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
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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.
One of the functions for America's first hospital was proposed by Benjamin Franklin and Thomas Bond to be the humane treatment of Lunaticks, who would otherwise be wandering the streets of Philadelphia. Nearly three hundred years later, it is possible to look back on the topic and see an uncertain history.
Essentially, the pendulum swings between a humane goal of bringing these poor victims inside, out of the weather, on the one hand, and getting them out of those snake pits so they can enjoy the benefits of being part of the community, on the other. Every couple of decades, the disadvantages of one approach attract attention, and public opinion demands the opposite. Even the era of effective treatment, which began with Thorazine in 1960, has not relieved the central difficulty, because these people often or usually rebel and stop taking their pills; it is not clear that forcing them to take pills is any greater denial of liberty than forcing them to live in a small room. In 2006 and for the prior five years, a grizzly, disheveled old man who talks to himself has pulled old cardboard around him and slept on the steam grate across the street from the Pennsylvania Hospital. Occasionally, someone summons a passing patrol car which sometimes does and sometimes does not, haul him away.
In March 1765, a remarkably neat and tidy sailor was admitted to the Hospital as insane, and was kept among the other insane patients in the basement rooms. He wandered out, however, and was chased around until he took refuge in the glass cupola that still adorns the roof of the East wing, facing Eighth Street. It was obvious that he would soon have to come down to eat, but the Quakers who ran the hospital at that time would have none of it; they didn't starve their patients. So a mattress was passed up to him, and regular meals. Nothing much could be done about the cold, which must have been pretty severe, but the patient was allowed to remain in the cupola until 1774 when he died. Nine years of room service in the cupola.
In 1790, the wife of Stephen Girard, the richest man in America, became insane and was admitted. The hospital felt she could go home in a couple of months, but her husband insisted that she stay. She died there, twenty-five years later. At today's rates, comparatively few people could afford that approach, even if the ethical issues could be settled. However, for over a century a great many people were essentially domiciled in the chronic psychiatric unit at Market and 44th Streets
For fifty years after that, a subacute psychiatric unit was maintained at 49th and Market, but ultimately the Federal Government found a smokescreen of confusion, sufficient to hide the awkward political backlash. One by one, the huge human warehouses at Byberry, Philadelphia General Hospital, Bellevue in New York and similar places, went out of business. The public wouldn't stand for "snake pits", even Medicare couldn't afford to put millions of insane people into luxury hotels like 49th and Market. And even though there were a few hundred or even a few thousand families that could afford to pay for humane domiciliary care, they had to be sacrificed. A government medical system, essentially run as a political pork barrel, can not afford to permit the continued existence of a visible rebuke by a two-class system.
So, now we're giving these people the benefit of integration into community life, right?
The brownstone house at 1710 Spruce Street is seemingly not remarkable, it's just an Edwardian house now converted to lawyers' offices on the first floor. But it's nevertheless a landmark, curiously linked to that 13-foot statue of Diana which dominates the top of the main interior staircase of the Philadelphia Museum of Art. Many Philadelphia gossips believe the model for the statue was Evelyn Nesbit, who lived in the brownstone on Spruce Street. But she was born in 1884, whereas Augustus Saint-Gaudens created the statue for the 1892 Columbian Exhibition. Since Evelyn was only eight years old at that time, however, it must have been some other woman who took off her clothes to pose for the sculpture; for us, it doesn't matter who she was. The statue was moved to the top of Madison Square Garden when that structure was really still located on New York's Madison Square, but when the Garden was demolished in 1925 the Diana statue came to Philadelphia. Madison Square Garden itself has moved twice in the meantime and is mostly associated in the public mind with prize fights and political conventions. However, when the first Garden was built, it had theaters and roof-top restaurants, and its spectacular nature instantly made the architect, Stanford White, the most famous architect in New York, eventually maybe the most famous one in the world at the time.
Thaw
Meanwhile, two residents of Pittsburgh independently came to New York where the action is, the iron and coal millionaire Harry K. Thaw, and an impoverished teenager named Evelyn Nesbit. Evelyn was accompanied by her mother who, recognizing the girl's extraordinary beauty, set about to steer her to fame and fortune. At the age of thirteen she was posing for artists, and in time became the favorite model for Charles Dana Gibson. Gibson created the "Gibson Girl", an idealized role model for millions of women who dressed the way she did, wore their hair the way she did, and behaved in the proper Edwardian style they imagined she did, too. It was in Gibson's studio that she encountered Stanford White. Evelyn had another life, however, as a "Florodora Girl", and one of her many stage-door Johnnies was Harry K. Thaw, the millionaire. That was no saint, having a reputation for using a dog whip on his numerous lady friends, but it is uncertain whether he was completely aware that
Evelyn Nesbit
Evelyn was one of the principle entertainers in half a dozen hide-aways that Stanford White is said to have established for naughty parties to amuse New York's fast set. That was certainly aware that Stanford White had been Evelyn's boyfriend before Thaw married her, and the two men cordially hated each other. One evening, some provocation made Thaw walk over to White's table in the rooftop restaurant of Madison Square Garden, and shoot him dead -- in front of hundreds of people. It's a curious sidelight that Stanford White was carrying a train reservation to Philadelphia, to discuss plans for the domed structure of the Girard Bank building. The notoriety of the murder trial was the sensation of the decade, with the prosecutor remarking that White deserved what he got, and Thaw's mother offering Evelyn a million dollars if she would give testimony supporting a plea of insanity. Everyone seems agreed that the money was never paid, although the jury was sure as impressed as the newspaper reporters with Evelyn's refusal on the witness stand to testify against her husband, quite evidently a sign of loyalty. Anyway, the jury let him off, and a famous cartoon depicted Stanford White in the pose of the statue of Diana.
Joan Collins
as Evelyn Nesbit "The Girl in the Red Velvet Swing"
Evelyn sort of dropped out of sight after the trial and the subsequent divorce, until TV interviews were conducted for the movie about the episode, \"The Girl in the Red Velvet Swing". By 1957, Evelyn was decidedly less of a beauty. Meanwhile, Harry K. Thaw had continued to live in the brownstone house in Philadelphia, where once he got sick and called a friend of mine to be his doctor, and eventually another famous professor to be a consultant. When the butler answered the door, the consultant told the butler to tell his employer that he must insist on cash in advance, an action that thoroughly embarrassed my friend in view of the famous wealth of the client. But the consultant had rightly assessed the situation since later Thaw's lawyer called up and told the family doctor he was sorry but his client was not going to pay his bill since the medicine was started by some botanical book to be a poison in excess quantity. In consternation, my friend called up the professor and asked what to do. "Chalk it up to experience," was the answer. "But what have I learned?" The consultant paused, and said, "Maybe you have learned to extend credit only to decent people."
Philadelphia is turning inside out. It used to be a commercial, financial and business center, surrounded by beautiful suburbs. It is now turning into a marvelous urban residential area, surrounded by a ring of commerce based on the ring of interstate highways. Commuters leaving the city in the morning outnumber the commuters coming in, and traffic jams are worse in the outer ring.
Phila Skyline
More precisely, the metropolitan area is a series of concentric rings. The bull's eye is Center City, with urban residences, culture, entertainment. Immediately surrounding the bullseye is a ring of decaying industrial slum. Surrounding that are the suburbs, and beyond them are the new malls and industrial parks. Further out is exurbia, where Philadelphia's "equestrian class" is mixed with what is left of the farmlands, rapidly being invaded by McMansions intended for employees of the commercial ring. Some people live their whole lives in just one ring.
Somewhere near Washington's old encampment at Valley Forge there is an invisible line. The people who live inside that line, live in Philadelphia. But just one house further out, on the other side of the invisible line, the orientation is toward central Pennsylvania. The people outside the ring mean "Pottstown" when they say they are going to town; if they say they are going to The City they mean "Reading". Going to Philadelphia is for them like going to Paris; they did it once.
There are other invisible lines. At the edge of the central city bullseye, there is gentrification; yuppie families are renovating the 19th Century mansions their grandparents abandoned for the suburbs, displacing working-class families who lived for a generation or two in decaying grandeur. The local bars are inhabited by one class, the neighboring restaurants are where the newcomers hang out. Beer in one, wine in the other, and sour looks when members of the wrong class blunder in. In London, you see the same thing, except it is usually a single building with two entrances.
There is another border region out further, where upwardly mobile minority groups are pushing out toward the suburbs. Curiously, working-class Philadelphia always tended to live in "neighborhoods", and their out-migration has more commonly leap-frogged to "Jersey", their places being increasingly taken by Asian immigrants.
Note: This article was written in 1999, long before Computerized Medical Insurance Exchanges were such a disaster:
First Computer
My first encounter with a computer was in 1958, and I have loved them ever since. As president of what called itself the Delaware Valley Hospital Computing Society, I remember giving a dinner speech concluding as follows: "If you want to be happy for a day, get drunk. If you want to be happy for a week, get married. But if you want to be happy for a lifetime, get a computer!" After fifty years, my affection continues. But to be candid, billions of dollars about to be spent on computers in medical care will mostly be wasted. Even worse, like malpractice suits computers will induce behavioral changes in the system costing far more than the directly visible costs.
That's unpopular news at present since the National Business Coalition for Health has launched a major lobbying campaign to persuade Congress to spend an initial billion dollars inducing physicians to maintain an electronic medical record. Various health insurance companies already provide financial incentives to doctors to file electronic claims forms, eventually threatening to reject any claim submitted on paper. The American College of Physicians has established a rather large department to develop programs for physicians to use in their practices; twenty years ago the University of Indiana started much the same thing. The College of Physicians of Philadelphia has spent close to a million dollars on such a project. It is reported that Microsoft Corp. has a massive project underway to supply electronic medical records. It sounds fairly easy to obtain large research grants from the government to devise something, anything, useful in this area. In my own case, training funds really weren't necessary, since I eagerly got into the field when everybody was a beginner. I was just as good a beginner as any other beginner. But let me repeat: the electronic medical record has been in the past and will be for decades, an expensive digression. In health care, creating more administrative work isn't the solution, it is the problem.
For fifty years the problem with an electronic medical record was that it took too much of the doctor's time to complete his part of the input, and then cost him too much to pay employees to do the rest. Presumably, automatic voice recognition and dictation will soon make it possible to record doctor's notes without handwriting or typing. Since, however, the elimination of current paper forms and check-off boxes will create a major problem in organizing the dictation verbiage, it could add five or ten additional years before programmers manage to rearrange dictation material and effectively integrate it into organized form, complete with laboratory results, dictated x-ray and EKG reports, even small images of the original material. Temperature, blood pressure, weight, photographs and the like can all be readily integrated into the stored electronic record, but to do so usefully is an expensive programming project. Doctors are quite right to be anxious they will lose control of the usefulness of their records in order to ease the task of programmers, speed up the sluggish pace of development, and reduce what will surely be an unexpected cost overrun. Storage and retrieval of such records is known to be an achievable but expensive task, which however also risks sacrificing the speed and ease requirements of the medical task it is supposed to serve -- in the name of cost-effectiveness.
Computers are no longer an unfamiliar tool; physicians have altogether too much experience with "vaporware", unrealized promises of convenience, and the damaging effect on the medical quality of the philosophy of Quick and Dirty. To respond to their resistance to design blunders with an accusation of undue conservatism is to provoke an icy stare and gritted teeth. Inevitably, the effective use of automation will require a redesign of workflow with major disintermediation of "gopher" staff; after all, that is how cost savings are to be achieved. That will provoke outcry that physician time is the most expensive component in the process, but unfortunately, physicians will discover Information Specialists with a business background will brush that argument aside. The most overpaid people on the face of the earth are investment bankers, but information consultants have persuaded business executives that inefficiency of the investment process is more expensive than even an investment banker's time. Having been through this themselves, insurance executives are unlikely to pay the slightest attention to physicians dancing to a familiar old tune.
For all that, data input is not the real problem; it's just the first problem. It's in a class with data storage and retrieval, which is expensive and cumbersome when you add a need for instant access and total privacy. But costs will come down steadily, and eventually, we can expect automated fingerprints or other biological identification, and cheap instant retrieval. Doctors will be able to make rounds in the hospital with a computer in their pocket, record telephone calls in their entirety, dial automatically and whatnot. There are problems with wireless transmission inside buildings with steel girders, and legal requirements for signatures on narcotic orders, but if we are determined, these problems can be overcome as easily as they were with electronic check writing and stock brokerage. Cost may top twenty billion dollars in twenty years, but it all can be done if we insist.
But then you encounter the real problem. Information will accumulate in these records in staggering amounts. Even if you resolutely resist demands to have the nurses record every groan, and the orderlies file every laundry slip, the legitimately important medical information will be exposed as the massive heap of transients that they really are. Plaintiff lawyers will insist no scrap of data may be deleted, hospital administrators will insist on compliance, when in fact most of a doctor's concentrated effort is devoted to brushing aside momentarily distracting data in order to see what's going on and react to it instantly. When a quick look doesn't solve the problem, the doctor goes back for additional data. If you disrupt these skills and traditions of coping with information overload, evolved over centuries, you will at best impose frustrating delays on a complex system under pressure, and ultimately inspire elaborate systems of short-cuts. The Armed Forces are famous for paperwork, but even they know better than to ask a pilot for his Social Security number as he starts a bombing run. The hospital nursing profession has already just about collapsed under paperwork pressure. If you see five nurses in a hospital, three of them will be sitting down writing something. The terrible truth is that no one reads it, no one checks it, and ultimately it sits in the record room waiting for a plaintiff lawyer with unlimited time to sieve out some misrecorded misconception or uninformed conclusion. My faith in the computer is such that I feel sure that methods can be devised to produce periodic summaries, automatic alarm signals, and mostly effective prioritization of data elements. Unfortunately, medical care is changing at such a rapid rate that ad hoc automation of physician thought processes cannot keep up with the current pace of change in medical progress. You would think some things would be unthinkable, but since I can remember the organized campaign to suppress the CAT scan as an unnecessary expense, I confidently predict that programmer inability to keep up with some advance in medical care will at times lead to organized outcry that we should slow down the pace of improving medical care, so that computer clerks can keep up with it. But that is only a small part of the issue, which at its center is that physician time will be dissipated and his attention distracted by presenting him with unwieldy amounts of neatly printed, spell-checked, encrypted and de-encrypted, biometrically secure, hierarchically prioritized -- avalanches of data which are irrelevant to the issues of the moment. The goal is not, after all, an electronic record. The local goal is to decrease the cost of medical care by increasing the productivity of the physician, and the overarching goal is high-quality patient care at a reasonable price. Behind all that, since the impetus comes from NBCOH -- the ones paying the insurance premiums -- suggests that the local goal is not so much the improvement of care as oversight reassurance that cares provided has been as good and as cheap as possible. The goal is legitimate, but this cybernation approach looks to be self-defeating by being overly specific.
If the reader has the patience for it, let me now cite a historical example of the third-party tail wagging the medical dog. In this case, third-party health insurance similarly overextended its reach by imposing internal health system changes, trying to facilitate the role of monitoring it externally. Specifically, the system of diagnostic code numbers was changed from one devised by the medical profession for its purposes, into a different coding system devised outside medial profession sponsorship, which seemed to suit the needs of payment agencies better even though it suited medical purposes less. After twenty-five years, it is now clear that third-party payers have shot themselves in the foot on this matter, and everyone is worse off. The topic, please pardon the obscurity, is the diagnostic coding system.
To go back to beginnings, the American Medical Association perceived a need for a diagnostic coding system in the 1920s. Organizing or even merely indexing vast amounts of information about a disease required more specificity than freestyle verbal nomenclature could provide. Quite a distinguished panel of specialists and consultants then produced the Standard Nomenclature of Diseases (SNODO) which in time became the Standard Nomenclature of Diseases and Operations. In order to reduce ambiguity, this system developed a branching-tree code design for anatomy, linked to a branching-tree for causes of disease, ultimately linkable to a branching tree of procedures. These three sets of three-digit codes linked the components together with hyphens (000-000-000). The first digit of each was the most general, as in Digestive, Musculo-skeletal, etc. and subsequent digits were progressively more specific and detailed, as in "Digestive, large intestine, sigmoid colon". The causes of disease would resemble "Infections, bacterial, streptococcal". An example of Procedures would be "Incision, incision, and drainage, drainage and insertion of the drain". In nine digits, it was thus possible to represent " incision, drainage, and insertion of a drain into a streptococcal infection of the sigmoid colon". After a while, the codes grew from three to five and six digits, again repeated three times, so an immensely detailed, unambiguous description might be coded in fifteen digits by a physician who knew the rules but didn't own a codebook. This code was ultimately taken over by the Academy of Pathology, expanded and is called SNAP. The pathologists absolutely refused to give it up.
The rest of the profession gradually yielded to the pressure of hospital administration, who was pressured by the Association of Medical Record Librarians, responding to the views of outside statistical interests, particularly insurance. A simpler, shorter coding system was needed, they felt, concentrating on the thousand most common diseases. The International Classification of Diseases was produced, reducing the millions of SNODO diagnoses to 999 by heavy use of several varieties of "Miscellaneous" or "Not Otherwise Classifiable (NOC)". Since the goal was to count the incidence of common diseases, the coding system was stripped of any logical tree-branching and became a short list of what was most common, starting with 1 and going to 999. In time, of course, the common-ness of conditions changed, and various complaints from various directions forced the ICD to go to 4 digits, then five. Unanticipated conditions or complications eventually required the patchwork of some alpha "modifiers", and the original short hodge-podge became a long and bewildering hodge-podge. Coding accuracy declined markedly, but ho-hum. The health insurance companies paid the bill, no matter what the code said. At another place, we will discuss the entertaining way that Ross Perot became a billionaire out of the computer chaos of Blue Cross and Medicare at this time, but right now the central theme to follow is DRG, Diagnosis Related Groups. Try to follow, please.
By 1980, Medicare was fifteen years old. It was clear that certain things just had to be changed because the excuse that the system was new and untried was beginning to wear thin. The early designers of the system based their payments on auditing a hospital's yearly costs, auditing the proportion of patients who were Medicare beneficiaries, and paying a proportionate share. That was easy and reasonably accurate, but it had a rather significant flaw that it took no account of whether the patients needed to be in the hospital in the first place. Or whether they needed to stay so long. The response they adopted (in the Budget Reconciliation Act of 1983) is a measure of just how desperate they must have felt. Knowing full well how inaccurate the ICD coding system was in practice, it was all there was. Consultants, particularly at Yale, ran computer simulations of various subsets of ICD codes to find a formula that would produce approximately the same hospital payments as the system of cost reimbursement. If memory serves, the original formula was to divide the thousand ICD codes into 27 diagnosis-related groups (DRG). Eventually, the process was tweaked to seventy or eighty groups. Walter McNerny, then Past President of the American Hospital Association told Congress hospitals could live with this system, and promptly we had a system for paying out hundreds of millions of dollars. It was touted as a highly sophisticated advance in the arcane science of hospital reimbursement, so it must have included a lot of deliberate overpayment. I can remember trying to remonstrate with McNerny, who felt he didn't have time for the discussion. Physicians had very little to do with the DRG portion of the 1983 Medicare Amendments because the AMA had long insisted that physicians and hospitals go their separate ways on reimbursement. Russell Roth, who was president of the AMA at the time, recounted many times the episode in the Oval Office, when it was announced to Lyndon Johnson that Dwight D. Eisenhower"was in the next room waiting for him. LBJ excused himself to leave, and on the way out said to Wilbur Cohen, "Give him anything he wants." Things were destined to change, but at least for a very long time, physician and hospital reimbursements were strictly independent.
Three Different Ways of Looking at the American Revolution.
If you are a resident of nearby Boston, the American Revolution began on April 19, 1775, at Lexington and Concord for reasons having to do with smuggling and tea. If you live near Philadelphia, the chances are fairly good you believe the Revolution began on July 4, 1776, because Admiral Howe attacked us. What's this all about?
The colonies had fought the French and Indian War loyally together, with George Washington at Fort Necessity and Ben Franklin supplying wagons to General Braddock with his own money, against the hated French and their Indian allies, English colonists fighting off the enemy, side by side from 1754 to 1763, even back as far as traveling together to the Albany Conference in 1745. Ben Franklin drew the first newspaper cartoon, Join or Die, at that time, and first proposed an alliance of the thirteen English colonies with the homeland. The Quakers would probably still dominate Philadelphia, if they hadn't chosen religious consistency over the dictates of power. And yet a few years later the British were chasing gunpowder stores around the countryside. The British wanted the Americans to help pay the cost of their own defense, but we were all Englishmen, together, and everybody wants something for nothing. New Englanders wanted a negotiated arrangement like Ireland or union like the Scots; these were only technical details.The slogan aimed at representation, not independence. "No taxation without representation" for English-speaking colonists. Eventually, they hoped for parliamentary membership. They were mainly fighting against mercantilism using taxation as a weapon to fend off taxes while they remained English settlers. Franklin wanted a little more, moving the capitol to America because it was biggest, and he nursed this view until King insulted him in person,a few weeks or months before he grudgingly returned to America to help lead the Independence movement.
But this is the story of the forming of the Constitution, and in the fight to remain untaxed, English settlers got left behind and will be left to drift along. Got left behind by the Treaty of Westphalia. Everyone hates to be persuaded of something which hurts his self-interest, and Westphalia said the land became private property if the King had the exclusive right to adjust the borders, and by implication the local religion. That may have been useful in dealing with Indian lands, but in the sixteenth century, people took their religion pretty seriously. That was a serious matter, and it was made worse for Protestants as a consequence of Catholic activity in which Protestants played no role. Even worse, it was accepted by an English King who was German about whom Episcopal Englishmen had some reservations. And still worse was to see German Hessian soldiers about to do most of the fighting arriving in the troop transports, paid for by a German King, enforcing a law most of them didn't understand which had unexpected twists to it which sounded like the fight they ware already fighting about taxation without representation. Remember, Ben Franklin only had a second-grade education, and most of the colonists couldn't read and write. There were only a handful of lawyers in America, and most of them had a conflict of interest about this subject, which was cataclysmic in its sweeping implications.
The logic of the new German law which only a few lawyers could follow sounded like a trap. The lawyers back in England at the Inns of Court might explain it, but the essence was that rebellion was punishable by hanging, while Independence was settled by treaty. The colonists might not understand how they got into this fix, but the new legal situation created a much worse punishment for rebellion than for Independence, and hence a strong incentive to prefer Independence. Admiral Howe was only 90 miles away with dozens of warships and hundreds of troop transports, and the Continental Congress was in Philadelphia with the power to make a choice. The Germans had just experienced a large wave of immigration, more German soldiers were sitting in the transports, anxious to obey the orders of a German King, which started as a law passed by other Germans without a vote by any of the colonists affected, starting fight a war about taxation without representation, which hardly anyone had the education to understand.
It was, so to speak, a perfect storm. We came very close to losing that war, so after three centuries it is still true: Whether it was the League of Nations or the United Nations, or changing the Health System -- you have a hard time convincing the American public that it's a good idea to follow he decisions of non-American leaders. If the idea was foreign, and particularly if control is left in non-American hands it's going to be a hard job persuading Americans to vote for it.
england
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.
