Planning the Patient-Centered Health Plan for America

Current Issue:

Health Care and Social Security Costs are Unsustainable.

Health spending totaled $74.6 billion in 1970 or $355 per Beneficiary.

By 2000, health expenditures had reached about $1.4 trillion or $4855 per Beneficiary.

In 2017, the United States spent about $3.5 trillion, or  $10,200 per person, 18 percent of GDP, on health expenditures. Of that $3.5 trillion, $1.5 trillion, is directly or indirectly financed by the federal government.

In 2018, the United States spent about $3.6 trillion, or $11,172 per person growing 4.6 percent.

Medicare costs are expected to rise rapidly in the coming years. In dollars, net costs are projected to more than double over the next decade. This growth is due to both the aging of the population – the number of beneficiaries will rise from 58 million to 77 million – and growth in per-capita health spending – cost per beneficiary is projected to grow from $10,200 to $16,400.

The Medicare trust fund will be depleted in 2026, the administration said. By contrast, the government said last year that the trust fund would be exhausted in 2029.

Social Security benefits will start to exceed the program’s costs in 2020, and the program will deplete its $2.9 trillion reserve fund in 2035. After that, the program is projected to pay out about 75 percent of benefits. … By 2033, the number of Americans eligible for retirement benefits will increase to more than 77 million from 46.6 million today.

Note: To keep Medicare and Social Security Sustainable, we must delay the onset of benefits. Early Medicare should be delayed 3 months every year until it reaches 72 years. Early Social Security should be delayed three months every year until it reaches 65 years. Regular SS should be delayed three months every year until it reaches 72 years.  The onset of SS and Medicare will then remain the same and will be index to 10 years less than life expectancy.

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Current Issue:

Employer based health insurance. American Academy of Actuaries

An address by George Ross Fisher, MD, to the Actuarial Society of New York, was featured in one of our annual medical conferences. His opening statement was that employers should move out of the health insurance business completely, as gracefully and as quickly as they can. His reasoning was medical, or at least based on medical predictions. For far too long, the nation has regarded the financing of medical care as in insurance problem, with insurance solutions, quite ignoring the fact that the purpose of the whole exercise is to help sick people to get well. But if we don’t have any illnesses, we won’t need any insurance, and that revolution may be closer than you would guess.

For far too long, the nation has defined the adequacy of health financing by counting the number of people who lack medical insurance. Better than anyone else, actuaries know the problems caused by over insurance, some as troublesome as underinsurance. Without asking you, I know you agree that universal health insurance surely promises more than it can deliver.

The Uninsured:
Let’s be brief: Of the 40 million uninsured, at least a third of them are caught by a sampling snapshot during periods of unemployment between jobs. The more permanently uninsured are mostly poor, mostly young.

Young people are seldom very sick; if anyone can do without insurance, they can. As they grow older they have more sickness, but also more income. Fifteen percent of the poorest 20 percent of the population eventually rises into a higher quintile of income. In the meantime,  many can fall back on their parents in an emergency. In most instances, coverage of offspring is required to age 26. At this time the majority have already embarked on their life work.

Disability provisions of Social Security are available to those who are disabled from employment and indeed, probably to many who are not. Thirty percent of people receiving Social Security checks are under the age of 65 and are mostly, therefore, eligible for Medicare.

Medicaid is available to the poorest segment of the population. Nowadays, a person usually joins Medicaid after sickness brings him to a hospital, where the hospital social worker then effectively activates the latent coverage.  Although health financing of the 40 million can’t be called a seamless system, but surely its imperfections don’t warrant the title of crises.

Disappearing Disease.
The bad news grows out of the good news that more and more diseases are being conquered and many of the old diseases are disappearing. This leads to the startling prediction, central to health care financing, that the population up to age 65 could be largely free of major diseases within one generation. Health costs and health insurance are going to be pushed into Medicare. [The late] Sen. Ted Kenney will then have his single-payer dream come true, and my [actuarial] profession will do it for him. The focus of the employer-based insurance industry goes in the opposite direction; the need for that product is going to disappear.

Dr. Fisher, also an actuary, which he considers the brains of the insurance industry, must concentrate on the costs of being born and the costs of dying. Of the two, obstetrics has always been an uninsurable risk swept under the actuarial rug with such tricks as mandating premium payments to those unable to have children.

The cost of basic health care is reduced when it is
separated from employment.

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Current Issue:

2. In the News: The U. S. District Court upheld racial discrimination at Harvard

New York, NY (October 3, 2019)The National Association of Scholars (NAS) reacted with disappointment to the decision by a United States District Court upholding racial discrimination in admissions by Harvard University. NAS had previously filed an amicus brief in the case, Students for Fair Admissions v. Harvard, in favor of the plaintiff. We noted that Harvard’s race-conscious admissions process discriminates against Asian applicants in order to achieve racial balancing.

“Racial discrimination is wrong,” said NAS President Peter Wood. “Unfortunately, Judge Allison D. Burroughs engaged in mental gymnastics to find Harvard’s behavior legal. Burroughs acknowledged that Harvard considers race ‘as a positive attribute’ for some races, but he’s refused to admit that this results in intentionally negative outcomes for non-favored races.”

Wood continued, “Race should play no role in college admissions. Colleges and universities should concern themselves with life of the mind, not the color of their students’ skin. Academic achievement, proven ability, ambition, and commitment to learning should form the basis for college admissions decisions.”

The National Association of Scholars has opposed racial preferences in admissions policies since its founding in 1987. NAS members wrote the text of California Proposition 209, which made race-based admissions policies such as Harvard’s illegal in 1996. NAS previously urged legislation to end race-based preferences, and still desires such an outcome.

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Previous Issue:

2. In the News: Editorial: Trust in Health Care JAMA: July 15, 2019

Building Trust in Health Care—Why, Where, and How

Dhruv Khullar, MD, MPP1


Promoting Trust Between Patients and Physicians in the Era of Artificial Intelligence

Shantanu Nundy, MD, MBA; Tara Montgomery, BA; Robert M. Wachter, MD

Trust in US health care has declined precipitously in the past half century. In 1966, 73% of US residents had confidence in medical leaders, whereas in 2012, only 34% did.1 In a survey of 1009 participants in 2017, only 18% expressed high levels of confidence in the US health system, and in a 2014 survey of 1608 participants, only 31% indicated that they trusted public health officials to share complete and accurate information during disease outbreaks.2,3 Recent high-profile events—such as those involving health care companies like Purdue Pharmaceuticals, Johnson & Johnson, and Theranos; vaccine misinformation contributing to the largest US measles outbreak in decades; and well-publicized examples of failure to disclose important conflict of interest information—have also contributed to mistrust and reduced confidence in health care entities.

Because of this trend, and a recognition that trust is vital for the delivery of quality medical care, the ABIM Foundation dedicated its 2018 Forum to examining trust in health care. Throughout 2019, JAMA has published a series of 11 Viewpoints based in part on discussions at the 2018 Forum that have explored trust among various constituents in health care including patients, clinicians, payers, media, and the government. Several themes and practices emerged as important for maintaining and restoring trust.

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Past Issue:

The Health Plan of Tomorrow: Deloitte’s Business Model

In general, Deloitte observes that industry transformations occur in three seven-year cycles. Health care organizations—and thus health plans—appear to be no different.

The Health Plan of Tomorrow:

What will the health plan of tomorrow look like? How will traditional health plans transform, and what choices do leaders need to make now to survive the forthcoming disruption? To begin answering these questions, the Deloitte Center for Health Solutions conducted crowd-sourcing research with 28 health care, policy, and technology experts. Over four days, these experts presented and discussed use cases for the next innovation cycle with a focus on four key areas: customer centricity; innovation; collaboration; and operational excellence.

In general, Deloitte observes that industry transformations occur in three seven-year cycles. Health care organizations—and thus health plans—appear to be no different. As the industry moves through these cycles, the pace of disruption will likely only pick up. Health plans are running short on time to adapt as nontraditional players enter the market; consumers, employers, and government purchasers scrutinize costs; and health care providers assume more care delivery risk, while insurers and the government shed it. Thousands of innovative solutions that enable consumer experience have been introduced into the marketplace, some of which are being enabled by digital and consumer giants such as Amazon, Apple Inc., and Google.

Deloitte’s crowd-sourced experts described a future in which health plans will shift to a focus on well-being and care using multidimensional data. Products will balance traditional population-level risk with being hyper-personal and easy-to-understand, based on consumer need. Moreover, health plans will have learned how to engage and influence consumers toward better health through a high-touch experience with digital devices. The experts converged on one overarching theme: Health plans will need to overhaul their current business models from managing enrollment and risk to focus on a framework that supports sustaining members’ well-being. . .

Read more: Adapting to Disruption – Deloitte Research on Business Model Transformation

Editor’s Note:

The very concept of managing wellness, which is primarily a personal endeavor, and insuring the process is ludicrous. Would anyone purchase an insurance plan that motivates you to do the things that are healthy when anyone can do this without paying for it?

Does this also remind you of the Soviet’s 5-, 10-, 15-, and 20-year plans for their agriculture which nearly destroyed their farmers? It also destroyed innovation.

Did the Soviets not understand that without farmers, their food supply would diminish? Some even starved. Some even died of starvation.

The Deloitte’s three seven-year cycle plans may similarly destroy physicians. It will also destroy innovative medicine.

Does Deloitte understand that without physicians, their health care progress will come to a halt? Diseases may progress more rapidly. Mortality may come earlier.


I’m getting ads daily to spend the $195 for this course.

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Past Issue:

The World Economic Forum at Davos is in Session this month

New Zealand’s Prime Minister Jacinda Ardern had some choice words for fellow heads of state who aren’t pulling their weight in the fight against catastrophic climate change.

Speaking in the session Safeguarding Our Planet alongside broadcaster and naturalist Sir David Attenborough, Ardern was asked by former US Vice-President Al Gore what she would say to world leaders who don’t believe the climate crisis is real.

“I wonder whether or not I would say anything or if I would just show them something,” she said. “It only takes a trip to the Pacific to see that climate change isn’t a hypothetical, and you don’t have to know anything about the science … to have someone from the Pacific island nations take you to a place they used to play as a child on the coast and show you where they used to stand and where the water now rises.”

“You don’t have to cede power by acting on climate change,” she continued. “There’s nothing to fear about your individual status … This is about being on the right side of history. Do you want to be a leader that looks back in time and say that you were on the wrong side of the argument when the world was crying out for a solution? It’s as simple as that.” . . .

Ardern also talked about her government’s plans to move away from traditional methods of measuring economic growth and development towards a “wellbeing budget” that considers both the health of New Zealanders and the natural world. Read more . . .

Key moments from World Economic Forum Annual Meeting

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Past Issue:

How can government determine the value of an employee?

Commentary by Pamela Villarreal

Source: Investor’s Business Daily | December 04, 2013

The bottom line is that those who want to make $15 an hour flipping burgers should . . .
pursue education and skills that warrant higher pay.

This week, another fast-food walkout will take place in 100 cities.

Evidently, this one claims to be much larger than previous protests.

And no doubt the Service Employees International Union and other organized labor groups play a major role in supporting the walkout and also make up the lion’s share of the protestors.

The goal? To push for an increase in the minimum wage to $15 an hour. (more…)

Past Issue:

A New Understanding of the Childhood Brain

Over the past decade, new research has revealed the link between early trauma and lifelong mental health issues. These discoveries have since revolutionized social work, healthcare, and early education. Policy changes enacted in response to our understanding of the biology of trauma are prioritizing earlier interventions like nurse home visiting services for at-risk families, and an increase in pre-kindergarten programs.

This short animation by Nadja Oertelt is part of The Atlantic’s Next America: Early Childhood project, which is supported by grants from the Annie E. Casey Foundation and the Heising-Simons Foundation.  (more…)

Past Issue:

Practice Fusion is agreeing to be sold to Allscripts

Christina Farr@chrissyfarr

Practice Fusion is scrapping free software model after agreeing to sell to Allscripts

Practice Fusion is planning to start charging doctors to use its software, sources say.

The change comes weeks after Practice Fusion agreed to a disappointing $100 million sale to Allscripts.

Practice Fusion has struggled to build a growing business model based on ads.

Six weeks after Practice Fusion agreed to sell itself to Allscripts for a fraction of its prior valuation, the medical software company is scrapping the business model that propelled it to unicorn status.

Practice Fusion gained traction by offering free electronic health records software to doctors — as an alternative to the expensive systems from big vendors — and the company made money by serving relevant pharmaceutical ads to its users. (more…)

Past Issue:

A Uniform Government Healthcare Record continues to be Fragmented.

State Department Issues RFI for New EHR System

by Heather Landi | April 3, 2018

The U.S. Department of State issued a request for information (RFI) for a new electronic health record (EHR) system on last week.

In the RFI, the State Department says it is considering a new EHR system to serve its Bureau of Medical Services (MED), which manages a worldwide healthcare program providing medical services for State Department and other U.S. government employees and their families serving abroad at U.S. diplomatic missions. The Bureau of Medical Services is comprised of a headquarters unit located in Washington, D.C. and MED Health Units located a number of U.S. diplomatic missions.  (more…)

Past Issue:

Trump touches the face of a service man without arms

John New‏ @JohnNew2015

It has been a movement from the beginning – God blessed the nation, with your candidacy, victory in the election and your presidency.

Replying to @JohnNew2015 @POTUS

The good citizens of the United States of America witness your sincerity of heart and true compassion for man. We’re grateful and fortunate.

Replying to @JohnNew2015 @POTUS

Since January 20th, the United States of America has begun to heal from the wounds of the past Marxist administration. Thank you, God.  Amen.

Replying to @JohnNew2015 @POTUS

Thank you, President Trump, for keeping your promise to nominate a conservative Pro-Life Supreme Court Justice. God bless you. Amen. (more…)

Past Issue:

The Changing Ideal Blood Pressure

The Ideal BP which has been 140 (160 in the elderly) systolic and 90 diastolic will be changing.

The cardiologists in Sacramento have long insisted that the ideal BP was 110/70. Many of our patients on their return from a cardiac consultation became lightheaded after achieving the new standards. Thus, we had to teach them to have a hold on a chair or table when they got up in the morning or made any sudden change in their position. This was to prevent falling or even loss of consciousness when the heart was pumping the blood in a horizontal plane and had to make a sudden change to pumping the blood in a vertical plane, so it would reach the brain. In the elderly, the blood vessels below the heart couldn’t tighten up and the blood vessels above the heart could relax as fast as they did when they were young, and the head of the BP didn’t quite reach the brain

How low should blood pressure go?

The answer: way lower than the current guidelines.

For years doctors have been uncertain what the optimal goal should be for patients with high blood pressure. The aim of course is to bring it down, but how far and how aggressively remained a mystery. There are trade-offs — risks and side effects from drugs — and there were lingering questions about whether older patients needed somewhat higher blood pressure to push blood to the brain.

The study found that patients who were assigned to reach a systolic blood pressure goal below 120 — far lower than current guidelines of 140, or 150 for people over 60 — had their risk of heart attacks, heart failure and strokes reduced by a third and their risk of death reduced by nearly a quarter.

The study, called Sprint, randomly assigned more than 9,300 men and women ages 50 and over who were at high risk of heart disease or had kidney disease to of two systolic blood pressure targets: less than 120 millimeters of mercury, which is lower than any guideline ever suggested, or less than 140. (Systolic pressure is the higher of the two blood pressure numbers and represents pressure on blood vessels when the heart contracts.) .

Also Sac Bee Sat Sept 12, 2015

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Past Issue:

Do Mammograms Save Lives?

Criticism of breast-cancer screenings is more about rationing than rationality.

By Daniel B. Kopans, WSJ

There is a disconcerting effort afoot to reduce a woman’s access to mammography screening for breast cancer by making it seem useless or even harmful. The movement dates to November 2009, during the debate over the Affordable Care Act, when the U.S. Preventive Services Task Force, which reports to Congress, dropped its recommendation for mammography screening for women in their 40s and instead recommended screening starting at age 50. . . Read more. . .

In 2009 no one on the task force had experience in caring for women with breast cancer, yet the task force decided that it would “altruistically” spare women in their 40s the “harms” associated with mammography. The main “harm,” as the task force saw it, was for a woman to be recalled after a screening mammogram for additional evaluation. This was made to seem more ominous by terming every recall a “false positive” if cancer was not found.

The task force neglected to explain that, although about 10% of women are recalled (the same rate as for Pap testing), more than half will need only a few extra pictures or an ultrasound showing all is well. Some will be asked to return in six months to be careful. Only 1%-2% of women screened will be advised to have an imaging guided-needle biopsy using local anesthesia, and 20%-40% of these biopsies will reveal cancer. This is a higher yield of more-curable cancers than when a surgeon would biopsy a “lump” in the pre-mammography days.

Remarkably, this new recommendation came even though the task force’s own computer models showed that as many as 100,000 women then in their 30s, whose lives could be saved by annual screening starting at 40, would eventually die from breast cancer as a result of waiting until 50.

The public outcry was immediate. Many saw the recommendation as an attempt to scale back health-care spending at the expense of women’s health. The Obama administration eventually said that it did not support the task force’s recommendations, and the Affordable Care Act, signed into law in 2010, mandated insurance coverage for mammograms for women in their 40s . . .

All the scientific evidence to date, including large randomized, controlled trials, show that screening for breast cancer saves lives. Screening began in the U.S. in the mid-1980s. In 1990 the mortality rate from breast cancer—unchanged for 50 years—began a steady decline. Today more than 30% fewer women die each year from breast cancer than would have died had the pre-1990 death rate continued. That’s about 15,000-20,000 lives saved annually, in large part due to screening.

Yes, cancer treatments (chemotherapy and radiation) have improved. But treatment saves more lives when a cancer is identified and treated earlier. Clinical studies in Sweden, Holland, Norway and Canada have shown that screening is the main reason for the decline in breast cancer deaths for women who begin screening at age 40. In one Swedish study, published in the journal Cancer (Feb. 15, 2011), researchers found that 30% fewer women in their 40s who were screened died from breast cancer compared with those who were not screened. Crucially, all had the same access to treatment.

In a study published last year, my Harvard colleagues reviewed 7,301 women diagnosed with breast cancer at major Harvard Medical School hospitals from 1990 to 1999 and the 609 women who died from these cancers (Cancer, Sept. 9, 2013). We found that 71% of the women who died from breast cancer were among the 20% of women who were not participating in screening. This relationship was particularly clear for women who were not being screened in their 40s compared with those who were being screened . . .

Dr. Kopans is professor of radiology at Harvard Medical School and senior radiologist at the
Breast Imaging Division of Massachusetts General Hospital.

Should Women Avoid Mammograms?

Some May Decide to Wait to Have Screenings

See further discussion, WSJ

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Past Issue:

The Great Society Declared War on Marriage: Obamacare Made It Worse

by Devon M. Herrick

President Lyndon B. Johnson declared an “unconditional war on poverty” in 1964 and followed up a year later with an avalanche of domestic social and antipoverty programs known collectively as the Great Society. Johnson persuaded Congress to support his welfare agenda — sending him more than 80 pieces of legislation to sign in a short period of time. Read the full article. –

Among the plethora of poverty-alleviating Great Society programs were food stamps, Medicare, Medicaid, Head Start, federal educational funding, housing assistance, increased welfare spending and other income transfer programs. The Great Society was intended not only to reduce poverty, but also to better peoples’ lives across the board. Ironically, the Great Society legislation seemed to simultaneously both ignore — and hinder — the most effective antipoverty program: marriage.

Indeed, this “War on Marriage” is a major reason for the lack of progress on poverty over the past 50 years! [See the side bar “Little Progress in the War on Poverty.”] And President Obama’s signature piece of legislation — the Affordable Care Act — has only exacerbated federal marriage penalties.

The Great Society without Marriage. Marriage has been on the decline for decades. According to the Pew Research Center:

  • Around 1970, about 84 percent of native-born 30-to-44-year-old adults were married.
  • By 2007, this proportion had fallen by nearly one-third to 60 percent.2
  • The marriage rate is even lower for men and women who lack a college degree (56 percent in 2007).3

And the marriage rate is even lower still for some racial demographics. According to Pew:

  • Only one-third of black women ages 30 to 44 were married in 2007, compared to 62 percent in
  • For black men, the corresponding rates are 44 percent (2007), down from 74 percent in 1970.4

Why do more low-to-moderate income couples skip the wedding bells? The reasons are partially economic: Financial penalties in the tax code kick in when couples get married. According to research from the Brookings- Urban Institute Tax Policy Center, the combined marriage penalty is significant for families earning less than $40,000.5 The method used to calculate income eligibility and antipoverty programs is the primary culprit: the so-called federal poverty level (FPL). The FPL’s income thresholds are for individuals or families of various sizes, and those with incomes below the FPL are by definition in poverty. The FPL is used to determine both eligibility and the amount of benefits for many different programs.

  • The Federal Poverty Level Penalizes Working-Class Marriages. The FPL does not rise proportionally with the number of individuals in the family. For example, the poverty level is $11,490 for an individual, but only increases to $15,510 for a married couple — just $4,020 more. Because this poverty designation does not increase equally for each additional family member, two unmarried individuals living together qualify for larger federal subsidies than they would if they were married.
  • Consider the example of two young lovers moving in together to share expenses. Assume each earns twice the poverty level (about $23,340 annually). If the couple were married, their combined household income would rise as a percentage of the poverty level from 200 percent (individually) to nearly 300 percent for a family of two. Depending on the program, this increase could have a profound effect on their eligibility for benefits ranging from food stamps to health insurance exchange subsidies (and many others). Thus, these two unmarried individuals living together qualify for larger federal subsidies than they would if they were married. As a result, this young couple, who might otherwise marry, may decide they cannot afford to.
  • Granted, not all couples meticulously calculate the loss of benefits and consciously decide whether or not to marry. Yet, the marriage penalty can still inhibit marriage as mores change over time. This can occur as others around them — friends, neighbors, siblings — forgo marriage to avoid loss of benefits and influence them to do the same.6
  • The Obamacare Marriage Penalty. Additional penalties under Obamacare may further discourage couples from “tying the knot.” The Patient Protection and Affordable Care Act (ACA) establishes health insurance exchanges where qualifying individuals can purchase subsidized individual or family health coverage. The exchange subsidies are more generous to cohabiting partners than to married couples. This disparity creates perverse incentives that further discourage cohabiting couples from marriage — especially moderate-income couples.

Why? Federal subsidies to purchase coverage in the health insurance exchange are based on the federal poverty level, and are rather generous to low-income individuals. Qualifying individuals and families earning 100 percent of the FPL will pay no more than 2.01 percent of their income for coverage that costs anywhere from $3,000 per individual to $15,000 per family, depending on their age and region. The federal government will cover the rest of their premiums. As income rises, the subsidies phase out, but a family earning 400 percent of the poverty level will pay no more than 9.56 percent of its income in premiums.

If the young couple (mentioned above) were to marry, their combined household income of $46,680 would rise as a percent of the poverty level from 200 percent (individually) to 297 percent for a family of two. As a result, instead of paying premiums that are capped at no more than 6.34 percent of income as two individuals earning 200 percent of FPL, their premiums would be capped at 9.47 percent of income for a married family of two earning 297 percent of poverty. Thus:

  • Individually they would each qualify for a subsidy of about $1,151 each, or $2,302 per (cohabiting) household.
  • If that same couple were to marry, their combined subsidy would fall to $845.
  • Their marriage penalty is $1,457 annually.

The Obamacare exchange marriage penalty is especially pronounced for couples with combined incomes of $30,000 to $55,000 annually. [See Figure I.]

What Causes Poverty? Some experts claim poverty is the result of bad choices, while others say bad choices are explained by cognitive overload.8 One theory posits that poverty becomes self-perpetuating by creating stresses that inhibit sound decision-making and the ability to think rationally.9 But those theories do little to explain the preventable lifestyle choices that cause many people to become poor and remain poor. When comparing those who are poor with those who are not poor to identify the differences in demographics and life choices, a handful of common poverty traits emerge. To quote George Mason University Professor of Economics Walter Williams, “[a]voiding long-term poverty is not rocket science.”10 Williams’ antipoverty strategy can be paraphrased thusly: 1) finish high school, 2) don’t have children until you’re married, and then stay married, 3) get a job, any job, and 4) avoid criminal activities.11

  • Williams’ advice is consistent with the conventional wisdom that research has confirmed over the years. Yet, while common sense suggests that educational attainment boosts lifetime earnings, people often don’t realize the degree to which marriage plays a role.12 Out-of-wedlock childbearing is highly correlated with poverty for both the mother and her child. Thus, marriage is an important institution for avoiding child poverty.13


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Past Issue:

Empowered physician leadership essential to transform Healthcare

Guest Commentary: Empowered physician leadership essential to drive healthcare transformation

By Dr. Margaret Ferguson

Last year I had the pleasure of meeting 2010 Oscar-winning director Kathryn Bigelow, who was honored for the Iraq war film “The Hurt Locker.” She was the first woman to win this award. However, during a session that I jointly hosted with my fellow executive medical directors, Dr. Imelda Dacones and Dr. Mary Wilson, in front of an audience of physician leaders, Bigelow emphasized that she wanted to focus on being seen as a “director”—not a “female director.”

Whether it’s directing a film or directing a healthcare organization or system, effective leadership is a monumental challenge. As Bigelow pointed out, we need to arrive at the point where gender, ethnicity and individual differences do not distinguish a type of leader; it’s the qualities and the results of the leader’s work that matter most. This precept is certainly true when it comes to physician leadership, where the end result ideally translates to exceptional and efficient care for the healthcare organization’s patients.

No matter a physician’s origin or background, I believe there are three key factors that distinguish a successful road to leadership: mentorship, training and empowerment to drive change. Every healthcare organization should examine its commitment to physician leadership through this lens.

Finding the right mentors. In virtually every career path, mentors play a critical role in supporting those finding their way in a profession. This is even more so in the field of medicine, where a doctor’s experience relies on the expertise gained when learning from other skilled practitioners.

It’s important for young physicians to look for mentors they trust. A mentor should be capable of building connections with people through their ability to empathize while still encouraging the sharing of strong opinions and independent thinking. Bigelow talked about how many of her mentors were men because of the industry she’s in; but in medicine, I believe that it’s possible to find mentors to connect with regardless of gender or background. The key is finding someone who is willing to take the time to help, as well as commonalities in the person’s approach to care or experience with similar struggles.

Developing new leaders. The educational path of physicians typically doesn’t include many, if any, leadership development classes. Practicing physicians are often focused on specialty skills for maintenance of professional certifications. Although medical schools are adding more management and leadership training to their curriculums, medical groups and hospitals need to invest in their physicians by supporting leadership education, with expanded professional development opportunities, often in partnership with existing professional and educational organizations that are known for their strength in management training and business education.

Every physician can and should be a leader in some form. It doesn’t always have to be administrative leadership, focusing on improving operations or the delivery of care. Simply having the skills to influence change and lead through action can significantly affect other members of a care team and bring about improvements for the patient’s benefit. Training helps physicians identify how they can not only lead, but mentor, coach, facilitate and communicate.

Empowering physicians to drivechange. A true physician leader is an agent of change. Simply assuming a title without having real authority is not physician leadership. Physicians must be empowered to initiate transformation, to find and pursue ways to modify systems and processes so that they work better and more efficiently, and to always be the watchdog over the mandate to put patients first.

In all of these areas, moving the needle forward on physician leadership means getting past long-standing barriers such as age, gender, race and culture. It means providing support, fostering development, and always being inspired by the change that leadership can bring about for improving the care system and benefiting the patient.

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Past Issue:

Authentic Medicine

Douglas Farrago MD, Editor, Creator & Founder


The mission of Authentic Medicine is to rediscover how much the art of medicine means and allow us to reconnect to our roots once again. It is about fighting back against those things that are taking us away from the direct care of patients while still pointing out the lunacy and hypocrisy of this job. Be part of the movement that will take back the healthcare system from the idiots who are ruining it.

Why we are moving to an era of Industrialized Medicine

The Quality Movement and why it is a scam

The ever-expanding Medical Axis of Evil

Medical Dogma and the Alphabet Soup (JC, HIPAA, CMS, etc)

Bureaucratic Drag and the distractions from treating patients

Burnout and depression amongst healthcare professionals

Humor in caring for the patient and the caretaker

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Past Issue:

On Tax Day, Friday, April 15, 2011, Atlas Shrugged Opens

The time has arrived!

Friday, April 15, the Atlas Shrugged movie will open on more than 300 screens around the country. Find the theater closest to you (and demand it in your city, if it’s not already there) by going here:

All of us who love Ayn Rand’s novels should bring our friends to see the movie on the opening weekend. This is hugely important; it shows theater owners how much demand there is for this independently produced and distributed movie based on Ayn Rand’s revolutionary novel.


Equally important, though, is to go back the following weekend—with even more friends. This helps demonstrate the movie’s momentum in no uncertain terms, and will draw even more theaters on board.


If you haven’t already seen the trailer and the excellent preview clips (‘Henry Rearden Comes Home’ and ‘Dagny Taggart Confronts the Union’) from the movie, you can watch those here:


Enjoy the show. Meantime, to help capitalize on this new wave of publicity for Ayn Rand’s writings, we’re hard at work building new functionality for the Atlasphere, including better search functionality, enhanced (and free) social networking options, and some innovative ways of sharing our enjoyment of Ayn Rand’s ideas. We’ll have more updates for you on this front shortly.

You may also wish to read Don Luskin’s review in the WSJ on “Atlas Shrugged.”

Remembering the Real Ayn Rand
The author of “Atlas Shrugged” was an individualist, not a conservative, and she knew big business was as much a threat to capitalism as government bureaucrats.

Tomorrow’s release of the movie version of “Atlas Shrugged” is focusing attention on Ayn Rand’s 1957 opus and the free-market ideas it espouses. Book sales for “Atlas” have always been brisk—and all the more so in the past few years, as actual events have mirrored Rand’s nightmare vision of economic collapse amid massive government expansion. Conservatives are now hailing Rand as a tea party Nostradamus, hence the timing of the movie’s premiere on tax day. . .

Read the entire Luskin Review in the WSJ – Subscription required . . .
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Past Issue:

Why Medicaid Should Be Easier to Fix than Entitlement Programs

Capital Ideas By: John R. Graham, Pacific Research Institute, 6.1.2011
Congress remains gridlocked on many important issues but not every politician is afraid to challenge the unsustainable growth of Medicaid. Consider S. 1031, by U.S. Senator Tom Coburn.

This measure would increase local control over Medicaid spending and improve the incentives that have led politicians to trap ever more low-income citizens in poverty and the poor access to care that characterizes this top-heavy system.

Medicaid is often described as an “entitlement,” but that is wrongheaded. Medicaid is welfare, targeted at low-income Americans. And Medicaid should be easier to fix, politically, than two other troublesome programs.

The politicians who invented Social Security and Medicare asserted that these programs would be funded by payroll taxes in order to foster the illusion of entitlement. We pay for the benefits in our working years, and the benefits arrive after we’ve retired. It’s all nonsense of course.
The taxes we pay do not go into accounts that belong to us. Rather, they pay current retirees and fund other government programs. Nevertheless, it is exceedingly difficult to convince people of the truth that we have not paid for our Social Security or Medicare. But Medicaid spending, to which nobody is “entitled,” is now greater than Medicare spending.

This has occurred because Medicaid’s funding formula incentivizes the political class to overspend. For every dollar a state politician spends on Medicaid, the federal government pitches in at least one dollar – or even more, as a result of the misnamed “stimulus” of 2009 – via the Federal Medical Assistance Percentage (FMAP). The federal government actually rewards states for making more residents dependent on Medicaid.

S.1031 would transform the federal government’s funding for Medicaid, but it would transform it into a “capped allotment.” This was the model of the successful welfare reform of 1996, which reformed Aid to Families with Dependent Children (AFDC) into Temporary Assistance to Needy Families (TANF).

The number of average monthly recipients dropped from more than 12 million in 1996 to fewer than 4 million in 2008 – and low-income Americans faced better incentives to seek productive work. We have recently experienced a successful example of a reform in this direction.

Rhode Island received a waiver on the last day of the Bush administration that capped its total (state and federal) Medicaid spending at $12.075 billion through 2013. At the current rate, it looks like the actual spending will be about $9.3 billion – with no evidence of reduced access to care. And Rhode Island’s waiver preserved the flawed FMAP.

Coburn’s S.1031 introduces even better incentives, from which all states and taxpayers will benefit. It gives states more control over their program dollars to get rid of waste, fraud, and abuse. It encourages states to make Medicaid providers accountable to the neediest patients in their communities, instead of remote federal bureaucracies. Finally, it will protect taxpayers from politicians’ worst impulses to spend unaccountably.

It is generally recognized that TANF, which passed with bipartisan support, produced positive outcomes. It is long past time to introduce similar reforms to Medicaid. The current stalemate on the debt limit should not prevent Congress from taking up S.1031 at the earliest convenience.

Read John R. Graham’s entire report at the PRI . . .
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Past Issue:

2016: Obama’s America

Get the real unvarnished truth about what 2016 will look like if Obama gets re-elected. You may not recognize the Home of the Free. There may not be any home of the free left on the earth if he wins. Some Freedom of Speech has been compromised. Some Freedom of Religion has vanished. This has been playing throughout our country this month. The DVD is now available. If you missed the widescreen, watch it on your PC by ordering it from Amazon and other outlets. It’s worth the price. It may save your life. It may save our country.
The theater listings
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‘2016 — Obama’s America’ — why is the media so afraid of this movie

If you thought being one of the producers of one of the greatest anti-hate films in history, one that exposed hatred, bigotry and anti-semitism would make you immune from being labeled a hate monger, think again. “Schindlers List” left its mark on the world and did so by telling the truth about man’s inhumanity to men. Yet the slings and arrows came at me to impinge my credibility, the work of Dinesh D’Souza and to once again use hate as their passport to the dark side.

Is there anyone else out there who sometimes finds movie reviews lacking in substance and objectivity? How about a film “review” written by an online journal prior to them even viewing the film? Does that sound like the classic cart before the horse scenario? Anyone else smell something dishonest, partisan and maybe even cynical? That kind of effort can only be suspect in its mission and intent.

I speak of an online journal writing an attack piece on my latest film, ‘2016 – Obama’s America’. It labeled the film, “Feature Length Obama Hate.” Nice. And they hadn’t even seen the film.

That kind of action has to come from pure chutzpah, ideology or just plain stupidity, you can pick.
It seems the left in America can only define something they don’t understand, something that frightens them, something so truthful it hurts or something they have no real response to that leaves them grasping for any kind of answer that comes with the hope that maybe it will just go away…and if it doesn’t, do all possible to destroy it.

That won’t happen. The film is complete, it’s scheduled for release and it stands on it’s own as a well thought out visual documentary based on two books written by author Dinesh D’Souza, “The Roots of Obama’s Rage’ and the soon to be released “Obama’s America.”

A dear friend reminded me to not take the attack(s) personally and remember what a true hero of American liberalism, Nat Hentoff,  wrote in his aptly titled book, “Free Speech For Me But Not For Thee: How The American Left and Right Relentlessly Censor Each Other.” Mr. Hentoff reminds all of us that the “right” and the “left” have both made blunders in their zeal to shut down the other side. But this attempt at fairness in reviewing a new film goes the extra mile in incredulity when the review comes EVEN BEFORE the film’s release.

This effort to de-legitimize the film is nothing less than “high-tech censorship,” since the first attack was trying to impugn the motives of the filmmakers and questioning how the project was funded and by whom, all in an attempt to dissuade people from watching it.

I don’t remember anyone in the mainstream press questioning Michael Moore about his motives (he wore them on his sleeve) or where the funding came from (deep pockets of those sharing his ideology). No questions asked….

The American way has always been to present ideas and new opinions, then through reason, logic, debate and even personalities, continue to expose as many points of view as possible. It makes the country a better one and stronger one for all of us.

“2016 – Obama’s America” presents a picture of an America changed through the passion of one man and his determination to turn America into ‘just another country.’ The movie should be required viewing by all Americans. Then you can do your own homework and make up your own mind.
But there are forces out there who don’t want you to view this movie and will try desperately to keep you away from the theater by impugning the character of people like me who created the work, hoping it’ll scare you away.

That’s not the American way.

I hope you’ll ignore these voices of fear and enjoy the show. And to these true forces of hate, who would seek to bully people into not seeing a movie they themselves haven’t even seen yet, let me remind them: it’s just a movie. Right?

Gerald R. Molen is the Academy award winning producer of films such as “Schindler’s List,” “Jurassic Park,” “Minority Report” and others. His film “2016: Obama’s America” will be released in theaters on August 10 and 17.

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Past Issue:

How can government determine the value of an employee?

Commentary by Pamela Villarreal
Source: Investor’s Business Daily | December 04, 2013
The bottom line is that those who want to make $15 an hour flipping burgers should . . .
pursue education and skills that warrant higher pay.

This week, another fast-food walkout will take place in 100 cities.

Evidently, this one claims to be much larger than previous protests.

And no doubt the Service Employees International Union and other organized labor groups play a major role in supporting the walkout and also make up the lion’s share of the protestors.

The goal? To push for an increase in the minimum wage to $15 an hour.

But as the old adage goes, the road to hell is paved with good intentions.

The arguments made by advocates of a living wage are flawed on so many levels, and will end up hurting the people they purport to help.

One needs look no further than the evolution of large retailers. Thirty years ago, there was no such thing as a self-checkout lane.
I used to walk in to my local big-box retailer, and there was very little that was high-tech about checkout lanes.

Scanners were just starting to be used to price and sell merchandise, but the clerks had to scan each item personally, with a hand wand. In spite of the burgeoning computer technology, a warm body was still needed.

But much of the retail transformation can be attributed to increasing labor costs and decreasing technology costs.

How does this relate to this week’s walkout? It is simple. If higher wages are forced on the fast-food industry, capital eventually will replace labor in that industry as well.

Sadly, this is all under the guise of helping people, but the result will be that teenagers and low-skilled workers get the shaft.

The unemployment rate among teenagers is the highest of all age groups.

In some areas, such as Washington, D.C., it is above 50%. Teenagers there would be happy to work for $8.25 an hour.

Recently, Washington’s council almost passed an ordinance that would require the area’s newly established Wal-Mart stores and other large big-box retailers to pay a “living wage” of $12.50 an hour.

Given that 23,000 applications were submitted for the 600 jobs that were available when Wal-Mart opened its first stores in the D.C. area, it is evident that many job-seekers are willing to work for less than $15 an hour.

The fast-food industry will also seek out those people.

But once those who are willing to work are employed, any excess demand for labor will be supplied in the form of whatever is most efficient, either by enticing more workers with a higher wage or using technology instead of human capital.

It does not matter what is mandated by a city or the federal government, or what is demanded by protesters.

Businesses seek to maximize profits, and if they must replace or supplement human capital with automation they will do it.

Advocates argue that many fast-food and retail workers support families and also depend on public assistance, which costs taxpayers.

A study from the University of California, Berkeley, found that 330,000 fast-food workers are enrolled in Medicaid, the health care program for the poor, and 432,000 children of fast-food workers are enrolled in CHIP, the Children’s Health Insurance Program.

But as many states offer Medicaid benefits to households living well above the poverty level, it is disingenuous to connect Medicaid benefits directly to fast-food workers.

In fact, there are 636,000 families enrolled in Medicaid and CHIP in Massachusetts, thanks to its generous eligibility criteria, but only 34,000 households with fast-food workers.

It would hardly make sense to blame Massachusetts’ Medicaid burden on the fast-food industry.
But far be it for facts to get in the way of a good push by living-wage advocates.

Furthermore, if a minimum wage hike results in more low-wage workers becoming unemployed or unable to find a job in the first place, the cost of public assistance programs will likely increase.

The bottom line is that those who want to make $15 an hour flipping burgers should put their picket signs down and instead pursue education and skills that warrant higher pay.

Read Villarreal’s entire Opinion, as well as others at the NCPA . . .

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Past Issue:

Obama Kicks Seniors Yet Again

Commentary by Devon Herrick

Source: | March 04, 2014

The Affordable Care Act (ACA) will have a negative impact on seniors’ access to care. Much of the funding for the ACA is derived by cutting $716 billion from Medicare over the next decade. One major cut includes a 25 percent fee reduction to physicians who treat Medicare enrollees. ObamaCare is also slated to cut funding for Medicare Advantage (MA) plans, which covers nearly one in every three Medicare enrollees. Compared to traditional Medicare, MA plans provide approximately $825 annually in added benefits to its mostly moderate-income enrollees.

The Obama administration is now poised to take another swipe at seniors — this time cutting their choice of Medicare Part D drug plans. The Centers for Medicare and Medicaid Services (CMS) wants to do away with the most popular Medicare drug plans: ones that offer seniors lower premiums (and lower cost sharing) in return for patronizing a preferred pharmacy network. CMS also wants to limit the number of plans an insurer can sponsor in each service region to only two, which will reduce seniors’ options for drug plans.

About 90 percent of seniors take a prescription drug in any given year. Compared to other therapies, drugs are a relative bargain. Drugs make up only about 10 percent of total medical expenditures. Nearly 39 million Medicare beneficiaries, including both seniors and the disabled, have drug coverage subsidized through the Medicare. Most of these are enrolled in coverage known as Medicare Part D.

The 6 million health insurance cancellations that occurred in the fall of 2013 will pale in comparison to the number of Medicare Part D drug plans cancelled next fall if these regulations are implemented. Nearly 14 million seniors will lose the Medicare Part D stand-alone plans they have currently if the use of preferred networks is banned.

The Medicare drug program has been quite popular. Participating seniors pay about one-fourth of the cost of their drug plan, while the government pays for about three-fourths of the cost. Overall, seniors are highly satisfied with their drug plans. Satisfaction rates average about 90 percent to 95 percent. As a result, the proportion of seniors who lacked drug coverage prior to the Medicare Modernization Act of 2003 (MMA) has fallen by 60 percent.

One reason seniors give their Medicare drug plan high marks is because they can choose among a wide range of drug plans. Nationwide, 1,169 Medicare Part D drug plans across 34 regions compete for seniors’ patronage. The number of plans varies among states, from a low of 28 in Alaska, to a high of 39 Pennsylvania and West Virginia. But that’s too many according to some within the Obama administration. Some Medicare administrators remain skeptical of the MMA — which was passed by the Bush administration with the help of congressional Democrats. The Bush administration wanted the Medicare drug program to be composed of private drug plans, whose primary mission is to vigorously compete for seniors’ patronage. Since its inception, the MMA mandated a statutory, non-interference clause. Contract negotiations between drug makers, pharmacy networks and drug plan sponsors were strictly left to the respective parties. Drug plan sponsors were responsible for negotiating prices with drug companies and drug distributors, and contracting with pharmacy network providers to secure seniors the lowest possible drug prices.

That is, until now. In January 2014, CMS proposed new regulations that would restrict the ability of drug plans to offer seniors lower drug prices in return for patronizing a preferred network. Low prices are the result of bargaining power — the ability of the drug plan managers to steer business to drug providers that agree to low prices, and deny business to a firm if their bid isn’t favorable.

The Obama administration wants to block drug plans from excluding the losing bidders — those drug provider networks that offered the highest prices during contract negotiations. The proposed regulatory change is not benign; it substantially weakens a drug plan’s power to bargain for lower prices on behalf of seniors. Without the knowledge that a “losing bid” threatens drug plan managers with losing out on all potential business from enrollees in a given Medicare drug plan, pharmacy networks will have little reason to offer low prices. The incentive is for all competitors is to bid higher, knowing a losing bid does not mean losing business — but could mean charging higher prices.

Medicare Part D premiums have remained affordable since the MMA’s inception because per capita drug spending has been far lower than projected. In 2013 the per capita cost was nearly 40 percent less than it was projected to be back in 2006.

According to the Federal Trade Commission, regulations that ban preferred networks raise prices and harm consumers. The actuarial firm Milliman estimates this regulatory change, proposed in January, would actually cost the Medicare program nearly $1 billion per year, and would add more than $9 billion to the cost of the Medicare Part D program over the next decade. Seniors seem to appreciate drug plans that feature low-priced, preferred pharmacy networks. Enrollment in this type of plan has shot up more than 60 percent in the past year. Seniors — and taxpayers — will be losers if this option is taken from them.

Read Dr. Devon Herrick’s OpEd, as well as other OpEd’s at the NCPA . . .

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Past Issue:

Commentary by Pete du Pont

Some thoughts on the views that have animated this column.

Source: The Wall Street Journal | May 27, 2014
Governor Pete du Pont is a Board Member of the National Center for Policy Analysis. He writes a regular column for, the online news service of The Wall Street Journal.
Pete du Pont has served as Governor of Delaware, U.S. Congressman (R-DE), and former candidate for President of the United States (1988). Gov. du Pont formerly hosted a nationally-syndicated radio commentary and appeared on several editions of the PBS Firing Line debates with William F. Buckley, Jr.

This will be the last of my columns for this publication, so I thought it fitting to note the views that have most influenced these writings. Foremost is my appreciation of America’s character and strength and my opinion that the only earthly thing that can stop this great country is a national failure of will or a continual series of misguided political decisions.

My optimism is driven primarily by the ingenuity and resilience of America’s people. A nation of more than 300 million will have its share of lawbreakers, slackers and charlatans, but America is so much more filled with people who are wise, honest and hardworking. The capacity of Americans to sacrifice—greatly at times—for others is truly impressive.

This is why I so often stressed that individuals, families and businesses should as much as possible be the ones making decisions instead of politicians and bureaucrats, no matter how well-intentioned. Some will argue against this view, and it is certainly true that individual decisions will not always provide the optimal result. But it is just as certainly true that this approach will work better over the long term than one-size-fits-all diktats of government. From the five-year plans of the former Soviet Union to ObamaCare, the troubles that can befall a country from top-down government control and political attempts to pick winners and losers are obvious.

My optimism has also been fueled by what history shows is the amazing ability of our economy to generate jobs, innovation and better standards of living, not just for our nation but for the world. We are rightly seen as the land of opportunity, and it is no wonder people from other nations flock here.
I must admit this optimistic view has been challenged over the past decade. One of the most obvious reasons for pessimism is the sad state of the national fisc. Deficits are not in and of themselves bad, but running large deficits for multiple years is. Burdening future generations with trillions of dollars of debt is a deplorable abdication of responsibility. One key to our future will be whether government can reduce the runaway spending that comes from trying to be all things to all people. It is critical that government instead focuses on its central responsibilities, reduces its tax bite, and gets rid of onerous regulations that sap the initiative of our people and the strength of our economy.

Another cause for concern is the stifling of economic growth and opportunity under the guise of environmentalism. We cannot afford continued attacks on our energy supplies. These policies, if carried to the fruition of which the left dreams, will crush our economy and with it our standard of living and our continued ability to be a strong presence in the world.

We are still the world’s sole superpower, and like it or not, that role comes with certain responsibilities. We cannot continue to be a force for good across the globe if we continue the recent trends toward isolationism and a hesitancy to get our hands dirty. Recent efforts to shortchange our military and defense preparedness are not harbingers of success in this critical area.

We cannot let political correctness muzzle free speech. That this occurs with regularity on college campuses, where open debate should be most welcome, is a sad irony. Nor can we continue to impinge on the freedom of religion. Encouragingly, the recent Supreme Court ruling in Town of Greece v. Galloway reaffirmed the view that God has a place in the public square.

Since our strength flows primarily from our people, the character of future generations is important. Will the left succeed in making more of us dependent on government? Will the generations moving into the mainstream of politics and the economy over the next decades be like the college graduates recently in the news who seem to have majored in taking offense or claiming victim status? Or will they be more like the young men and women who have performed so amazingly in Iraq and Afghanistan, and the ones starting careers and families? The next generation does not have to be the greatest generation, but it cannot be the weakest generation.

Of course, education is critical. We must not let union bosses and other forces of the status quo stop innovations that would ensure a good education for all. We must find a way to make higher education more affordable so those needing a degree to pursue their profession are not blocked from seeking that degree or saddled with significant debt.

These are the views of, and hopes and concerns for, America on which my columns have been based. I must note my gratitude to James Taranto, my editor par excellence for these columns, and to Brad Zuber, who has provided me with research and other assistance for nearly two decades. These columns have been better because of their efforts.

Finally, I want to thank all of you, the readers. I know from the comments section that not all have agreed with what I wrote each month, but I hope you enjoyed thinking about and debating the issues I raised. Please continue to read the editorial section of this great publication. It is rare to find such an abundance of writers in one place who can so interestingly write in a way that separates the truly important policy essentials from the dross of today’s political rhetoric.

It’s been a pleasure to be associated with all this over the years, and I wish everyone the very best.

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Past Issue:

Medicare has a drug problem

Drug Fraud Is Growing, And Costly, Problem For Medicare
NCPA Commentaries by Devon Herric. October 29, 2014
Source: Investor’s Business Daily

When Congress passed the Medicare Part D drug program, it inadvertently created a license to steal. A small minority of Medicare beneficiaries abuse prescription drugs for recreation and/or profit. In the process they also steal from taxpayers and their fellow Medicare drug plan enrollees — all of whom suffer higher premiums as a result.

Questionable drug use typically involves addictive painkillers that create a heroin-like euphoria. More than 16,000 people die each year from abusing pain relievers — double the number that die from cocaine and heroin.

For every death, there are 10 admitted to a treatment program for substance abuse and 32 emergency room visits. For each person who overdoses, 130 chronically abuse prescription drugs and 825 casually use them for nonmedical purposes.

Drug fraud costs insurers nearly $75 billion per year — about two-thirds of it from programs such as Medicare and Medicaid. That makes Uncle Sam the U.S.’ biggest illicit drug dealer.

How does this happen? The most common way Medicare drug fraud occurs is by “doctor shopping.” This involves seeing multiple doctors every month with bogus complaints about chronic pain. The drug-seekers get redundant exams and medical tests from each doctor, and ask them to prescribe powerful pain medications.

Unnecessary medical care to obtain drugs wastes far more than the cost of the drugs themselves. For every $1 worth of drugs lost due to fraud, an additional $41 is wasted for unnecessary physician visits, medical tests and ER visits to obtain the drugs.

To avoid detection, drug-seekers generally fill their prescriptions at multiple pharmacies to avoid being tracked or questioned. This tactic often fools individual doctors and pharmacies into believing their customers are not abusing prescription painkillers or reselling them.

But drug plans could easily detect drug-seeking behavior when reimbursing medical claims. The problem: federal law. Medicare drug plans aren’t allowed to restrict the benefits of enrollees thought to be abusing or reselling prescription drugs.

What could stop this? A program called Lock-In would help. It’s already been successfully used in most states for Medicaid enrollees. However, it requires a change in federal law to implement in Medicare — something that Kevin Brady, R-Texas, chairman of the House Ways and Means subcommittee on health, supports.

He recently circulated a draft bill, “The Protecting Integrity in Medicare Act of 2014,” to help Medicare drug plans fight back against prescription drug fraud and abuse.

Under a Lock-In program, enrollees exhibiting unsafe, drug-seeking behavior — such as doctor shopping and using multiple pharmacies for getting pain drugs — could be required to designate one specific doctor for pain management and one specific pharmacy to dispense pain medications.
No other physician or pharmacy could prescribe or dispense pain medications — but all other Medicare benefits would remain unaffected.

Another good idea is to expand Lock-In to include more drugs than just narcotic pain relievers if needed. Case in point: A recent government investigation found Medicare spent $32 million for AIDS drugs in 2012 for 1,600 people with questionable drug claims — more than half of which did not appear to actually have HIV.

Many of these visited multiple doctors for prescriptions and/or filled their drugs at multiple pharmacies — often obtaining excessively high doses or excessively large quantities of costly HIV drugs.

What explains this rather odd behavior? Some of these drugs were likely resold on the illicit market due to their high resale value. Another possibility is unscrupulous (possibly bogus) pharmacies stole Medicare enrollees’ identities and bilked Medicare for drugs never dispensed.

Scary thought: Sovaldi is a breakthrough Hepatitis C medication that has a 90% cure rate. The catch: it costs $1,000 per pill and requires an 84-pill course of treatment. Hepatitis C is rampant in the U.S. prison population, and among drug addicts and people with a criminal record.

How long do you think it will take the Medicare fraudsters to figure out that having a dozen different doctors prescribe Sovaldi — and then reselling it for, say, $50 per pill — could be a lucrative business model?

Medicare needs the ability to lock in troubled enrollees found to be abusing (or reselling) drugs and shut out fraudsters billing for bogus transactions. Otherwise, the rest of us will continue to pay for the abuse.

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