Congratulations to Mercy Healthcare Sacramento for embarking on Process Redesign. The first of an ambitious series of customer/ vision conferences lasting 24 hours each were held in November. The conference attendees of physicians, nurses, administrators, managers, health care workers, and patients discussed the organization’s history, the current situation, and the kind of organization that’s desirable to create in the future; the external customer/provider relationships, how they work, and what’s required for the future. Three hour “walk throughs” of the distillation of this information were held in December and January. The next three day sequence, the internal customer/technical conferences will occur this month. Sister Bridget is establishing her leadership and innovation in addressing the current healthcare dilemma.

Gary Stix in Scientific American (7/94:20) reviews managed care, circa 1300. He notes that Bernat de Berriac, M.D. received five to 20 sous a year from each of several dozen men of modest means from a village in Catolonia. For this paltry sum, the youthful doctor agreed to treat these men and their wives, children and servants “for every illness that requires the art of medicine.” In Medicine Before the Plague, McVaugh shows that a major preoccupation of this era, not to mention the 20th century, was who was covered and how a physician would get paid. Quality of care was an issue… Practitioners entered into a contractual arrangement–in effect, a form of managed care… Count-kings paid a lifetime retainer to… physicians… Society worried about coverage for its less fortunate. Combing through old histories, contracts and wills, McVaugh found that physicians agreed to become service providers in what were inexpensive, prepaid health insurance plans. Many towns set up a post-Dark Ages version of a public health service by simply putting a doctor on the payroll… Edward H. Davis replies (10/94:10): Managed care involves a feature not entertained by our medieval forebears: the control of medical care by an entity other than the patient or the patient’s physician. Such control serves to restrict diagnostic and treatment options, based on the financial interests of the manager, which is usually a commercial insurance company. Permit me to doubt that our medieval predecessors would have tolerated such “management.”

Oregon passed the physician assisted suicide initiative which then was discussed on American Medical Television rounds chaired by George Lindberg, MD, Editor, JAMA, with Roger Bone, MD, Pulmonologist, Dennis O’Leary, MD, Internist, Pres of the Joint Commission, Leon Kass, MD, JD, Jack Bierig, JD. The entire spectrum of total agreement with the initiative to opposition in crossing a line physicians should never cross was discussed. The Health Forum in Sacramento has noted that the euthanasia issue will pale the whole abortion debate… I’m sure most physicians prescribe medications which allow patients to end their suffering by simply taking a one to three months’s supply on retiring. Most cardiopulmonary meds (glycosides, antihypertensives, theophyllines, etc) will do the job before arising and prevent arising… One of our member physician told me when interning at LA County, a young lady came in who was committing suicide regularly. He explained to her that to be successful, she should take a full bottle of both her tranquillizers and her sleeping pills and she should NOT make that phone call to a friend after taking the pills. He stated she never returned.

Forbes (11/21/94): “Expatriation has been called the ultimate estate plan.” Are taxes that oppressive that many of our greatest entrepreneurs are giving up their American citizenship to avoid taxes? And I thought American citizenship was as important to us as Roman citizenship was to Paul of Tarsus.

Vice President Al Gore translated the US motto, E pluribus unum, as “out of one, many,” rather that its proper translation, “out of many, one.” If his predecessor had made the same reversal of meaning, we probably could have read it in the media rather than in a medical editorial in Kansas Medicine.

Dr. Marion Jenkins, anesthesiologist, who declared President Kennedy dead on November 22, 1963 at Parkland Memorial Hospital ER died on November 21, 1994, at the age of 77. He also treated Lee Harvey Oswald and Jack Ruby… One physician treated the assassinated, the assassin, and the assassin of the assassin.

The budget of the medical staff distributed at the last American River Staff meeting included the following staff salaries (half paid by the hospital) Chief of Staff: $50,000; Chief Elect: $25,000; Chair of Surgery: $15,000; Secy/Treas, Chairs of Med, ObGyn, Peds, FP, QAC, URC: each $10,000… One comment overhead at the meeting, “No wonder our leaders are hospital whores…” Perhaps we ought to move forward to the time when we again donate a year or three for medical staff services to maintain our integrity. We can not have it both ways.

Alan M. Garber, M.D., Ph.D., internist and health care economist at the VA Medical Center, Palo Alto, and Stanford, states that cutting waste is not going to solve all the issues of health care reform. There has been a dramatic growth in the number of medical procedures being performed. A detailed breakdown of Medicare expenditures from 1985 to 1989 show payments for office visits grew by only 11%, but for selected procedures, e.g. CABG, by 17%; PTCA, by 79%; and MRI, by 407%. He feels that cutting waste will come down to cutting procedures. The feds won’t say, “We won’t cover bone marrow transplants because they cost too much.” They will say, “We won’t cover it because it hasn’t been proven effective.”

Harold Fine, a former federal auditor with the Dept of Energy’s inspector general, alleged that UC Berkeley and its two nuclear weapons labs fraudulently diverted $232 million from their intended projects during the late 1980’s and 1990’s. The Feds dismissed their own audits and refused to press charges. Fine then sued the university on behalf of the nation’s taxpayers in 1991. The Feds then joined UC in fighting Fine saying an employee is not eligible to sue. Fine has now obtained court permission to sue on behalf of us, the taxpayers.

We recently had GE come out to service our dishwasher. It took about 15 minutes of the service man’s time and about $25 worth of parts. The bill was $188 including travel and one hour minimum… An elderly lady reported that she called a service man to change a light bulb in her cathedral entry way. It took him only a few minutes. But the $45 travel plus $45 minimum charge did add up to $90 to change a light bulb… Do all service people make more than physicians for making house calls? If you have other examples, please telephone or fax them to my private office number, 488-5880, day or night.

The British Columbia Medical Assn reports an unusually large return on their membership survey with a margin of error of 1.4%. A majority of 62% believe their current system is headed for trouble and 67% take issue with the government’s scheme for change–regionalization. An overwhelming 88% favor reducing universal coverage to a defined, limited set of essential “core” services with the private sector filling in the rest… Unfortunately, those are the same services that insurance can best cover. Elective hospitalizations and surgery always lead to abuse and can’t be insured. That’s like expecting our car insurance to pay for a paint job because we’re tired of the present look.