellar told us that he voted in favor of Planned Parenthood funding yesterday because they give care to “mothers” and he does everything he can do to support mothers. (I suggested that we go to any PP office today and that I bet no mothers come out of the building.)

The people of Guadalupe County- maybe 100 to 150? - turned out to protest the health bill and tax and cap. There were some tough questions about gas prices and about whether private insurance will survive.

People laughed when Cuellar said the bill is “revenue neutral.”

Believe it or not, the man was adamant that he has good private insurance and that he wants to keep *his* private insurance! Why not put all the government employees on Medicare or the VA (depending on their background). Why do we give and give so that our employees can have better benefits than we can afford?

He constantly talked about organizations and corporations that supported the bills, ignoring that the constituents in front of him do not. He handed out paper after paper (how green is that?) supporting the health bill and tax and cap.

He talked against the Blue Dogs, but did say that he wouldn’t allow Pelosi to bring the bill to a vote by bypassing the Committees.

Myth: doctors take out tonsils needlessly

Then, there's the charge that doctors will needlessly take tonsils out. First, it's unlikely that your Family Physician or Pediatrician does surgery. Second, I don't think the ENT's are getting paid for these anymore, unless they jump through hoops to prove that they're not over-doing it.

AP: In trying to rally support for health care overhaul, Obama described a patient who sees a physician for a sore throat, or a parent who brings in a child with a sore throat.

"Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. ... The doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out,'" Obama told a prime-time news conference.

The president added: "Now, that may be the right thing to do, but I'd rather have that doctor making those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change — maybe they have allergies. Maybe they have something else that would make a difference."

Video and here.

Obama Press Conference Transcript

The transcript of the press conference is on line at the Washington Post.

However, if you want an annotated version, try this blog.

Thoughts on Obama's health speech July 22, 2009

Why doesn't the President just say that the Executive branch employees in his Administration will get rid of their insurance and go on Medicare???

Not a doggone thing that the President is talking about tonight - except for the taxes, the increased bureaucracies and the requirements that Pharmacy companies discount meds - is in the Bills that are being proposed by the House or the Senate.

The government is not paying for those private insurance costs -- the tax cuts for insurance is not the burden that will break the federal budget.

(And by the way - the White House is the people's house. It's only being used by this man.)

Ann Coulter on government Health Care finance

On the other hand, there's Ann Coulter's take.

Give Ann a chance, here. She makes some very good points.

Addendum -- Including this one:

Now the Democrats want to force us all into one gigantic national health insurance plan that will cover every real and mythical ailment that has a powerful lobby. But if you have a rare medical condition without a lobbying arm, you'll be out of luck.

What works and what doesn't

Art Caplan has written his two cents worth about the health care reform push. Dr. Caplan needs to read the current bills being hashed out in the Senate and the House. The House bill is over 1000 pages. (The expectation is that, like the last 3 Big Bills, the actual final version will appear in the wee hours of the morning, hours before the final vote.)

First, what President Obama is talking about is prepaid chronic care and catastrophic care. These should be addressed separately. Most people can pay for their own physical and for their own blood pressure medicine -- just ask the majority of the Medicare "covered" who saw their deductible go up this year and who hit the "donut hole."

Or ask the veteran who has a job that offers private insurance.

In the '90's, when I was in med school and doing my residency in Family Medicine, the VA was not the stellar government medicine that Art thinks it is today. And the requirements for coverage - who was "service connected" - were constantly being tightened. Men who should have been covered because of their service in WWII and Korea found that the only way to get care was to show up at the ER and wait their turn.

All of the paper work and regulatory hassles - especially the risk of "fraud and abuse," now "fraud, waste and abuse" - that I've faced in practice are the result of Federal laws interfering in normal practice: 1968 then 1974, on through the amendments to the Social Security Act in 1997.

I certainly hope that the powers that be will offer a "basic plan" that is really a basic plan. I know that it cost much less to insure and care for my family back when we had major medical insurance. However, I doubt that the various special interest groups will allow that. The bills mandate that pap smears, mammograms and "preventive services" will be provided at no cost to the patients. No copay, no coinsurance. No deductibles.

This means that we docs will be under pressure to do everything at "preventive visits." However, the House bill mandates qualifiers and diagnostic codes for all services.

Didn't that complicated chart originate from one of the Democratic proponents of health reform?

If you do ask your doctor about the paperwork and hassles, ask them whether they'd rather fight Medicare or United Health.

If Medicare truly has a lower administration cost, it's because laws and regulations shift the burden to your doctor and the hospital social services and patient advocates.

When I run up against a Blue Cross or Humana requirement that I disagree with, I can argue with the Medical Director or even drop their plan and see their patients outside of the plan for cash. However, if I disagree with a Medicare ruling that I can't admit my 82 year old who's falling, has a low potassium level, is running a fever, and has a bladder infection unless he's septic as defined by Medicare, there's no doctor to talk to. There's thousands of pages of regulations each year and that risk of "fraud and abuse."

Another difference - the government is not paying for those private insurance costs. If they will leave us alone, the insurance costs will either cut their growth or price themselves out of business. If the government increases its payment by the plans proposed in the House and the Senate, the costs will simply grow as they have.

These costs will be added to the 23 Trillion dollars our grandkids already owe.

Mayo Clinic calls health care plans bad medicine

I've always said that if the Mayo Clinic docs were so smart, they'd come to Texas where it's warm and they can golf year around (like their patients who visit us from October to April).

Nevertheless, doctors at Minnesota's Mayo Clinic have come out against the current plans for health "reform." They are joined by the US Chamber of Commerce.

And then, of interest to those of us who are pro-life, there's the President's assertion that he will leave the decision to pay for abortion up to the "experts."

The President's history of overturning restrictions on federal funding of abortion and of regulations strengthening the conscience rights of medical professionals does not back up his assertion that his administration will not support abortion by federal health care funding.

How many pro-life doctors will he put on the MedPAC???

Governor Jindal reminds us how FEMA helped flood insurance

You may not be aware that the only way to buy flood insurance is through FEMA, the Federal Emergency Management Agency. In fact, the Agency draws the lines for the Flood Plains and so, decides whether you need flood insurance.

Executive Order 12127

President Carter's 1979 executive order merged many of the separate disaster-related responsibilities into the Federal Emergency Management Agency (FEMA). Among other agencies, FEMA absorbed: the Federal Insurance Administration, the National Fire Prevention and Control Administration, the National Weather Service Community Preparedness Program, the Federal Preparedness Agency of the General Services Administration and the Federal Disaster Assistance Administration activities from HUD. Civil defense responsibilities were also transferred to the new agency from the Defense Department's Defense Civil Preparedness Agency.
John Macy was named as FEMA's first director. Macy emphasized the similarities between natural hazards preparedness and the civil defense activities. FEMA began development of an Integrated Emergency Management System with an all-hazards approach that included "direction, control and warning systems which are common to the full range of emergencies from small isolated events to the ultimate emergency - war."

As we learned in 2005, the centralized bureaucracy is not the most efficient method of responding to the disasters of flooding. (It might have helped if the former Governor had allowed earlier response.)

Governor Jindal discusses possible "bipartisan" health care reform measures, here.

Redefining, Reducing and Rationing Health Care

Peter Singer, in his op-ed for the New York Times this weekend, seems to be unaware of the difference that our mobility in the United States - both in geography and society - can make. We have choices, can call on friends and family and/or gain sympathy of the wider community (as demonstrated by the pink ribbons on so many cars and products) to obtain what we need and sometimes what we want. (Hear those Rolling Stones in the background? )

I don't expect perfect this year, but I'd sure like to have more options than Pelosi, Rangel, Waxman and Kennedy seem to allow. And, like many other Americans, I'd be more reassured if the Speaker and the House Ways and Means Committee would agree to sign up for the "public option" and if Ted Kennedy would accept the same rationing he's proposing for the rest of us. (No Chappaquiddick health care jokes, please - but isn't he aware that he's going to need readmission to the hospital soon? And don't you think the anecdotes he tells are ironic?)

Or, if the President could get his budget report out on time.

However, the AMA has endorsed the House Bill (no number, yet) as unveiled last week, in spite of the fact that the definition of "primary care provider" includes nurse practitioners. The White House immediately began pushing for cuts in physician payments to ensure that there's no deficit. Orszag hinted on TV yesterday that the 20% cut due next year would work just fine.

My letter to the Board of Trustees of the AMA resulted in a reply from Dr. Rohack:
"As noted, there are elements in the bill that will help you as a family physician in Texas. And as fellow Texan {sic}, you know as well as I that leading the nation in the number of uninsured patients is not a proud statistic and having some federal help will be needed for our patients since our Texas legislature continues to pass on opportunities to help them."

(And Texas' economy is relatively stable as our State government is solvent, too, Dr. Rohack.)

I'm not sure how many of you remember the retroactive tax increases passed by Congress and even instituted by IRS rules. But I'm sure that you remember this Congress' threat this year to retroactively tax the bonuses given to AIG employees.

The House "Reform" Bill allows the Secretary of Health and Human Services not only to set what we are paid, but to set the Nation's mandated insurance coverage, premium rates and then the taxes and penalties that are supposed to pay for half the cost of the Bill, all coordinated with the IRS.

The other half will come from proposed savings. That 20% cut in Physician payments from Medicare is going to look awfully attractive to the bureaucrats.

Everyone's income is no safer than the payment your Family Nurse, uh, Doctor may receive under this Bill.

Health Care Reform: Tax and Spend (and abortion on tax dollars)

(Editorial correction: Sermo was not begun by the AMA. It is a private group, possibly funded originally by pharmaceutical companies. But, no one there knew the funding source.)
(The vote is now nearly 11,000, and still against the new plan.)

How about a simple solution to the rising government expenditures for health care: don't "force Congress" (See President Obama's press statement video, here. At 6 minutes 40 seconds, he says "force Congress.") to spend more money!

Or, we could try Biden's plan to spend more so we won't go bankrupt as we bankrupt the insurance companies and increase the numbers of people on government-paid health care and increasing mandates that health care funding cover more and more "benefits."

The AMA started a blog-type website that can only be accessed by licensed physicians in the US. 94% of the 2949 docs who have responded to the poll on that site, Sermo, oppose the AMA's endorsement of the current House plan. 96% say that the AMA does not speak for them. The top concerns that the doctors have include interference in the doctor-patient relationship (34%) and malpractice/tort reform (32%).

I've already sent my request to the AMA Board of Trustees to rescind their endorsement. CBS news reports that

"Separately, the White House urged Speaker Nancy Pelosi to toughen the emerging bill so it will hold down the future increases in Medicare payments to doctors, hospitals and other providers. The request, in a letter from Budget Director Peter Orszag, came one day after Congress' top budget official warned that as drafted, the legislation fails to slow the growth in health care costs nationally."

The House Bill still doesn't have a bill number. It's gone from 300 pages to 600 pages, to the current 1018 pages. It's here http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BillText-071409.pdf

All of the Democrat-controlled committees in the House and the Senate have blocked amendment after amendment that would have limited or blocked taxpayer funding of abortion. This is at the same time that the House Finance Services legislation passed, which will allow tax money to pay for abortions in the District of Columbia!

The House's plan will make it impossible to have private insurance if you don't have it at the time the plan passes and those plans will be restricted from changing, except for adding costly benefits that the House mandates. They won't be able to charge anyone any copays for "preventive services" - well child care, physicals and colonoscopies, etc. These requirements will bankrupt the insurance companies.

Everyone who does not have a plan at the time the House "reform" goes into effect will be forced onto the public plan on day one. If they don't sign up, they pay a fine of 2% of their income - this is in addition to the new employer tax and the new "surcharge" tax on the rich - or as Speaker Pelosi says, "a very few people will help with the revenue stream."

(Cross posted to Comal County GOP blog)

Will you pay for abortions?

One more problem with federal interference in the payment for health care is whether or not Federal tax money will be used to pay for abortions. I've been worrying about what I'd do about my taxes if the law makes me complicit to this extent.

From the Kaiser Foundation:

An ultimatum against using federal money for abortion procedures could reopen the politically treacherous rift over the issue, creating yet another obstacle for congressional Democrats to overcome if they are to achieve their health reform goals, Time reports. "While current versions of the [health reform] legislation do not address the abortion issue at all, late last month 19 anti-abortion Democrats in the House sent a letter to Speaker Nancy Pelosi, warning 'we cannot support any health care reform proposal unless it explicitly excludes abortion from the scope of any government-defined or subsidized health insurance plan.'"

Congress banned spending federal Medicaid dollars on abortions in 1976, and all but 17 states banned paying for the procedures with state Medicaid funds, too. However, as many as 90 percent of private insurers do pay for abortions and the restrictions the legislators are demanding could compromise those benefits. Under one proposal, individuals earning up to $43,000 a year who get subsidies to buy insurance could not purchase a policy that has abortion coverage. "And it would raise all sorts of other questions if insurers were allowed to discriminate among their customers based on whether or not they are using federal dollars to pay for their policies," Time reports.

"Abortion rights advocacy groups are pushing back. On Monday, the National Women's Law Center released a poll of 1,000 likely voters conducted by the Mellman Group indicating that 71% favor including reproductive services such as birth control and abortion as part of health reform," Time reports. "The poll also found that 75% believe an independent commission should determine what medical services are covered among the basic benefits offered under health reform" (Tumulty, 7/8).

Obama cancels meeting of President's Council Bioethics

I wonder whether the new commission/committee/council will have even one pro-life member? Will Robert P. George (one of only 3 or 4 conservative bioethicist with tenure at a major university), for example, have a spot?

And remember the fuss and bother when some of the members of President Bush's Council were replaced in March, 2004? Bet there's none, now!

Obama Plans to Replace Bush’s Bioethics Panel
By NICHOLAS WADE

Members of the President’s Council on Bioethics were told by the White House last week that their services were no longer needed and were asked to cancel a planned meeting, a council staff member said Wednesday.

The council was disbanded because it was designed by the Bush administration to be “a philosophically leaning advisory group” that favored discussion over developing a shared consensus, said Reid Cherlin, a White House press officer.

President Obama will appoint a new bioethics commission, one with a new mandate and that “offers practical policy options,” Mr. Cherlin said.

$1 Trillion to cover 11 Million people

According to the Associated Press, 37 Million people would remain uninsured under the legislation discussed in Kennedy's Senate Health, Education, Labor and Pensions Committee. If there are 48 million uninsured, now (not, more below), then one trillion dollars to cover an additional 11 million people.

Can you imagine? There's no coverage at all for people who aren't eligible for Medicaid, but who make less than 150 percent of the Federal poverty level ($33,000 for a family of four.)

Of course, some of this cost comes from subsidizing families of four who make $110,000 a year. In fact, 60% of the cost will be in the subsidies for people who make 150% to 500% of the Federal poverty level.

(We won't mention the cost of regulating restaurant menues and forcing the placement of nutrition information on those menues and on notices next to each item on a buffet line. Or the as-yet uncounted costs to the chefs who must calculate and document their recipes in order to know those nutrition facts.)

Daschle/Dole/Baker! Health care on the fast track -along with the entire Nation's finance

Right after this Yellow Brick Award ceremony, I'm thinking that it may save my life for me to learn to use Twitter and Facebook. Now.

While President Obama is planning to take over the entire finance world ASAP, ABC is planning their all-day infomercial for Obama and his push - there is no "plan," yet - for health care "reform" by July 4. No opposing or alternate viewpoints will be allowed. They're even refusing to take a paid-for program in rebuttal, according to the Drudge Report.

ABC REFUSES PAID ADS OFFERING ALTERNATIVE VIEWPOINT FOR WHITE HOUSE HEALTH CARE PROGRAM
ABC is refusing paid ads for its health care program at the White House. Thus they're refusing even a paid-for alternative viewpoint.

Conservatives for Patients Rights requested the rates to buy a 60 second network spot immediately preceding the broadcast of the Town Hall meeting.

While looking for verification of this story, I came across several that report that former Senators Tom Daschle, Bob Dole and Howard Baker are working on a health care "compromise." (Come on! there's a reason they aren't Senators any more!)

See their report, "Crossing the Streams Lines" here.

So, we'll have a Secretary of the Treasury (who claims to be unable to do his own taxes using Turbo Tax) running Wall Street and all the banks. We'll have a known plagiarist and serial failed Presidential candidate (who also can't figure out that gifts and services are taxable) working with another serial failed presidential candidate (who took money for telling the world that he needs a little pharmaceutical help in the bed room) working to reign in the cost of doctors, hospitals, and those pharmaceutical companies. (The third player in the health care waters is Baker, another serial failed presidential candidate. It's just that no one's ever heard of him.)

But don't worry -- even if you are able to vote for a completely new House and a turnover of a good portion of the Senate in 2010, Obama will still run the Census out of his Committee to Reelect the President.

In the meantime, Obama is planning to cut Medicare fees to Hospice, hospitals and doctors while instituting a new tax on health care insurance benefits from employers, according to the Washington Post.

Why not? After all, Daschle had to pay taxes on his limo and driver and Geithner had to pay them on his kids' summer camp!


Addendum after skimming the report:
The "Crossing the Lines" report is full of calls for more regulation with a sprinkling of pablum.

First, they demand that everyone have health insurance. (Could be acceptable if we were allowed to chose between Major Medical and From-First-Dollar. And if it weren’t for the rest of the trash.)

They believe - or at least claim to believe - that it will pay for itself. (Who knew old white haired men could be so funny?)

How will the money be raised?

By a “trigger” to enforce cuts when costs reach a certain point and by not paying for those treatments that are considered less effective.

What are they going to do with all the men and women who insist on antibiotics, today, for their bronchitis? Will they protect the doc when the patient develops bacterial pneumonia?

How about my man in his mid-80’s with a 102 fever in the ER, a bladder infection, multiple falls that resulted in bruises and skin tears, and potassium at 2 (normal is 4)? Medicare would not allow me to actually admit him because he turned out not to be septic by their criteria. He ended up on “Observation” for 3 days while his wife and I tried to find some safe place for him to go after discharge and I tried to get a handle on his potassium. He left for the rehab hospital with a potassium of 2.6. On a heart monitor. Because Medicare rules threaten us with charges of “fraud and abuse.”

How about our local hospice? Obama has announced his intention to cut funding to hospice. I guess there’s not much efficacy in hospice. After all, the hospice patient is, by definition, expected to die within 6 months. However, hospice patients are less likely to present at the ER, with the costs of their care much less than hospitalization.

Force Medicare "reform" without proof that it will work?

The Washington Post reports on the latest findings of the "Medicare Payment Advisory Commission" (MedPAC) today. According to the WaPo, this is a "commission that advises Congress on the federal medical program for older Americans."

In other reports, there is mention that President Obama plans - at the same time - to cut Medicare and Medicaid funding by over $900 Billion dollars, to somehow expand the numbers of Americans who are given "guaranteed health care" under some government "public plan," and to pay for any expansion by taxing insurance benefits given by employers.

And it all has to be done in the next two weeks:

For months, Obama remained on the sidelines of the health-care debate because "he felt it was important to not be too proscriptive," Axelrod said in an interview. "Now we're into a different phase, where decisions are being made very quickly, so it's time to weigh in to a greater degree."

The Obama strategy, articulated in the speech here and in a series of private meetings, is to present each major stakeholder with an enticement in return for a bit of sacrifice.

Again, there's mention of "accountable care organizations," and how to force doctors into them. This time, we do learn that coercion will be necessary to form these organizations and that there's evidence that these sort of interventions don't save money or improve the health care of patients caught up in the schemes. In fact, some of these interventions are now considered wasteful and the first place to cut:

To illustrate what it might take to save Medicare, the commission describes how primary-care doctors, specialists and hospitals could be reorganized into "accountable care organizations" whose members would receive bonuses if the organizations met quality and cost targets. To ratchet up the incentives, health-care providers that fail to meet cost and quality targets could be penalized, the report says.

Even then, any projected savings would be highly uncertain, the report says. What is certain is that Medicare cannot maintain its current trajectory, it adds:

"If current spending and utilization trends continue, the Medicare program is fiscally unsustainable. . . . Part of the problem is that Medicare's fee-for-service payment systems reward more care -- and more complex care -- without regard to the quality or value of that care."

The report underscores the challenges facing President Obama and Congress as they seek to overhaul the health-care economy. The administration has put a spotlight on what it considers wasteful spending, but it has offered sparse details as to how it would change the incentives that produce the waste.

The report identifies some areas that are ripe for savings. MedPAC estimates that the government is paying private Medicare health plans -- which were supposed to save the government money -- much more than it should. In addition, the government could save money by adopting a more streamlined approval process for "follow-on biologics" -- products that imitate biotech treatments already on the market.

Getting doctors to join accountable care organizations may require pressure, MedPAC Executive Director Mark E. Miller told reporters: "If you want people to voluntarily organize, you may want to make sure that the current system isn't as pleasant a place to be."

The model for accountable care organizations resembles that of large, tightly managed physician groups, practices that have been the subject of demonstration projects, and Medicare's experience with those offers limited encouragement, according to the report. Measurable quality improved in the areas of care monitored, such as for diabetes and congestive heart failure. But "whether the demonstration has actually generated savings for the Medicare program is debatable," the report says.

Policymakers hope that money can be saved by better coordinating care. But, according to the MedPAC report, Medicare pilot programs intended to coordinate care for patients with chronic diseases -- programs that involved insurance companies and other private groups -- generally achieved modest quality improvements. Most of the programs cost Medicare more money than it would have spent without them, the report says.

Public Funding for Health Care in Real Life

I don't see how this will cut costs to the government for Medicare and Medicaid.

The group Physicians for a National Health Plan, published a link to an April, 2009 report from the Lewin group by Sheils and Haught outlines the expected effects on insured, employers, doctors and hospitals under various types of public plan financing. At Medicare rates, doctors would see their income go down if everyone is covered, and go down slightly if only the self-insured and small businesses were covered. In the long run, if the public option is offered to everyone, 119 million people would switch over from private insurance.

The numbers in the news say that the Kennedy-Dodd Bill before the Senate Finance Committee will offer Medicare plus 10% to doctors and hospitals - so those decreases are not quite accurate.



Here's a report on one example of just such an effect.

Real world experience comes from Hawaii's short attempt to cover all uninsured children. It also describes the increased Medicaid coverage in Hawaii in the last few years, and the Federally Qualified Health Clinics that give care to uninsured and underinsured.

Texas Medical Association Health Care Principles

Available for members on the TMA website, but looks okay to post here.

The TMA House of Delegates adopted the principles as official TMA policy in May. They include:

* Promote portable and continuous health care coverage for all Americans using an affordable mix of public and private payer systems.
* Promote patient safety as a top priority for reform, recognizing an effective mix of initiatives that combine evidence-based accountability standards, committed financial resources, and rewards for performance that incent and ensure patient safety.
* Adopt physician-developed, evidence-based tools for use in scientifically valid quality/patient safety initiatives that incentivize and reward the physician-led health care delivery team, and include comparative effectiveness research used only to help patient-physician relationships choose the best care for patients.
* Preserve patient and physician choice and the integrity of the patient-physician relationship.
* Incorporate physician-developed, evidence-based measures and preventive health and wellness initiatives into any new or expanded health benefit package to promote a healthier citizenry.
* Recognize and support the role of safety net and public health systems in delivering essential health care services within our communities to include essential prevention and health promotion public health services.
* Support the development of a well-funded, nationwide emergency and trauma care system that provides appropriate emergency and trauma care for all Americans.
* Support public policy that fosters ethical and effective end-of-life care decisions, to include requiring all Medicare patients to have an advance directive that a Medicare enrollee can discuss as part of a covered Medicare visit with a physician.
* Provide sustainable financing mechanisms that ensure the aforementioned affordable mix of services and create personal responsibility among all stakeholders for financing and appropriate utilization of the system.
* Invest needed resources to expand the physician-led workforce to meet the health care needs of a growing and increasingly diverse and aging population.
* Provide financial and technological support to implement physician-led, patient-centered medical homes for all Americans, including increased funding and compensation for services provided by primary care physicians and the services provided by non-primary care, specialist physicians as part of the patient-centered medical home.
* Through public policy enactments, require accountability and transparency among health insurers to disclose how their premium dollars are spent, eliminate preexisting condition exclusions, simplify administrative processes, and observe fair and competitive market practices.
* Reform the national tort system to prevent nonmeritorious lawsuits, keeping Texas reforms in place.
* Abolish the Medicare SGR annual update system and initiate a true cost-of-practice methodology that provides for annual updates in the Medicare Fee Schedule as determined by a credible, practice expense-based, medical economic index.
* Support the implementation of an interoperable National Electronic Medical Records System, financed and implemented through federal funding.
* Require payers to have a standard, transparent contract with providers that cannot be sold or leased for any other payer purposes without the express, written consent of the contracted physician. This principle, in effect, calls for a prohibition against so-called silent PPOs.
* Support efforts to make health care financing and delivery decision-making more of a professionally advised function, with appropriate standard setting, payment policy, and delivery system decisions fashioned by physician-led deliberative bodies as authorized legislatively.

AMA offers public plan compromise

One more post before I have to work, from the American Medical Association morning newsletter.

Unfortunately, I can't access most of the links:

AMA offers public plan compromise.

The AP (6/12, Tanner) reports that the American Medical Association "has long opposed government intrusion into healthcare and believes reform can be achieved by revamping private health insurance plans." Now, AMA President Dr. Nancy Nielsen "says the group wants details on Obama's proposal for a public health insurance plan to compete with private plans." She noted that the AMA "opposes any public plan that forces physicians to participate, expands the fiscally challenged Medicare program, or pays Medicare rates."

But, she explained that the group "remains open to the idea of a government-run health insurance plan, as long as doctors are not required to participate and the plan pays doctors more than Medicare does," CQ Today (6/12, Wayne) reports. Dr. Nielsen said that "doctors would accept a public plan that competes on a 'level playing field' with private insurers." She claimed that "at a minimum...the government should not require doctors to participate as a condition of retaining their Medicare billing privileges, and the plan must pay higher rates than Medicare does." Among "other variations of a public plan" that "the AMA 'is willing to consider,'" include Senate Budget Chairman Kent Conrad's (D-ND) proposal to "create a system of publicly owned insurance cooperatives in place of a government-run public plan."

AMA said to be open to considering Sen. Conrad's co-op proposal. CongressDaily (6/12) reports, "The American Medical Association wants to see details of Senate Budget Chairman Kent Conrad's (D-ND) compromise proposal for a public health insurance plan, the group told senators Thursday." The group's statement "could help an already promising compromise gain more traction." AMA Trustee Samantha Rosman told the Senate Health, Education, Labor and Pensions Committee at a roundtable meeting that "the AMA is open to consideration of a new health insurance option that is market based." She added that although "no legislative details have yet been put forth," the group is looking "forward to reviewing those ideas." Sen. Conrad's proposal includes that creation of "a nonprofit co-op that would serve as a public plan alternative to private insurance."

Chamber Of Commerce, insurance industry join AMA in push against public plan. In a follow-up to Wednesday's New York Times (6/10, Pear) article about the American Medical Association's (AMA) push to eliminate the public plan from the health reform legislation, Shirley S. Wang observed in the Wall Street Journal (6/11, Wang) Health Blog that the AMA is arguing that a public plan "threatens to restrict patient choice" by crowding out the private insurers. In this effort, they are joined by the US Chamber of Commerce, which "says it is concerned that the proposed mandate that employers help pay for insurance would add new costs to already struggling businesses." Finally, "private insurers also are pushing back against the idea of government-run exchanges where consumers could buy policies." In an update to the blog entry, Wang added, "The AMA later issued a statement saying it might be able to support some version of public plans being discussed."

Public plan debate sparks Democratic "civil war." The Politico (6/12, Brown) reports that President Obama's calls for a public health plan "has touched off an increasingly fierce Democratic civil war on Capitol Hill, as liberals fearful about squandering the chance to achieve that goal are taking aggressive steps to keep moderates in line." The Politico notes that Democratic strategist Joe Trippi "launched a campaign" accusing Nebraska Sen. Ben Nelson (D) of "being a 'sellout' for special interests" when he spoke out against the concept. Meanwhile, bloggers on the Daily Kos "went on the attack" after the centrist Democratic think tank Third Way "cautioned Democrats on overreaching on a public plan." Louisiana Sen. Mary Landrieu (D) "is the next target," the Politico reports.

In the Washington Post (6/12) 44 blog, Ben Pershing notes "the increasingly heated debate over healthcare reform...within the Democratic party," adding that the formation of a public plan option is a major point of contention.
From the AMA

Obama to address AMA House of Delegates. President Barack Obama will speak at the Annual Meeting of the AMA House of Delegates on June 15 in Chicago about the nation's need for health system reform. "President Obama has made health reform a top domestic priority, as has the AMA," AMA President Nancy H. Nielsen, MD, PhD, said. "[His] speech to AMA physicians shows that he values the input of those who dedicate their lives to caring for patients." The House of Delegates opens tomorrow, June 13, during which physicians and medical students from around the country will debate and set policy on health system reform and a variety of other matters that affect physicians and patients. The meeting runs through June 17.