Roaming About Moscone January 1997

At a recent meeting of the American College of Chest Physicians it was of interest to note the large number of presentations with titles such as: Ethical issues… in medicine… In the ICU… In death and dying…. In withdrawing life support… In health care delivery… Most were rather thin on any ethical discussion and should probably have just been given a cost emphasis title. The honest topics simply said: Economics: cost-effectiveness and resource utilization; or Impact of Managed Care on Physicians; or Taming the Beast: Managing Cost and Quality of Critical Care. This was a small meeting of only 3500 for the Moscone Center in San Francisco which can comfortably handle 15,000 and even seat 7500 at a banquet. But with a dozen or so countries represented, it did allow for interesting discussions at breaks, lunches, and in the latrines.

A Korean physician reported that he was now seeing 150 patients in a 10-hour day which gave him about four minutes to obtain a medical history, physical examination, and review lab work and other data; give his instructions to a physician assistant as to what further tests he should order; what Rx he should write; and the final disposition of the patient before walking to the next room and patient. He stated that even the wealthy could not buy better care because it was illegal. They had to go to Japan or the USA for private care… If we eliminate private care in this country, we can essentially consign the world to mediocre medicine.

A VA doctor from Long Beach stated that the new patient appointment has been reduced to 20 minutes and follow up visits to 10 minutes.

A Canadian Thoracic Surgeon stated that he feels medical practice and medical care is deteriorating rapidly in his country. He said that it is difficult to obtain approval for any surgical procedure in less than 6 weeks, generally it takes three months. Doctors are hesitant about doing emergency procedures. The penalties are severe if, in retrospect, some reviewer thinks it really was not an emergency.

A Chinese doctor explained that it was comforting to be in San Francisco Chinatown. All those dragons drive the evil spirits away. All those bells attract good spirits. Therefore, you are in really good hands.

A Canadian Pulmonologist stated that things are so rigid in his country that you can not do any private practice. If you get caught, it’s a felony and you go to jail… He wasn’t sure if you would be put in the same cell with your patient (who is also guilty).

A San Francisco native boasted that his city has the best politicians that money can buy.

One discussant claimed that the only reason we have managed care is that doctors refused to be concerned about cost containment. He pointed out that many doctors still are not concerned about cost. He felt some still view a clinical indication, that may have been valid in the past, as adequate reason to proceed with a procedure or test regardless of costs or other variables. He assured us that they would be deselected… soon.

Are things ever going to get better? One presenter quoted Yogi Berra: “Predictions are very difficult, especially about future events.”

A presentation from Germany was on the quality of life (QOL) in their health care system. From the perplexed looks on the faces of the audience, this seemed like comparing apples and grapes. Transcultural comparisons, although important, are difficult at best.

A Minneapolis consultant, who stated that the Twin Cities, Los Angeles, San Diego and Worcester have the highest managed care penetration in the country, mentioned he had received a phone call from a Sacramento double-boarded surgeon who was deselected and now makes one-fourth of his previous income scrounging for surgical assisting jobs. (Sacramento was in the second tier along with Salt Lake City.)

Question: Can physicians survive the managed care environment? With difficulty. The bigger question is: Can patients survive the managed care environment? From all that was presented, the answer was quite clear. Only with a decreased QOL.

Epitaph on Tombstone: Here lies Billy Osler, Jr, MD, a medical felon, who spent his last years in prison when his only crime was trying to give a higher level of medical care.

The Politics of Organized Medicine February 1997

Organized medicine is our topic of the month as we re-organize our organized medicine structure with new leaders via our own political process. Looking at the cross references between just those three terms yields some interesting insights. We trust they give us pause for reflection… concern… and enlightenment.

Organize: to routinize, normalize, standardize, harmonize, or synchronize.

Organization: An administrative coherent structure to unify, integrate, or arrange interdependent parts to function as one organ.

Organizations, like individuals, have their growth, their adulthood, their decrepitude, their decay, their death. If they have a rebirth or rejuvenation, it is quite by accident. As Earl Nightingale says, an organization never has more than one knight on a white horse.

An organization man is a yesman, a conformist, a conventionalist.

Never judge an organization by its politics…

Organizational politics at times are not worth a pitcher of warm “urine.” (J Gardner, revised)

There are times in politics when you must be on the right side and lose. (J Galbraith)

Medicine is for the patient. Medicine is for the people. It is not for the profits. (Merck)

Medicine sometimes snatches away health, sometimes gives it… The art of medicine is generally a question of time. (Ovid)

The whole imposing edifice of modern medicine is like the celebrated tower of Pisa – slightly off balance. (Charles, Prince of Wales)

We have to ask ourselves whether medicine is to remain a humanitarian and respected profession or a new but depersonalized science in the service of prolonging life rather than diminishing human suffering.
(E. Kubler-Ross)

… Organization is at once necessary and fatal. Humans are forever creating such organizations for their own convenience and forever finding themselves the victims of their home-made monsters. (after A. Huxley)

Confucius, a Chinese political and moral philosopher in the sixth century BC, whose confusing system of social, familial and political organization was generally not accepted during his lifetime, was considered to have been wise by the second century BC yielding great influence for nearly two millennia.

Despite our imperfections, we have elected new leaders. I have spoken with the new president and the president elect. I think our society is in good hands. Let’s give them our ideas, insights, opposing points of view, and then our support after adequate discussion has occurred to air all points of view. Sacramento Medicine is an excellent forum for this process to occur. We have been assured that all points of view will be heard. Don’t resign if you’re unhappy. Let us hear from you. If your ideas have merit, others will support them. If they don’t, let us convince you by discussion, dialogue, and debate, in the pages of this forum which is the best way to revitalize our organization. Growth can only come through the exploration of a wide variety of ideas so that conflict will not become contrary, counteractive or counterproductive–rather it will lead to a confluence, convergence and concurrence of ideas for resolution. Remember if we trade a dollar, we still each only have a dollar. If we share an idea, then we each have two ideas.

Maintenance Mania March 1997

National Public Radio had a report on the success of HMOs. They suggested that there were other things that were expensive and we might apply HMO techniques to bring down their costs. I didn’t have my recorder in the car and so am describing this 100% from recall. My apologies to the author inasmuch as I have probably missed a few words and also missed her name.

Everyone knows the price of cars is too high. To get the price down, we could form a car maintenance organization (CMO). Our CMO executives would tell the dealers that they would henceforth be re-imbursed at 60% of retail costs for the members of the CMOs that purchase cars. The car maintenance organization (CMO) would sign up potential car buyers, which eventually would include almost everyone. The CMOs would enter into contracts with the various dealers to acquire the cars. The dealers, in order to protect themselves, would form Independent Dealers Assns (IDAs). As the number of consumers joining these CMOs increase, the car dealers would not have enough business to go solo and eventually would have to contract at the reduced price. Americans would enjoy the pleasure of driving their automobiles at a 40% savings.

We also know the price electricians charge is too high. The charge of $65 to come to your house plus a labor charge of $65 for an hour or fraction thereof, can amount to $130 for a ten minute job. If 47 million unfortunate Americans with hazardous wiring in their homes could not afford electrical upgrades, the need for an Electrical Maintenance Organizations (EMO) would become obvious. The deserving public living in electrically hazardous homes would join an EMO which would in turn contract with the electricians for their services at $35 a hour (which just happens to be what the latest data shows that doctors in the 25th percentile income, working 3,000 hours per year, are making). As more and more Americans sign up with an EMO, the electricians wouldn’t have any work unless they contracted with our EMO and so we would be able to get the electrician’s hourly rate down to $35 an hour. (Thus the EMOs would bring skilled labor down to the same cost as professional labor.)

Everyone agrees that athletes are definitely making too much money. In fact the cost of professional sports is so high that deserving school kids have difficulty seeing their heroes in action. Why should a jock get $3 million dollars for 20 weeks of work? That’s $150,000 for a 30 hour week–about the same as the 50th percentile for family physicians for a 3000 hour work year. Sport fans should form a Jock Maintenance Organization (JCO) and the public would join these JCOs for the purchase of tickets to football, basketball, baseball, and hockey games that contracted with our JCO. As the coliseums become emptier and as the jock salaries fall, league managers would contract with our JCO to re-acquire fans. We and our deprived children would then be able to see NFL, NBA, NHL, AL & NL games at about 40% or $8 each, as the players learn to live on a doctor’s salary.

The HMO’s CEOs are definitely making obscene amounts of money. Even our local boys are making $5,000 ($5K) per hour. One national HMO CEO made $1 billion. Suppose he worked real hard, maybe three-fourths as hard as some doctors, and put in a 3,000 hour work year? That would be $333K per hour. (Even Bill Gates, the world’s wealthiest man only makes $55K per hour.) What we need is a CEO-Maintenance Organization (CEO-MO). People would join a CEO-MO which in turn would purchase their HMO insurance. But they would only purchase HMO insurance from those that maintain a contract with our CEO-MO which would require that their CEOs starve themselves on a primary doctors average salary. They would also be required to keep their profit and overhead the same as Kaiser. This would mean they would have to reduce the fat from 33% to 8%, a 25% health care cost savings. The shareholders would lose interest and the price per share would plummet. With the price per share below a quotable price, there would be no further interest in merger-mania with billion dollar CEO bailouts. The HMOs would then again become nonprofit and would again compete on an even basis with Kaiser, preserving the worlds finest HMO structure, which would then be the best defense as an alternative to private practice. This would give all Americans a choice for private fee for service or real HMO care. Then with a few tweaks, we would be close to universal health care in a free environment.

Uncle Sam’s Solutions April 1997

The government is now paying some hospitals “not” to train resident physicians. Uncle Sam has the uncanny ability to pay the same amount of money for providing a service as for not providing one.

Some time ago a family physician mentioned to me that he always had an internist or surgeon take care of his patients in the hospital. He was not able to provide daily hospital care. In fact he normally saw his hospitalized patients only twice a week. His office just automatically entered a hospital charge on Tuesdays and Thursdays for his hospital patients since on those days his scheduled stopped an hour earlier to allow him time for hospital rounds. Once, because of family obligations, he saw the patients Mon, Wed, and Friday after work. Unfortunately he failed to tell his office which then failed to change the date of service… On medicare audit, he was charged with Medicare fraud, and was about to be cited and fined, for charges on this patient for a Tuesday and Thursday evaluation that did not occur. He pleaded that he had actually seen the patient three times rather than twice and that medicare really saved money. Uncle Sam’s position was that not charging for Mon, Wed, & Fri that week was his choice. But charging for Tues & Thurs and not seeing the patient was fraud. It cost him about ten hours of legal fees for his attorney to straighten that out.

When I did my training in Michigan, there was a referendum for farmers to vote on whether they wanted price supports, an artificially high price for grain, to compensate them for not growing grain. It failed by 80 to 20. However, Uncle Sam enticed individual farmers to sign up for price supports. Gradually most farmers were induced to obtain funds for not growing grain. Payments gradually increased so that some corporate farmers were making nearly a million dollars by not working a portion of their land.

Tobacco farmers had the same inducements. As the epidemics in strokes, heart, and lung diseases related to smoking reached astronomical proportions causing huge medical expenditures, some state governments are trying to sue the tobacco industry to recoup their health care losses. Uncle Sam, however, continues to subsidize the tobacco farmers with price supports.

Tim Draper of Redwood City in a recent column reports on the “technology summit” held near Palm Springs. A lawyer and three lobbyist suggested that Silicon Valley should build better relationships with Washington. They should educate politicians and bureaucrats. The response: Our industry now accounts for 11% of the gross domestic product, employing 4.2 million people who earn double the average salary of similar workers, making the US the world’s most competitive economy. They pointed out that the industries that had done the “best job” of lobbying and teaching Uncle Sam about their business are among the most heavily regulated and the least attractive investments. Teaching folks inside the Beltway about our business is a dumb idea, he says. He explains that one must understand the mind of a bureaucrat who lives to regulate and make rules to justify his existence. One must also remember the success of your industry is not very important to him. Draper thinks they have done just fine without Uncle Sam and are anxious to keep him 2500 miles away so he doesn’t raise barriers to information. He states that without regulations we’ve even come up with an alternative to the post office and the phone company: E-mail.

The number of patients who spend their entire day on the internet seems to be increasing. Some spend 12-15 hours a day at their computer keyboard. The Wall Street Journal reports that some of the porno lines on the World Wide Web are having problems with password promiscuity–the sharing of passwords with friends for only one monthly fee… Reminds me of the psychiatrist who was listening to a patient talk about having sex online. The psychiatrist mentioned, “That must be one form of safe sex.” The patient said, “I don’t know. It seemed very real to me. And I wasn’t even wearing a condom…” Our president can’t stand the freedom of the internet. He wants Uncle Sam to regulate it. Maybe we all better get online quickly. It might be the only thrill left in life.

The Medical Marketplace May 1997

Aetna’s CEO & COB (Chairman of the Board) received a 23% raise in cash compensation to $2.6 million. This Hartford, Conn., health-care benefits and insurance company, which last July acquired US Healthcare Inc, also increased the pay of its President by 66%. The CEO also received $3.2 million in bonuses for exceeding company performance goals for the past three years. (Thank you to all the doctors who made this performance possible.)

Our MCO had a performance evaluation last month. We noted a whole list of adjustments were inserted into the marketing concept of “per member per month” to try to correct for the variations in different practices since we only see those patients that come in. The percentage of patients to total members is now factored in. There is a dramatic increased allowance for patients of advanced age. However, acuity is still not in the equation. It would appear that those patients who have major diagnoses in three organ systems may take longer and cost more to evaluate than a similarly aged patient with stable disease in one organ system. There should be another adjustment factor for each additional organ system involved for those of us who prefer the challenge of multiple medical problems.

The president and former CEO of Humana who resigned in July 1996 was given a “goodby” package of $4.7 million.The compensation of Humana Inc’s current CEO dropped 30% in 1996 to just under one million. The company explained that despite a 45% increase in revenue, it’s profits fell 20% to $152 million. Perhaps it’s a mistake to highlight this or someone will run to Congress or the Legislature to pass a law that no healthcare CEO should have to starve on a salary as meager as only ten times the 25th percentile average of primary care physicians’ incomes.

The Bureau of Labor Statistics has projected that the employment market in the home health services industry will increase 120% by the year 2005 adding 600,000 workers. The greatest needs are for RNs and LVNs… On Easter Sunday I was hoping for uninterrupted family time, when I received a call from the hospital. They had a patient whose husband was a patient of mine and they would like for their Home Health Care Service make a visit to my patient since their patient’s doctor could not write the order on behalf of my patient. When I called him to get his permission, he declined. Isn’t it amazing that in the health care field we can do all this aggressive marketing under the guise of helping people and sometimes “help” them when they don’t want or need help? To criticize that, might appear insensitive in the eyes of the public, the media, and lawmakers.

Dr Fred Garcia, owner of Slim & Slimmer Medical Associates of Newport Beach, Calif has opened 24 Diet Clinics since May 1995. “I’ve never seen a vehicle like this for seeing large number of patients. You may be talking to the next billionaire!” he says. . . Mitchell Rubinson, CEO of QPQ Corp, the Polish pizza business of Miami Beach who has opened four weight-loss centers staffed by doctors says, “It’s a wide-open market. The profit margins are much larger than in restaurants.” He hopes to expand to 36. . . Dr Don S Jensen, a former family practitioner, says his chain of 18 Manhattan Weight Control clinics has reaped $15 million in revenue last year from 45,000 people it has treated. He feels the threat of pulmonary hypertension is “a red herring… pretty much a media creation.” Last year doctors wrote a total of 18 million prescriptions a month for phentermine and/or fenfluramine (Phen/fen). Dexfenfluramine racked up an additional 2.4 million prescriptions in just its first six months. Marketing was successful to the tune of $400 million last year. Three fourths of that went to American Home, which makes “fen” and “dexfen”. (“Phen” is generic and covered by most HMOs.)

The $4.6 billion FHC and Health Systems International (HSI) merger has been completed. It trades on the stock exchange under a new name, Foundation Health Systems, Inc., (FHS) and provides coverage to 5 million “members.” FHC’s CEO who expects to get $21 million from this merger said, “I’m exhausted. . . I had no idea how much energy this would take and how emotional it would be.” A doctor who was a member of the IPA which was “spun off” in the process said she was exhausted also. Other doctors in the staff room said they would like to experience just $1 million worth of exhaustion. I guess if was rough all the way around.

Medicine vs Witchcraft (or just a notch above) June 1997

A prospective juror in an insurance case was asked if he had ever done business with the insurance company in question, and what he thought of insurance agents. He replied that he placed them “just a notch above lawyers.” We may think of this as just another way ploy to avoid serving on a lengthy jury trial, but the association is sobering–even if you don’t drink. Remember when “public confidence” polls placed doctors near the top along with priests, ministers, rabbis, and supreme court justices? At the other end of the spectrum were congressmen, legislators, lawyers, and used car salesmen. As we leave the high moral ground and become increasingly preoccupied with the bottom dwellers, might we not also fall to “just a notch above lawyers?”

Online discussion between two attorneys as excerpted by the Wall Street Journal:

Stuart Taylor, Jr (Author): The implicit point of all this seems to be that feminists are right to support Anita Hill and not Paula Jones–regardless of which of the two women has a stronger claim to being a victim of sexual harassment–because supporting Anita Hill helps the feminist political agenda, and supporting Paula Jones would hurt that agenda. In other words, it seems to me that you have implicitly conceded that the positions of feminists in these two cases are fundamentally unprincipled–that they are driven by political expediency and not by a commitment to evaluation of individual claims of sexual harassment on the basis of a neutral analysis of the evidence. Please correct me if I’m misinterpreting you…

Susan Estrich, (USC law professor): You believe in principle. I believe in politics. Here is what I learned in law school. I learned that if you push any legal questions hard enough and far enough, principle turns into politics. No avoiding it. We live on the slippery slope. You and I were the best in our class at arguing both sides of every issue–but you could type faster, and so you got the Fay Diploma, and I worked harder, so I got to be president of the Law Review. But we both got the game. “The Legal Process” …took the place of those much-feared value choices…

Yes, medicine has always represented those much-feared (and respected) value choices. As we deal more with the professions on the slippery slope, we can only slide down hill. When we’re in the mire with everyone else, we will all look, smell, and act the same. There is “no avoiding it.”

Congratulations to the UCD School of Law for making the list of top 50 law schools according to the USNews “Best Graduate Schools.” UCD Vet School was number one, the Medical School was 13th in Primary-Care, and the MBA program was No 44.

Hostess pointing out guests to new arrivals at a cocktail party: “The Von Soostens under the chandelier represent old money; the Hendersons by the champagne punch represent new money; the Gibbons admiring the bookcase represent lottery money; the Krogers sitting on the velvet divan ladened with gold and diamonds around their wrists, waist, and necks represent managed care money; and Dr Livingstone, my HMO doctor, bending over the diving board with his wife tugging on his coat represents no money.”

A patient brought in a hospital bill stating “here’s one for your column.” He had gone through a pulmonary rehabilitation program at one of the hospitals. The bill to medicare was $4576 for 18 three hour sessions. He said with a class of 12, it was $54,912 for the hospital or $3000 per session. He said he was unable to find any medical benefit. He call some of the twelve and they couldn’t either… Who needs beds anyway?

The current Fortune magazine reports that Lovelace Health Systems, a subsidiary of CIGNA, is combing through hundreds of medical charts in search of those “customers” who might benefit from mood-elevating drugs which Fortune termed “sinister but laudable.” The Zung Questionnaire is mailed to “heavy user” patients defined as those who have visited the ER or been admitted to a hospital three times in a year, or are taking seven or more medications, or have medical bills of $25,000 per year. If they are considered depressed, they are referred to their doctors for a prescription of Prozac, Zoloft, or Paxil. The impact has been dramatic. The medical expense of one group of 2,079 patients who took part in the program decreased by $2.1 million. Fortune’s response: Prozac and its siblings could be an important remedy for rising health care costs… An alternate response: If they could find ten more groups like that, they’d save enough to pay their CFO like a CEO for figuring this out.

More Than I Know July/August 1997

The California Department of Social Services computer project, designed to track deadbeat parents who owe child support, is reported to be on “life support.” Although the initial cost was projected to be $99 million, current costs are at $260 million. This comes on the heels of the DMV disaster in which the California government pulled the plug having spent $54 million before the system was terminated. This was followed by the failure of the Department of Corrections computer project which spent $40 million to track inmates and parolees who could not be tracked. The Department of Social Services is reportedly still optimistic that its computer project can “be salvaged” for 23 remaining counties. Sacramento is not on the system. San Francisco County pulled out opting for its far superior 1980s computer system. SF stated that the state computer system could not perform the three basic functions it was designed for: locate people, produce forms and process funds. Los Angeles had previously developed its own system with a separate budget not included in the above figures. However, the report did find comfort in the fact that less than 10% of these funds were from California taxpayers. (Isn’t there an ethical issue involved when the moneys the Federal government forcibly extracts from the citizens of the other 49 states are used to pay for our incompetence in California?) … Maybe we can now understand why the government wants to take over health care. With it’s track record, we can be almost certain that the computer would never get to the stage where it had to process forms to deliver payment to doctors and hospitals.

The auction of 128 government licenses to provide wireless phone, television and data services, including Internet access, brought less than $14 million. Congress, which had ordered the sale, had predicted returns of $1.8 billion… Since the government generally spends $1.90 for every dollar of predicted new revenue, the $3.4 billion being spent as a result of this faulty prediction should translate into a 24,000% increase in federal deficit on this single budget line.

The IRS computers are only slightly better than our state computers. A recent audit found that 6400 tapes, cartridges and magnetic-storage devices are missing. Taxpayers’ data is being improperly used, modified, or destroyed… So far, however, we are assured that all the “dirty facts” on physicians in the national data bank’s computer are accurate.

Dave Barry’s annual tax-advice column this year was in a question-and-answer format. “Q: Are we EVER going to have a federal tax system that regular people can understand? A: Our top political leaders have all voiced strong support for this idea. Q: So you’re saying it will never happen? A: Right.”

Citizen: They finally figured out that jailing drug users just doesn’t work. Congressman: Looks like we figured out just in time how to start jailing doctors before we had to close prison beds. (After the Drawing Board)

Congratulations to Donna Wallace of Biggs, California who returned her $160,000 rice subsidy payment to the US Department of Agriculture for two consecutive years. Mrs Wallace, who barely avoided bankruptcy following the death of her husband in 1983, toured Washington, DC as a rice lobbyist and learned the true colors of the Government and International Marketing. On her return she decided to be innovative and started farming, marketing, and selling without restrictions from the government. Her operation now includes new varieties of rice, gourmet rices, organic rice and new farming techniques. She has her own network of suppliers and contracts with gourmet restaurants and a mail order business… Perhaps we could have her talk to the medical society about how to break away from Government intrusions into an even more personal relationship–the doctor/patient one.

AD of the month: Vagistat-1 is equal to Femstat-3 or Monostat-7… I wonder where Nitrostat-4 fits in?… Saw a patient the other day with a scrotal rash. He said his wife diagnosed it as a yeast infection and gave him some Vagistat-1 to apply stating that “this new stuff was potent.” Well, he was exfoliating. He’s hoping to go for an employment interview as soon as he can get back into his briefs.

Patient: I’d feel a lot better about my disease if you’d tell me all you know about it.

Doctor: I’ve already told you more than I know. (After Adams)

Tobacco Fallout September 1997

Health organizations have been extremely successful in their drive to increase the taxes on cigarettes in order to pay for various health-related programs. Cautioned that this amounts to a “sin tax,” these organizations were warned that this could back fire some day should folks decide “not to smoke.” If the significant revenue stopped would we then encourage people to “resume sinning” so we can fund the programs telling us about the “harm of smoking?”

John Grisham, an attorney, in his recent book, The Runaway Jury, foreshadows the first successful litigation against the Tobacco Industry with a billion dollar award.

The press reported that one state attorney general after another is suing the tobacco industry for the excess in health care costs caused by smoking cigarettes. The cigarette industry noted that the taxes paid on cigarettes exceeds the health care costs that can be attributed to cigarettes.

Grisham in his latest book, The Partners, reflects how law partners divide their fees, and insist on one-third, even if millions. In this scenario, the law firm was to obtain thirty million of ninety million dollars of misappropriated tainted congressional funds.

Headlines in the press in June reflect a HUGE Tobacco deal which settled 40 state lawsuits and 17 class-action suits by paying out $360 billion over 25 years. It will also outlaw cigarette vending machines, license tobacco retailers, place nicotine under FDA regulations, and even allow the FDA to ban cigarettes after the year 2009.

Bob Butterworth, Florida attorney general sums it up: The Marlboro Man will be riding into the sunset on Joe Camel.

Paul A Gigot’s Potomac Watch points out that the “mother of all lotteries,” otherwise known as the tobacco settlement, has made Sultans out of tobacco lawyers like Hugh Rodham Jr. Gigot suggests that Hillary should give brother Hugh a copy of her 1992 speeches about the evils of “greed.” He suggests that there is more going on here than “public health.”

Russ Herman, a class action lawyer in response to keeping the fees for the 250 attorneys at one billion dollars, stated that he believed a 3% or 11 billion dollar contingency fee would be reasonable. This adds up to about $50 million per attorney.

The White House is unbelievably quiet. They are confident that the trial lawyers will return significant amounts to them for the next elections.

Richard Klein, Cornell University professor and author of Cigarettes are Sublime, call this “Prohibition II.” He notes that strong warnings will cover 25% of the front of every cigarette pack. Were negotiators unaware that “Death Head” cigarettes are drop-dead chic in London? He feels that prohibition is the logical outcome of the tobacco settlement and reminds us that “Prohibition I” didn’t work.

Elliot Liff, MD, from Mill Valley points out the fallout from the tobacco suit. There are implications for even broader and further litigations against other industries. Just wait until someone finds a secret memo in the fast food industry that owners knew that serving greasy burgers with cheese and bacon is good for business despite all the data about risks of high fat diet and its relationship to heart disease, strokes, peripheral vascular disease, and premature death–perhaps even earlier than cigarette deaths?

Japan Tobacco Inc, that nation’s cigarette manufacturing monopoly, is still majority-owned by the government. The government itself is the defendant in two class action suits. Japan’s Ministry of Finance both regulates the tobacco industry and collects taxes on cigarette sales. The law banning sales to minors and advertising in childrens’ magazines or during prime time is only sporadically enforced, and there is no significant punishment to those who break the rules.

In Brazil, B.A.T. Industries, controls 83% of Brazil’s cigarette market and is the largest taxpayer in the country. It is reported that the anti-smoking movement in Brazil faces an uphill climb. Roberto Attuch, a tobacco analyst in a brokerage house states the 73.5% tax rate on cigarettes will not be placed in jeopardy “Because tobacco is such an important source of public revenue.”

Well, albeit in other hemispheres, it looks like the Marlboro Man is still riding Joe Camel into the sunrise telling the kids coughing on their first cigarette: “I’ll have you able to smoke up a storm before you can say malignant neoplasm.”

Theater Lines October 1997

The theater has been called the fabulous invalid because for a least half a century it has been described as dying. Broadway, the legendary “great white way” of the state, was labeled as doomed when talking picture came upon the scene. When television developed into the nation’s most popular theatrical form, the prophets of doom for the legitimate theater renewed their prophecies. But the vitality of living theater went up. Off Broadway and Off Off Broadway bloomed. Regional theater became a thriving reality. Theater studies at universities prospered. Foundation support for resident companies was a new development of the 1960s and 1970s. In any community of size, the theater today is present, whether struggling or flourishing. It behooves the cultural leaders to facilitate the latter. May our profession be among them.

On Tragedy:

Tragedy on the stage is no longer enough for me, I shall bring it into my own
life… Antonin Artaud (1896-1963)
Ours is essentially a tragic age, so we refuse to take it tragically.
D H Lawrence (1885-1930)
Tragedy delights by affording a shadow of the pleasure which exists in pain…
Percy Shelley (1792-1822)
When you close your eyes to tragedy, you close your eyes to greatness.
Stephen Vizinczey (1933- )
On Comedy:

Comedy is the only honest art form. You can’t fake it… Lenny Bruce (1925-66) Comedy is tragedy that happens to other people… Angela Carter (1940-92)
Life is a tragedy when seen in close-up, but a comedy in the long-shot… Charlie Chaplin (1889-1977)
Comedy is an escape, not from truth but from despair; a narrow escape into
faith… Christopher Fry (1907- )
The only rules comedy can tolerate are those of taste, and the only limitations are those of libel… James Thurber (1894-1961)

One of my chief regrets during my years in the theatre is that I couldn’t sit in the audience and watch me…
John Barrymore

‘How’s the acoustics in the new theatre?” “Splendid. The actors can hear every cough.”

“His last play had the audience in the aisles.” “Applauding?” “No, stretching and yawning.”

“After tonight I am going to have you killed in Act I instead of Act III,” the stage manager said to his leading man. “Wherefore the change?” asked the heavy villain. “I don’t want to take the chance of having the audience do it!” replied the manager.

The struggles of an actor are exemplified in a story told by Faye Copeland about a banker and actor seated next to each other. Banker: “So you are an actor? It must be I 5 years since I’ve been to a theater.” Actor: “I’m quite certain it has been at least fifteen years since I was in a bank.”

Hostess pointing out guests to new arrivals at a cocktail party given for the theatre patrons: “The Von Soostens under the chandelier represent old money; the Hendersons by the champagne punch represent new money; the Gibbons admiring the bookcase represent lottery money; the Krogers sitting on the velvet divan ladened with gold and diamonds around their wrists, waist, and necks represent managed care money; and Dr Livingstone, my HMO doctor, bending over the diving board with his wife tugging on his coat represents no money.”

Murray Banks tells about the New York couple who took their Golden Lab to the theatre to see Auntie Mame. The dog sat between them. The man behind the dog missed the entire first act. After the second act, he couldn’t take it any longer and tapped the man on the shoulder. “That’s truly an amazing dog you have there. Not only does he seem to be enjoying the play, he actually applauds in all the right places. How do you explain it?” The man with the dog turn somewhat dismissively saying, “I have no idea. He hated the book.”

As I write this, Fay Dunnaway is on stage in Sacramento performing in “Master Class” at the Community Center Theater. “Tap Dogs,” “Bring in ‘Da Noise,’ Bring in ‘Da Funk,”‘ and “Chicago” will be produced on our stages. Sacramento has also been visited by two world-acclaimed dance groups in the last two years–Mark Morris and Twyla Tharp. Superb performances are playing in this quiet river town. Don’t miss them.

Legal Fees November 1997

Sen Paul Wellstone, former Carleton College professor who represents Minnesota has been promoting his image by courting groups such as the Children’s Defense Fund. However, he gutted the proposal by Sen Jeff Sessions who represents Alabama to limit attorney fees in the tobacco settlement to $250 per hour with leftover billions going for research on children’s health. He preferred that the trial lawyers pocket up to $100 billion.

The four lawyers who settled the lawsuit in Florida are demanding $1.4 billion or about 25% of the $5 billion settlement.

Florida Attorney General Bob Butterworth noted that a family of four could live a year on 20 minutes of one trial lawyers income.

The American Trial Lawyers Association recently announced it would embark on a massive public relations campaign to improve the steadily deteriorating public image of its members.

The Sacramento Bee ran a Tampa Tribune cartoon depicting the all “teeth and smiles” of the lawyers who won billion dollar cases against cigarette companies. It then showed a nearly identical picture of all “teeth and smiles” of the lawyers who lost billion dollar cases defending cigarette companies. Both got rich.

The Association of Trial Lawyers of American have now come out to say that the tobacco settlement is not a good deal because it limits citizens legal rights for redress. In this age where millionaires are common, and tobacco lawyers are now billionaires, greed has no upper limit. They want more law suits.

McDonald’s spent $16 M on a 314 day trial and won $98,000 from an unemployed postman and part-time barmaid vegetarian activist for defamation. McLibel has since announced that it will not try to collect attorney fees or the award from the losers. What a waste of time and money after nearly one year in court, the winners felt like losers and the losers didn’t have to pay. What is never highlighted is that the attorneys who won the case for McDonalds were paid handsomely by McDonalds and the attorneys that lost were also paid well. Better read that first line out loud: Sixteen million dollars for the lawyers to win ninety eight thousand dollars they didn’t bother to collect.

A trial attorney once told me that they can milk the client for money much better in a large group. You always have at least two attorneys assigned to a case and keep one working on it but both bill their hours to the case.”

A correctional lieutenant stated that one of their famous criminals at maximum security in Folsom State Prison had two teams of attorneys defending him. One civil rights firm had four attorneys assigned to the case and the other a criminal law firm also had four attorneys assigned to the case. The lieutenant said both sides already had billed the State for several million dollars, and they were still at least a year or two away from trial.

Reminds me of the story of the 30-year-old-attorney at the pearly gates screaming at St Peter and Moses, “How can you do this to me? A heart attack and dying at my age?” “Well, when we looked at your total billable hours, we figured you had to be at least ninety-five,” the voice from the other side said, “So we thought we’d just make it nice and clean for you and save you a coronary bypass.”

LeRue Grim, one of SF most prominent criminal defense lawyers has been suspended from practicing law for 2 1/2 years because he lied about having sex with a client’s wife while the client was in prison. The state bar recommendations were upheld by the supreme court. Grim said, “I’m so disappointed in the state bar.” He further stated he was so disappointed with the legal profession after 31 years as a lawyer, it was time for a new career anyway. He hopes to become a political consultant… Doesn’t sound like a change in careers to me.

My attorney gave me the book, LAWYERS and Other Reptiles. And then he added, “You know why we can swim with sharks?” “They grant us professional courtesy.”

Ethical Delimmas December 1997

Two members of the UCD faculty recently published an article about preferential admissions in the October 8 issue of JAMA. Profs Robert Davidson and Ernest Lewis reported that their 20-year study proved that preferential admission policies are harmless–that they do not affect the quality of the doctors who graduate. Gail Heriot, a law professor at the University of San Diego reported in the Wall Street Journal that there was just one small problem: their study’s data support the opposite conclusion. An editorial in the same issue of JAMA called for preferential treatment as a means of restoring trust to the medical profession. Professor Heriot said that JAMA editors should be concerned about trust. When doctors are torturing data to make a political point, whom can you trust? … To which we might add that there is a serious problem of equal opportunity for the disadvantaged and some minorities. But let’s interpret the problem correctly and then look for an appropriate solution.

Employees at Oxford Health Plans Inc had just received their first stock options at an exercise price of over $70 a share. Some employees bought their shares on margin–borrowing money to make the purchase–and one postponed her wedding to become a part of this revered managed care company. But on Bloody Monday, the tenth anniversary of Black Tuesday, their stock dipped to slightly over $25 a share. On Sunday evening when Oxford CEO Stephen Wiggins called in the managers for a meeting, they knew something was wrong. One manager stated that he felt like he had been hit in the back of the head with a bat. Some employees had heartburn while others just felt ill. The whole “HMO Feels Sick” according to headlines in the Wall Street Journal. Although the CEO had a paper loss of $115 million, he had already sold enough shares at $70 recently to put $15 million in his bank. Should be enough to get him through a wet spell while the doctors continue to save costs to replenish his paper losses.

Trial lawyers rush to turn the diet-pill ills into money in the bank. One disaster chaser has run ads, hit the talk show circuit, and written legal articles in an attempt to cash in on a “business opportunity.” The “Fen-Phen Litigation Group” was formed at an Association of Trial Lawyers of America meeting. Other critics say such lawyers are in it for the greater good of their bank accounts, not of their clients. The trial lawyers respond that this is the reality of the legal marketplace and they are capitalizing on just another business opportunity.

The California Trial Lawyers Association has taken the lead in changing its name to the Consumer Attorneys of California. This image enhancer should be easy to remember: CACA.

A week after the alarming 32% incidence of heart valve abnormality in 291 patients taking “Fen-Phen” was published, the Wall Street Journal surveyed 21 other medical sites across the country and found an incidence of 8% in 750 patients studied. Some sites had studied as many as 25 patients without finding a heart problem and others studied 50 with only one “leaky valve.” Others have stated the 8% incidence may be an acceptable risk for severely obese people with a high incidence of diabetes, hypertension, and heart disease with a greater combined risk. They feel the problem was that “Fen-Phen” was prescribed for the marginally overweight. The WSJ wonders whether the FDA and American Home Products Corp, which markets Redux and Pondimin, might have acted prematurely in withdrawing the drugs. The WSJ felt that perhaps they should have waited another month for the meeting of the North American Association for the Study of Obesity meeting. Maybe if we start doing a large series of echocardiograms on normal people, we will find a small incidence of valvular abnormalities in asymptomatic people. Remember when we started doing chemistry panels some 25 years ago and found a lot of people had elevated uric acids who never had gout? Do you suppose we could get Oxford Health to pay for a few thousand screening echocardiograms to document the real risks?