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.
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Philadelphia Revelations
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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.
The 2006 annual scientific meeting of the American College of Physicians used six or eight auditoriums simultaneously over a three-day period, to accommodate the gratifying number of new advances in medical science. I wandered into one session devoted to pulmonary embolism because it affects a close member of my family. But every citizen ought to ponder the non-scientific message of this session. Indeed, the anti-scientific message.
It turns out that 1% of the relatives of patients with pulmonary embolism will test positive for inheriting a gene that promotes this often fatal disease. But the speaker, invited as a national authority to speak for the College, cautioned the audience that it would be wrong to test the relatives of their patients with pulmonary embolism for the possibility of running a significant risk of this disease themselves. Why so? We have a pretty good way of preventing this often-fatal disease, by giving blood-thinners, and blood thinners are getting better all the time. So, naturally, there were questions from the audience of doctors. Why in the world wouldn't you test people for this preventable condition?
With obvious discomfort, the speaker did a little tap-dancing in his answers; but here is the substance of it. There is a risk of complications from the therapy, of about 5% a year so you must choose carefully among those who have a positive test. If the individual tests positive but is not treated, he may develop an embolism and sue you for not having treated him. Even if he doesn't develop the condition, he will probably be stigmatized for life and find that health insurance is overpriced or unobtainable. If you treat everybody, you will cause problems more often than the disorder would. So, don't test. If you don't know about the problem, you can't get into trouble for acting in an ambiguous situation.
Personally, I doubt that. If the person has an embolism, a keen lawyer can ask if any relatives ever had the same thing, and if so, the other doctor can be sued for not testing the relatives, hence not discovering, and not preventing the present sad, sad, situation. I'd like to think the rest of the medical profession will join me in disregarding this preposterous advice, testing these families to identify the people who are at risk, and then treating them with the best method then available.
But, you know, in the present climate of managed care and lawsuits, I'm not so sure that's what will happen. Meanwhile, my own children are all going to be urged to go get themselves tested, whether the test is covered by insurance or not.
The legislation removes the hampering restrictions of the 1995 Law. What follows is a brief outline of the main features of the HSA/MSA clause in the 2003 law,
U.S. Capital
as published by the main authorizing committee, the House of Representatives, Committee on Ways and Means. From this point forward, more specifics of the program will probably be written by the Executive Branch and published in the Federal Register. The Ways and Means Committee will continue to exercise oversight authority, however, in conjunction with the Senate Finance Committee. As a consequence, statutory modifications of the program are likely to appear in future annual budget reconciliation acts, or else in any new Medicare amendments. The legislative route map becomes more understandable when it is recalled that Medicare itself is considered to be an amendment (Title XVIII) of the Social Security Act.
Working under the age of 65 can accumulate tax-free savings for lifetime health can needs if they have qualified health plans.
A qualified health plan has a minimum deductible of $1,000 with $5,000 cap on out-of-pocket expenses for self-only policies. These amounts are doubled for family policies.
Preventive care services are not subject to the deductible.
Individuals can make pre-tax contributions of up to 100% of the health plan
deductibles. The maximum annual contributions are $2,600 for individuals with
self-only policies and $5,150 for families (indexed annually for inflation).
Pre-tax contributions can be made by individuals, their employers, and family
members.
Individuals age 55-65 can make additional pre-tax "catch up" contributions of
up to $1,000 annually (phased in).
Tax-free distributions are allowed for health care needs covered by the insurance policy. Tax-free distributions can also be made for the continuation
coverage required by Federal law (i.e., COBRA), health insurance for the
unemployed, and long-term care insurance.
The individual owns the account. The savings follow the individual from job to
job and into retirement.
HSA savings can be drawn down to pay for retiree health care once an
individuals reach Medicare eligibility age.
Catch-up contributions during peak savings years allow individuals to build a
nest egg to pay for retiree health needs. Catch-up contributions allow a married
couple to save an additional $2,000 annually (once fully phased in if both
spouses are at least 55.
Tax-free distributions can be used to pay for retiree health insurance (with no
minimum deductible requirements), Medicare expenses, prescriptions drugs, and
long-term care services, among other retiree health care expenses.
Upon death, HSA ownership may be transferred to the spouse on a tax-free
basis.
Contain rising medical costs- HSA's will encourage individuals to buy health plans that better suit their needs so that insurance kicks in only when it is truly needed. Moreover, individuals will make cost-conscious decisions if they are
spending their own money rather than someone else's.
Tax-free asset accumulation- Contributions are pre-tax, earnings are tax-free, and distributions are tax-free if used to pay for qualified, medical expenses.
Portability- Assets belong to the individual; they can be carried from job to job and into retirement.
Benefits for Medicare beneficiaries- HSA's can be used during retirement to pay for retiree health care, Medicare expenses, and prescription drugs. HSA's will provide the most benefits to seniors who are unlikely to have employer-provided health care during retirement. During their peak saving years, individuals can make pre-tax catch-up contributions.
Let's confess my meager authority to generalize about trends in retiree convalescence. When I graduated from medical school in 1948, average American longevity was twelve or fifteen years shorter than today, and most assumptions rested on it's remaining the same forever. Someone who reached eighty was really old, obviously facing a prompt decline. Today, essentially everybody lives to be eighty. We only half-expect such long life, which is modest of us, and only halfway plan for it, which is foolish.
Picking the right CCRC is as hard as picking the right spouse.
In 1950 a general practitioner in Haddonfield, NJ called for help from the son of one of his patients. The son was a doctor on the staff of the Pennsylvania Hospital, where I was finishing my internship. The GP hadn't had a vacation for twenty years and wondered if one of the graduating internets might take his practice for a month. I volunteered and then learned about retirement in a prosperous suburb. My employer had many tasks, among them a schedule of ten or twenty monthly house calls. There may have been some male patients on those rounds, but all I remember were old ladies living on the third floors of big old houses. I wasn't expected to do very much when I visited, at least by Emergency Room standards in the hospital. The families with whom the grandmothers were living wanted to be reassured that nothing was neglected. They also wanted to form their own assessment whether the doctor really knew them, and would come immediately if needed.
Doctor House Call
My next insight came a few months later when another doctor on the staff of the hospital had a heart attack; the Chief of Medicine gave me the time off to take care of this practice while the doctor recovered. When I first arrived at the door of the brick Philadelphia row-house where the doctor had his office, I was met by his nurse already wearing a raincoat, handing me an umbrella. We visited ten or fifteen other row houses along the neighboring streets, where to my amazement I found patients with oxygen tents and intravenous infusions. If the patients needed blood tests or electrocardiograms, the nurse arranged for them to be performed at home. Drugs by injection were administered, hospital-like bedside charts were maintained. This was a working-class neighborhood substitute for hospital care, but I was astonished to see how adequate it was. By this time, we had many resident physicians at the hospital who had seen service in the war and returned for specialty training; they regaled us at the lunch table about treating major illnesses -- in a tent. This wasn't the Civil War we were talking about, it was 1950.
Fifteen or twenty years later, my personal situation had improved; Medicare had arrived in 1965, but I was in practice as a center-city specialist and hardly noticed the new insurance system. But I did have three patients who insisted on being treated at home, which even by then had become an unusual arrangement. All three lived in condominium apartments in buildings with dining rooms on the main floor which would send up take-out dinners. All three patients had live-in nurses and hospital beds rented from an agency. One spinster lady absolutely refused to be treated in a hospital, because the Queen of England set up a little hospital in her palace when she needed it, and this lady said for practical purposes she had as much money as the Queen. Because she was dying of cancer, I resisted this idea, but if you had seen Katherine Hepburn in The Philadelphia Story you got the helpless feeling this dame was going to have her way. We called in laboratory and x-ray services as needed, administered injections, maintained a hospital chart. In this case, when I made a house call, her chauffeur would pick me up and deliver me, helping to ensure my promptness. Her lawyer and I kept careful financial records of the experience, which was new to him, too. After she died, we totaled it up and discovered with astonishment that the whole thing had been cheaper, a lot cheaper, than going to the hospital. Since she left a sum to the hospital in her will, even the hospital was pleased.
Well, nowadays there are more than fifty retirement communities scattered around the periphery of Philadelphia, many or most of them sponsored by Quakers. It's a national movement, and there are people in California who feel they had the idea first. There are now enough of these organizations to permit some classification of them into types, which mostly follows the sort of community model they resemble. There are some that look and are run like college dormitories, some that resemble convalescent homes, some are very like big-city apartment condos, and some behave like resort hotels. One of them, the Kearsley, sits in the middle of the Bala golf course, attempting to provide the first-class service to indigents by using existing government assistance programs, but has lately had to fall back on the Episcopal Church for financial help.
CCRC
Since a financial shadow hangs over all of them, it should be mentioned first. Every person in a retirement village is eligible for Medicare and Social Security, and with the help of a social worker can fall back on less-known assistance programs. It's impossible to ignore the existence of these funds, but most unwise to depend on them. As the age and number of retirees constantly grow, state and federal governments are starting to draw back from initial generosity. Laws have passed that a CCRC resident may not be evicted for non-payment of debts, so the institutions have had to impose conditions which guarantee them payment from new entrants in the case of later inability to pay. The risk remains that clients who entered before the rules were imposed, can only be extricated by going before Congress and raising a piteous cry on bended knee. Such laws and embarrassments vary from state to state, and from year to year, but unstable finances destabilize any business. When the customers all depend on their savings, and average investment experience is a drop of 30-50% in the past couple of years, no one escapes anxiety.
Although there must be college courses in how to administer a CCRC by now, current administrators are drawn from the environment the place mostly resembles, so the resemblance gets stronger. The former manager of a country club tends to neglect the infirmary; the former directress of a convalescent home doesn't notice institutional food. If the administrator treats customers as complaining nuisances, you get one kind of war; if the board of directors is accustomed to ruling corporations by dictate, you get another. Mainly, these institutions differ from models of other institutions by the degree to which they have active volunteers in charge. The inmates may run the asylum, but only if they become useful volunteers. A curious distinction evolves between those CCRCs which emerge from college alumni associations and those which are sponsored by churches. University faculties are not accustomed to, nor generally sympathetic with, teamwork. Every faculty member is on his own career path, which he hopes leads straight upward; teamwork to them is a code term used by business executives to imply blind obedience, Charge of the Light Brigade, or worse. Church groups, on the other hand, prize volunteerism. In a church environment, the proposal that Let's Have a Picnic is supposed to be met with a chorus of Great, I'll be Glad to Bake a Cake. Church-sponsored CCRCs, therefore, are generally more adaptive to innovation in a formless society. University groups have camaraderie and complaining, but little follow-through. By contrast, business people know what you are supposed to do, you are supposed to make something happen. Church volunteers want to know how they can help. Paradoxically for that reason, the more evidence of golf clubs around the place, the more likely it is to be innovative.
Let's return to the point, succinctly. Life-threatening and potentially convalescence-requiring medical conditions are destined to segment increasingly into Medicare, to the point where what remains outside of Medicare is elective, preventive or outpatient. Obstetrics is an exception, remaining more naturally part of the hospital than the CCRC. The rest of medical care thus seems inclined to migrate toward the suburban ring of retirement communities. The more natural transportation flow is for younger people to travel to either a hospital-centered medical cluster or a CCRC-centered cluster, not for frail old folks to leave the convalescent environment except for major surgeries from which they soon return to their infirmary. It doesn't have to be that way, it just seems like the natural arrangement.
Probably the main reason it doesn't work that way today resides in the Medicare law. The 1983 amendments restrained inpatient reimbursement much more than outpatient care or home nursing care, and consequently, inpatient costs have risen 18% in five years, compared with 47% for outpatient. Outpatient care is not migrating toward retirement communities because hospitals need revenue. Somehow, it seems easier to modify these reimbursement rules than to upend suburban CCRCs and relocate them next door to an urban hospital. If the payment rules become reasonable, the system will readjust its geography in a reasonable way, without coaxing.
Surely, non-residents of the CCRCs are destined to wish to convalesce in the spare beds of CCRC infirmaries which should then treat younger people as a much-needed revenue source; any licensing requirements which block this seem unreasonable. Medical hardware,-- x-rays, MRIs and the like,-- is most naturally concentrated in the periphery of CCRCs, as are pharmacies, outpatient labs, doctors' offices. That's going to require a lot of parking space. It's a good thing this will take a couple of decades to happen; many mid-course adjustments will be imperative. But the basic fact is that the whole community's medical need is getting concentrated in CCRCs via Medicare, and so the community's facilities should move closer to that need. The younger community is well able to travel anywhere for elective medical services, especially when they move away. Makes a good chance to visit the grandparents while they are there, too.
All of these proposals depend on getting the attention and cooperation of other self-centered institutions: Medicare, hospitals, medical societies, municipal governments. The CCRC community has scant experience with asserting itself; its future will depend on how skillfully it begins to do so.
Nearly every retirement village has four or five retired physicians living in the place, as well as a dozen retired nurses, lab technicians, and others with medical experience. Every CCRC infirmary has four or five patients whose spouse is a resident of the community, visiting the infirmary regularly, and with sharpened insight. Some other people are natural leaders. If these people could be assembled into a permanent committee of medical oversight, charged with visiting other CCRCs in the region for ideas and perfecting the interface between the CCRC and nearby hospitals, medical facilities, transportation vendors, and politicians -- things would start to move. Spending twenty percent of our gross domestic product on health is, quite enough. Let's either stop spending so much or else make something good of it.
Center-city continuing care retirement communities
Probably because of cheaper land and construction costs, retirement villages are generally found in suburban or semi-rural regions. In Philadelphia for example, forty or so retirement communities dot the outermost edges of the city while the urban center contains only two or three of them. As was true during the migration of the national frontier Westward throughout American history, cheap land costs seem generally to overcome the attractiveness of urban habits and culture. Or at least that now seems a more universal theory of migration patterns than the attraction of suburban schools for the parents of teenagers. It has generally been argued in the past that the automobile made it possible for families to escape the turmoils of inner-city schools by fleeing to the suburbs. But now we see families without children continuing to flee from the center of town. Center-city continuing care retirement communities have certainly been built in the center of town, right next to libraries, museums, clubs, and department stores, but real estate salesmen know very well that it is a safer bet to locate one of them in cheap farmland, well beyond the ring of much-praised suburban school systems. When random inhabitants of such villages are asked what attracted them, most of them say it was the medical system, but that can't be precisely right since they all have Medicare. More likely, they want to locate near the suburban doctors, hospitals and pharmacies they grew accustomed to during their compulsory residence near the high school. And the circle of friends they made there; although the aging process makes that into a dwindling band.
The point here is that automobile commuting and much-praised high schools probably created suburbs, but are no longer the strongly attractive issues which induce empty-nesters to settle nearby for the rest of their lives. The CCRC is like a ship at sea, pretty much entirely self-contained because of the progressive locomotion difficulties of the residents. At first, the residents can feel free to go on living as they "always had", but habit and convenience rather quickly narrow their horizons and circle of friends. They may have been community leaders a year or two earlier, but soon after making their monastic choice, they begin to withdraw into the more limited community of their new chosen monastery. Limiting perhaps, but not confining.
That's unfortunate in one way since a theme of this book is that the young older group needs to find ways to continue productive lives. The country can't afford to have them remain unproductive, and they themselves need to have more useful things to do. An entirely recreational life simply cannot continue to get longer and longer as a sole justification for all the expensive health care we seem capable of providing for them. Therefore, one promising experiment which needs to be tried is to organize the whole suburb into a half-way house, amicably intertwined with neighboring houses full of teenagers. With people living in their own homes a few years longer than they originally planned after the kids are out of the house.
The town where I live is now surrounded by miles of other suburbs, but I think of it as on the edge of farmland because that was the way I found it sixty years ago. The borough itself has seven thousand houses, probably somewhat too few to suit urban planners, but presenting no convincing argument for us to consolidate with neighboring suburbs except the nagging of those sociology professors. The town has plenty of doctors, most of whom practice somewhere else, and plenty of dentists. No hospitals, no nursing homes, no rehabilitation centers. But several drugstores, two ambulatory x-ray units, and two specimen-collecting laboratories for nearby hospitals. We have a busy volunteer ambulance corps, run out of the firehouse, and frequently seen racing and honking its siren around the town. The composition of these independent medical facilities has varied over the decades but is not greatly different from what can be found in a dozen near-by suburbs. The one thing we don't have is a CCRC, and there seems to be enough demand for one, even enough empty land to hold it. Just about every retiring family in the town has been heard to express a wish that a retirement village could be made available, so they wouldn't have to pull up their social roots in addition to all of the other disruptions of retiring. Having spent most of their adult lives envying people with larger, more luxurious houses, they are now at the point where they are sick and tired of fussing with the big house they do have. They want less number but smaller houses, especially apartments, just don't exist in the town. So they are forced to consider moving away.
Especially after one of the two elderly marriage partners dies, there is the worry of living alone. Twice in my own experience, an elderly widow living alone in a big house has broken her hip bone with no one in the house to call the police. One of these ladies was lucky; she lay on the floor for two days without food or sanitary support, until the mailman came by and noticed the mail piling up. The other lady was not so lucky; she had bought a big dog which apparently ate her when she was helpless on the floor. Old folks living alone tend to think they can cope with anything. Until suddenly they can't.
Very likely, the mobile cell phone has reduced the number of such tragedies, just as it has apparently reduced armed robberies almost by half. The mobile phone gets progressively more clever with the invention of 500,000 applications, or apps. We can probably expect to see visual surveillance systems and the like, very soon and very inexpensively. Handbags in the bathroom and other safety devices are regularly more ingenious; there are even companies which will outfit a whole house with such improvements and suggestions for use. It's a great pity that installing a home elevator is comparatively cheap when the house is being built, and almost prohibitively expensive after the builders go away; nobody over the age of 60 should really buy a house without an elevator, except for the fact that so few houses have them. They seem expensive until you realize that moving your home once or twice is going to cost $100,000, mostly because of universal tendency to buy the biggest house you can afford rather than the biggest one you need. But even so, my little town needs one more thing before it can be said to have coped with its retirement needs.
What's missing in all this is management. Relatives who live close by will often suffice, depending on their other commitments. With a competent manager, what's needed is a part-time employment agency, to supply the nurses aides, physiotherapists, and babysitters of various skill -- and to cope with the mountain of redundant government paperwork. Regulatory paperwork can rather easily be coped with by someone who has a programmed home computer, so the right equipment and program must be located, or commissioned. Since the Obama administration was recently willing to spend $29 billion dollars to equip every doctor with a computer system, what's probably most needed is a loud angry lobbying group to get the necessary money, and to cope with the passive aggressive resistance which any competitive environment is filled with. We're talking here about reducing the number of people who need to enter a CCRC, so nursing homes and other CCRSs can be expected to express hurt feelings and discover a myriad of ways it is totally unsafe to provide a competitive alternative to their business model. Getting a sympathetic congressman will help about half the time; the other half of the time you should consider the advantages of replacing him.
There are advantages to starting one of these retirement villages without walls in a rural area, with lots of experience with volunteers pitching in and helping out. The community officials are sympathetic in such areas, and costs are generally lower. In a suburban neighborhood, the environment is more sympathetic to the approach of applying for a government grant, or if there is no available program, asking for the creation of a demonstration program. That's an egg that will generally take five years to hatch, and prove to have higher costs. The rural environment needs enthusiasm, the urban one needs tenacity, and will generally find it is an advantage to have a congressman who is chairman of a committee. But everyone who wants to see a local retirement village without walls also needs a slogan, so here it is. "Anything a retirement village can do can be done at home. Only cheaper."
Your bill, The Managed Care Public Choice and Improvement Act, reflects growing concern about the techniques and effects of HMOs and other forms of so-called managed care. It has been said that managed care stands convicted in the court of public opinion. That's about right, but it may miss the whole point. Let me explain.
Ordinarily, when a commercial product for sale has annoyed and frightened great masses of the public, it is unnecessary, and may even be counterproductive, to pass laws about it. The public will simply stop buying the obnoxious product, and the vendor will then either change his ways or go out of business. The customer is always right, we say, and businesses which do not acknowledge the reality are soon part of history. I'm afraid, however, that health insurance is a different sort of product.
In the first place, it has been given an almost unique income tax advantage. It is tax exempt as a business expense for the employer, it is not taxed as income to the employee, and it is not taxed when you use the insurance. This bizarre feature was created during World War II when we had wage and price controls, and it was never repealed. After the war, the IRS attempted to have the tax shelter repealed, but Congress lacked the political courage to change the law and it persists, now fifty years after the end of the war which was its excuse. This tax feature is the reason that almost everyone tries to have the employer buy it for them since it is about 30% cheaper that way. I buy it for my secretary and it gets the tax dodge, but when I buy it for myself, it does not get the tax credit because I am self-employed, not working for a salary. You might think this obvious unfairness was an accident, but the events of the recent Kennedy-Kassebaum bill prove it was not accidental at all. The K-K bill granted me and other non-salaried people 40% of the salaried exemption and gradually increased it to 80% of the salaried situation in ten years. Even this grudging concession to fairness was qualified by a clause which states even partial exemption is not available to anyone eligible for insurance to be bought through employer plans, I Make the strong surmise that insurance industry lobbyists must have been fluttering around the door of the House-Senate conference committee which enacted it.
So, the customer isn't always right, the customer must take what the employer chooses to give him. Managed care would have been history two years ago except for this tax provision. Now, there exists a second quirk of managed care which helps it persists in spite of public hostility. Public reaction quite naturally supposes that the high-handed and impertinent to save money. I doubt that. There has been enough experience with this matter to demonstrate that the high costs of this intrusive administration eat up most or all of the savings to the employer. The best that can be claimed is the rather weak argument that costs might have been even higher without managed care. Since the larger health insurers are currently before the Pennsylvania Insurance Commissioner requesting a 23% rate increase, it is far from certain just who is cheaper than whom on a five-year basis, regardless of appearances in any singer year.
If managed care doesn't save money, why do it? Weel, the central profit center in health insurance today is "adverse risk selection." If an HMO achieves a mixture of clients who are mostly healthy, its costs will be far less than with a mixture of clients who are sick. Healthy people don't get hassled by managed care; for them, the HMO is just a card in their wallet. The people who are getting hassled are sick, using the system, and generating the costs. Since the insurance company makes a considerable profit if such people get discouraged and choose another insurance, you can see there is actually a financial incentive to be obnoxious. The fact that the public doesn't like it is not a handicap, it is an asset. Therefore, this may be one of those peculiar situations where people like me, who dislike governmental intrusions, began to turn to the government for relief.
On a philosophical level, I am consoled by the fact that it was a government which started this mess, by creating the tax dodge which forces people to surrender their health care choices to their employers. In that sense, the government created this mess, and perhaps only the government can solve it.
This situation is far more serious than it has been portrayed to be. What the Health Care providers are doing to themselves to combat managed care is, in my opinion, more damaging and likely more permanent than what the HMOs are doing to providers. A central feature of this financial war is the aggressive assault by insurers on hospitals, to force them to reduce prices. In responding to this assault, hospitals have attempted to band together to resist demands for discounts. The usual method is for a nonprofit hospital to create a for-profit subsidiary and then sell it. That leaves a nonprofit shell with a lot of money, and no fixed mission to spend it on. In the Philadelphia region alone, I am aware of for-profit conversions foundations which have as much as $280 million in assets, and it seems likely the aggregate is nearly 4 billion dollars in what was once the community's reserve for charity, teaching, and research. That buffer is now out of the hands of the hospital operating units but remains threatened by potential claims of bondholders of municipal bonds sold for the original purpose of building hospital structures. If managed care finally succeeds in causing a train wreck of the community health delivery system, this reserve is going to be unavailable.
Hospitals are not the only entities which are merging in response to the managed care threat. Indemnity health insurance companies, or insurance with minimal managed care, may be defined in the present environment as providing "generous" health insurance. However, these generous health plans are being driven out of the marketplace by a quirk known as "adverse risk selection." Whatever an employer provides a choice of several health insurance options with fixed dollar employer contributions, it is well recognized that this system will quickly destroy the most generous options. Persons who perceive they will have significant health costs next year will tend to select the most generous plan, thus driving up its premium. On the other hand, people who perceive they will have little or no health costs next year will select the cheapest plan regardless of its benefit provisions, since they see it as buying nothing but a card in the wallet. And with a disproportionate number of clients who make no health claims, the premium of the cheapest plan is driven down even further. The adverse risk selections process will thus send the most generous plan into a "death spiral", and the following year the process will be repeated with the next most generous plan until eventually nothing but managed care is left, the more obnoxious the better from the insurer's point of view. The health benefits provided by Harvard University to its employees experienced this death spiral, in which the most generous plan went from being the most popular choices to having zero clients, in three years after Harvard instituted a fixed contribution system, while the other Boston employer plans showed no such tendency. I imagine that many faculty members of Harvard would claim to believe that healthy people should help share the costs of people who are sick. However, their own behavior seems to show that in fact, they are quite unwilling to pay their own actual costs, once the subsidy by well people are removed.
Hospitals are not the only ones merging. The statewide Blue Shield plan (which pays doctors) is involved in a contested merger with Western Pennsylvania Blue Cross (which pays hospitals), within a resulting combined entity called Highmark. Highmark is requesting a 22% rate increase, reflecting a loss of about $300 million last year by the Western Pennsylvania Blue Cross. Since no similar loss by Blue Shield is known, a concern must be expressed that premium payers in Central and Eastern Pennsylvania will be in effect subsidizing losses in Pittsburgh. This disturbing development can be ultimately traced to the destructive effect on Blue plan indemnity insurance by HMO managed care; the Blues are on the edge of an insurance "death spiral," which they are attempting to stop by engaging in managed care themselves. any number of innocent bystanders are liable to be hurt in the process.
The one legislative charge which would probably correct the whole managed care mess is to extend equal tax exemption for health insurance purchased by individuals. That change is only possible for the United States Congress. It was well on its way toward passage in the Kennedy-Kassebaum bill when it suddenly got limited in a variety of ways. I happened to meet one of the authors of the bill at a social function and asked why it happened. The answer was, "I was afraid I might hurt the insurance companies."
I hope you find these remarks useful. I would happily answer any questions.
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.
