The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
... William Penn's Quaker Colonies
plus medicine, economics and politics ... nearly 4,000 articles in all
Philadelphia Reflections now has a companion tour book! Buy it on Amazon
Philadelphia Revelations
Try the search box to the left if you don't see what you're looking for on this page.
George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
1a. TAX EQUITY. All tax exemptions stimulate overuse because they amount to a discount. For example, federal tax exemptions now mainly extend to two consumer purchases: health insurance and home mortgages. We currently have national crises in both at the same time. The tax-subsidized home-mortgage housing bubble played a major role in the 2007 financial panic, while tax-subsidized health care threatens to lead health costs into a second unsupportable bubble. Higher education seems to be going the same way, and it becomes difficult to imagine what would result if two or three of these bubbles merge. The expression "Children playing with matches" comes to mind. Giving a tax advantage to one group but not to its competitors is essentially just a variant, containing the paradoxical advantage that the competitors will object to it if they can't extend it to themselves.
Giving a tax subsidy to employees but not to self-employed or unemployed persons nevertheless created a uniquely American system of employer-based health insurance, and lobbying now perpetuates this rather odd system. Noting the allegedly temporary origins of this tax quirk (as a wartime expedient) merely dramatizes its lack of justification for seventy years afterward. It should not be necessary to describe collateral damage like job lock and internal hospital cost shifting. The issue of equal justice alone should be enough to justify the abolition of this unfairness. To mandate individual coverage but differentially exclude large subpopulations from tax exemption, is to invite a Supreme Court case. And since such a law has been passed, the sooner a damage case is granted certiorari , the better.
To achieve equity, it does not matter whether tax exemption is given to everyone, denied to everyone, or limited to part of the cost (reducing the exemption for some, partly extending it to those who do not have it). Any choice between these three would make it equitable, although gradual elimination would be better, still.
If health insurance is mandated, its tax treatment must be uniform.
Hidden Cost
Once the tax is equalized, this proposal clears away the main obstacle to
1b. INDIVIDUAL OWNERSHIP OF HEALTH INSURANCE POLICIES, already proposed in Congress; but seemingly without hope of adoption. Determined opposition from the current owners of "self-insured" groups, the employers, or the unions who have acquired this function from employers. Since most such arrangements are de facto "administrative services only", insurer protests of higher administrative costs for individual ownership are often just relics of ancient combat between Blue Cross and commercial insurers.
Regardless of the internal structuring of incentives, healthcare reform cannot be permanently settled without individual ownership. It must be understood, however, that eliminating the tax preference could be resisted at first by patients who acquire it, because of fear the eliminated tax would in some way be shifted to them. That need not be true if consideration is given to the relative size of the losers and gainers. Since the membership of group policies greatly outnumber individual policyholders, the redistributed revenue cost of tax equity would be considerably smaller than 50/50. The CBO should provide a sliding scale estimate for negotiating purposes.
1c. ENCOURAGE WIDE-SPREAD DIRECT MARKETING OF HEALTH INSURANCE. Since Health Savings Accounts and Catastrophic High-Deductible Health Insurance are libertarian ideas without religious overtones, it is uncomfortable to advocate them as mandatory, even passing laws to that effect. However, the libertarian doctrine does not seem to preclude creating incentives for universal adoption. This doctrinal attitude imposes slower adoption than mandating them, although a better product result from more trial and error as the idea spreads. Therefore, readers may be surprised to see me advocate electronic insurance exchanges as a way to speed up trial and error spread of the idea's adoption. It is a way of preserving the flexibility of deductibles, benefits, alternative uses of surpluses, and vendor arrangements. It is also a way of narrowing the conflict with the Tenth Amendment, combining state regulation with inter-state marketing. If multiple alternative details prove necessary, direct computer marketing would be a quick way to discover what the permissible alternatives would be. Finally, the widespread examples of other interstate marketing can be employed to search out how to convert marketing from intra-state to interstate, rather than assume certain commerce is inherently (and permanently) interstate or inherently within-state.
An accidental feature of Health Savings Accounts is that the account can be growing for a number of years before the re-insurance feature is frequently needed. Indeed, young people may need a certain form of reinsurance protection and a different form as they grow older. The important feature is to have permanently stable savings vehicle in place while different forms of re-insurance are proving themselves. It seems heresy to say so, but we might even discover niches of the marketplace where first-dollar coverage or service benefits have some useful temporary role.
The States Are in the Road
1d. PRE-EMPT STATE LAWS WHICH INHIBIT CATASTROPHIC COVERAGE. State mandated benefits now severely limit high-deductible insurance in many states, and are the main reason Health Savings Accounts have been slow to spread. The provisions of ERISA shield employer-based health insurance from the unfortunate health coverage mandates in question. ERISA could not have been successful without this pre-emption, so unions and management unite in absolute concern to isolate ERISA from congressional meddling, although for different reasons.
1e. REVISIT McCarran FERGUSON ACT . This act effectively makes the "business" of insurance the only major industry restricted to the state rather than federal control. It should be amended to permit the sale and portability of health insurance policies across state borders and interchangeability of individual policies when people change state residence, thus greatly increasing competition and reducing prices. Once more, present law discriminates in favor of the employees of interstate corporations, who are also exempted by ERISA.
1f. MANDATE DISPLAY OF DIRECT COST MULTIPLES NEXT TO PRICES (FEDERAL PROGRAMS ONLY) (whenever prices are displayed, as in bills, price lists, etc.) FOR ITEMS COVERED BY HEALTH INSURANCE. Some high mark-ups are justified, but the public has a right to criticize them. This would not prohibit, but would considerably hamper, cost-shifting. It should be presented to provider groups as forestalling the prohibition of cost-shifting because of abuse. For this and other reasons, it would enhance provider competition.
1g. REIMBURSE HOSPITALS ONLY ON RECEIPT OF ASSURED POST-DISCHARGE HANDOVER OF MEDICAL RESPONSIBILITY (FEDERAL PROGRAMS ONLY). Unfortunately, hospitals do need increased incentive to improve post-discharge communication, which now increasingly occurs on a Saturday. Payment by diagnosis, otherwise a seemingly attractive idea, results mostly in sequestration of medical charts within the accounting department. That's undesirable at any time, but is most destructive at the vulnerable moment of hand-over.
1h. Similarly, REIMBURSE HOSPITALS FOR LAB WORK ON THE LAST DAY OF HOSPITALIZATION ONLY AFTER DEMONSTRATION IT HAS BEEN REPORTED TO A RESPONSIBLE PHYSICIAN. Such lab work, frequently obtained within hours of discharge, is sometimes overlooked and may even be unobtainable for the previously mentioned reasons, which in this case also apply to the hospital's own physicians.
1i. RESTORE ORIGINAL FORM OF PROFESSIONAL STANDARDS REVIEW ORGANIZATIONS (PSRO). These physician organizations effectively regulated many issues which are now the subject of the complaint. They were lobbied into ineffectiveness in 1980, and together with "Maricopa", essentially turned medical oversight over to insurance companies who thus receive no physician advice except from their own employees.
Treat liabilities like debts. And transfers from the general fund as liabilities.
Accounting, for Congressmen
1j. ENCOURAGE THE ESTABLISHMENT OF REGIONAL BACKUPS FOR AMBULANCES DRAWN OUT OF AREA. At present, ambulances are limited to going to the nearest hospital, rather than to the hospital of patient preference. The main justification for such behavior is the possibility that a second call might come while the ambulance was in a distant area. Fire departments have long solved this problem by shifting reserve vehicles into an overstrained area, to cover that area while the home vehicle is temporarily unavailable. In some areas, a reserve vehicle backup might require additional ambulances, but mostly it requires a mobile phone network. In areas of extreme distances between ambulances, the main need would be to relax regulations which exclude volunteer vehicles from serving that function. In densely settled urban areas, we now have the preposterous situation of mothers in active labor being stranded at the wrong hospital, only a few blocks away from the obstetrician who has their records. When such situations are repeatedly encountered, the current IRS exemption from financial reporting should be rescinded from the ambulance sponsor.
1k. As a general principle, when a service, device or drug is used in both the inpatient area and the outpatient one has its price exposed to regular market forces in the outpatient arena, the same price should be applied to it in the inpatient arena. It would be sensible to add a (separately negotiated) inpatient overhead adjuster reimbursement which generally applies to inpatients, and a second adjuster for the emergency room. There will be some services which are totally unique to inpatients or emergency rooms, which will have to be treated as outliers. In this way, a mutually reinforcing restraint is placed on such dual-use items -- with the market holding down outpatient costs, and the DRG ultimately holding down inpatient/emergency costs including outliers. As a general rule, the overhead cost-multiple established for dual-use should apply to the single-use items of either in-patient or out-patient. The key to all of these balancing limits is to permit open competition between hospital emergency services and private competitors, and an absolute prohibition of linkages between providers and emergency vehicle operators. After a brief trial, all such price constraints should be exposed to re-negotiation with an eye toward establishing transparent regional norms.
The Supreme Court Needs Help, Too
2. LEGISLATE OVER-RIDE OF 1982 MARICOPA CASE. This unfortunate U.S.Supreme Court 4-3 decision was never tried and upholds only a motion of summary judgment about a per se violation. It prohibits physician groups from agreeing on lower prices and has been taken to mean physicians are excluded from exercising control of HMOs and Managed Care. It also perpetuates the notion of individual competitors in a profession which is rapidly acquiring larger groupings as units of competition. By some quirk, the full tape recording of the 1982 U.S. Supreme Court arguments can be heard on the Internet. It is "above this author's pay grade" to know whether it would be better to ask the Supreme Court to review its earlier decision, or to make legislative changes in the antitrust law which would somehow result in a better outcome.
Some waggish but wise publication, perhaps The Economist, reported on the accuracy of predictions at various times in the future. Predicting what you can accomplish in a year is almost always an over-estimate; you can't possibly accomplish that much in a year. Predicting twenty years in advance has the opposite flaw; things will change so much in twenty years, the average person will almost invariably under-estimate the future. So, what's the best time for predictions? According to The Economist, it comes out to be about six years.
Five years seems somehow easier to remember, so let's state a principle of financial planning: review your goals every five years with some professional help. The young fellow needs to have a lawyer review his will because he probably doesn't have one. He needs someone to take a hard and skeptical professional knife to the insurance salesmen who are currently circling their prey. And someone needs to review all of the government, tax and regulatory changes that will affect a young family. For most young people, the investment decisions about stocks and bonds are small because accumulations are small for everyone except professional athletes and entertainers.
If your investment pile is small enough, you can fool around a little. My father used to say the best thing that can happen to you is to lose some money when you are young. When you become tired of that, just make regular automatic deposits into a low-cost widely diversified no-load mutual fund that is very large, say, holding a trillion dollars in assets. It will pretty surely grow steadily in good times and bad, and serve as a warning benchmark for assessing all those fly-by-night investment managers who will besiege you when you accumulate enough money to be worth fleecing.
It's a pity to waste ten or so years of investment opportunity, however. Money at 7% will double in value every ten years. You will probably want to double your nest-egg as many times as you can, which is likely to have a ceiling at 10%, so figure doubling every seven years the rest of your life expectancy, and it is easily shown that frittering away those opportunities to double is a regular, pathetic, loss of opportunity for most of us between the age of sixteen and thirty. Take your hoped-for nest egg at retirement age and double it two and a half times, and you will see what a huge opportunity is regularly lost by just about everyone.
Your parents can improve on that by making investments on your behalf, starting the day you are born. That would cause five extra doublings of your investment accumulation at retirement. But plenty of people have learned the disappointments of betting on infant futures. If you can essentially afford to throw the money away as bad luck, go ahead and do it, but if you are risking someone's college education to do it, then you had better stay away.
A probably more serious debate can be generated by discussing the risks of giving money to teenagers, who may then get all out of social control, throwing in your face, "It's my money and I'll do as I please". The main answer to that offensive discussion is to point out just what it is that most teenagers would do if they had the freedom to do it. Some frugal cultures like the Pennsylvania Dutch will give children some money, hide it secretly in a safe-deposit box without telling the child, and then reveal it when the child seems to be sensible enough to withstand the fever of a gold-rush. The worst outcome of all is to drain the incentives, depriving the child of reasons to work hard. Unfortunately, most teenagers now grow up in a suburb, where it is difficult to conceal the probable existence of assets.
Although the Pearls on a String design seems to hold great promise for matching American health finances to the medical lifetime it proposes to finance, it contains the flaw of taking 90 years to test it in action from birth to death. That is, almost no one would live long enough to know if it, for certain, worked the way it promised. But on the other hand, there is a significant chance scientists will discover cures for many expensive diseases during the next ninety years-- and so it might work far better than anyone expected. What kind of bet would we be asking people to take?
To be blunt about it, if some fool blows up the earth with atom bombs, it scarcely matters what kind of health insurance anybody had. And if some expensive diseases are cured, all you get for your hundred dollars is a return of $5000 to $29,000. So the main risk is mismanagement. A good idea badly managed can be as risky as a poor idea. Mismanagement includes poor design at the beginning, or poor management along the way. In this case, it's pretty much up to Congress, to neglect it or to use it as a piggy bank. So it's a little early to judge the risk, but it's not too early to anticipate the problems. Congress needs to enable the program, but not to overspecify it. Somehow, the program has to anticipate the early adopters will be those people who are in a position to regard the loss of a hundred or two hundred dollars as no big deal (mostly richer ones) but to leave the door ajar for later entry of timid folks, poor folks, and those who will take no risk except on a sure thing. That means voluntary entry with graded incentives for late-comers (a dollar at birth, 2 dollars at age 10, 4 dollars at age 20, etc.) And it means avoidance of political control except to close it down if its managers misbehave, with the ability to re-open it after the loophole has been fixed. If it works, early adopters will have made a pile of money. And if it doesn't work, well, you only lost a few bucks.
What Are the Reasons to Believe Science Will Cure Some Significant Diseases in the Next Century? 1. In the first place, the National Institutes of Health research budget is currently $33 billion a year. It concentrates on basic research, leaving applied research to patent-seeking companies in the private sector. That is, drug companies and medical device makers. When the private sector produces a patent, the product price is initially high enough to pay for the research and some hefty profit; after a few years, the price comes down. If private sector research should ever seem to diminish, some sensible modification of the Kefauver "efficacy" requirement or its enforcement ought to kick-start it, again.
2. Let me tell you a personal story of a trip to an invitation-only investment seminar, limited to private foundations. On the opening day, the moderator said, "Let's get acquainted. Would everyone who represents less than $30 million dollars, please raise your hand." Of the roughly two hundred attendees, I was one of four who raised his hand. The Dean of the Harvard Business School was on my left, and the representative of the Bill Gates Foundation was on my right. I would estimate that ten times the amount of the Rockefeller Foundation was represented, and that four times the assets of that room would be found in the foundations of the rest of the country who were not attending the conference. By no means all of them are involved in medical research, but many of them fund universities and other research centers. The amount of money available for medical research in the next century is astounding, and it's America's collective bet on success.
3. A relative of mine took a PhD course in mathematics at MIT. He was the only American citizen among the 73 enrollees. The amount of medical research we can anticipate coming from abroad, is very considerable and may in time exceed our domestic production. There is no shortage of available resources, or talent, world-wide. Nor research opportunities, although few foreign countries have caught the American fever for "thinking big". We have gone from the discovery of the DNA helix to complete identification of the human genome, during my lifetime. Only 2% of disease has been connected to the genome, so attention is shifting to the "silent" protein of the cell. Disease can run, but it can't hide. There are lots of diseases, but fifty percent of medical cost is associated with only ten diseases. So, find 'em and get rid of 'em, before we start to become impatient.
4. Nor do we foresee a labor shortage. Self-driving cars should be on the streets in a decade, following which people will summon fleets of them by cell phone, followed by a decline in accidents and accident insurance. Since his entire holding company is balanced on the float from auto insurance, it will be interesting to see how Warren Buffett addresses the issue. The leader of a very large investment company also predicts self-correcting computer code will soon cause wide-spread unemployment. This is all creative destruction. A third of the country will be retired without sufficient income to live on, but an ample pool of employees for terminal care of the others will surface.
But enough. A real early-adopter doesn' t need four reasons to adopt early, and a timid soul won't be persuaded by forty arguments. Only America has the bit in its teeth at the moment, and that seems to be part of our culture. Only America would gamble ridiculous amounts of money on research, assuming that timid gestures like Otto von Bismarck's health insurance plan would only worsen the problem, creating many more problems of its own. What sane person wants to rule the whole world, anyway?
No amount of scientific research can eliminate the twin cost of being born, and of dying. Nations differ about such costs, but if you want to know what they should be, just look at what they are. Such irreducible healthcare costs are about half of the present total. That leaves the other half of the cost, which might be eliminated by scientific research. If it takes a century to do it, the total elimination of disease cost might be accomplished at a price of about a half a percent per year. That's not totally impossible.
But scientific healthcare cost is different from truck maintenance, in part because some of the components cannot be replaced. The cost of prolonging useful truck life is largely the cost of devising improved maintenance; it's the best we can do within remaining mindful of what it costs. What's mainly different from healthcare is we have declared an end to economic ("useful") life at the time of retirement. Unless productivity of the elderly starts to improve, their retirement costs will rise, even if the cost of healthcare approaches zero. Let's put it another way: the faster healthcare costs come down, the faster retirement costs will go up. Simple arithmetic shows real healthcare costs can only be further reduced by half or $175,000 per lifetime. Useful lifetimes, on the other hand, have already been declared finished by the age of 60-65. The gap is still widening, but even if research stops that trend, things will get worse. Using actuarial methods, it has been calculated that average lifetime medical costs are now about $350,000 per individual, denominated in the year 2000 dollars , and assuming present longevity. That doesn't count health insurance cost, by the way. And it doesn't help to say Social Security payments should be progressively raised, because that's also incomplete arithmetic. Old folks must find something remunerative to do.
With some reservations, the Medicare agency calculates half its expense is devoted to the last four years of someone's life, all of its present expense is approximately $50 billion annually. Unfortunately, 9 million Medicare recipients are disabled but not yet aged 65, so terminal care costs less than $143,000 per person in the year 2000 dollars if you include many permanently disabled persons. Reversing the calculation, you might save $200,000 per person if you paid for nothing but terminal care. Additionally paying for childbirth and neonatal costs might still reduce average savings to approximately $175,000, or about half. That's approximately how you might justify the slogan, "Paying for only the essential two ends of life, would likely cut government costs in half." Another way of looking at it would be to accept Mrs. Sibelius's approximation that half of Medicare costs are borrowed. Paying only for birth and death would leave the present system roughly intact, except it would eliminate the borrowing. Better hurry up, interest rates are expected to rise.
Leaving things roughly intact would assume research costs are lumped with treatment costs. Both offsetting costs might be projected to disappear in a century, although probably at variable speeds. Furthermore, providers of treatment and providers of research are only human; they tend to attack the most expensive diseases first, particularly focusing on painful and mortal conditions. That's only a rough approximation. Everybody has lobbyists, and Congress must take care to balance inputs against the goal: to reduce the net sum of research costs and treatment costs in the year 2000 dollars, by a fraction of a percent (?half a percent?) per year, and to keep that up for a century.
It doesn't sound impossible to construct and enforce such a budget on the combined treatment and research communities, even recognizing the vagaries of taxation and demography. Perhaps a five-year running average would be manageable. But there is one big thing missing. We swept this issue under the rug for fifty years and we could do it for another fifty if we tried hard enough. That is -- we have neglected to consider the cost of success. As the health of the public improves, they live longer. In our system, that means they will need more money for retirement. Lots of money.
With a fixed retirement age, things get worse. Someone is currently running for President of France on a platform of lowering the retirement age to 55. We are, by contrast, at least grudgingly raising the retirement age to 67, at the risk of tearing the political parties apart attempting it. Although Medicare is technically an amendment of the Social Security Act, the retirement age of Social Security has remained essentially stationary, while benefits rise slowly but menacingly in response to inflation at 3% a year. Retirement costs are almost certain to rise more quickly than health costs fall because illnesses are episodic whereas retirement is continuous. Aside from the impossibility of negotiating a solution to this monetary quandary, there is the social disruption of having nothing remunerative to do. There is only so much golf or bridge a normal person can stand to do. Only so much traveling to do before you meet yourself coming back. Only so many fish to catch, entertaining to do, and booze to drink. We have some serious thinking to do before we find anything which is as satisfying as having an occupation. Young people imagine taking a vacation from age 18 to 48 is the same as from ages 60 to 90, but it isn't the same at all. Let's repeat: the cost of improved medical care is not primarily that the doctors will fail, it is that the doctors may succeed, and then you won't know what to do with yourself.
Your Money Matters: Michael Waldholz (Staff Reporter of The Wall Street Journal)
If you aren't already paying a larger portion of your health-care bills, you probably will be soon.
In an effort to break their rising health-insurance costs, a growing number of companies are for the first time requiring employees to pay a deductible typically $100 to $200 a year family member before receiving benefits. Some companies that already had deductibles are raising them to as much as $500 a person. And some employers are no longer paying 100% of hospital bills.
You may pay as much as $1,000 to $2,000 a year of your medical bills under the new plans, instead of several hundred dollars. Adding to the pain, recent tax changes have made deducting medical expenses more difficult.
What can you do if your employer wants to change your health insurance? Although looking for a new job may seem to be the only solution, many personnel managers and benefits consultants say you may be able to persuade your company to ease the additional cost burden if you have the right information. It won't be easy, and many employers won't budge. But, in exchange for requiring you to pay more of your doctor bills, employers can upgrade other aspects of the health plan that won't necessarily cost them extra and could save you plenty.
"I'd adamant with my employer," says Joseph H. Rossmann, a consultant with A.S. Hansen Inc., "If he wants me to pay more of my medical bills, he has a responsibility to set up programs to help me be a better buyer of medical services."
Benefit managers say recent research shows that employees who pay a greater share of their health bills sharply reduce their use of company health-insurance plans. Although some public-health officials say higher costs may cause patients to postpone needed care, insurers and employers say there isn't any evidence that employees health suffers. Rather, they say, the new plans encourage employees to seek less expensive but equally effective treatment.
Exactly how much this actually reduces health care costs isn't known. But Hewett Associates Inc., a consulting firm, estimate a $100 deductible can save an employer 14%. A $200 deductible can mean a 21% savings, and a $300 deductible can save 25%, the firm says.
Much of this savings result from what H+James Norton, a principal partner with benefits consultants William M. Mercer-Meidinger Inc., calls a "blatant cost shift" from employer to employee. To soften the blow, many employers couple higher deductibles and other changes that cost employees more money with broader coverage and added benefits including fitness programs, or other Sweeteners.
Berol Corp., a Danbury, Conn., company that makes pencils and Pens, used to cover almost all medical bills after employees paid a $100 deductible for outpatient treatment. It now covers 80% of medical bills after employees pay a deductible of $175 per person or a maximum of $350 per family, But as an incentive to limit the use of the plan Berol also pays each employee $500 a year, less any benefit payment. For instance, a worker who has $350 in covered medical bills will pay the first $175; the insurance plan will cover 80% of the rest, or $140. At the end of the year, the employee will get $360-$500 minus the $140 benefit payment.
Moreover, Berol pays for service it didn't previously cover, including routine doctor visits, physicals, and all infant medical care. The company also invites area doctors and nurses to speak at seminars advising employees on how to diagnose common illness and on where to find less expensive, out-of-hospital services. Berol's medical insurance spending, which had been rising 18% a year, has been steady since the new plan began three years ago.
Employers are finding that higher deductibles are more effective in reducing costs when targeted at the most expensive types of care. William Byrd Press Inc, of Richmond, VA., requires employees to pay the first $100 of every hospital admission, an additional $20 for each hospital day outside intensive care 20% of the doctor's hospital bill. "We want our employees to have an incentive to ask their doctor's whether they really need to be hospitalized, and then, if they are admitted, to press their physicians to discharge them as quickly as possible," says Stephen Lane, the company's director of human resource management.
Some companies use other approaches, such as paying the full cost of laboratory tests needed for hospitalization if they are performed before a patient is admitted. Some pay 100% of certain operations, such as tonsillectomy, that is performed in a doctor's office or surgery center that doesn't require an overnight stay. Others waive the deductible for hospitalization if it is approved by the company's insurance carrier or other so-called pre-admission certification agency.
There are also special programs that can save money for your employer and you. Health-maintenance organization, for example, usually provide all care without any deductibles, often charging employers a premium at or below the cost of other coverage. No Law requires employers to offer HMO membership, but you can encourage an HMO in your area to make a presentation to your company. Remember, though, most HMO's keep costs down by using their own doctors; if you join one, you will usually have to give up using your physician.
Another program increasingly available throughout the country is the PPO or preferred-provider organization. This type of program, usually organized by insurance companies, promises employers lower health-costs by signing contracts with doctors and hospitals with records of being cost-conscious. As an incentive to use these less-costly professionals, your deductible will be eliminated or reduced. Unlikely another of your choice belongs to the PPO Your employer can find out if a PPO exists in your area by asking its present insurer or the local chamber of commerce.
Finally, if your employer reduces its coverage of a hospital stay from 100% to 80% of the costs, check whether there is a limit on the amount you can be required to pay in one year. Many companies limit employee payments to $1,000 to $2,000. Without such a limit, even a short hospital visit could cost thousands of dollars.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
