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 Let Us All Praise Medical Woo [13:35m]: Play Now | Play in Popup | Download (667)

It is quite popular for certain medical bloggers who count themselves as scientifically sophisticated to disparage so-called “alternative medicine.”

Indeed, some have built entire websites to demonstrate (Penn-and-Teller-like) that various forms of alternative medicine – such as homeopathy, therapeutic touch, the medical application of crystals, Reiki, naturopathy, water therapy, bio-photons, mindfulness training, energy healing and a host of others – are completely devoid of any scientific merit whatsoever; are pablum for the uneducated masses; are, in short, irreducibly and irredeemably woo.

These same bloggers are scandalized into virtual apoplexy by the fact that the NIH has funded an entire section to “study” alternative medicine, and worse, that some of the most respected university medical centers in the land now seem to have embraced alternative medicine, and have established well-funded and heavily-marketed “Centers for Integrative Medicine,” or other similarly-named op-centers for pushing medically suspect alternative “services”.

(An astounding list of prestigious institutions of medical science now sporting Centers of Woo is maintained by Orec.)

Until quite recently, DrRich counted himself among the stalwarts of scientific strict constructionism. He was truly dismayed that the NIH and some of our most well-regarded academic centers (under the guise of wanting to conduct objective “studies” of alternative medicine) have lent an aura of respectability and legitimacy to numerous bizarre ideas and fraudulent claims masquerading as legitimate medical practices. To DrRich, such developments were yet another clear and unmistakable sign of the End Times.

Furthermore, DrRich (a well-known paranoid when it comes to covert rationing) saw a more sinister advantage to the official and well-publicized support that government-funded institutions were giving to the alternative medicine movement. Namely, fostering a widespread impression among the unwashed rabble that alternative medicine is at least somewhat worthwhile (and plenty respectable) advances the cause of covert rationing. That is, the more you can entice people to seek their diagnoses and their cures from the alternative medicine universe, the less money they will soak up from the real healthcare system. With luck, real diagnoses can be delayed and real therapy put off until it’s far too late to achieve a useful outcome by more traditional (and far more expensive) medical means.

So, for several years alternative medicine was seen by DrRich pretty much as it is seen by all of the anti-woo crowd – as an unvarnished evil.

But in recent days the scales have fallen from DrRich’s eyes. He now realizes he was sadly mistaken. Rather than a term of opprobrium, “alternative medicine” may actually be our most direct road to salvation. Indeed, DrRich thinks that far from damning alternative medicine, we should be blessing it, nurturing it, worrying over it, in the precise manner that a mountaineer trapped in a deadly blizzard would worry over the last embers of his dying campfire.

What turned the tide for DrRich was a recent report, issued by the U.S. Centers for Disease Control and Prevention, estimating that in 2007, Americans spent a whopping $34 billion on alternative medicine. That’s $34 billion, for healthcare (in a manner of speaking), out of their own pockets.

The implications of this report should be highly encouraging to those of us who lament the impending creation of a monolithic government-controlled healthcare system, and who have been struggling to imagine ways of circumventing the legions of stone-witted, soul-eating bureaucrats now being prepared (Sauron-like) to descend upon us all, doctor and patient alike.

This is why DrRich has urged primary care physicians to break the bonds of servitude while they still can, strike out on their own, and set up practices in which they are paid directly by their patients. Such arrangements are the only practical means by which individual doctors and patients can immediately restore the broken doctor-patient relationship, and place themselves within a protective enclosure impervious to the slavering soul-eaters.

One reason so few primary care doctors have taken this route (choosing instead to retire, to change careers and become deep-sea fishermen, or simply to give up and become abject minions of the forces of evil) is that they do not believe patients will actually pay them out of their own pockets.

Well, ladies and gentlemen, this new report from the CDCP demonstrates once and for all that Americans will, indeed, pay billions of dollars from their own pockets for their own healthcare – even the varieties of healthcare whose only possible benefits are mediated by the placebo effect. DrRich believes that many of the people buying homeopathic remedies are doing so less because they believe homeopathy works, and more because they feel abandoned by the healthcare system and by their own doctors, and realize they have to do SOMETHING. The CDCP report, in DrRich’s estimation, reflects the magnitude of the American public’s pent-up demand for doctors whose chief concern is for them, and not for the demands of third party payers.

Perhaps more importantly, this new report implies that it may be somewhat more difficult than DrRich has thought for the government to outlaw private-sector healthcare activities. As DrRich has carefully documented, a government-controlled healthcare system will require the authorities to make it illegal for Americans to spend their own money on their own healthcare, thus rendering direct-pay medical practices illegal, and putting the final stake into the heart of the doctor-patient relationship.

But the rousing success of the alternative medicine universe will make such laws difficult to enact.

To see why, consider just how encouraging this new CDCP report must be to the third-party payers. Thanks in no small part to the efforts of the government (and the academy) to legitimize alternative medicine, Americans are spending $34 billion a year on woo. This amount indicates tremendous savings for the traditional healthcare system. The actual amount saved, of course, is impossible to measure, but has to be far greater than just $34 billion. Some substantial proportion of patients spending money on alternative medicine, had they chosen traditional medical care instead, might have consumed expensive diagnostic tests, surgery, expensive prescription drugs, and other legitimate medical services. Furthermore, those legitimate medical services (as legitimate medical services are wont to do) often would have generated even more expenditures – by extending the survival of patients with chronic diseases, by identifying the need for even more diagnostic and therapeutic services, and by causing side effects requiring expensive remedies. (While alternative medicine is famous for being useless, it is also most often pretty harmless, and tends to produce relatively few serious side effects – except, of course, for causing a delay in making actual diagnoses and administering useful therapy, but if you’re a payer, that’s a good thing.) So the amount of money the payers actually save thanks to alternative medicine must be some multiplier of the amount spent on the alternative medicine itself.

What this means is that payers (which, let’s face it, will soon mean the government) will be loathe to do anything that might discourage the success and growth of alternative medicine, and this fact alone may stop them from making it illegal for Americans to pay for their own healthcare.

Still, we musn’t be too sanguine about these prospects. Under a government-controlled system, the imperative to control every aspect of healthcare (in the name of fairness) will be very, very strong, and it will be very tempting to the Feds to declare at least some varieties of alternative medicine to be covered services.

But the alternative medicine establishment (bless it) will be largely impervious to government control. Practitioners of alternative medicine are expert at designing vague products and services whose techniques, theories, processes and protocols are fluid, nebulous and ill-defined. So if the Feds declare, say, homeopathy and therapeutic touch to be legitimate, covered services under the Fed’s health plan, why, the alternative medicine gurus will simply come up with entirely new forms of alternative medicine, specifically to remain outside the government plan. (New varieties of alternative medicine already appear with dizzying speed, and can be invented at will. No bureaucracy could ever hope to keep up.)

Therefore, as long as the central authorities depend on alternative medicine as a robust avenue for covertly rationing healthcare, the purveyors of woo will always be able to flourish outside the real healthcare system. And this, DrRich believes, represents the ultimate value of woo, and establishes why we should all be encouraging and nurturing woo instead of disparaging it.

DrRich has speculated on various black market approaches to healthcare which could be attempted by American doctors (and investors) should restrictive, government-controlled healthcare become a reality. But now, thanks to the success of alternative medicine, there is a direct and straightforward path for American primary care physicians to re-establish a form of now-long-gone “traditional” American medicine, replete with a robust doctor-patient relationship, right out in the open – the kind of practice where patients pay their doctors themselves.

Simply declare this kind of practice to be a new variety of alternative medicine. Likely, PCPs will need to come up with a new name for it (such as “Therapeutic Allopathy,” or “Reciprocal Duty Therapeutics”), and perhaps invent some new terminology to describe what they’re doing. But what’s clear is what they will be doing is so fundamentally different from what PCPs will be doing under government-controlled healthcare as to be unrecognizable, and nobody will be able to argue it’s not alternative medicine. In fact, it will seem nearly as wierd as Reiki.

The success of medical woo, in other words, can provide American doctors who want to practice the kind of medicine they should be practicing with the cover they need to do so. And this is why we must support medical woo, and celebrate its continued growth and success.

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Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

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 Mediating An Electrophysiology Dispute (With Bias) [13:31m]: Play Now | Play in Popup | Download (169)

A minor dispute – and an extraordinarily (almost disturbingly) polite one – has developed between the only two other electrophysiologists, that DrRich knows of at least, in the blogosphere. DrRich, being the third, ought to weigh in – not because his “vote” would break the tie, but because (as always) DrRich knows best.

Dr. Wes started it all off with a post noting, with some degree of dismay, that “(b)oth the Department of Justice (DOJ) and the Recovery Audit Contractors (RAC) are focusing investigations on Medicare billing for implantable cardiac defibrillator (ICD) surgery.”  Wes, with an appropriate degree of paranoia, concludes,”Consider yourself warned, criminals,” then recalls the halcyon days when the prospect of spending time in court conjured up for physicians nothing worse than malpractice suits.

Dr. John M. counters with a post whose purpose is to “welcome the upcoming policing of cardiac device implants.” John goes on to chronicle several examples he has witnessed of physicians implanting ICDs when, clearly, they should not have. The investigations of ICD implants by the Feds – and their private counterparts, the RACs – John posits, will serve to root out the bad eggs.

To his credit, John allows right off that his post is published “at the risk of exposing my naivete.”

To which DrRich replies, “Indeed.”

When DrRich was young, his grandmother, an immigrant from the Old Country who never shed her rustic habits, and not owning a motor vehicle, kept an illegal henhouse in her garage, buying the silence of her neighbors with eggs. It was from her that DrRich learned that if a rooster is behaving badly – engaging in hen abuse, for instance, or perhaps chasing grandchildren around the yard – one does not deal with it by sending Uncle George’s pit bull into the henhouse to take care of the offender. While the nasty rooster (never one to avoid a confrontation) might well be taken down, so would a lot of innocent bystanders.

John, you are laboring under the charming delusion that the purpose of these new investigations is to carefully review ICD implants and tease out only those unethical and/or poorly-trained device implanters, who are clearly and habitually engaging in untoward medical practices. If this were the case, then you and Wes and all those other honest EPs would have nothing to be concerned about, and the audits would indeed make the world a better place.

But alas, DrRich must tell you otherwise.

First, he urges you to read about his own experience. DrRich is a bit older than you, John, and was around the first time the Feds decided to conduct such an “audit” of ICD implantations. DrRich – like you, as pure as the driven snow – was absolutely certain he had nothing to worry about. But as matters unfolded, the fact that DrRich is not today writing this blog from a federal prison (do they let you do blogs in the penitentiary?) is more a matter of luck than anything else.

This new “audit” is much more intimidating than the one DrRich endured. That one was done by the relatively benign Office of the Inspector General (part of HHS). This one is being done by the Justice Department. So if they finger you, you are by definition, as Wes suggests, a criminal.

DrRich has talked about the Regulatory Speed Trap many times. Regulations inevitably become obtuse by evolution if not by design, so that, if you are practicing medicine, it is likely that somewhere – in the hundreds of thousands of pages of indecipherable and self-contradictory Medicare regulations – you are guilty of failing to comply with a regulation somewhere or other, and thus are guilty of healthcare fraud – which is a federal crime. The only thing that likely separates you from a convicted (or, more likely, self-confessed as part of a plea bargain) criminal is that the Feds haven’t decided to “audit” you yet.

The Feds know this, of course. The fact that they know it is documented in a recent GAO report entitled “Improvements Needed in Provider Communications and Contracting Procedures.” The GAO report notes that the bulletins which Medicare carriers are required to send doctors periodically (to make sure they understand the regulations) are filled with dense, lengthy and poorly organized prose sufficient to make them unreadable. Even if they were readable, the GAO continues, these bulletins would do doctors little good since they routinely announce new regulatory policies well after the implementation date, when doctors will already have been guilty of violating such policies (and thus committing fraud). Finally, the GAO finds that when confused doctors contact the Medicare call centers for clarification on the regulations, they get the correct answer only 15% of the time. (Even the IRS does substantially better than that.) And the Medicare websites, required under the regulations to clarify everything for the providers, universally lack “logical organization and navigational tools,” and as a consequence are nearly unusable.

So even when a doctor prospectively asks for instruction on how to comply with Medicare regulations (so as to avoid committing healthcare fraud and incurring huge fines and jail time), nobody is able to give him/her a straight answer. For, while it’s easy to look at a provider’s actions retrospectively (as the auditors are about to do), and find something in the dense regulations that makes those actions imperfect, it’s not so easy to tell providers ahead of time how to navigate those regulations in pristine fashion. As the GAO report reveals, nobody knows how to do that.

Now, DrRich is not calling the DOJ evil. The Feds are not being evil when they set out to conduct audits of physicians’ compliance with uninterpretable regulations; indeed, from their way of looking at it they are being humane.

They are only doing what they have to do, which is find a way – any way – to reduce healthcare costs. In this instance they do not really want to label hundreds or thousands of electrophysiologists as criminals, and ruin their careers and their reputations and their lives. They just want to ruin a few, and make sure the other ones know about it. This limited-bloodshed approach will accomplish their goal, which is, to make all the other electrophysiologists think twice (or thrice) before using ICDs again, in anyone, ever.

But in this instance it gets even worse. With this audit, in addition to dealing with the relatively-restrained Feds, electrophysiologists will also be dealing with the slavering RACs.

The RACs are a fun tidbit brought to us by the Medicare Prescription Drug Act of 2003. Under the RAC initiative, private contractors are to be sent out to perform audits of billing already done by insurers, health plans and physicians. The objective is to find “overbillings,” which the providers will have to repay along with penalties. Further, the act explicitly allows for prosecutions to be brought for “fraud and abuse,” even if the providers have repaid any overbillings.

The purpose of the Recovery Audit Contractors is, well, recovery. During the 3-year pilot of the RAC initiative, which took place in only 3 states, over $300 million were recovered. This wonderful success is the reason RACs are being turned loose elsewhere.

The RACs are paid by commission. Essentially they are bounty hunters, and they get to keep 20% of whatever they collect. According to the Associated Press, hospitals and providers are just a tad worried that these contractors, being so generously incented, will prove a little overzealous in their enthusiasm to find fraud. But worried auditees should not look for sympathy from the public. “A little zealotry is what we’re looking for on the part of the taxpayers,” said Leslie Paige, spokeswoman for Citizens Against Government Waste. “We think it’s about time.” Indeed – everybody can get behind fighting fraud, which is what makes the fraud gambit such a powerful tool for covert rationing.

DrRich surmises that it is good to be a RAC, and thinks you should consider buying stock in these companies, if you can. These outfits are about to harvest the vast bounty of obfuscation that Medicare has been carefully cultivating in its regulations for over 40 years, and has been carefully fashioning as fraud-traps for a somewhat shorter period of time. The RACs see the vast herds of physicians (violators one and all) placidly grazing all across the fruited plains, just waiting to be harvested. Their chief problem will be in pacing themselves; showing some restraint so they don’t use up their resources all at once.

And so, in addition to the dogged, officious, unsympathetic countenances of the lawyers employed by the DOJ, electrophysiologists this time around can also look forward to seeing the leering faces of the RACs’ commission-drunk forensic accountants. Electrophysiologists will experience the worst excesses of both worlds – the excesses of the state, and the excesses of unfettered for-profit outfits.

John M. can welcome this if he wants, and DrRich will wish him the very best good luck. DrRich, though, is still a little shell-shocked 15 years after his own encounter with federal audits of medical practices, and is very glad he’s only a spectator, and not a participant, this time around.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

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 DrRich's Global Solution To All Our Problems [8:47m]: Play Now | Play in Popup | Download (65)

Dr. Marya Zilberberg has an interesting post on Kevin,MD, speculating on the effect a worldwide oil shortage will have on healthcare, and what we ought to do about it. Marya is herself a notable blogger who has commented here several times (but whose comments, alas, were among those lost when the catastrophe struck), and she is one of the more thoughtful critics of DrRich. Her criticisms are always fact-based rather than ad hominem, and thus she always gets DrRich to thinking. Her post on Kevin, MD had that typical effect.

So DrRich hopes his readers will give Marya at least a little of the credit for what follows.

We as a nation face several apparently intractable problems at the present moment. Indeed, the problems individually seem so unsolvable that it will obviously take some major “outside of the box” thinking to solve any one of them, let alone the whole mess.

DrRich refers, of course, to the following five problems:

1. We as a nation face more than $50 trillion in debt obligations over the next several decades, thanks to Social Security and Medicare alone. This is an obligation we have no prayer of meeting.

2. Thanks to that massive accumulation of debt, we as a nation are mortgaging our futures to foreign nations, principally China. In fact, this totalitarian power will soon have veto authority on any initiative the US proposes to take.

3. We face an apparently growing threat of terrorist attacks whose base of operations (while it may be insensitive to say so) is in the Middle East.

4. Thanks to our profligate use of oil products, we are causing runaway global warming (and anyone mentioning the past decade of global cooling is a global warming denier).

5. As Marya points out, we appear to be drawing ever closer to a worldwide oil shortage that will threaten every aspect of our lives, even our healthcare.

Marya’s post was the key for DrRich.

DrRich, being a conservative American, has previously subscribed to a “Drill, Baby Drill” sort of philosophy. After all, we have oil in the ground, and we need oil to run our economy – so let’s go get it ourselves, instead of paying all that money to Middle Eastern and Venezuelan dictators, who just turn around and give it to terrorists.

But now DrRich sees the error of his ways.

There is a simple and straightforward solution that addresses all five of our intractable problems, indirectly if not directly.

Here it is: Stop drilling altogether. Leave American oil in the ground. And buy up all those other peoples’ oil (and take physical possession of it) – as fast as we can.

The estimated worldwide oil reserve is about 1 trillion barrels. Let’s buy as much as we can of those reserves, and bring it here. At $100 a barrel that’s only 100 trillion dollars, or only twice what we’re obligated to pay for our old farts over the next few decades. But the difference is, when we spend all that money on Social Security and Medicare, all we’ve got to show for it is old farts who are even older. But when we spend that money buying up the world’s oil, we’ve got a corner on the market.

Where are we going to put all that oil, skeptics might ask? Why, we’re going to store it in the rapidly-depleting Ogallala Acquifer, which is capable of holding up to 978 trillion gallons. The world’s oil reserves, if we choose to follow DrRich’s plan, will be right under Kansas and Nebraska – the heartland.

Even if the price of oil rises to substantially higher than $100 per barrel (which it certainly will as the world’s supplies become sequestered beneath Lincoln and Dodge City), it will still be a bargain for us to buy it up. It will be a bargain at any price. After all, we’re already in a debt hole so deep we cannot possibly get out of it. If we’re destined to perish in a sea of debt, we might just as well drown in $500 trillion as $50 trillion of debt. We’ll be just as dead either way.

So we should be delighted to accumulate whatever amount of debt is required in order to corner the world’s oil market. It’s our only hope.

Because, when the only oil left in the world is American oil, we strike back. Our oil will be a precious, life-sustaining commodity, which nobody in the world can do without. Even if energy technology develops to the point where people can really fly around in airships powered by solar batteries, oil will remain precious. Just try building those solar batteries without petroleum products. Marya herself points out that it’s only petroleum products which allow us to do all the remarkable stuff we do every day in healthcare, as well as in every other modern endeavor.

We’ll be able to charge whatever we want for our oil – DrRich (a humanitarian) is thinking merely $1000 a barrel, as a nice round number. We’ll be able to pay China back, and any other of our debt holders, in a trice. And in another trice they will all owe money to us (like in the good old days).

The Middle Eastern terrorists will become defunded.

Since nobody else in the world will be able to engage in hydrocarbon pollution any longer without our say so, we can control worldwide carbon emissions as we see fit, and “tune” the earth’s temperature like a fine clock.

Best of all, since (according to the current plans of our leaders) the American government will remain permanently in the hands of benign progressives, who by definition care very deeply about the people of the world, all this will be done with the most beneficent of intents, which will assure the very best of outcomes.

Of course, none of this will work if it turns out the world’s oil reserves are vastly greater than current official estimates. This might be something to think about, considering that today’s oil reserves are twice what they were in 1980, even though we’ve burned through (and, of course, spilled) 30 years of oil since then. Thankfully, the experts assure us that this time they’re correct. And if we’re not going to listen to the experts, what the heck are we paying them for?

Besides, given our current situation, we have nothing to lose by trying. So: Cap, Baby, Cap!

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

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 Even Dermatologists Have Skin In This Game [15:44m]: Play Now | Play in Popup | Download (176)

Recently, DrRich wrote a series of posts detailing how the American healthcare system – even before the new reforms kick in – is taking steps to prevent individual citizens from being allowed to spend their own money on their own healthcare. Part of that effort, of course, is to restrict physicians from offering direct-pay medical services to their patients.

DrRich may have given the impression that only primary care doctors are affected by efforts to restrict their practices in this way. If so, he apologizes.

He particularly owes an apology to his friends the dermatologists. Indeed, DrRich has been reminded of an article that appeared in the New York Times a while back, which castigated dermatologists for the sin of establishing direct-pay practices, and in particular, for creating their own brand of a two-tiered healthcare system – one for patients with skin disorders, and one for “cosmetic dermatology.”

As the Times describes it, patients who wish to see a dermatologist for, say, possible skin cancer are put on a waiting list, and when their appointed time finally arrives (generally several months later) they are subjected to modern medical hell. To wit: Upon arriving in a lackluster office, the patient is shelved for a while in an unattractive, poorly lit waiting room equipped with a broken TV, fuzz balls on the floor, old magazines, the unruly children of other patients, and surly office personnel. Eventually the now-even-more-disheartened patient’s name is called by an indifferent nurse practitioner, who, operating from a checklist of questions, will “triage” her to the appropriate patient-category (e.g., acne, fungus, cancer, warts- you know, dermatology stuff), then have her strip in order to fully expose the large organ (i.e., the skin) for which she has sought assistance, hand her a scratchy yellow paper gown to cover her nakedness, and have her wait for some time in a chilly exam room to see His Holiness, the actual doctor. At last the dermatologist arrives, mutters a greeting (or some other ritual uttering), glances at a clipboard, and announces, “Show me your [acne, fungus, cancer, warts];” whereupon, having regarded the cause of cutaneous concern, and having made a professional determination, he either signs the prescription that has been pre-written for him by the nurse practitioner, or schedules a procedure. Then, placing her bundle of clothing into her arms and wishing her a good day, the doctor shoves her out into the hall to finish dressing, as the formal interview is completed, and the exam room is at a premium.

Presumably, one hopes, some dermatology practices not visited by the New York Times might not be quite so bad. Still, anyone who’s been seen by an American PCP lately will nod sympathetically at the dermatology patient’s ordeal.

Now observe what the Times observes when the patient, instead of having an actual skin problem, merely is sagging here and there and wishes to be shorn up. That is, the patient has a cosmetic issue. That is, the patient wants Botox.

The same dermatologist will often have an entirely different setup for these patients. This time the patient is seen immediately, possibly the same day, as dermatologists are sensitive to the needs of their clients who have an impending public engagement, and thus need to look their best. If this patient is to wait at all, she will wait in a modern, tastefully decorated private room. She will then be seen not by a mere nurse practitioner but by an aesthetician, who will do a careful assessment of the sagging parts, and, aside from suggesting more injection sites than the patient might originally have had in mind, will offer a complete program for long-term cosmetic maintenance, which naturally will include quarterly Botoxification. At just the proper moment the dermatologist comes in, greets the patient warmly and reassuringly; then reviews the recommendations of the aesthetician and discusses those recommendations at length with both the aesthetician and the patient, studying the patient’s face in depth as he does so, pointing, nodding, studying, adjusting, all the while smiling confidently. Yes, he indicates, we will all be very happy indeed with the results. Finally the doctor begins to make the now-thoroughly-discussed-and-agreed-upon injections, doing so with the greatest solicitude and sensitivity. The patient is then given as much time as she needs to collect herself, and is invited to “recover” in a room set aside for this purpose, with flattering lighting, soft music, a cappuccino machine, and perhaps a glass of wine. She leaves the office a new person. And, just as the dermatologist has promised, all are indeed very happy with the outcome.

Naturally, the New York Times is scandalized by the dichotomy which its discerning readers will note here. Why should a patient with a mere cosmetic issue be treated so well, when a patient with an actual medical problem, possibly even skin cancer, is treated so shabbily? How can dermatologists openly encourage such a two-tiered system?

DrRich has a word of advice for the scandalized reporters of the New York Times, and any other concerned Americans who are worried that dermatologists, by setting up separate-but-not-equal practices for their two kinds of patients, are moving us one step closer to the dreaded two-tiered healthcare system we all abhor. That word is: Chill.

Allow DrRich to support this friendly recommendation with two observations.

1) We already have a multi-tiered healthcare system, and little or none of it is the fault of dermatologists. It is the fault of human nature. All countries have at least a two-tiered healthcare system, including countries (like Cuba and China) that have specifically embraced egalitarianism (rather than individual autonomy) as the fundamental operating principle. A second tier is necessary if for no other reason than political leaders and other individuals critically important to the collective effort must have somewhere to go for their healthcare.  The second tier, like the poor, will always be with us.

2) When a dermatologist spends Tuesday afternoon in her run-down office, treating people who come to her for bona fide skin disorders like they’re not really patients but widgets on an assembly line, then spends Wednesday in her other, much more amenable offices, treating the merely cosmetically-challenged like they are minor nobility, she is not really engaging in two-tiered healthcare. Not at all. Instead, on Tuesday she is practicing real, true, prescribed-by-society, by-the-book American healthcare, just as our leaders (in their wisdom) have carefully set it up for us, and on Wednesday she is doing Something Altogether Different.

Injecting Botox is officially and formally not part of American healthcare. How do we know this? Because it is not covered by Medicare or health insurance. If you want Botox you’ve got to pay for it your own self, just as you do if you want a TV or a car. So by all that is sacred, injecting Botox is NOT American healthcare.

Furthermore, when one looks at it objectively, injecting Botox is not even really practicing medicine, at least not in any true sense. In actual truth, it takes very little training or expertise to inject Botox. There’s no reason one must go to college, graduate from medical school, or do several additional years of training in dermatology (or any other specialty) to do this. Anyone with a needle and syringe, an alcohol wipe, and access to Botox could do as well. Just find the wrinkle and stick it. If they made the materials available over-the-counter, most folks would do just fine with it.

The sheer arbitrariness by which injecting Botox is deemed by the authorities to constitute the practice of medicine can also be illustrated by considering a somewhat different, equally well-known cosmetic procedure, one that also involves injecting substances through the skin via needles, and that has much more to do with the actual skin itself than Botox injections (which do not really affect the skin itself, but only the muscles under the skin). DrRich speaks, obviously, of the tattoo. But unlike making Botox injections, tattooing requires real skill, knowledge, training, expertise and artistic talent. Most dermatologists simply could not manage a highly technical skill like that.  The point being, of course, that if you were to describe Botox injections and tattooing to a visitor from Mars, then ask him/her/it which of these two dermatological procedures ought to require a medical license and board certification, the Martian would get it wrong every time.

DrRich understands, of course, that while administering Botox is, in practical and objective terms, no more practicing medicine than is applying an ice-pack to a bruised knee, legally it is indeed deemed to be the practice of medicine. Accordingly, doctors in general (and dermatologists in particular), relying on this nonsensical designation, have legally cornered the market on Botox injections. So it’s not like you could just set up a booth at the Mall and hire high school students to do this (as you can for, say, ear-piercing – which, in contrast to Botox injections, is an actual surgical procedure which is intended to result in a permanent structural change in a body part). If you set up a chain of Botox Booths, you would be practicing medicine without a license, which is a serious crime.

But fundamentally, while performing Botox injections may have a certain legal status, in any true sense it is not really practicing medicine.  Not when ear-piercing and tattooing are not. Rather, in real life, injecting Botox is simply an activity some dermatologists may choose to do when they’re not doing real dermatology.

To say it another way, when the dermatologist goes to her “other office” to cater to a self-paying variety of clientele, she is practicing medicine only from the most arbitrary and strictly legalistic viewpoint. In real life, she is doing Something Else. She is engaging in a Pastime.

Doctors, of course, often have Pastimes. That is, they partake in activities other than practicing medicine when they could, in fact, be seeing more patients. Some have taken up golf. Others have started side businesses such as restaurants or software companies. Some do charity work, or go to graduate school for an MBA. Still others have opted to work part time in order to raise their families.

Society generally finds such activities acceptable, and – to this point – does not insist that all doctors forgo all other human endeavors in order to see as many patients as humanly possible, during all their waking hours. While society seems to be moving closer to declaring that doctors owe this duty to the collective, it has not reached this point quite yet.

Until society sees fit to legislate otherwise (which, DrRich supposes, could happen really very soon now), doctors will continue to spend some of their time engaging in hobbies and business or family activities outside of the formal healthcare system. Some may even leave the formal healthcare system altogether in favor of these other activities. DrRich himself has done this. And until society renders it officially illegal for doctors to do so, DrRich respectfully asks that doctors be left alone to celebrate their individual autonomy as granted to them under America’s founding documents, whether it’s by establishing authentic Indian restaurants, setting up Botox clinics, or even becoming direct-pay practitioners.

One last word of advice for DrRich’s dermatology friends: Have fun with your Botox clinics for now, fellas and ladies, but please don’t become too invested in them.  This is definitely a shallow-moat line of business, and the only thing that gives you any protection at all is your aura as highly trained specialists, with special and secret knowledge about an organ (i.e., the skin) which visibly droops when the underlying muscles become lax with age and gravity. A single action by forces entirely out of your control – say, Congress or the FDA – could render your monopoly entirely moot overnight, and you will be instantly priced out of business by hordes of PCPs, nurse practitioners, Botox booths in Walmart, and even home Botox injection kits. So please remember to at least keep your hand in genuine dermatology, or get your MBA, or perfect your long iron shots, or even learn a real skill, like tattooing – but do something that will provide you with a Plan C. Because Plan Botox is definitely a high risk endeavor over the long term.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

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 Black Market Healthcare - A Few Concrete Suggestions [10:13m]: Play Now | Play in Popup | Download (50)

In his previous post, DrRich offered some general issues to consider before one dives into black market healthcare, and reminds his readers why this will not be an endeavor for the faint-hearted. In this post, we will get into some specifics.

DrRich must first assure his readers (and any government officials who may inadvertently stumble upon this blog) that he is a law-abiding citizen, and does not condone illegal activities. So he will suggest here only activities for black market healthcare which, strictly speaking, will not be illegal under American law; though not so much by complying with the law, but by avoiding it.

DrRich trusts that his readers can think up the more illegal kinds of black market activities for themselves, and thus they do not need his help with this aspect of the endeavor. Many of these more obvious illegal forms of black market healthcare (e.g., “medical speakeasies,” located in back alleys for the proletariat, and in swanky office buildings for public officials; rolling surgical suites hidden in semi-trucks; smuggling rings for drugs and medical equipment; an “underground-railroad-style” transport system for itinerant physicians who need to ply their illicit trade while on the move; etc.), can be established by individuals, or by relatively small groups of entrepreneurs, and with relatively little up-front capital or lead time – and with no coaching from DrRich.

But the varieties of black market healthcare which DrRich has in mind – certain “less illegal” activities, which will drive the U.S government into states of apoplexy but over which it will have little legal jurisdiction – will require a much larger scale, and a significant investment in time and energy.  So anyone who is interested ought to get started with the necessary organizational activities right away.

DrRich has three such suggestions. With all three of them, DrRich envisions that implementation would be driven by a major private healthcare organization (or a consortium of them) which has a record of innovative thinking, as well as access to significant financial resources through their own holdings, or through their connections with rich benefactors from around the world. He is thinking of organizations like the Cleveland Clinic, the Mayo Clinic, or the Kaiser system.

For the sake of mankind, DrRich offers these suggestions free and clear. They may be taken up, with his blessings, by any institution or organization that wishes to employ them, with no obligations or strings attached whatsoever.

1) Floating Off-Shore Medical Centers. In this scenario, the Cleveland Clinic (say), with the help of their friends in Abu Dhabi, buys or leases a mothballed former Soviet aircraft carrier (nuclear power preferred), and refurbishes it into a floating, world-class medical center. The ship will ply the international waters off the American coasts, providing regular helicopter transport to and from major cities. There’s a lot you could do with an aircraft carrier, of course, to make it an attractive destination aside from medical care, including (for instance) establishing a world class hotel, food services, casinos and other entertainments. But the chief attraction would be that Americans will be able to buy the best healthcare services in the world, without fear of being arrested.

The fact that this floating medical center will be based on a former warship may turn out to be an advantage. Obviously, it would be useful to maintain at least some weaponry on board, if only to repel “pirates” But given the anger this ship will generate among American government officials, the Cleveland Clinic (or whoever) might be wise to remain intentionally ambiguous about just how much firepower the ship has retained. Just sayin’.

2) Native American Medical Centers. There are two things about the current state of Native American culture which make this approach to black market healthcare at least feasible, if not compelling. First is the recognized “sovereign status” of Native American reservations, the same status which has allowed various tribes across the land to open gambling casinos, even in states which otherwise do not allow such establishments. If their sovereign status justifies casinos (establishments of mere entertainment, which, in fact, encourage bad behaviors of all sorts such as alcoholism, prostitution, smoking and – gasp!- obesity), then surely the same sovereign status would justify establishing advanced institutions of healing.

Second is the deep guilt that Americans rightly feel about the treatment Native Americans have suffered over the years, much of which was arranged by the U.S. government. Note, in particular, that one of the ongoing claims which Native Americans have against the larger American culture is the chronically substandard state of the healthcare services they are provided. So, who will dare stand in the way of these oppressed peoples, when they propose to dedicate a portion of their pitiful remaining sovereign lands (with the help of, perhaps, the Mayo Clinic and its benefactors) to the development of world-class medical centers?

One advantage of the “Native American Strategy” for black market healthcare is that it would allow medical centers of various sizes and emphasis to be established in numerous convenient tribal locations around the U.S., as the need and logistics allow. Within a decade or two, if they play their cards right, Native American tribes may even find themselves controlling nearly 20% of the American economy – which would be justice at its finest.

3) Medical Centers Across the Mexican Border. There are several potential benefits to this suggestion. Converting Tijuana, Nogales, Laredo and Juarez from hotbeds of human and drug smuggling into hotbeds of illicit healthcare would probably be a boon to the local populations on both sides of the border. It would create tens of thousands of good jobs in Mexico, for Mexicans. The heavily-armed gangs of Mexican drug-runners along the border could be hired by the Cleveland Clinic Juarez, or the Mayo Clinic Nogales, as security guards, thus absorbing their “talents” into a more legitimate economy. (Being located so close to the border of a powerful nation which will badly want to terminate these medical centers would, one must understand, create a certain need for security.)

If nothing else, world-class medical centers just across the Mexican border would reverse the flow of illicit border crossings. Americans (and Canadians, who, bless them, would now have to travel much farther south for their healthcare) would suddenly be streaming across desert border crossings into Mexico in the dark of night – and Mexicans would be staying put. And its desperate need to get rid of black market healthcare would, at long last, give the U.S. government a compelling reason to control the borders once and for all. We would suddenly see American troops all along the Mexican border, supported by such features as a “no-man’s land” seeded with land mines, and constant surveillance by drone aircraft armed with cluster bombs.

And before long, Californians wanting to go to the Kaiser Tijuana Medical Center would have to get there by way of Cuba.

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 Some Considerations for Black Market Healthcare [9:34m]: Play Now | Play in Popup | Download (40)

DrRich recently finished a four-part series describing our government’s attempt to prohibit individual Americans from spending their own money on their own healthcare. He believes that any open-minded person who reads this series, what with its numerous, well-documented and specific examples, related in DrRich’s own engaging and erudite prose, will become convinced that our government is very serious about, and much dedicated to, affecting this harmful prohibition.

DrRich’s critics have insisted that he is simply making too much of this. Our government, they insist, whatever its tendencies, will not really act in this way, for the simple reason that Americans would never put up with such limitations on their individual freedoms. And in fact, DrRich fundamentally agrees with his critics, at least to this extent: Americans – many of us, anyhow – just won’t put up with it.

Where he quibbles is in the specifics. DrRich’s critics insist that our government (presumably, taking American character into account) would never actually try to limit the freedom of Americans in such an egregious way. In contrast, DrRich (having carefully demonstrated for his readers that the government will indeed use every means at its disposal to make it illegal, infeasible, or both, for Americans to spend their own money on their own healthcare), finds, sadly, that the many Americans who “won’t put up with it” will find themselves having to act counter to the wishes of their government. That is, Americans who insist on exercising their natural right to become “the proper guardians of their own health,” will have to do so extra-legally.

To say it even more bluntly, Americans wishing to enjoy the individual liberties which our Constitution promises us will, in this instance, need to engage in black market healthcare. DrRich has talked about this before, but finds this a propitious time to discuss it again, and to offer some words of wisdom and caution to anyone who might be inclined in this direction.

Black markets develop naturally whenever a society’s controlling authority attempts to prevent its citizens from acquiring an otherwise available good or service which they very much want (or need). In fact, it is a law of nature that, wherever a group of people exists who badly desire a certain product, and another group of people exists who very much want to provide that product, there is no force in the universe – governmental or divine – which can keep those two groups from engaging in commerce.

To see what is likely to happen when the government institutes its healthcare prohibition, we ought to think about what happened when that same government instituted its alcohol prohibition (i.e., Prohibition). The 18th Amendment (one of the big triumphs of the Progressive Era, and one which, quite typically, relied for its ultimate success entirely on a fundamental change in human nature), went into effect at midnight, January 1, 1920. By noon that day, an entirely new industry had sprung up. This industry – the alcohol black market – eventually employed hundreds of thousands of Americans in various capacities, such as distillers, alcohol “re-naturizers,” bootleggers, rum-runners, speakeasy proprietors, accountants, individuals who today might be called “lobbyists,” and various species of “muscle.”

DrRich’s own dear grandfather, who had only recently arrived from Eastern Europe to work in the steel mills, found more profitable employment instead, through the ’20′s and into the Great Depression, as a gun-toting rum-runner. Each weekend he filled the hidden tank under the back seat of his big Buick sedan with 250 gallons of prime home-made spirits, and would place DrRich’s young grandmother (wearing an impressive hat)  next to him, and seat their three innocent little children (among them DrRich’s toddler mother) over the hidden contraband in the back – the very picture of a happy young family out for a Sunday drive – and in this guise would make his deliveries across northeastern Ohio. DrRich will never understand why, at the end of Prohibition, Grandpa ended up as a laborer for the city street department, instead of the filthy-rich Ambassador to England like his fellow bootlegger, Joe Kennedy. (But on second thought perhaps it is better this way. If Grandpa had ended up like Ambassador Kennedy, DrRich today would be spouting the Progressive mantra, like all those other guilt-ridden souls burdened by unearned wealth.)

In any case, the government took great issue with the new industry that had been created, overnight, by Prohibition, and attempted to end the new black market by employing the ultimate expression of any sovereign authority – the legal exertion of violence. (The enforcers, it happens, were Treasury Agents, the very same enforcers who now will be ensuring compliance with certain mandates being imposed by our new healthcare system.) This effort on the government’s part led to an organized response, and resulted in the maturation of American organized crime. (Interestingly, this organized crime effort happened to be centered in Chicago, a happenstance which resulted in a persistent and evolving thugocracy within that city, whose ultimate ramifications – some say – are now affecting current events on a much broader scale).

When its concerted application of force against the the bootleggers failed to end the black market, our government turned to applying a different kind of force, this time to the consumers. The recalcitrant consumers of illicit alcohol were, after all, guilty of failing to change their behavior, despite all the heroic efforts which were being made to educate them about the pitfalls of demon rum.  The understandable frustration this caused finally led our government resort to deadly force against the obstinate public itself. Author Deborah Blum has recently documented how the U. S. government caused poisonous substances to be added to the alcohol supply, an act that is estimated to have eventually killed 10,000 people. The chief medical examiner of New York City at the time called this action “our national experiment in extermination.” And in 1927, the Chicago Tribune said, “It is only in the curious fanaticism of Prohibition that any means, however barbarous, are considered justified.” It was partly the revulsion against such official atrocities that forced the end of Prohibition in 1933.

DrRich relates this little-remembered episode merely to illustrate the lengths to which our government will go when its attempts to control human nature through legislation fail. It is worth keeping in mind as we conjure up ways to establish what he hopes we will not need, but fears we’ll not be able to avoid, namely, a black market in healthcare.

Black market healthcare will not be for the faint of heart. But then, no great human endeavor ever is.

In his next post, DrRich offers some concrete suggestions for black market healthcare.

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 More Evidence that Pay for Performance is Working [8:47m]: Play Now | Play in Popup | Download (37)

DrRich has long praised Pay For Performance as a particularly effective tool for covertly rationing healthcare.

Traditionally, pay-for-performance efforts (modeled after time-honored techniques used on trained seals), produce checklists of approved “activities,” which physicians of quality will always perform when engaged in a “patient encounter.” By examining filled-out checklists, the payers (both health insurance companies and the government) can thus determine which doctors are of sufficiently high quality to deserve their full reimbursement allotment, and which doctors are of substandard quality, and therefore deserve at least to have a portion of their reimbursement withheld, and possibly to be sent away for “re-education,” or to have their names published on a potentially embarrassing list.

When these pay-for-performance checklists are combined with the need to see one patient every 7.5 minutes, thus leaving no time for the discussion of health problems (or other issues) that the payers have not seen fit to include on their checklists, pay-for-performance becomes a very serviceable addition to the covert rationing armamentarium. Which brings us to the latest good news about the success of pay-for-performance.

This week, at Digestive Disease Week (the year’s major scientific gathering of gastroenterologists), doctors from Johns Hopkins will present a paper demonstrating that pay-for-performance reimbursement schemes create financial incentives for surgeons to shun obese patients.

Under this species of pay-for-performance, surgeons are “rewarded” (i.e., not punished) for meeting specified quality standards which have to do with certain patient outcomes. (For pay-for-performance to occasionally equate quality with outcomes is a particularly useful formulation, since expressing reservations about such pay-for-performance measures immediately brands one as being against good medical outcomes, in the same way that being concerned about illegal immigration brands one as being against immigrants, or having reservations about certain of President Obama’s policies brands one as being a racist.)

The Johns Hopkins researchers have found that performing surgical procedures on obese patients results in substantially more complications than performing the same surgical procedures on non-obese patients. For instance, fat people had 27% more complications after gall bladder surgery, and 11% more complications after appendectomy, than thinner people. They also had substantially longer hospital stays, and generated much larger medical bills. The researchers conclude that surgeons (some of whom are literate and understand rudimentary statistics, and therefore not only have access to this kind of information, but are also capable of processing it to at least some extent) can only conclude that, in order to maintain a viable surgical practice, they will need to avoid operating on obese patients. At the very least, they will need to avoid doing elective surgery on fat people, waiting instead until they are in extremis, and require emergency surgery (since at least some effort is made to “adjust” the expected outcomes in these situations).

This result, of course, is similar to the result DrRich reported some time ago regarding the publication of Physician Report Cards. Namely, thanks to publicly-available report cards, cardiologists in the state of New York have been more reluctant than cardiologists in other states to aggressively treat patients with severe heart attacks, and as a result (while the report cards are cleaner) the mortality of these patients is higher in New York.

And the situation with surgeons being quite similar (i.e., doctors being incented to avoid treating higher-risk patients, for fear of being punished because of an unavoidably higher rate of complications), DrRich feels quite confident in offering his surgical friends the same advice he offered the New York cardiologists. Namely, he suggests the Designated Driver strategy.

The Designated Driver strategy requires the Chief of Surgery (ideally, an imposing and feared figure) to approach a promising young surgeon who is just entering practice after the end of a very long course of training, and saying, “Son, you are going to have a brief but spectacular career. You are going to be our Designated Driver.”

For an extraordinary annual salary and immediate vesting in a generous pension plan, this young surgeon is going to have the honor of being the one who gets all the high-risk surgical cases for the group. He will agree to do this as long as it is feasible, that is, as long as he’s not run out of practice because his pay-for performance reports, or his physician report card, have become so abysmally bad. With careful management, and with his colleagues tossing him a few “easy” cases now and then in order to extend his longevity, he may be able to survive as a surgeon for five or ten years (longer, for instance, than the average NFL player), after which he can enjoy a lucrative retirement, or simply change careers. (There are obviously other approaches for conducting the Designated Driver strategy, for instance, as a way for surgeons nearing retirement age to go out in a blaze of glory. But you get the idea.)

The Designator Driver strategy is a win-win for everyone except the government – so surely it will eventually become illegal. But what doctors have to realize, when practicing medicine in a healthcare system driven by the covert rationing imperative, is that one either gives in to the bizarre incentives created by programs like pay-for-performance (which will cause measurable harm to their patients), or one fights back guerrilla-style, striking where one can, and changing tactics as the enemy adjusts.

To the government, however, such guerrilla activities amount to a mere nuisance, an annoyance which (like the poor and the uninsured) will always be with us. Looking at the big picture, our government will doubtless rejoice to hear the Johns Hopkins research results. The Feds will be particularly pleased to learn that their pay-for-performance efforts are achieving both of the desired effects (i.e., reducing the volume of elective surgical procedures, and advancing prospects for demonizing and discriminating against the obese.

Say what you will about pay-for-performance. It’s working.

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 Medicare Already Does It (Limiting Individual Prerogatives, Part 4) [12:33m]: Play Now | Play in Popup | Download (32)

Part 1 of Limiting Individual Prerogatives

Part 2 of Limiting Individual Prerogatives

Part 3 of Limiting Individual Prerogatives
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DrRich could go on and on about how our government is intent on restricting the right of individuals to spend their own money on their own healthcare, but (for now, at least) this will be the final post in this series. DrRich has made his point.

Even some of his critics, who have accused DrRich in the past of being overly paranoid on this topic, seem to have gotten it. Some who previously were quite vocal have remained suspiciously silent. Others have fallen back to quasi ad hominem accusations (suggesting, for instance, that DrRich must be a follower of Mr. Beck, with all the horrific connotations that condition entails). And then there is the esteemed Praveen (author of the excellent True Cost Blog), who conceded as follows: “Massachusetts’ attempt to ban direct pay is both unfortunate and unconstitutional. Perhaps you’re right, and the bureaucrats are sneakier than I think.”

So maybe DrRich should just declare victory and move on.

But it is important to make one final point, namely: the notion that our government is intent on limiting our individual healthcare prerogatives is far more than just one of DrRich’s theoretical constructs. Indeed, our government has been acting on this intent for over 15 years. The main case in point, of course, is Medicare.

It has always been recognized that every American citizen “is the proper guardian of his own health,” (Supreme Court Justice Joseph Story, 1873), and accordingly, has a natural right to employ his own individual resources to that end. Roe v. Wade, for instance, was a particularly explicit recognition that a woman has a fundamental right to purchase medical services which she determines to be necessary for her own well-being.

Indeed, when Medicare became law in 1965, Congress also explicitly recognized this right, stipulating that nothing in the new law “shall be construed to preclude [an individual] from purchasing or otherwise securing protection against the cost of any health services.” (DrRich reminds his readers once again that a bold, restrictive statement like this, appearing in legislation, generally heralds an outcome opposite to the statement itself.)

DrRich has already pointed out that under Hillarycare, private medical practice would have been nearly criminalized out of existence. So one ought to expect that the Clinton administration would view an individual right to purchase healthcare as a threat. And indeed, it did. But, as it happens, the erosion of the rights of Medicare “beneficiaries” began even before the Clinton administration. (And even again, DrRich must remind his readers that any universal healthcare plan, even under a Republican administration, will always tend to limit individual liberties.)

In 1991, Medicare administrators published a “carrier bulletin” warning physicians that direct-pay contracts between patients and doctors were strictly prohibited, unless the contract was initiated solely by the patient, and even then, payment rates must be set by Medicare, and further, if the patient later became dissatisfied with that (patient-initiated) contract, Medicare would severely (and retroactively) sanction the physician.

When physicians sued Medicare to prevent this odious new policy from being implemented (Stewart et al. v. Sullivan), the government took the position that it had, in fact, not made any new policy after all, arguing that stuff that shows up in its “carrier bulletin” doesn’t really count. But once this argument was successful in having the lawsuit thrown out in a summary judgment in 1992, Medicare then cynically turned around and immediately made that selfsame new policy “official,” by publishing it in their 1993 Medicare Carrier’s Manual.

But the Feds were still not satisfied. The new, restrictive policy technically still allowed private-pay contracts, as long as the patient initiated them. So the Clinton administration engineered an amendment to the Balanced Budget Act of 1997 – Section 4507 – which prohibited any self-pay contracts whatsoever between Medicare patients and their doctors for medical services which are covered under Medicare. Under Section 4507, which is still the law today, if a doctor provides even one self-pay medical service to a single Medicare patient, that doctor is punished by complete banishment from the Medicare program for at least two years.

The federal government was eventually challenged again in court over Section 4507, but that lawsuit was also thrown out in a summary judgment. The rationale the government offered to the court in justifying its restrictions on individuals’ prerogatives, however, is instructive: “…what you will have is a system whereby the rich can buy what they want and those many beneficiaries who are on fixed income will not be able to afford those services” (United Seniors Association et al. v. Shalala). So again, the interest of the collective (“social justice”) was invoked to justify a law which stifles an individual’s fundamental right to purchase medical services he or she determines to be necessary for his/her well-being.

In any case, since 1997 Medicare patients have been able to purchase Medicare-covered services for themselves ONLY if they obtain that service from a doctor who agrees to opt out of Medicare entirely. This severely limits a patient’s opportunity to self-pay for covered services. The fact that Medicare patients can still buy these medical services from direct-pay physicians, however, is one reason the government hates direct-pay practices, and wishes to stamp them out. More importantly, while some primary care physicians have indeed opted out of Medicare in order to establish direct-pay practices, this path is not a realistic option for medical specialists. So in practical terms, the only “covered services” available for self-pay by Medicare patients, on even a limited basis, are primary care services.

There are several legitimate reasons a Medicare patient might want to self-pay for a medical service that is covered by Medicare. If Medicare “covers” heart valve surgery, for instance, a patient might want to pay for a new, minimally-invasive surgical approach that is inadequately reimbursed by Medicare, rather than the big, open-heart surgery that Medicare reimburses fully. Or, one might want to self-pay for “covered” psychiatric care, or for treatment for a venereal disease, in order to keep embarrassing or harmful medical records out of government-controlled databases.

Furthermore, it is important to recognize that just because a healthcare service is “Medicare-covered” does not mean that it will be covered for a given patient. Whether a specific individual is covered is often determined by a “medical necessity” ruling, made by a bureaucrat. Section 4507 essentially precludes a patient’s ability to purchase a denied (but “covered”) medical service, no matter how badly they want it, or believe they need it.

One can argue, and with some merit, that at this juncture denials of medically necessary services by Medicare have been relatively judicious, and therefore that the “Section 4507 rule” has not had much of an actual impact. In fact, it is likely that most Medicare beneficiaries do not even know that this rule exists.

But while its impact might be relatively small so far, the Section 4507 rule has now been in place for 13 years – it is well-established. So, once Medicare begins reducing reimbursements to physicians and hospitals, to the point where they can no longer afford to offer certain services to Medicare patients (and Medicare has just recently begun doing so, specifically, for some cardiac imaging studies), those patients will be left in the cold. Services which are officially “covered” by Medicare, but which are reimbursed at such a low rate that they cannot actually be provided to them, will become unavailable even to Medicare patients who are willing and able to pay for those services.

DrRich’s main point, once again, is that our government has a deep and abiding need to limit our individual prerogatives when it comes to our healthcare, and has been acting on that need for a long time. The principle for these limitations on our individual liberties, the principle of social justice, has already been established, and has survived court challenges.

Extending these limitations on personal liberties to Obamacare, and broadening their usage, will not require any major changes in direction, or principles, or policy, but will merely require an expansion of already existent – and even “venerable” – rules, rules which have been an established part of Medicare for many years.

DrRich has expressed the idea that such restrictions by our government on such fundamental individual liberties are a very big deal indeed, and, in fact, signal an end to the Great American Experiment. His critics admonish him, however, that he makes too much of it, that, presumably, our government in its benign wisdom is just doing what’s best for us.

DrRich begs his readers to forgive him if he sees, in such a reply, even more evidence that the only nation in the history of mankind to be founded on the principles of individual freedom is well on the way to abandoning those exceptional principles, for the sake of the same, soothing-but-empty blandishments that have been offered, throughout human history, by well-meaning people who end up producing – or becoming – tyrants.

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 Breaking the Doctor-Patient Relationship (Limiting Individual Prerogatives, Part 3) [20:54m]: Play Now | Play in Popup | Download (14)

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Part 1 of Limiting Individual Prerogatives

Part 2 of Limiting Individual Prerogatives

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The thing about Progressives is that the characteristic which makes them most endearing (and, which makes them most attractive to the unaware), is the very characteristic which makes them the most dangerous.

Fundamentally, Progressives believe in the perfectibility of mankind, or at least, of society. Indeed, they have discovered the very Program which will lead to the perfect society, a society which will maximize the good of the whole. Their vision is so compelling, and their ends so utterly and undeniably right, that it becomes legitimate for them to engage in whatever means are necessary to achieve it. (Indeed, for those who have been paying attention, “By Whatever Means Necessary” appears to have supplanted “Hope and Change” as the catchphrase of our current political leaders.)

The thing that always trips up Progressives (and their more revolutionary cousins, the Communists), is, of course, human nature. In order for their Program to work, it is necessary for each individual to behave in the prescribed fashion. And, at the end of the day, a substantial proportion of the population (any population) will insist on striving for their own individual benefit, rather than (as the Program requires) for the benefit of the collective.

The major competing system of societal organization – capitalism – recognizes this facet of human nature (i.e., the essential imperfectability of mankind, as manifested by the non-suppressibility of self-interest), and attempts to channel it into relatively productive and non-destructive (but still competitive and individually-directed) behaviors that limit the damage, and maximize the public good to a reasonable degree.

In contrast, Progressives attempt to change human nature to fit their inherently superior Program.

The fact that you cannot change human nature to fit the Program is what makes them dangerous. Their initial wide-eyed optimism that us folks will just “get it,” once they explain it to us, invariably evolves to an essential contempt for our limited intellectual capacity. This contempt justifies all manner of prevarications, to fool us into going along. Even in societies where the tyranny of correct-thinking has gone so far as to elicit the cooperation of the people at the point of a gun (rather than through the preferred methods of “education” or misdirection), the achievement of the predicted perfect society is invariably prevented by the recalcitrance of human nature. (The final realization that not even an all-powerful central authority can make people behave in the prescribed way always produces a nearly psychotic frustration that – in virtually every Communist country – has led to atrocities against various subsets of the recalcitrant people.)

DrRich does not believe there will ever be pogroms in the United States.

But this does not mean that the Progressives will always be kind and gentle as they attempt to achieve their goals. As DrRich sees it, in the U.S. the Progressives have clearly evolved to the “contempt for the masses” phase of their Program, a phase which justifies all manner of techniques – just this side of violence – to get us all to cooperate. Currently they are intent on demonizing their opponents as being racist, stupid, uneducated, selfish, overly dependent on outmoded supernatural beings, violent, and (of course) obese. This demonization is quite useful, since there is obviously no need to address any actual ideas put forth by such as these, even if they were capable of the feat of “ideas.”

Healthcare is, at present, the chief battleground in the war between Progressives vs. non-Progressives in the U.S., and the outcome of this battle will likely determine the success or failure of the entire Progressive Program. And the most fundamental (and emblematic) aspect of this battle is over what to do about the “doctor-patient relationship.”

The classic doctor-patient relationship was a celebration of the primacy of individual rights. And, for over 2000 years (at least since the advent of the Hippocratic Oath) guaranteeing the sanctity of that relationship was the basis of all medical ethics.

Until very recently doctors, patients, philosophers and ethicists recognized that, when you are sick, you are no more capable of navigating a complex and hostile healthcare system than are accused felons a complex and hostile legal system, and you are no less in peril if you run afoul of that system. And, just as the felon has a right to a personal advocate, a professional whose job is to protect his individual interests against the conflicting aims of the “system,” so does the patient. That is (quaint conventional wisdom held), when you are sick, you should be entitled to at least the same protections as when you rob a convenience store. And the doctor-patient relationship was supposed to guarantee you that right.

This is why, throughout the ages, the basic precepts of medical ethics were aimed at guaranteeing the sanctity of the doctor-patient relationship. Fundamentally, these ethical precepts required the physician to place the needs of his or her individual patient above all other considerations.

It should be clear to everyone that, under either our “old” healthcare system or the one that Obamacare promises us, this formulation of the doctor-patient relationship cannot be allowed to stand. Neither the insurance executives nor government officials can allow spending decisions – that is, decisions on how to spend their money – to be made by individual patients (and their personal advocates). For this reason, the classic doctor-patient relationship had to go.

And so, in 2002, official medical ethics was formally amended to require physicians (while still giving lip service to their obligation to individual patients) to strive for a “just distribution of healthcare resources.” That is, official medical ethics now makes it ethical for physicians to ration healthcare, covertly, at the bedside – and indeed, makes it unethical for them to fail to do so.

The New Ethics has been enthusiastically supported by medical ethicists worldwide (a field which now seems to be dominated by utilitarians), and worse, has been embraced by all the world’s major medical professional organizations. DrRich has not embraced the New Ethics (on the grounds that it places individual patients at great peril, and destroys the profession of medicine), and neither have many (possibly a majority) of older physicians. But it has been taught in medical schools around the world for over a decade, and in another decade it is likely that the vast majority of practicing physicians will accept as a matter of course that their primary obligation is to control healthcare costs, and only secondarily to try to meet the needs of their individual patients.

The plan, therefore, is for Obamacare to provide physicians with directives from expert panels on which medical services to supply to which patients and when, and for the New Ethics to allow physicians who go along with such directives to live with themselves. The feasibility of this plan depends entirely on physicians acceding to the program.

So, incentives are being put in place to “help” doctors cooperate. Quality measures will be implemented, with “quality” being defined as doctors doing what they’re told, and reimbursement will be tied to one’s quality rating. Possibly more persuasive will be the fact that the Feds can construe the failure to follow handed-down rules, regulations and guidelines, at any time, as a federal crime. (Even doctors who don’t mind being labeled as “substandard quality” – perhaps even considering the label as a badge of honor – will mind going to jail.)

But by whatever means necessary, the happiness of the government is to be the doctor’s first consideration, and not the happiness of their individual patients. The classic doctor-patient relationship is being terminated with extreme prejudice.

To see just how important it is to destroy the doctor-patient relationship, one merely has to observe what is happening to primary care doctors who have the audacity to leave the system, and set up a direct-pay medical practice.

Part of the problem, to be sure, was caused by these doctors themselves. The first few to do so unabashedly catered to rich patients, and to attract the rich, referred to themselves as “concierge” practitioners. This name (and its elitist connotations) have been forcibly affixed to all direct-pay practitioners, even as this style of practice has evolved into a much more democratic form. Today, more and more doctors are starting direct-pay practices (in which patients pay the doctors out of their own pockets) which are easily affordable to anyone who can afford a cell phone or cable TV contract.

While many direct-pay practices offer patients certain benefits they can usually not get from primary care doctors who remain in the approved system (such as phone and e-mail access, same-day appointments, appointments lasting as long as necessary instead of the allotted 7.5 minutes, etc.), the fundamental benefit, to both the patient and the doctor, is that it restores the classic doctor-patient relationship. The physician’s primary obligation is no longer to the 3rd-party overlord, or to the Progressive ideal of social justice, but to the patient.

And while critics (who abound) attack direct-pay practitioners for their elitism, laziness, and greed, their real issue is that direct-pay practitioners are acting as if their primary duty is to their individual patients, and not to the needs of society. This latter fault simply cannot be tolerated.

Having gained nearly complete control over the behavior of primary care practitioners, it is critical for Progressives – in making sure that practice by handed-down “guidelines” is not simply the only legal way to practice, but also the only ethical way to practice – to shut the door to any alternative forms of primary care. Direct-pay practitioners are a menace because they threaten to raise the expectations of both doctors and patients. Perhaps, doctors and patients might tell themselves, there really is a way to maintain individual autonomy within the healthcare system.

The attacks on direct-pay practitioners have followed the usual scheme Progressives follow when they discover a faction they need to suppress. First, they were ridiculed. “For a Retainer, Lavish Care by ‘Boutique Doctors,’” said a headline in the New York Times in 2005. Then, they were demonized, widely attacked for their elitism, laziness, greed, and lack of fundamental medical ethics. In this latter effort, it was not difficult to find fellow physicians – generally, from the medical organizations which promulgated the New Ethics – to lead the attacks. There are countless examples. DrRich will give just two.

Anthony DeMaria, then President of the American College of Cardiology, criticized the practice of direct-pay medicine in an article in the JACC in 2005, saying, “Personally, I do not mind if people acquire yachts or personal trainers if they have enough money, nor would I object if they secured a physician at their beck and call. However, unlike yachts, health care is not discretionary, and everyone should be entitled to the same quality.” As a matter of social justice, direct-pay physicians improve healthcare quality for only some patients, and so have no place in the healthcare system.

In an article in the New England Journal of Medicine, Troyen A. Brennan (M.D., J.D., and M.P.H., so we know we’re in trouble) really gets to the point. Referring to direct-pay practices as “luxury primary care,” he notes that “traditional medical ethics is rather poorly equipped to address issues related to luxury primary care.” That is, while “traditional” medical ethics always places the individual patient first, that kind of thinking is now outmoded. “(M)ost ethicists now agree that the financial structure of health care is an important subject for ethical consideration. Access to health care, in particular, is a salient ethical issue.” Direct-pay practitioners threaten (by their elitism and the limited size of their practices), to limit access to primary care, and thus are in fundamental violation of medical ethics.

The argument here, for those who missed it (advanced by fellow physicians no less), is that, of the two competing ethical precepts now established by New Medical Ethics (i.e., the physician’s obligation to the individual patient vs. the physician’s obligation to society), clear primacy is to be given to the physician’s obligation to society. Physicians must (like it or not) participate in covert bedside healthcare rationing. Physicians who take the only path remaining to them that allows them to make the individual patient their primary obligation are to be castigated as ethically deficient.

When ridicule and demonization fail to suppress their opposition, Progressive dogma indicates it’s time to resort to force. The first pass in this regard, of course, is always to render the opposition illegal. (Actual violence is reserved for criminals who persist in their misbehavior, despite more polite efforts to get them to behave lawfully.)

Making direct-pay medical practice illegal has not been accomplished yet, but clear efforts have been made in this regard. Noting with alarm the rise of direct-pay primary care, numerous Congresspersons have issued statements of concern, suggesting that perhaps Congress should look into the propriety of such activities.

Indeed, the first step by Congress has already been taken. In 2003, as part of the Medicare Prescription Drug, Improvement, and Modernization Act, Congress directed the GAO to study and report on the effect of direct-pay practices on Medicare patients. The GAO did so in 2005, and a fair paraphrase of its report is as follows: “The practice of direct-pay medicine is not currently a threat to Medicare patients, because the direct-pay movement is not large enough yet to have an impact. If it does begin to have an impact on Medicare patients, action will have to be taken.” That is, direct-pay medicine was considered OK in 2005 not because it was inherently an ethical and legal form of medical practice, but simply because there were not enough practitioners at that time to significantly affect Medicare patients. The clear implication is that Congress stands ready to pass laws outlawing – or, at least, severely limiting – direct-pay practices, as soon as those practices begin to “impact” the system.

Certain state governments are not waiting for Congress to ban direct-pay practices. The state of Maryland (and a few others) have taken the creative position that, because many direct-pay practices work on a retainer basis, they meet the definition of a health insurance company. And as a health insurance company, to be considered legal entities, they have to have millions of dollars set aside to pay for unforeseen “claims.” (Interestingly, this same argument was not applied to Maryland lawyers, who also often work on a retainer model.) According to the Baltimore Sun, the state’s stance in this regard has already successfully caused several primary care physicians to abandon their plans to become retainer practitioners.

Less devious (but more draconian) than the state of Maryland is the state of Massachusetts (whose universal healthcare system, we’ve all heard, is a preview of Obamacare circa 2015). A bill is under consideration in the Massachusetts Senate (Bill 2170) which requires doctors, as a condition of their licensure, to accept payment rates as determined by the government. If it passes, it will be the first actual legislation in the U.S. to ban direct-pay medicine, if only by making it completely impracticable. (Thanks to Dr. Wes for pointing out this important development.)

Since medical licensing is controlled by the various states, of course, it would take 50 bills like the one in Massachusetts to really get rid of direct-pay healthcare. But there are other ways for the Feds to accomplish the same thing. Now that the federal government directly controls all student loans, for instance, it would be a simple matter to make those loans contingent on agreeing to become primary care doctors working strictly within the government controlled system, or to offer loan forgiveness for doctors who agree to do so, or to rescind favorable re-payment conditions (retroactively, and decades after the fact, if necessary) for doctors who go to a direct-pay model later in life.

DrRich does not really know how the Progressives will actually place the final nail in the coffin of the doctor-patient relationship. All he knows is that they have – well, more than the desire – the deep and abiding need to kill that relationship, once and for all. Unless we the people decide we ought to stop them, this is going to happen.

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Part 4 of Limiting Individual Prerogatives

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 Hillary Started It (Limiting Individual Prerogatives, Part 2) [15:16m]: Play Now | Play in Popup | Download (4)

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Part 1 of Limiting Individual Prerogatives

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Have you ever wondered where Obamacare came from? From where, exactly, did those 2700 pages of undecipherable prose arise?

It is clear that our Congresspersons never read it, let alone wrote it. At the President’s “Health Care Summit” in late February it seemed pretty plain, to DrRich at least, that the only people in the room who had read the bill carefully were Republican Congresspersons Ryan and Cantor. The proponents of the bill stuck to generalities, platitudes, and vignettes about recycling dead people’s dentures. When Ryan and Cantor used their knowledge of the bill to question the President about its details, they were admonished to stop using “props.” The President was not just being mean; he needed to avoid getting into the details because he himself had only a broad general idea of what the bill actually said. This is not a slam at the President; the bill is designed to be fundamentally indeterminate in its meaning, so that the regulators who will later translate it into rules, regulations and guidelines, under which healthcare providers can then be prosecuted, can at that time interpret it as directed. This is what Nancy Pelosi meant when she said, a few days later, that Congress would have to pass the bill so that we all could find out what was in it. (This also explains why none of our legislators read it – except for those pesky Republicans, who were only trying to make trouble. What’s the point in reading a long, boring document whose actual meaning will only be sorted out later?)

So, DrRich asks again, where did this bill – whose actual meaning was elusive even to the President and the legislators who were promoting it – come from? Who actually put the words to the page, and crafted this remarkable piece of legislation?

We may never know the name(s) of the person (people) who held the pen(s) which scratched out the actual words, any more than we will ever know the real names of the individuals who wrote the gospels of Matthew and Luke. But, just as New Testament scholars have been able to trace these two gospels to a common prior source – the so-called “Q document” – it is not difficult for anyone with a smattering of interest in the art of legislative exegesis to trace the source document for our new healthcare law.

The Q Document for President Obama’s Patient Protection and Affordable Care Act, was, of course, Hillary Clinton’s Health Security Act, which went down to ignominious defeat in 1994.

DrRich, who is rapidly developing an expertise in forensic diplomatics, and having spent significant time examining aspects of the Obamacare bill, decided to go back in time, and re-examine Hillary’s original proposal for fundamentally transforming the American healthcare system.

While Hillary’s Health Security Act was widely castigated by contemporaries as being a vast monstrosity of bureaucratic legerdemain, filled with complexity and labyrinthine passages that attempted to hide its true meaning, DrRich, after spending some time with Obamacare, found Hillarycare to be a model of legislative brevity and clarity. In fact, DrRich believes, its very straightforwardness is what killed it.

For instance, Hillarycare is only 1368 pages in length. How could they be so concise?

Even more remarkably, Hillarycare spells out pretty plainly what it actually means to do. For instance, in the Obamacare bill, in order for a reader to assemble the information that the  Independent Medicare Advisory Board is actually to be called the Independent Payment Advisory Board, and that its “advisory opinions” which are to be submitted to Congress for “consideration” are actually formal dictates which must be followed to the letter, and that it can inflict its cost-cutting mandates to all of healthcare and not just to government programs, one must jump around to numerous distant sections in the 2700-page document. In the Hillarycare bill, in stark contrast, the analogous National Health Board (which, like the Immutables, was to have been the Supreme Court of Healthcare, beyond which there was to be no appeal, no revision, and no repeal) is presented in an entirely straightforward way, and all in one place.

And now, having immersed himself once again, however briefly, in the relatively refreshing model of clarity and precision that was Hillarycare, DrRich is convinced that the people who actually wrote the Obamacare bill (and may God keep these invaluable masters of legislative poetry safe, as we will be needing them), simply began with Hillary’s old Health Security Act, disassembled it into various bits, padded each bit with a little more than twice its weight in verbiage, and reassembled the pieces in some nearly random fashion, puzzle-like, into the exceedingly difficult-to-read document that became Obamacare.

That is, Hillarycare is demonstrably the Q document to Obamacare.

Obamacare’s debt to Hillarycare is obvious. Hillarycare included individual mandates requiring everyone to have government-approved health insurance; it reduced private health insurers to government-directed utilities, whose products, rates, and profits were to be controlled by the feds; and it created omnicient and omnipotent panels which were to hand down dictates to let doctors know what services they may or may not provide and under what circumstances.

DrRich, therefore, formally advances the thesis that if you want to understand what Obamacare is actually getting at – what with its inherent and intentional obscurity, obscurity designed with care to provide its proponents with plausible deniability – simply examine the much more straightforward model from which it was derived, namely, Hillarycare.

And this brings us, finally, to the theme of this current series of posts. For Hillarycare strictly limited, in practice, the ability of individuals to spend their own money on their own healthcare.

In this instance even Hillarycare had to be a bit obtuse. For, as DrRich’s critics have pointed out to him so very many times, Americans are jealous of their own personal liberties, and are not likely to simply tolerate a frontal assault on their right to guard their health with their own resources. And of course DrRich agrees with this idea. Indeed, the fact that Hillarycare was insufficiently obtuse on this matter had a lot to do with why it ultimately failed to become law.

The attempt at limiting individual prerogatives under Hillarycare was, to be sure, devious (though not devious enough to fool people). So it began with a straightforward statement declaring that it was not doing what it was actually trying to do: “Nothing in this Act shall be construed as prohibiting…an individual from purchasing any health care services.”

Now first of all, for readers who persist in thinking that restrictive language like this, when it appears in federal legislation, actually means anything in particular, let DrRich disabuse you of that notion with two examples. 1) The legislation that created Medicare contains the following language: “Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine, or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer, or employee, or any institution, agency or person providing health care services.” (Section 1801, Medicare Act, 1965). 2) Obamacare contains language that prohibits healthcare rationing.

In any case, after making this broad promise in favor of individual liberty, Hillarycare went on to limit individual liberties. It attempted to do this in the Fraud and Abuse section of the proposed law, which sought to dry up most of private medical practice, and criminalize the rest. It provided for strict governmental controls over the fees that could be charged by fee-for-service doctors or private practitioners. And if the feds decided that a private doctor’s fees were too high, they could charge him/her with bribe-taking, a serious federal crime under the new law. Indeed, Hillarycare attempted to make illegal most of the ways patients could go outside the approved system to get “extra” healthcare. Criminal penalties could accrue to both the doctor and patient. According to Paul Craig Roberts, writing in the Washington Times in December, 1993, “Mr. Clinton’s plan turns normal patient advocacy into a federal criminal offense. For example, a doctor who wants an earlier date for surgery for a needful patient can be accused of using wrongful influence and accepting a bribe and sentenced, along with the patient, to 15 years in prison.”

While none of this got much publicity in the general media in 1993-1994 (which goes to show that things really haven’t changed that much), you can be sure that doctors were aware of it. That Hillarycare would make it so very easy to inadvertently commit a federal crime – which would lead to massive fines, loss of license, and jail – was, in fact, one of the main reasons most physicians were so violently opposed to it.

The point DrRich is trying to make here is to demonstrate just how deeply reformers feel the need to control the behavior of physicians (and through physicians, the behavior of patients) in order to gain the control they need over individuals, and just how far they are willing to go to this end. It was partly because the Clintons showed their hand in this regard that their healthcare plan failed.

DrRich will now make two final points, and then end this already-too-long post. First, while Hillarycare failed to become law, many of the over-the-top anti-fraud provisions within Hillarycare actually became the law of the land a few years later, in the HIPAA legislation. DrRich has discussed this in detail in his book, and demonstrated how, during the rest of the Clinton administration, the healthcare police worked diligently to let doctors know that their careers, life savings, and physical freedom were dependent on making the happiness of the government – and not of their patients – their chief concern. This activity stopped during the Bush presidency, and has not yet picked up again under President Obama. But the infrastructure is in place already for an unusually effective coercion of doctors, in order to keep them from providing services, and thus to keep patients from buying those services, that the government does not like. There was, in fact, no need to add this infrastructure to the Obamacare legislation. The only thing that’s necessary is for the government to decide (as it did for a few years during the 1990s) that it’s time to take off the gloves.

And second, the intent of the people who brought us Hillarycare – the same people, in philosophy if not in person, who brought us Obamacare – ought to be very plain to all of us. We know their mindset. They may not have gotten away with limiting individual prerogatives in 1994 – but they certainly tried to.

And while it is true that Americans greatly value their liberty, and will chafe at overt restrictions on their ability to use their own resources for the sake of their own health, DrRich reiterates that actually preventing these restrictions will depend on our continued vigilance, and our willingness to stop the people who so plainly want to stifle our individual prerogatives, for the sake of the control they must have.
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Part 3 of Limiting Individual Prerogatives

Part 4 of Limiting Individual Prerogatives