Dr. Sevelius repeals the myth of cost control in healthcare

Posted 24 May 2012 at 13:51 UTC (updated 24 May 2012 at 15:33 UTC) by badvogato Share This

Retired medical director, author of 'Nine Pillars of History', Gunnar Sevelius, M.D. asked help to get his message out. As a reader of his books, I feel very much obliged to fulfill his wish and obey his order.

And here's my thank-you note to him after receiving ~4000 word of his writing on the subject.


"My understanding is that the cost of health care in human society or any of the nine pillars you fashioned in your book, ought not to be 'controlled' by any ruling party or one ideological system but ought to be built 'open' and 'fair' on moral ground which follows commandments that each willing participant is allowed to exercise his own interpretative power to its utmost human capacity.

Of course my above statement can still be regarded as pure preaching or rhetorical. Yet your writing cleared up my thinking process. I thank you for your work and your dedication to our health care. I hope people of United States have the will to rewrite and reconfigure our healthcare law/policy into a new constitutional amendment . And thus the whole world can use our system as an examplified copy of Western democracy at its best'
Constructing 9 pillars into a new constitutional amendment
by Gunnar Sevelius, M.D.

For the last 40 years the cost for access to medical care in the US has
increased at an unsustainable rate of more than 16% of the GDP, the
gross domestic product. This cost is double that of Sweden, even when
corrected for PPP, the purchasing power parity of each country.
Neither increase is sustainable.

I grew up in Sweden and have worked as a licensed physician in both
Sweden and the US. I have worked both as a clinical physician and a
medical scientist. I have also worked as a medical director for a major
US corporation. As a medical director I had an insight into the
insurance side of the medical business. In retirement I have studied
political history as revealed through nine sides of anthropology.
Together my past experiences have given me a unique knowledge of the
workings of medical cost in both US and Sweden.

Professor James Sheehan, recently retired from the History Department
of University of Stanford had for the last ten years mentored my work
of analyzing world history of anthropology. Professor Sheehan
encouraged me to make a excerpt report from my book: The Nine Pillars
of History, an anthropological review of history, sexuality and modern
economics, all as a guide for peace. Numbered paragraphs in this
presentation are lifted directly from this book.

Before the French-1789-revolution Francois Voltaire stated "Truth has
not the name of a political party" and the tone setting anthropologist
of the 1900s Paul Radin "No progress in ethnology will be achieved
until scholars rid themselves once for all of the curious notion that
everything possesses history, until they realize that certain ideas and
concepts are ultimate for man".

In the past four years we have learned that anything with a dollar sign
has a floating value. What then is permanent Truth? Can a real Truth be
defined? I asked myself this question some ten years ago and undertook
a most extra ordinary undertaking of trying to find an answer. I went
back to tribal time to find what actually mattered for a very first
human social group and still is very fundamental for any society. I
found what I called The Nine Pillars of History. The Nine Pillars of
history have three characteristics:

1) They are eternal; they were all there from the start of
human society 200,000 years ago and are still critical for society.

2) They are interdependent because they are all present at the
same time.

3) The cost for society of any of them cannot be controlled
but for competition just like any cost paid from the common tax base.

Which are these Nine Pillars of History? What is the pillar need they
fill? The first is a group of pillar needs that are necessary for any
life on earth and then the eight pillar-needs important for society.

1) food, water, air, energy, sexuality

2) dwelling

3) cleanliness

4) art

5) communication

6) community support

7) religion

8) access to medical care

9) trade

To prove that the Nine Pillars of History are eternal, interdependent
and that their cost cannot be controlled I took on the immense
challenge to review the world history for 1) political life, 2) the
history of four major religions, 3) the history of the female role in
society and 4) the history of economics. I used the Nine Pillars of
History as common denominators to show what happens to a society if any
of the nine historical pillars is abused. Because each Pillar-need is
necessary for society each one can indeed use its influence for abusive
social power.

Right away I could divide human social history into three main
historical time-periods based on how food has been transported:
handheld in tribal time, animal transported in agricultural time and
machine transported in industrial time. The modern city is a product of
machine-transported food.

The female role in our society through history has been distinctly
different in each of these time periods. The female was at least an
equal member of society during 190,000 yearlong tribal times. The
female had very limited political power during agricultural time but
recovered her political equality during industrial time. General and
equal voting rights was first introduced in Sweden in 1909 and in the
US in 1920. Exceptions from this rule are pockets of people still
living in tribal groups or still living in very conservative
agricultural societies.

An in depth historical review of each pillar need is presented in my
book The Nine Pillars of History, An Anthropological Review of Five
Religions, Sexuality and Modern Economics, All as a Guide for Peace.

Today I will limit my comments to the Eighth Historical Pillar; access
to medical need, the cost of which can only be controlled through
competition. This fact has serious consequences for any nation.
Professor James Sheehan of Stanford University encouraged me to make
this limited excerpt from my nine-historical-pillar review.

My background for this discussion is unique in that I grew up in
Sweden, has worked as a licensed physician in both Sweden and the US.
At the University of Oklahoma, in Oklahoma City, Professor Stewart Wulf
mentored my work at the OU. My assignment was at first the technical
work for a quantitative method to measure heart blood flow through the
skin and eventually to predict and, if possibility offered itself,
prevent heart attacks. For this work we, 18 scientists from our
Neuro-Cardiology Center, followed 140 volunteers for seven years. The
National Institute of Health (NIH) and the Federal Aviation Agency
(FAA) sponsored my medical research for thirteen years. The work had a
complicated finish and was published in an obscure book. In retirement
I asked for permission and has recently republished the report: An
Unpublished Medical Story, Coronary blood flow, Heart attack
prediction, prevention and treatment. This book was recently released.

Since my academic years I have worked in the Silicon Valley area as a
Medical Director, first for NASA for two years and then for the
Lockheed Martin Corporation. I retired from the Lockheed Martin
Corporation 1989.

At NASA I started a health education program to prevent heart attacks.
This work was quoted in Runners World. At Lockheed my health education
efforts expanded to include all kind of employee health education in
order to control work and family stress. With help from the Lockheed
computer department I developed a program to follow the health effect
on the close to 30,000 working population. In this effort I worked with
scientists from SRI. The health education was presented to numerous
industrial medical conventions and became a model for the Silicon
Valley employers. This work I recently also published in book form: Add
Years to Your Life and Life to Your Years parts I and II.

Doctor Wesley Alles PhD assigned his first sabbatical academic year to
my Medical Department at Lockheed. After a few years working with me
Wes was offered to take over the Health Improvement Program (HIP) for
the Stanford University.

The Stanford program became the model for a national health educational
program through YMCA and also for large medical insurance companies in
Japan and Brazil. Besides his work at Stanford Doctor Alles became the
Chairperson for our local El Camino Hospital. Lockheed had initiated
the first computerized medical records here. El Camino Hospital is now
identified as one of the technically most advanced hospitals in the
nation.

As a Medical Director for the largest local employer I had intimate
contact with the surrounding medical community. In retirement I am now
a benefiter of medical care from both Sweden and the US.

As noted above in the definitions of the Nine Pillars of History, none
of them, including the cost of medical care cannot be controlled
without competition but on the other hand this privileged situation
should not be abused.

Medical care often covers life-maintaining and life-threatening
situations that make the customer dependent of the medical support
system - in a way a monopoly situation. Let us analyze a medical
support system from its call for service. A doctor and his/her staff
are responsible to fill this need. On the other hand the health
provider team is dependent on the patient's payment for making a
reasonable living for their families.

All health workers are a selected, intelligent and exceptionally
trained group of society recognized for their knowledge and integrity.
In order to win the public's trust the team has gone through extensive
training, has specific licenses and has generally recognized
documentation to practice informed and rationally controlled practice
of medicine and also to educate the public about consequences of
damaging life habits. The medical team is thereby allowed to charge a
fee for its service. Hopefully competition limits the medical cost to a
reasonably value within a certain geographical area. Inflation within
the medical field still tends to be high because of limited competition
and the patient's eagerness to pursue the best possible care.

In my publication The Nine Pillars of History I compared and analyzed
the cost of access to medical care in Sweden and the US. In order to
limit the length of this correspondence I will here limit myself to the
description of the US system. My book has numbered paragraphs to invite
specific discussions. Paragraphs here with a number are lifted directly
from my original publication.

The medical care in the US is spotwize on par with the good medical
standard in Sweden or most OECD-countries. The standard of living for
medical providers is also about the same.

The medical efficacy based on medical evidence such as the survival of
the newborn and of its mother and the longevity of the general
population are both considerably worse in the US than in Sweden.
Despite worse care in the US, the cost corrected for purchasing power
parity (PPP) of both countries, the cost of access to medical care in
the US is double that in Sweden.

As money is the cause of all evil we might take a closer look into how
money for access to medical care is utilized in each country and do
this from a holistic view or how everybody in both countries live their
life.

Doctors in Sweden have a lot more free time for their families and a
lot more security for their employment and family. Swedish doctors have
a salary contract with regulated 8 hours/workday, special compensation
for holiday and night work, a regulated 6 weeks vacation, a one-year
parent holiday (split with wife). For their children the doctors have
free childcare, food and transport all through high school. The doctor
has had study support for his/her higher education, medical and
pharmaceutical coverage from childhood all through retirement including
for long-term sickness, (Alzheimer) and including paid cost for burial.
The local and federal tax base supports a "from cradle to funeral"
social support system.

In the US doctors has to pay for their seven-year medical school, have
a minimal salary during their one-year internship and three-year
residency working 100 hours a week with no consideration for holidays.
Doctors ready to start their practice do not dare to work in some areas
of medicine that have high exposure to malpractice claims. The
litigious atmosphere in the medical field in US has essentially broken
down the access to medicine. The whole system is, if not at totally
broken down, at least fractured along economical fissures. I am here
referring to Doctor Jeffrey M. Lobosky's very revealing book: It's
enough to make you sick. The failure of American health care and a
prescription for its cure.

Doctor Lobosky, a board certified neuro-surgeon with a long
professional experience, points out that for the last some twenty years
doctors avoid to work in emergency room and within the fields of
orthopedics, neurosurgery, vascular surgery and OB-GYN. The malpractice
insurance fee in these fields today is $200.000 - $250.000/ year or
greater than the cost of living for the doctor.

The fissure in the medical access system stretches between patients
who have adequate medical insurance and those who do not. Some years
back this was not a major problem; doctors and hospitals just swallowed
the cost. As the cost has kept on increasing this unpaid cost of access
became more and more difficult to accommodate.

The Federal and the State governments split the cost for uninsured
patients 50/50 but the bill paid covers just 20% of what insured
customer pay.

When hospitals and doctors complained the Congress responded with a
law, the EMTALA law, that requires that all patients that seek help in
the emergency room have to be treated, if they have the means to pay or
not. The law is enforced with a $50.000 fine. Besides the $50.000 fine
a malpractice shadow is hanging over the whole scene. No doctor with
any self-preservation would enter such a battlefield.

Doctor Lobosky has some solid suggestions to mitigate cost control in
medicine. Starting from the definition of a historical pillar, one that
cannot be controlled but through competition I am afraid most of his
suggestions will fall for deaf ears. The approach the problem has to
come from a more fundamental standpoint because we are addressing a
historical pillar need.

Most medical situations are so common the treatment team has worked out
routines to meet the need. The profession has numbered all routine
procedures and generates its cost accordingly. This information is
computerized and therefore offers a unique opportunity to check the
medical efficacy of any procedure, any medication or any medical
practice similar to how we proved the efficacy of health education at
Lockheed. A computerized test program can be limited to a geographical
area recognized for excellent medical care and good computerized
medical records. El Camino hospital in Mountain View, California, with
its surrounding individual and group practices would be a good
population to sample for such a study. The El Camino hospital is a
not-for-profit hospital recognized for its superb care and the
surrounding patient and doctor populations are typical for a
well-planned community. This information can be used as measuring stick
to compare against for-profit run medical enterprises.

Behind of his/her doctor medical license stands a hospital service with
unionized workers, the pharmaceutical manufacturer for supplying
medications that are patented for 16 years, an insurance company
mitigating the doctor fee through group coverage and bill processing
and finally a malpractice insurance company mitigating the risk of
every medical procedure.

The participating cost-demands are all part of the unlimited eighth
pillar need and assured to be paid in the shadow of the doctor's
medical license; the doctor is really just a pawn.

Once the pillar need of access to medicine is recognized, cost control
becomes clearer. The cost can only be controlled by competition, but if
such control is impossible, pay has to be according to a
"cost-plus-contract". The "plus" in such a contract is a negotiated
percentage change acceptable to both parties. Such contracts are common
in many situations where cost is difficult to establish. I saw many
such contracts negotiated in contracts for large space programs at
Lockheed.

The Nobel Laureate Milton Friedman addressed the cost problem for
access to medicine already in the 1970s. His solution was to open more
medical schools and graduate more physicians. This would be a more
permanent solution but would take considerable investment.

The graduation of more physicians' assistants would also help. Most
medical situations are not that complicated eleven or more years of
training is necessary. A triage referral system might help but most of
us are spoiled of having a chat with our doctor during our visits.

With a four faceted economical interest zone of access to medical cost
(doctor/hospital charge, malpractice charge, group insurance charge and
pharmaceutical industry charge) it is still very unlikely competition
can control the cost in a foreseeable future. What we are left with
today for cost control to medical access is a "negotiated cost-plus for
a service-charge-contract".

Malpractice lawyers will blame any unexpected medical outcome on any of
the other three of the four faceted- medical-care umbrella.

Malpractice lawyers won't even charge a fee for the opportunity to sue
a doctor, hospital or a pharmaceutical manufacturer knowing that just
about all claims are settled outside of court with up to half of the
settlement going into the lawyer's pocket.

Medical care should be as good as possible but to challenge any risk
and to charge any cost as judged according to a layman's jury-judgment
can be abusive. In 2008 US doctors and hospitals paid $11 billion to
insure themselves from malpractice claims. (The Economist Jan.16, 2010)
Cost for malpractice has to be controlled by so called tort regulation
or we will not have any access to medical care.

In Sweden the malpractice claims go first to a medical board of
uninvolved, generally recognized competent colleagues. This
professional board makes a judgment of the involved parties before the
problem is addressed in a court. Most conflicts are resolved at this
level without any cost.

In 2010, the U.S. expanded the medical coverage to include some 46
million of non-insured people out of a total population of some 307
million. With present long-term unemployment this number of uninsured
might rise to 100 million.

(1180) Access to a personalized quality medical care as perceived
by the individual is the "Eighth Historical Pillar." Many of the people
in the U.S. without medical coverage are foreigners. If people are
working legally and paying tax they should be able to have access to
medical care as all legally working people. Everybody in the US does or
will have access according to the so named Obama care. The basic
question is--who pays for access, if the patient is unable to pay?

(1181) History has shown that any monopoly power will destroy a
society, be it dogmatic religious or dogmatic political. A medical
need, a life or death situation, can be interpreted as a situation for
a monopolized need; access to medicine is indeed a pillar need, the
Eighth. Professor James Sheehan, who was my mentor for my history
writings, encouraged me to write about the "medical access system" in
Sweden and the US.

(1182) The majorities of working U.S. citizen pay for their
medical access by themselves through their employers' complimenting pay
to a worker/salary plan or have access paid for through a tax based
plan through national and/or regional funding.

(1183) The cost of this access to medical care has recently
increased by a minimum 16% a year. This means that it doubles about
every fifth year according to the 70-rule (70:16=4.4). Such an increase
in cost will overwhelm any resource that underwrites it.

(1184) A malpractice insurance company does not have much
incentive to control its abusive access because the medical need is a
pillar need (the Eighth) and will always in some way be compensated.
The cost of malpractice forces many young doctors to sign up and limit
their work to hospital salary employment, where the hospital helps to
pay the malpractice costs. This practice pressures young doctors to
seek employment in only for-profit-run-hospital chains with only
for-profit- incentives. Such hospital incentive makes the hospital to a
manufacturing plant that places cost control before patient care.

(1185) The malpractice game destroys the doctor/patient
relationship. Already the father of medicine, Hippocrates, warned
against talking bad about colleagues. The public is really not an
informed judge of medical interventions. Hippocrates had newly licensed
doctors promise not to talk bad about each other. But, of course,
lawyers never made such a promise and live off controversy. The "law
making" part of government has more lawyers than doctors, making sure
that patients' rights cannot be compromised--and the malpractice game
in the US to continue.

(1186) I would think the medical malpractice game played in the
U.S. explains most of the difference between the cost of medicine in
the U.S. and the rest of the OECD world.

(1187) Another explanation to the difference in medical cost in
Sweden vs. the U.S. is that the government is in control of its large
national market. The buying power of a state has more negotiating
strength than individual doctors and hospitals. Also in Canada, the
cost of medicine is cheaper than in the U.S. The government can, at
times, be a smarter buyer of medicine and medical equipment but one
have to watch out for kickbacks for privilege connections.

(1188) Paying for health care in the U.S. is a labyrinth system
of individual, group, state and federal resources. Two separate armies
of people execute bills--one army that write the bills and one that pay
the bills. Individuals or a myriad of more or less comprehensive group
plans plus state-run "Medicaid" or federal run "Medicare" pay for the
bills.

(1189) The cost of medical insurance was a part of the U.S. car
company's financial difficulties. The same problem is now facing
federal and state employees. The public will not pay for an unlimited
cost to state and federal employees' medical costs. The public request
a negotiated cost control, not a free for all give away from those
sitting close to the tax paid state and federal money-purse.

(1190) Final long-term care at old age in the U.S. requires
special insurance. Private, luxurious retirement communities attached
to long-term adult medical care has been a solution for a few lucky
ones. The private investment for this type of insurance is accomplished
by selling their equity in their family home. Still the attached
medical care is again paid for from federal Medicare plus private
insurance.

(1191) Both in Sweden and in the U.S. retired people try to stay
in their home as long as they physically can. Both Medicare and
Medicaid help pay for some home care. (Google Medicare or Medicaid for
information about Home care.)

(1192) The cost for long-term medical care in the U.S. causes
elderly their most anxiety. Regular medical insurance has smartly left
out the cost of long-term insurance (Longer than 90 days) in their
regular medical care contracts. If the final years of one's life end up
to be a family member with the syndrome of Alzheimer's, the cost for
years of total nursing care will ruin the finances of most families in
the U.S. The family impact for long-term medical care in Sweden is
mitigated through contribution from the local and federal taxes. The
senior care is housed in especially dedicated, well cared for, medical
housing.

(1193) The insurance system in the U.S. gives work to an army of
insurance processors beyond the medical personnel caring for the
patient. Federally administered insurance accomplish this overhead
administration with just 3% of the total insurance cost. The cost for
the same administration in for-profit insurance corporations can easily
amount to about 30-35% of the total pay. Again, insurance cost will be
recovered, but never be controlled, because the need rests ultimately
on a pillar medical need.

(1194) Adult working people pay for their own medical insurance
from their salary, but as it is voluntary, people may not. This is true
and common for many young people, who think that nothing will happen to
them, and is particularly common for drug addicts who certainly will
have health problems, but who don't care. People without insurance are
a burden for the state Medicaid system. (50% is still Federally funded)

(1195) Pharmacies are usually independent services. They may have
contracts with hospitals, be small independent pharmacies, or very
large corporate chains. Patients pay for the cost of filling a 30 or
90-day prescription. Pharmacies charge $10.00-$15 or more for filling a
prescription. They determined that they cannot be responsible for a
prescription beyond 30 days -- even for chronic conditions. For any
longer prescription they refers to mail delivered medication. Why?

(1196) The cost of medicines is supported either from Medicaid or
individual privately paid medical insurance or corporate sponsored
insurance. After age 65 the cost of physicians, hospitals and
medications are complemented with federal tax funded Medicare from
Washington.

(1197) Swedish citizens are now the heaviest taxed people in the
world and taxed for every human need except sex. They are getting
service back after they have paid the salaries and the pensions for all
the people administrating and delivering their social needs, all
sitting closer to the control of citizens' earned money than the
citizens are themselves.

(1198) The U.S. and Sweden, or actually all of Western Europe, stand
at a crossroads. Access to medical support is a pillar need. The basic
question is--should the common tax base finance a pillar need that
cannot be controlled without competition? The cost will take from other
needs financed from the common tax fund and eventually affect the cost
of all production and therefore jeopardize production-workers' access
to their own Nine Pillar needs.

(1199) The term Commons with capital C stands for an economical
problem affecting what I call "what many own, nobody owns" or is
responsible for. The Common tax base is a "Commons". To have cost of
access to medicine placed on a Commons may have serious consequences in
the long run for any nation.

(1200) The Eighth Historical Pillar is a four-facetted need working
in the shadow of a doctor's privileged license. An open and informed
discussion within a democratic system has to decide which way can be
considered most fair for most people without jeopardize anybody's right
to their own Nine-Historical-Pillar- needs and where each highway has
to be a two-way street for a society to survive.





a friend of mine's complaint on his hospital visit, posted 24 May 2012 at 19:00 UTC by sye » (Journeyer)

A colleague of mine, a nice gentleman, worked for IBM for a number of years, now soon to be retired as a State worker, recently had cataract surgery on his two eyes. We had lunch together last week. He told me the medical bill for each eye surgery amounts to $13,000. Our state employee health care plan paid it all. But he still had a little complaints. The nurse who administered eye drops, were a busy type, gave him a bottle, go back to her desk, busy typing, give him another drop, go back to her desk again, busy typing... three rounds. "Accountability in books are paramount to her job function, apparently."

Over at family gathering, my mother-in-law was discussing hospital billing dilemma in maternity wards. How do you design a billing and accounting in medical supplies/services for unborn baby? In their mother's account? in their own account no matter how brief it might be( with no name no ssn# no sure thing of surviving etc)? In their father's account etc?

Then there is Dr. House TV drama. How I love his game disregards any other-ly concerns.

No doubt health care is a complex system, interconnecting with financial, judicial, cultural and social belief system. Yet we MUST make it work for one and for all.

Here's a few reference I'd like to share:

"The Social Ideas of American Physician (1776 - 1976)" by Eugene Perry Link.

"The memoir of Samuel Insull" - the man who lit up this land with Edison's invention.

"Ubi tres medici, duo athei", posted 26 May 2012 at 23:53 UTC by badvogato » (Master)

-- quoted from Medieval Ecclesiatics by Oliver Wendell Holmes., M.D.


"where there are three doctors, two are atheists," is taken from Dr. Holmes' delightful and insightful Medical Essays. Holmes states that doctors must deal with things seen, not within the unseen a theologians do.
...
To organize the varying ideas that important physicians held about the supernatural, we might adopt some categories presented by Dr. William Osler and add one. In Soler's Ingersoll lecture "Science and Immortality" given at Harvard in 1904, he placed physicians into three groups giving each a name from the classical tradition - the Gallionians, Laodiceans, and Teresians. A forth group not identified by Osler might be called the Delphians, those who accepted the occult and the ambiguous teachings of spiritualism.
...

Finally, if physicians were generally indifferent toward religion and two out of three were atheists as Holmes contended, there are apparent, ample reasons to help explain their thought and behavior. Their help for suffering human beings gave them a special status of confidence and respect, even a power over others, which made their lives active an stimulating. They could lie down with pleasant dreams sans Comforter, sans Heaven. In a service that more than compensated them through the reward of healing, they had little need to seek extra-worldly blessings."

Dr. Sevelius writing in respond to Supreme Court's ruling, posted 11 Jul 2012 at 13:47 UTC by badvogato » (Master)

Defining the total problem of cost to access to medical care

Comments to the definition

Access to medical care in the US has become a critical part of the 2012 presidential election campaign. The situation is critical. At the same time that Congress has asked for medical coverage to be expanded to cover 50 million uninsured the cost of medical care has increased to demand 16% of the total GDP. The situation is not improved with unemployment over 8% with many long-term unemployed, which means also uninsured. Besides the big people cohorts from after WWII are retiring and entering the age of more intensive medical care. The medical support system really has its work cut out for itself.

Doctor Jeffery M. Lobosky, a board certified neuro-surgeon with a long professional experience, points out that for the last some twenty years doctors avoid to work in emergency room and within the fields of orthopedics, neurosurgery, vascular surgery and OB-GYNbecause the malpractice insurance fee in these fields today is $200.000 - $250.000/ year or greater than the cost of living for the doctor.

The fissure in the medical access system stretches between patients who have adequate medical insurance and those who do not. Some years back this was not a major problem; doctors and hospitals just swallowed the cost. As the cost has kept on increasing this unpaid cost of access became more and more difficult to accommodate.

The Federal and the State governments now split the cost for uninsured patients but the bill that is eventually paid still just covers only 20% of what insured customer pay.

When hospitals and doctors complained the Congress responded with a law, the EMTALA law, that requires that all patients that seek help in the emergency room have to be treated, whether they have the means to pay or not. The law is enforced with a $50.000 fine. Besides the $50.000 fine a malpractice shadow is hanging over the whole scene. No doctor with any self-preservation would enter such an unfair battlefield.

Behind of his/her doctor medical license stands the four facetted economical interest zone: a hospital service with unionized workers, the pharmaceutical manufacturer for supplying medications that are patented for 16 years, an insurance company mitigating the doctor fee through a group insurance bill with an army of bill-processing people and finally a malpractice insurance company mitigating the risk of every medical procedure supported by an army of malpractice lawyers soliciting any reason to sue the medical support system. Malpractice lawyers won’t even charge a fee for the opportunity to sue a doctor, hospital or a pharmaceutical manufacturer knowing that just about all claims are settled outside of court with the major portion of the settlement going into the lawyers pockets.

The participating cost-demands are all part of the unlimited Eighth Historical Pillar need and assured to be paid in the shadow of the doctor’s medical license; the doctor is really just a pawn.

A malpractice insurance company does not have much incentive to control its abusive access because the medical need is a pillar need (the Eighth) and will always in some way be compensated. The cost of malpractice forces many young doctors to sign up and limit their work to hospital salary employment, where the hospital helps to pay the malpractice costs. This practice pressures young doctors to seek employment in only for-profit-run-hospital chains with only for-profit-incentives. Such hospital incentives make the hospital a manufacturing plant that places cost control before a personal patient care.

The malpractice game destroys the doctor/patient relationship. Already the father of medicine, Hippocrates, warned against talking bad about colleagues. The public is really not an informed judge of medical interventions. Hippocrates had newly licensed doctors promise not to talk bad about each other. But, of course, lawyers never made such a promise and live off controversy. The “law making” part of government has more lawyers than doctors, making sure that patients’ rights cannot be compromised—and the malpractice game in the US to continue.

In a June 12, 2012 the GAO office reports that the medical mal practice adds less than 1 to 2 % to the total medical bill. However the total medical bill is between 2 or 3 Trillions and therefore still adds to substantially to the cost. The main problem is that it adds very substantially to the bill insuring the doctors and hospitals, which has also other consequences like the choice for young doctors’ specialty.

Medical care should be as good as possible but to challenge any risk and to charge any cost as judged according to a layman’s jury-judgment could be abusive. In 2008 US doctors and hospitals paid $11 billion to insure themselves from malpractice claims. (The Economist Jan.16, 2010) The litigious attitude within the medical pay zone is indeed out of control.

Adult working people in the US pay for their own medical insurance from their salary, but as it is voluntary, people may choose not to. This is true and common for many young people, who think that nothing will happen to them, and is particularly common for drug addicts who certainly will have health problems, but who don’t care. People without insurance are a burden for the state Medicaid system, (still more than half Federally funded)

If the final years of one’s life end up to be a family member with a handicapped stroke or a Alzheimer’s syndrome, the cost for years of total nursing care will ruin the finances of most families in the U.S. The cost for long-term medical care in the U.S. causes elderly their most anxiety. Regular medical insurance has left out the cost of long-term insurance (Longer than 90 days) in their regular medical care contracts because cost of end of life care tends be so high. The family may steps in but few can ill afford the major cost and efforts this demands. Families give up their equities in their homes to accommodate a generation change with some dignity but many times not even this will cover the cost.

I have two unique perspectives. First, I grew up in Sweden and have worked as a licensed physician in both Sweden and the US. I have worked both as a clinical physician and a medical scientist. I have also worked as a medical director for a major US corporation. As a medical director I had an insight into the insurance side of the medical business. Together my past experiences have given me a unique knowledge of the workings of medical cost in both US and Sweden.

Second in retirement I have studied political history as revealed through nine sides of anthropology and have written a book, The Nine Pillars of History where access to medical care is Historical Pillar need number eight. (See the appendix for a narrative about how my book, came to be and about why I have a uniquely relevant background to address access to medical care)

Access to medical care is a Historical Pillar need for a society. The Nine Pillars of History share three characteristics:

1) They are eternal; the Nine Historical Pillars were all-present from the start of human society 200,000 years ago and are still critical for society.

2) They are interdependent because they are all present at the same time.

3) The cost for society of any of them cannot be controlled except by competition.

All nations in history have had as a goal a system for its citizens that would meet people’s need for security according to the Nine Pillars of History but none has so far defined all of them and recognized their influences over society. In order to survive from one generation to the next all societies have to make the Nine Historical Pillar need sustainable.

The necessary competition within each Historical Pillar need has to be recognized. It is this type of competition that is denied when considering cost of medical access. With a four faceted economical interest zone within medical cost it is still very unlikely competition, as presently organized, can control the cost in a foreseeable future. An economical market always fails to control costs due to a monopoly power. Professionals within medicine, law, indemnity and pharmacy all earn their living in the shadow of the physician’s medical license. History has shown that any monopoly-power will destroy a society, be it dogmatic religious or dogmatic political. A medical need, a life or death situation, is perceived as a situation with a monopolized need. Medical access should therefore be looked upon as a threat to society just like any threat to any of the Nine Historical Pillars.

What about the public sector? The U.S. and Sweden, or actually all of Western Europe, stand at a crossroads. Access to medical support is a Historical Pillar need. The basic question is: should the common tax base finance a Historical Pillar need that cannot be controlled without competition? The cost will take from other needs financed from the common tax fund and will eventually affect the cost of all production and therefore jeopardize production-workers’ access to their own Nine Pillar needs. This question still has to be answered with an unequivocal yes. Only a person with insight in history can answer this question with conviction. Yes, because we need to preserve dignity in generation transitions. US has done more for preserving democracy than any nation. America has earned and deserves this dignity.

To provide for the birth of a child is now too expensive for a young couple without insurance to even plan and to provide for an Alzheimer-sick grandmother would bankrupt any couple in the US. Health insurance has to be mitigated across generations and has to be mandated so the total population together carries the responsibility. This is what binds a nation together just as the responsibility for defense. This is the foundation on which Bismarck joined several hundred of small nations into a common Germany, how the Christian church has stayed together for two thousand of years through Its Holy Spirit and Islam through its Holy Hummah. They all have formed a community across generations, a community that generations can be proud to belong to, a community withdignity.

The family impact for long-term medical care in Sweden is mitigated through contribution from the local and federal taxes. The senior care in Sweden is housed in local, especially dedicated, well cared for, medical housing with 24/7 nursing care. This allows citizens to leave his time in this life with a dignity, adiginity to be followed in the new generation.

According to the Census Bureau’s 2011 report the US has 50 million uninsured, mostly working citizens. U.S. Congress used its mandate to include the medical coverage for all these 50 million of non-insured people. This will for sure challenge an unprepared medical support system in 2014 when these 50 million will demand care together with present long-term unemployed+uninsured and people from the large generation cohort now ready to retire.

All health workers are a selected, intelligent and exceptionally trained group of society recognized for their knowledge and integrity. In order to win the public’s trust the team has gone through extensive training, has specific licenses and has generally recognized documentation to practice informed and rationally controlled practice of medicine and also to educate the public about consequences of damaging life habits. The medical team is thereby allowed to charge a fee for its service. Hopefully competition limits the medical cost to a reasonably value within a certain national area. Inflation within the medical field still tends to be high because of limited competition and the patient’s eagerness to pursue the best possible care.

In my publication The Nine Pillars of History I compared and analyzed the cost of access to medical care in Sweden and the US. In order to limit the length of this correspondence I will here limit myself to the description of the US system. The medical care in the US is mostly on par with the medical standard in Sweden or most OECD-countries. (OECD = Organization for economic co-operation and development and essentially means Western Europe) The standard of living for medical providers is also about the same. (The GDP/citizen corrected for Purchasing Power Parity (PPP) rank Sweden in 2010 as number 8 and US as number 14.

The medical efficacy based on medical evidence such as the survival of a newborn and of its mother and the longevity of the general population are both spot-wise worse in the US than in Sweden. Despite worse results in the US, the cost corrected for PPP of both countries, the cost of access to medical care in the US is 50% greater than that in Sweden. (16%) vs. 9%). Sweden is the only Western industrialized country that actually recently decreased its medical cost. Sweden has 20% immigration and accommodated this addition of citizenships by introducing competition in medical care; Japan is a second country that also had a decrease in its medical cost but this is probably due to a specific shrinking in its large aging population. Sweden decreased its medical care cost only with 0.7% in 2011, but still it was a decrease.

As money is the cause of all evil we might take a closer look into how money for access to medical care is utilized in each country and do this from a holistic view or how people in both countries lives.

Doctors in Sweden have a lot more free time for their families and a lot more security for their employment and family. Most Swedish doctors have a salary contract with regulated 8 hours/workday, special compensation for holiday and night work, a regulated 6 weeks vacation, a one-year parent holiday (split with wife). For their children the doctors have free childcare, food and transport all through high school. The doctor has had study support for his/her higher education, medical and pharmaceutical coverage from childhood all through retirement including for long-term sickness, (Alzheimer) and including paid cost for burial. The local and federal tax base supports a “from birth to grave” social support system as originally proposed by Gunnar Myrdal. Both Gunnar and his wife Alva Myrdal were Nobel Laureates, he in Economy in 1974 and she in 1982 for her early strong stand for peace during the Vietnam War.

Sweden has for the last couple of voting periods had a right wing political coalition government. The shift from left to right is mainly driven by the imposing cost of medical care. During the present right wing leadership independent doctor services have been allowed to open medical clinics in competition with government, provided quality care is maintained.

In the US doctors have to pay for their seven-year medical school, have a minimal salary during their one-year internship and three-year residency working up to 60 (in my time 100) hours a week with no consideration for holidays. Doctors through with their residency and finally ready to start their practice do not dare to work in some areas of medicine that have high exposure to malpractice claims. The litigious atmosphere in the medical field in US has essentially broken down the access to medicine. The whole system is, if not totally broken down, at least fractured along economical fissures.

In Sweden the malpractice claims go first to a medical board of uninvolved, generally recognized competent colleagues. This professional board makes a judgment of the involved parties before the problem is addressed in a court. Most conflicts are resolved at this level without any cost. With most complaints settled here it would take a very serious claim for a lawyer to pursue a further claim.

Another explanation to the difference in medical cost in Sweden vs. the U.S. is that the government in Sweden is in control of its large national market. The buying power of a state has more negotiating strength than individual doctors and hospitals. Also in Canada, the cost of medicine is cheaper than in the U.S. The government can, at times, be a smarter buyer of medicine and medical equipment but one has look out for privilege connections.

Paying for health care in the U.S. is a labyrinth system of individual, group, state and federal resources. Two separate armies of people execute bills—one army that writes the bills and one that pays for the bills. Individuals or a myriad of more or less comprehensive group plans plus state-run “Medicaid” or federal run “Medicare” pays for the bills. Such billing system adds 30-35% to the medical bill while the one-payer Medicare bill adds only 3% - 5%.

The cost of medical insurance was a part of the U.S. car company’s financial difficulties. The same problem is now facing federal and state employees. The public will not pay for an unlimited cost of state and federal employees’ medical costs. The public request a negotiated cost control, not a free for all give away from those sitting close to the tax paid state and federal money-purse. A buyer from the common tax purse really doesn’t have much incentive for cost control.

Final long-term care at old age in the U.S. requires special insurance. Private, retirement communities attached to long-term adult medical care has been a solution for a few lucky ones to meet the cost of end of life medical cost with dignity. The private investment for this type of insurance is accomplished by selling their equity in their family home. Still the attached medical care unit is again paid for from federal Medicare plus private insurance.

Both in Sweden and in the U.S. retired people try to stay in their home as long as they physically can. Both Medicare and Medicaid give some help to pay for home care. (Google Medicare or Medicaid for information about Home care.) In Sweden all home care is supported through the local tax base with intimate knowledge of the individual’s need.

Pharmacies in US are usually independent services. They may have contracts with hospitals, be small independent pharmacies, or very large corporate chains. Patients pay for the cost of filling a 30 or 90-day prescription. Pharmacies charge $10.00-$15 or more for filling a prescription. Some chains arbitrarily determined that they couldn’t be responsible for a prescription beyond 30 days — even for chronic conditions. For any longer prescription they refer to mail delivered medication. Why? What is the rational reason except for more frequent fees?

Many of the people in the U.S. without medical coverage are foreigners. If people are working legally and paying tax they should be able to have access to medical care as all legally working people. Everybody in the US does or will have access according to the so named Obama-care. The basic question is—who pays for access, specifically if the patient is unable to pay?

An open and informed discussion within a democratic system has to decide which way can be considered most fair for most people without jeopardizing anybody’s right to their own Nine-Pillars-of-History-needs even with dignity at the end of life. The eventually chosen way has to be a two-way street for a society to survive.

The purpose of tribal life was to be able to raise a family for the tribe’s survival. The purpose of modern social life is to raise a family, educate the children to be of service to our modern society and for our self to contribute our service so we leave this life with a dignified memory left for our modern society to maintain and live by. The quality of life achieved in a modern society should therefore be sustainable.

In order to accomplish these goals for the richest country in history we have to analyze the problem in a very rational way.

Our modern civilized society has implemented old age pensions, minimum salaries, and health and unemployment insurances as expressions for this effort towards our common social goal. The cost of these social services has for most modern countries landed on the common tax base.

The term Commons with capital C and ending on s stands for an economical problem affecting what I call “what many own, nobody owns” or is responsible for. The Common tax base is a “Commons”. To have the cost of access to old age pensions and the other social services mentioned is after a while taken for granted. Should cost of medicine also be placed on a Commons may have serious consequences in the long run for any nation because, as a pillar need medical cost cannot be controlled.

Medical care often covers life-maintaining and life-threatening situations that make a patient totally dependent on the medical support system - in a way a monopoly situation. The Nine Pillars of History pointed out that monopoly will lead to social destruction be it from political or religious monopoly. Here I must again recognize that the social need for medical care is a unique situation that may lead to social destruction. Medical care has to be placed on the side of defense as a common necessity but should still be controlled through competition just like defense cost.

The Problem

After having described the total problem in general terms might now be ready to address it more specifically.

Give is that in 2010 the cost of access to medical care in US is rising to an unsustainable 16% of GDP and still rising; almost double that in other industrialized countries. In Sweden medical cost in 2010 was 9% of GDP when corrected for local PPP. Even at 9 % medical cost in Sweden was crowding out other social obligations. (GDP stands for gross domestic production and PPP for purchasing power parity) 16 % annual increases in medical cost will double the cost in just 4.4 years ((70: 16= 4,375). Such percentage increase is unsustainable for any organizations that subscribe to underwrite. (Klugman, Blinder) To face the problem we have the following choices:

A) Take a Passive role

1) Wait for crisis to culminate; kick the can down the road.

President Bill Clinton tried to introduce a medical care bill in 1993. I worked at Lockheed at the time. A local branch of Kaiser Permanente had provided Lockheed employees with access to medical health care for many years. Kaiser Permanente is an organized HMO, Health Maintenance Organization. President Clinton tried through a mandate to impose a plan similar to the Kaiser plan to cover medical coverage for all citizens. Pressure from insurance companies and smaller employers blocked a general plan. Lockheed still picked up on the idea and offered for other, not yet organized medical groups to get together and compete with a Kaiser-like Plan (HMO). This held back medical cost for some time while the surrounding offices matched the Kaiser plan. This was ten years ago. Now even Lockheed is requiring its new employees to help pay for medical cost.

According to the Wikipedia HenryJ.Kaiser and a Physician Sidney Garfield founded Kaiser Permanente medical group in 1945.The Permanente group operates in nine states and the DC, has 8,9 million members served by 14,600 physicians or one per 600 patients. In its recently reported year, the non—profit Kaiser Foundation Health Plan and Kaiser Foundation Hospital entities reported a combined $1.6 billion in net income on $47.9 billion in operating revenues or 4.3%. Each independent Permanente Medical Group operates as separate for profit partnership or professional corporation in its individual territory, and while none publicly report their financial results, each is primarily funded by reimbursements from respective regional Kaiser Foundation Health Plan entity.

HMO- organization has helped to have access to medical care while having access to work. Still the cost within the HMO keeps on going up. Many employers opt out for plans for new employees or ask employees to help to pay for the increased cost. This may need to renegotiate new contracts like for state employees in Wisconsin. Many employees have now lost their job and with that also lost their access to medical care.

The Federal government plans to add 50 million new citizens to have access to the same size medical provider base. This certainly accelerates the whole problem. Who will or even can pay?

2) Hope that technical advances will bails us out???

B) Take an active role

After the Swedish model England made physicians into public salary employees. France like the Kaiser health plan has made all doctors independent contractors but here medical cost is even higher ($3470 for Sweden and $3696 for France) All OECD countries have a medical cost at around 9% of GDP. In a Federal report released June 2012 on cost/ PPP corrected GDP the medical cost will climb to 20% of GDP. This report is according to Kaiser health care news and a Bloomberg financial report 2011.

The Nobel Laureate Milton Friedman addressed the cost problem for access to medicine already in the 1970s. His solution was to open more medical schools and graduate more physicians. Also Dr Lobosky is asking for “lots of more doctors and doctor extenders. This would help but would not address all facets of the medical four-facetted economic interest pyramid.

The graduation of more physicians’ extenders would also help. With physician extenders is meant physician’s assistants, nurse practitioners and nurses specialized for specific medical treatment like pregnancy, delivery, tuberculosis, diabetes and so on. Kaiser Hospital has made efficient use of physician extenders. But small independent medical offices are not apt to hire medical extenders. Most of us enjoy the personal care that individual offices provide. Medical care is indeed a very personal need filled only through a personal, confidential relationship.

Most medical situations are however not that complicated that eleven or more years of training is necessary. A triage referral system would certainly help, specifically for emergency admissions.

1)Single payer would lower administration cost from 35 to 3 or 5%

2) personally I support the president Obama’s mandate for general access to medical care.

3) I propose to measure efficacy according to the following recipe.

4) Most medical situations are so common the treatment team has worked out routines to meet the need. The profession has numbered all procedures and generates its cost accordingly. This information is computerized and therefore offers a unique opportunity to check the medical efficacy of any procedure, any medication or in any medical practice. I proved medical efficacy of health education at Lockheed using such a computerized program (See my publication: Add years toy our life, and life to your years Part I)

5) A computerized test program does need not to be for a whole country. It may be limited to a geographical area recognized for excellent medical care and good computerized medical records. El Camino hospital in Mountain View, California, with its surrounding individual and group practices may together comprise such sample. The El Camino hospital is a not-for-profit hospital recognized for its superb care. The surrounding patient and doctor populations are typical for a well-planned community. This information can be used as a measuring stick to compare against for-profit medical enterprises.

6) Start a medical review board for every medical county as a first instance for patient complaint.

7) Require a legal tort program for any state receiving Federal assistance.

8) A review of medical malpractice policies.

9) A review of pharmaceutical prescription policies.

Letter from the President of DeSale Univ. , posted 24 Jul 2012 at 14:29 UTC by sye » (Journeyer)

The following Letter is printed on very colorful PSF 2012 program.

NOTES FROM THE PRESIDENT OF DESALES UNIV.

DESALES UNIVERSITY AND THE HEALTHCARE MANDATE FROM THE DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

Since the beginning of the institution, both Allentown College of St. Francis de Sales (1965 - 2000) and DeSales Univ (2001- ) have provided generous healthcare benefits for all fulltime employees. We have done this because we believe that it is the right thing to do.

Three years ago, DeSales Univ. became a founding member of the LVAIC
(Lehigh Valley Association of Independent Colleges) Healthcare Consortium,
along with Muhlenberg and Moravian colleges. This healthcare consortium has
been very successful in managing healthcare costs and has allowed the Univ.
to offer manageable cost increases over the three-year period, with a 0%
cost increase for the current year for healthcare coverage.

We offer two different plan designs. The Univ. pays ofr 82% of the total
cost of healthcare for our employees. Healthcare coverage costs the
university approximately $17,000 for a family and $7500 for a single
person. The Univ has budgeted $2.9 million for healthcare coverage for
fiscal 2013. Currently, 286 out of 350 employees use the Univ.'s healthcare
plan.

The LHAIC Healthcare Consortium is considered to be a 'self-funded'
healthcare plan because we directly pay approimately 75% of claims
presented to the plan, with the additional 25% of claims paid by stop loss
insurance. Therefore, the 'concession' to HHS mandates that the 'insurer'
pay for contraception, sterilization, and abortion inducing drugs makes no
real concessions, since essentially we are the insurer.

As with many religious communities in America, we are very concerned with
the notion that the Secretary of the Department of Health and HUman
Services can determine the content of the healthcare coverage that we must
offer to our employees. This is an intrusion into the inner workings of a
private ( and in our case religious) institution that constitutes possible
grave dangers. Religions began caring for people before governments were
formed. In many cases, religions know more about the life and health issues
of human beings and what constitutes a healthy life than government
bureaucrats will ever know.

If the power of Congress to mandate healthcare issue is affirmed in June by
the Supreme Court of the United States, many religious institutions will
simply ignore the mandate. We will state that the mandate is an
infringement of our first amendment rights to religious freedom and liberty
of conscience. Courts will then become engaged in a different issue - can
Congress mandate items that violate the consciences and religious
convictions of citizens. Eventually, various state appeals courts will rule
on this issue. This new issue will eventually reach the Supreme Court.
Notice - we are taling about a lengthy process. My guess is years! During
all this time, DeSalezs will continue to offer our regular healthcare
program.

To paraphrase St. Thomas More, we seek to be the king's good servants, but
God's first!

Bernard F. O'Connor, OSFS
President

A private letter to President of DeSale , posted 27 Jul 2012 at 10:11 UTC by sye » (Journeyer)

Dear Sir:

I read your Note from the President of DeSales University in the Pennsylvania Shakespeare Festival program, while babysitting my sleeping grandson. (My son and daughter-in-law had been unable to get a babysitter for the production of The Tempest, so I was taking my turn, and I hadn’t brought a book.)

No doubt the issue of whether the university’s health insurance should provide contraceptives for female employees is important—more important even than issues such as the student tuition loan crisis, the more than 50 million Americans who lack health insurance, the 13 million who are unemployed, the approximately 700,000 who are homeless, global warming, clerical sexual abuse…

But how important is this issue? As you are no doubt aware, 98% of married Catholic women have used contraceptives. Among Catholic women who are not married (and who are not Religious), the percentage is lower, since only 70% of them are sexually experienced. The women who work for you buy contraceptives out of the generous salaries you pay them and will continue to do so until (unless) the Affordable Care Act requires your health insurance to make more compassionate provisions.

The argument has been made that if 98% of Americans cheat on their taxes, that does not make cheating on taxes morally acceptable. However, this is a false analogy. The use of contraceptives is in no way similar to cheating on taxes. Note that while Jesus had a great deal to say about economic injustice, he said very little about sexual morality.

You describe the issue as one of “religious freedom.” How did “religious freedom” come to mean license to treat female employees shabbily?

Yours Sincerely

Craig E. Laird

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