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.
Creative destruction seemed a violent driver for the past two centuries, injuring a lot of harmless occupations and provoking their resistance to progress. The Industrial Revolution was bad enough, arousing Engels and Marx. But the computer revolution works faster, putting the pedal to the floorboard in a lot of ways, changing almost every life in some way, only faster. We could be approaching a violent second Luddite reaction if we don't keep our heads.
The legitimate complaint about the electronics revolution is that it is going in the right direction, but exceeding a reasonable speed limit. Elegant novelties that function smoothly deceive us into expecting perfection too soon, developing a habit of depending on innovations which are still a little shaky. But the banking industry, which presently bemoans securitized mortgages, swaps, and other products of the computer age, could not possibly have coped with the vast expansion of bank transactions without computer assistance. Computerized fraud is a problem, but street crime has markedly declined in response to ubiquitous cell phones in the pocket of every innocent bystander. The press is vexed by Internet competitors and bloggers by the million, but democracy is the better for it. Sometimes a simple solution will solve a problem created by computers, but to a major degree, only computers can get us out of the fix we are in.
For example, it seems plausible that the flaw in securitized mortgages lies in the inevitable loss of diligence by banks who originate mortgages with full knowledge that they will immediately be sold. Requiring an originating bank to retain 10% of the mortgage permanently would also force it to maintain an accurate tracking system for the other 90%, providing analysts a way to assess the performance of the originator, and regulators a way to control the volume. Maybe a simple rule like that would suffice, but if not the solution would probably consist of a massive computer programming effort to maintain records in excruciating detail.
Madam LaFarge
It's probably true that five years ago hardly any bank president could have offered a simple coherent explanation of what a derivative is, and it is certainly true that's the case for 99% of the population today. But that is the worst possible reason to destroy derivatives, which offer a breath-taking advantage in scale and diversification, and ultimately in risk abatement. Bundling thousands of mortgages leads to a much more precise estimation of the risk of the bundle than a banker could make of a single mortgage. If you know the risk with precision, the assessment of risk will be more accurate and almost certainly cheaper. There will be, there must be dislocations of prices as one system morphs into another. Temporary halts and moratoriums are justified, but demagoguery and Luddite riots are pitiful harmful responses. Politicians up for election are a menace in any crisis, where they come in various guises. There's giggling while the heads roll. There's also Charles de Gaulle, purring that he wanted to go to Heaven, he just was in no particular hurry to get there.
Charles de Gaulle
But let's be careful of our slogans, here. It certainly is preposterous to say that anything which is poorly understood must be a villain. It's also unwise to be drawn into a swamp. The banking industry faces dissolution if they can't keep up with electronic advances in their industry, so it is inevitable that speeding up wrong approaches will only make some parts of the credit crunch worse. Most of the cost-effectiveness of computers in the past have grown out of revising and replacing old methods, not from speeding up dumb ones. For example, if you want to know why health insurance is so expensive and cumbersome, you need only ask why it is so profitable. Once the huge investment in computerizing a system has been made, replacing it with a better system gets to be nearly impossible.
Ultimately, our present dilemma is this: we don't yet know how bad the problem is. It seems a reasonable possibility that this crunch happened just in time. Bad, it is true, but not yet catastrophic. If 3% or even as much as 10% of mortgages are foreclosed, the present system can absorb the loss, learn its lessons, and move on. A loss of a hundred billion dollars would probably lead to business more or less as usual. A loss of four hundred billion would however probably imply a serious recession, but when you start talking trillions, you are talking disaster. Most of the immediate uncertainty arises from ARM, the adjustable rate mortgages, and the degree of leverage in the debts of financial intermediaries. It's quite uncertain how many people took out mortgages they will not be able to afford at higher future rates of interest, or how many people took advantage of low rates for five years knowing they were planning to sell and move on during that interval, anyway. With regard to business loans, a mild drop in the economy will make it hard for businesses to cover highly leveraged loans. A huge drop will make it impossible for many businesses to survive, and they won't. A trillion-dollar aggregate loss would certainly provoke some welcome bipartisanship in Congress, but it might trigger a collapse of the Chinese economy or other unthinkable contingencies. Forcing more transparency into the present murk is the most urgent need, and that might well imply a concerted crash electronic analysis effort, with the way opened by some enabling legislation. Speeding up is only a good thing if you are headed in the right direction.
Lifetime Health Savings Accounts (L-HSA) would differ from ordinary HSA in two major ways, and the first is obvious from the name. In addition to meeting each medical cost as it comes along, or at most managing each year's health costs, the lifetime Health Savings Account would try to project whole lifetimes of medical costs, and make much greater use of compound income on long-term invested reserves. The difference in net income would be quite considerable. The concept seeks new ways to finance the whole bundle more efficiently; one of which is that health expenses are increasingly crowded toward the end of life, preceded by many years of good health, which can build up unused reserves and earn rising rates of income on them. Since the expanded proposal requires major legislation to make it work, it must be presented here in concept form only, for Congress to think about and possibly modify extensively.
This proposal does not claim to be ready for immediate implementation. It is presented to promote the necessary legal (and attitudinal) changes first needed to implement its value. And frankly, a change this large in 18% of GDP is really best phased in gradually, starting with those who feel adventurous. Experience has already shown HSA is most popular with the age group 30-40. By the time the timidest among us have joined up, the transition will have become more predictable. As a first step, let's add another early proposal for the present Congress to consider:
Proposal 17b. Tax-exempt Hospitals Should be Required to Accept the DRG method of payment for inpatients from any Insurer, although the age-adjusted rates should be negotiable based on a percentage surcharge to Medicare rates. The DRG should be gradually restructured, using a reduced SNOMED code instead of enlarged ICDA code, and designed to be used as a Google-like search engine on hospital computers rather than numerical look-ups, except for very common hospital diagnoses.
Overfunding and Pooling. Lifetime Health Savings Accounts, besides being multi-year rather than annual, are unique in a second way : they overfund their goal at first, counting on mid-course corrections to whittle down toward the somewhat secondary goal of precision -- amounting to, "spending your last dime, on the last day of your life". To avoid surprising people with a funding shortfall after they retire, we encourage deliberate over-estimates, to be cut down later and eventually added to retirement income. For the same reason, it is important to have attractive ways for subscribers to spend such surpluses, to blunt suspicions the surpluses might be confiscated if allowed to grow. An acknowledged goal of ending with more money than you need runs somewhat against public instincts and is only feasible if surpluses can be balanced with pleasing alternatives.
Saving for yourself within individual accounts is more tolerable than saving for impersonal groups within pooled insurance categories, but nevertheless must constantly defend itself against the administrative urge to pool. Pooling should only be permitted as a patient option, which creates an incentive to pay higher dividends for it. It also eases the concern about confiscation by making it more cumbersome; very likely, inflation is a realistically greater concern. The menace of rising health cost at the end of life induces more tolerance of pooling in older people, whereas small early contributions compound more visibly if pooling is delayed. Young people must be taught the instinctive belief it gets cheaper if you don't spend it. The overall design of Lifetime HSAs is to save more than seems needed, but provide generous alternative spending options, particularly the advantage of pooling later in life. Because it may be difficult to distinguish whether underfunded accounts were caused by bad luck or improvidence, the ability to "buy in" to a series of single-premium steps should, both create penalties for tardy payment, as well as incentive rewards for pooling them. This point should become clear after a few examples.
Proposal 17c: Where two groups, by age or other distinguishing features, can be identified and matched, as permanently in revenue/expense deficit, or surplus, internal borrowing at reduced rates may be permitted between the two groups to the extent they consistently match. Borrowing for other purposes (such as transition costs) shall be by issuing special purpose bonds. These bonds may also be used to make multi-year intra-family gifts, such as grandparents for grandchildren, or children for elderly parents.
Smoothing Out the Curve. There is a considerable difference between individual bad luck with health, and mismatches between average costs of different age groups. Let's explain. An individual can have a bad auto accident and run up big bills; as much as possible, the age group should smooth out health costs by pooling within the age cohort to pay the bill. On the other hand, compound investment income follows one curve, while illnesses predominate in bulges on a different curve. It isn't bad luck that concentrates obstetrical and child care costs into a certain age range, it is biology. No amount of pooling within the age cohort can smooth out such a systemic cost bulge, so the reproductive age group will have to borrow money (collectively) from the non-reproductive ones.
With a little thought, it can be seen that subsidies between age groups are actually more nearly fair, than subsidies based on marital status or gender preference, or even employers, who tend to hire different age groups in different industries, and can accordingly game their health costs in various ways. On the other hand, if interest-free borrowing between age cohorts is permitted, there must be some agency or special court to safeguard that particular feature from being gamed. All of these complexities are vexing because they introduce bureaucracy where none existed; it is simply a consequence of using individual ownership of accounts to attract deposits which nevertheless must occasionally be pooled, later. Because these borrowings are mainly intended to smooth out awkward features of the plan, every effort should be made to avoid charging interest on these loans or bonds. However, if gaming of the system is part of the result, heightened interest may have to be charged. Using bonds to borrow between age groups is probably cheaper than constant bookkeeping, and more reassuring about the political risk.
Proposal 17d: A reasonably small number of escrowed accounts within a funded account may be established for such purposes as may be necessary, particularly for transition and catastrophe funding. Where escrowed accounts are established, both parties to an agreement must sign, for the designation to be enforceable. (2606)
Escrowed Subaccounts. Buying Out of Medicare.Both Obamacare and Health Savings Accounts are presently expected to terminate when Medicare begins, at roughly age 65. Nevertheless, we are on the subject of lifetime coverage, where we have a rough calculation of the cost ($350,000) and the Medicare data is the most accurate set, against which to make validity comparisons. We want to start with $350,000 at the expected date of death, spend some of it in roughly 20 installments, and see how much is left for the earlier years of an average life. Then, we repeat the process in layers down to age 21 and hope the remainder comes out close to zero. There are several things missing from this, most notably how to get the money out of the fund, but let's start with this much, in isolation for the Medicare age bracket, age 66-85, more or less. For simplicity, we are going to assume a single-premium payment at age 66, which both life expectancy and inflation in the future will increase in a predictable manner, while changes in health and health care eventually reduce healthcare costs, not increase them. Not everyone would agree to the last assumption, but this is not the place to argue.
We know:
(a) The average cost of Medicare per year ($10,900)
(b) How many years the beneficiaries on average are in the age group (18).
(c) Therefore, we know how much of the $350,000 to set aside for Medicare ($196,200),
(d) And know how much a single premium at age 65 would have to be, in order to cover it. ($196,000 apiece)
(e) We thus know how much all the working-age groups (combined as age 21 to 66, 60% of the population) must accumulate, in advance for their own health care costs, when they reach Medicare age($196,000 apiece).
(f) And by subtraction therefore how much is left for personal healthcare within ages 21 to 66 ($128,800).
(g) We can be pretty certain average Medicare costs will exceed those of anyone younger, setting a maximum cost for any age.
Shifts in the age composition of the population will produce very large changes in total national costs in any given year, but should by themselves not change the average lifetime costs. What they may do soon is increase the proportion of the population on Medicare, thereby paradoxically making both Obamacare and Health Savings Accounts relatively less expensive. Obamacare can predict its future costs with information already available. But the Health Savings Account must still adjust its net future costs for whatever income is produced by investments. We don't yet know is how much each working person must contribute each year, because we haven't, up to this point, yet offered an assumption about the interest rate they must produce. Let's construct a table of the outcome of what seems like reasonable income results. There are four relevant outcomes to consider at each level: the high, the low, and the average. Plus, a comparison with what Obamacare would cost. But there are two Medicare costs: the cost from age 21 to 66, and the cost from 67-85, advancing slowly toward a future life expectancy of perhaps 91-93. These two estimations are necessary for displaying the relative costs of Medicare and also Obamacare.
Someone is sure to notice the apportionment for children is based on income rather than expenses. The formula can be adjusted to make that true for any age bracket, and a political decision must be made about where to levy assessments if income is inadequate; we made it, here. We have repeatedly emphasized that if investment income does not match the revenue requirement, at least it supplies more money that would be there, without it. Somewhat to our surprise, it comes pretty close, and we have exhausted our ability to supply more. Any further shortfalls must be addressed by more conventional methods of cost-cutting, borrowing, or increased saving. In particular, attention is directed to the yearly deposit of $3300 from age 25-65, which is what the framers of the HSA enabling act set as a limit, perhaps arbitrarily.
And finally but reluctantly, the figures include provision for phasing out Medicare, which everyone treats as a political third rail, untouchable. But gradually as I worked through this analysis, I came to the conclusion that uproar about medical costs is never likely to come to an end until the Medicare deficit is somehow addressed. I believe we cannot keep increasing the proportion of the population on Medicare, paying for it with fifty-cent dollars, and pretending the problem does not exist. So it certainly is possible to balance these books by continuing our present approach to Medicare for a while. But it would be a sad opportunity, lost.
In summary, we have concocted a guess of the outer limit of what the American public is willing to afford for lifetime health coverage ($3350 per person per year, from age 21 to 66), and added an estimate of compound income of 6% from passive investing, to derive an estimate of how much we can afford. From that, we subtract the cost of privatizing Medicare if our politicians find the courage for that ($196,000) and thus derive an estimate of how much is available for health care of the rest of the population ($128,000).
No doubt, data from the Obamacare program will soon reveal some information, but it will derive from a non-representative sample group. It would seem dangerous at this point to use data from that source to make a judgment about the soundness of this one. Because of the longer time spans available for compound income, at 6% it would actually cost more out-of-pocket to finance the $128,000 than the $196,000; it would actually be financially better to do it. The non-investment cost would only be small, for an expense which otherwise seems almost insurmountably crowding out everything else in the national budget.
What remains is to see if it is possible to finance the average healthcare of younger people with a budget of $128,000. All told, we could foresee a limit of a dollar a day for life, but that would assume using all of the revenue-enhancements together. If for no other reason, a slow transition would make this unrealistic.
Enacted 2003. Subscribers as of Jan.1, 2015: 17 million.
Provisions: Briefly stated, any approved high-deductible indemnity health insurance plan, when attached to an approved tax-deductible saving account for the accumulation of the insurance deductible, or payment of other medical expenses. Deposits are limited to $3,400 tax-deductible annually and are not taxable on withdrawal for medical purposes. Accounts presently may not be used to pay the insurance premium. The account is exchanged for a regular IRA at the time the subscriber begins Medicare coverage. (In this sense, an overfunded account earns interest until age 66 when unused funds are taxed but exchanged for any Individual Retirement Account which may then be used for any purpose. Up until that time, there is a 20% penalty for funds used for non-medical purposes.)
Suggested technical amendments: 1. Permit the account portion to pay the premiums for the insurance portion, making the entire
Health Savings Account tax exempt. 2. Improve flexibility by eliminating age and employment limits. 3. Relax the deposit limits with a COLA and switch from annual limits to lifetime limits.
Suggested regulatory changes: 1. Limit costs and charges for deposits, withdrawals, and investment income to 1%, applying all the rest to the customer's account. The main purpose was not rationing, but to block expansion from Congressional intent of before-tax funding of deductibles, health expenses, and retirements. 2. Permit subscribers the option to purchase index funds and take delivery on the certificates into defined escrow sub-accounts.
Suggested Areas for Future Expansion:
1. First/Last Years-of-Life Re-insurance. (To shorten the transition but extend the period for compounding interest, plus reduction of Retirement cost.) These four years consume 50% of medical costs. They are seldom paid by the patient himself and affect 100% of the population. The present system is largely a transfer system to these four years, paid for by people who are not themselves sick.
2. Study how the savings from future disease cures could be applied to retirement (rather than misapplied to battleships, etc) by flowing such savings into HSAs. The planning should contemplate eliminating Medicare gradually as its need disappears, a feature seldom included in the design of entitlements.
3. Study the Dis-intermediation of HSA investing. Privatization creates complicated agency problems, sometimes with excessive costs. Savings are possible from investing rather than borrowing, but the savings should reflect the risks better. The problem is how to invest several percents of GDP without using price controls.
4. Decentralize. Centralization of medical care has led to running it at great intermediary cost, unlike most businesses which become cheaper if centralized. Old people have most of the disease and do most of the medical commuting. The effective way to restore physician control is to decentralize from urban silos to suburban retirement communities. To do so gracefully requires protracted planning. Begin with the Maricopa case of the U.S. Supreme Court.
In the usual funding and billing operation, the main concern is finding enough money to pay the balances. In this circular system, however, if a balance keeps going around and around for generations, it will eventually reach infinity. Anticipating this loophole, with the absolute certainty that someone will try to take advantage of it somehow, the laws of perpetuity provide that inheritances may only last a single lifetime, plus 21 years. The main concern, however, is to be sure there is enough money without pooling.
In this case, what individuals have available are sixty years duration(age 25-85), or 85 years if we start the clock at birth (0-85), and maybe 90 years if longevity inches up during the 90 years of a coming lifetime. Using the 7% in 10 years doubling rule, that's 9 doublings. Compounded quarterly, these age durations create a multiplier of the $400 we plan to donate, of 64x, 256x, and 512x, leading to contingency funds at death of $25,000, $102,000, or $205,000, respectively. Those are multipliers which surprise most people. Keeping the compound interest within present Medicare ranges just isn't enough, but $145,000 might scrape by, and $206,000 is quite comfortable for the purpose. The specified goal is to bequeath, donate or tax $18,000 to the designated grandchild, and $100,000 to Medicare as a last-year-of-life reinsurance transfer, all of which grew out of the original $400.
We compound 7% as an example because it's easy to double every ten years in your head, but 7% relates well to a century of large-cap common stock returns at 11% (re Ibbotson), less 3% inflation, less 1% more for overhead. And it correlates well with the mode for the last 50 years of the S&P, which comes to 6.6% (see my son George's calculations in the special index.) That's in the ballpark of what we seem to need. And remember, by doing this, the heaviest and most permanent expense of life (terminal care and death) has been transferred away from lifetime cost burdens, into Medicare. (Birth costs are not saving; they are merely transferred from the mother's account to the child's). For reasons we won't go into, reducing the volatility of buy-and-hold investments might lower their transaction cost somewhat.
Obviously, someone must be designated to watch this drama unfold, with latitude to make small mid-course corrections re-aiming it toward its goal. Eventually, Congress must reserve to itself the right to change the ground rules if serious miscalculations begin to appear. It may begin to fall short, which results in raising the initial donations. Or someone may figure out a way to game the system by overfunding it, turning it into a perpetual money machine.
For that rather vague goal, I advise adjusting the choke point at age 25. That's when childhood subsidy runs out and the adult funding for death begins; in a sense, it's the beginning of financial life. It fits the existing laws about perpetuity. Every dollar you change it, up or down, can have a leverage of roughly $300 at the time of the subscriber's death. Of course, there's such a thing as outright fraud, where you ultimately have to send someone to jail rather than allow him to topple the financial system.
Essentially what you would have done, is identify a safety buffer for first and last year of life insurance, with an approximate risk cost ($400), toward which we work as scientific advances slowly modify the rest. Any other surpluses go into the retirement fund for seniors, as healthcare surpluses appear. How long it will take to come into equilibrium is uncertain, but at least it's a plan. Leftovers from the first year of life gift from grandparent to grandchild will appear at birth, but shift over to the grandchild's own account at age 25. After that, he's on his own.
This directory contains Fee Screen Year 1984 Medicare reimbursement data based on physician charges submitted to
Medicare during the calendar year 1982 in each of the reasonable charge localities within each Part B carrier's service area.
Maps are provided for each State which outlines the separate charge districts (localities) the Carriers use
in reimbursing claims under the Medicare program. The counties within each locality are listed to aid in
identifying the exact geographic breakdowns. More detailed locality information can be obtained on selected
carriers by referring to AppendixA in the back of the directory.
The directory was compiled from magnetic tapes submitted by each of the carriers. Every effort has been made
to minimize errors in the data displayed for each of the carriers however because of differences in coding
systems it may sometimes be necessary to consult directly with the carrier for clarification.
EXPLANATION OF MEDICARE CHARGE DATA
The dollar amounts shown in the directory are the prevailing charges in the indicated locality for each of the
services listed. Except where there are unusual circumstances or medical complications so that more than the
normal service is provided, these figures represent the highest dollar amounts that Medicare can use in determining
the medical insurance benefits which can be paid on Medicare claims for services in the locality. Others factors,
explained below, are also used in determining the medical insurance benefit that is payable.
How The Medicare Allowed Amount Is Determined
Under the law, the allowed amount for a given service shown on a medical insurance claim is generally the lowest of (1) the actual charge made by the physician for the service; (2) the customary charge generally made for that service by the physician; (3) the prevailing charge, which is the charge most physicians in the locality would find acceptable for that service; or (4) the charge that would be recognized by the carrier for its own (non-Medicare)
subscribers or policyholders for the service.
The rules that are applicable in calculating the amounts allowed for physicians' services also apply to other
services covered under the medical insurance program.
How The Medicare Prevailing Charge Is Determined
Under the law, just before the beginning of each fiscal year Medicare must review the actual charges billed by
physicians in the preceding calendar year. The mid-point of these actual charges by a physician for a service is established
as his customary charge for that service. The prevailing charge is then established at the 75th
percentile of all the individual physician's customary charge for each service. In effect, the prevailing charge
for any given service is the amount which is high enough to cover I full the customary charges of those physicians
whose billings accounted for at least 75 percent of all claims for that service in the locality in the preceding
calendar year.
The amount of prevailing charge recognized under Medicare is also affected by an additional program restraint.
In accordance with Medicare law, prevailing charge levels for physicians services for any fiscal year after fiscal
year 1973 may not exceed the fiscal year 1973 level except to the extent justified by an economic index that
reflects changes in the costs of physician practice and in general earnings levels.
The prevailing charge data represents the Maximum amounts upon which reimbursement is based with the Medicare
Part B program. It also reflects the influence of the Economic Index Provisions. For each locality, prevailing
charges are listed for 29 medical services performed by General Practitioners (GP) and for 100 physicians services
performed by medical Specialists. Where the carrier makes no specialty differentiation in its screens, the top of
the page states "combined locality designation". Blank spaces in the prevailing charge columns indicate that
(a) prevailing charge data was not collected for GP specialty category, (b) the procedure is not performed in the
locality, or (c) the carrier does not use the same definition of the procedure as listed. When an asterisk (
*) appears beside a charge, it means that the charge is adjusted by the application of economic index. When
a letter "P" appears next to a charge, the amount represents the Professional component only. The letter "L"
stands for the lowest charge levels applying to selected laboratory and durable medical equipment screens.
The physician procedure (excluding lab and DME) lists represent the amounts established at the "freeze" level and
will continue to be in effect until October 1, 1985.
When reviewing the specialist charge screen data, it should be noted that the amounts represent the prevailing
charge screen for the specialist who most frequently performs these procedures. Therefore, the procedure list
in Table A contains the category of medical specialists for which charge screen data was collected for the 103
procedures. Seven additional procedures are listed for durable medical equipment.
If you have any questions about the data or locality information displayed in this directory, please direct your
questions to James Barnett (301) 594- 6743), Health Care Financing Administration, Bureau of Program Operations,
Room 367 Meadows East Building, 6325 Security Boulevard, Baltimore, Maryland 21207. For technical questions
involving computer programming of the data, contact our Bureau of Support Services (301) 594-0810).
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.
