George R. Fisher, III, M.D.

Obituary

George R. Fisher, III, M.D.

Age: 97 of Philadelphia, formerly of Haddonfield Dr George Fisher III

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.

Lithuanian Law

The Right Angle Club was recently entertained by its rugby-playing, Kilimajaro-climbing member, John Wetzel, about his two-week stint teaching law students at the University of Vilnius. This ancient Lithuanian institution was founded in the 15th Century by Jesuits, and after a bumpy history of invasions and occupations has now re-established itself. It participates in Erasmus mobility, meaning it is one of 47 European universities which exchange credentials and permit students from any one of them to take courses in any other member of the association; evidently, similar mobility of faculty is also part of the concept. It sounds like a great idea, which American universities might well consider.

For reasons not entirely clear, 75% of the law students at Vilnius are female, and the whole local legal profession is similarly woman-dominated. John made several allusions to the general pulchritude of his students, which a class picture with him confirms. One striking feature of such a picture is how slim the ladies are; this is another European feature our own representatives might consider imitating. Since there are 2500 law students in a country of 3 million inhabitants, whose main industries are agricultural, balance is restored by only admitting 15% of the graduates to a passing grade on the bar examinations. It seems remarkable that studying law remains so popular under the circumstances, but it was explained that most of the graduates end up working for banks or government. Governments including our own frequently feel their laws don't apply to themselves.

University of Vilnius

If you think about it, a country which is attempting to convert from a Soviet colony to a member state of the European Community has a lot of loose ends to tie up. The title to a property is regularly clouded by the experience of confiscation by the government and then subsequently return to a free economy; if banks accept such collateral, there may well be a lot of legal work to be done to assure its security. Since the thirty-odd members of the European Community all have different legal systems in different languages, all banks and businesses which attempt to operate across borders require partners or consultants in law firms in many countries. While there is a continuous effort being made to establish some uniformity of laws in the various nations of the Community, it takes a fair amount of study just to know what the laws are and how they differ. Therefore, while a handful of lawyers are sufficient to appear in court in disputes and litigation, a great deal more legal background is required, just for businesses to know how they are expected to behave.

Since, as Justice Holmes remarked, the life of the law has not been logic, it has been experienced, it emerges that a great deal of effort must be expended to create the logic when there has been no preceding useful experience. The example is offered of American bankruptcy law, which did not exist until Robert Morris forced its creation. Morris had become an enormously wealthy man, and thus created an enormous tower of debts when his speculations failed, amounting to the then-staggering sum of $12 million of debt. They put him in debtors prison on Walnut Street, but that scarcely addressed the real problems of all those creditors tangled up in the mess. Lithuania is in a similar position, and although it has created a bankruptcy law for corporations, there is as yet no bankruptcy law covering individuals, and hence credit cards, etc. are difficult to establish.

There is a notable difference in attitudes between the eastern nations which were former members of the Soviet Union, and are intensely eager to learn more about the evolution of American law, and the more western parts of Europe, where disdain and hostility for American exceptionalism is presently dominant. A moment of reflection about this difference in a situation should make Americans more tolerant of western European problems. If the logic of law evolves out of the contemplation of experience, it may well be easier to begin without any usable experience, than to begin with centuries of experience which has to be re-examined. It must in fact be a wrenching experience, but one which has the potential to teach Americans a great many things we never had to cope with. The eventual outcome should be a healthy one, providing of course that we can keep our tempers, and acquire a little humility along the path.

Co-Insurance (2)

New blog 2013-07-01 16:26:04 contents

It's a convenience for the insurance company perhaps since it reduces the insurance cost by 20% and is easily figured on the back of a salesman's envelope. Therefore it helps in the three-way negotiation between the employer, the insurance company, and the union. The union calculates how much income tax the employees save by how much income is split between the "fringe benefits" (non-taxable) and the "pay packet" (taxable), and the negotiations shift around these offsets, usually at the end of grueling collective bargaining.

It was once explained to me that Co-pay was very popular with negotiators for unions and management because it was easy to calculate the total cost of it for an entire self-insured corporation. If a proposed budget for the employees was known, and the budget for health benefits was agreed, the arithmetic was easy. If the company has a 20% co-pay, it can reduce the company's total insurance cost by 20%, and if it doesn't come out right, you can negotiate 18% or 22% or whatever. Late at night when these negotiations characteristically get serious, the cost of the offer and counter-offer can be quickly calculated. By contrast, if a deductible is proposed, you have to know how many people use the program, how often they would get sick per year, and even so the calculation is difficult, requiring actuaries or at least accountants. So, the explanation ran, everybody, likes co-pay, and everybody hates deductibles. The insurance people present especially like co-pay, because there will soon be a demand to add it to the package as second insurance, and the premiums for that are also easily quoted, up or down as the negotiations proceed. When it got to involve Medicare and Medicaid, the Congressmen were in essentially the same position of only wanting to know what bulk costs of the whole program would be. In short, co-pay is easy to "score". But the best that can be said for it is, it's just another short-term benefit for which long-term costs are increased because there are diminished incentives for the third-party to hold them back. Just kick the can down the road.

It has never seemed completely credible that anyone would base expensive decisions on considerations so trivial, but you never know. Having invented Medical Savings Accounts with John McClaughry in 1980, for me the mysterious resistance to high deductibles has never seemed adequately explained. Negotiators must easily see that two (or three) insurance policies will be more expensive to administer than just one. They must immediately acknowledge that being 100% insured will increase costs by making the beneficiary ignore the cost, and they are probably willing to accept (off the record) the American Actuary Association's estimate that costs are thereby increased 30%. That much alone would free up about 5% of the Gross Domestic Product since we are currently spending 18% of GDP on Health care. There has almost seemed no point to go on that wages could be increased by diverting this wasted money to the pay packet, to say nothing of the frustration many doctors feel at having no idea of the true cost of what they order, and hence little interest in making the number smaller. Obviously, if true costs are concealed, they go up. This blinding of the doctor to true costs is what makes cost-shifting easy to do without criticism. The absence of a pool of deductibles makes it impossible to generate compound interest, and that in turn makes it less practical to consider "portability" of health insurance from one employer to the next. It is at the very root of fictitious costs for medical care of all sorts, which somehow seem to the advantage of many participants in the health field. Eliminating co-pay would result in a small saving, and it probably would result in a big saving in healthcare costs. The aggregate national savings would be astonishing. Health Savings Accounts are slow to be adopted, not because they fail to save money, but because state laws have imposed mandatory insurance benefits for small-cost items, apparently passed for the main purpose of undermining deductibles.

Most people initially resist the idea of a high deductible on the ground that poor people can't afford it. When it is explained that what is intended is basically to give the poor the money to pay for it, most resistance disappears. A more correct description is that some method is constructed to give them the money, but in a way that allows them to spend money left over from healthcare, for something else they want to buy. The ability to buy something else is not the same as wasting it, and safeguards are only prudent. Retirement is the use most commonly considered. Because interest rates are being suppressed by the Federal Reserve, this proposal may be somewhat retarded for a year or two, until interest rates return to normal levels. Addition of an inflation-protection feature (like TIPS) might well enhance its attractiveness. Ultimately, the first step would be to eliminate Co-pays. Completely and permanently.

Reflections on Age Groups

Only the age group 20-65 contributes much revenue to health care, but health costs affect every age group. In fact, children and retirees probably run up more health costs than the group paying the bills. Obstetrics and terminal care are among the most expensive services which the medical industry provides, and absolutely everybody is born and will die. Therefore in modern society, one of the most essential services a nation provides is for some mechanism to transfer the medical costs of people who can't work, to other age groups who can. There's nothing hidden or underhanded about it, that's just the way things have to be. The fact that working-age people themselves have fewer illness costs than their dependents is an awkwardness of our present state of scientific advancement, but nevertheless, it makes working folks restless; it tends to destabilize the societal compact, and therefore it is a thing to obscure if we cannot remedy.

But since we cannot make it go away, the problem-solving approach is to make the transfers as painless as possible. It soon splits into two issues: how could we equitably transfer the costs of being born, forward into debt for later repayment? And, secondly, how could we transfer the cost of dying, backward into a debt openly anticipated by every working person? Insurance has already made a start on paying for coming death, so the hard part is to convince the eight-pound squalling infant that he must expect to pay for a birth he never asked for, plus nurturing that may appear to have been deficient? Multitudes of distraught parents of teenagers have decided these obstacles are too daunting and throw up their hands. The fact remains, however, that if we could find a way to do it, the reward would be 26 extra years of compound interest. In our way of calculating at 10%, that would be more than three doublings or eight dollars in return for one. Let's just day-dream a minute. If you have a child a dollar at birth, it would be worth $4000 at age 90. But if you gave him a dollar at age 26, it would only grow to $512 by the time he is 90. The difference is roughly $3500, per person, per dollar.

That amounts to $18 trillion extra dollars if you gave just one dollar to each one of the 4.5 million newborns in America, but at birth rather than compared with age 26, and held it at 10% interest to age 90. Don't bother to quibble about inflation or recessions, or wars, or cures for cancer. The staggering magnitude of the numbers should be enough to convince almost anyone, that it would make a big difference if we could find a way to include an extra 26 years to the remaining life expectancy of the child compared with attributing those 26 years to a child's parents. How in the world could we do it?

Instead of arguing about how much less than $18 trillion it would actually prove to be, because of all sorts of objections, let's agree that doing it would still amount to a ton of money. Let's assume that loans between parents and children are interest-free and that subsidies to poor people of much greater than a dollar are seriously contemplated by every single proposal for health care reform ever devised, and let actuaries and accountants devise proposals for the best way to do it. It requires us to consider lifetime health costs instead of just next year's costs, and it requires both a trustworthy institution to suggest mid-course corrections and a monitoring system which can keep a wet finger to the wind. And it requires an extensive and extended education program for the public, in order to make it inconceivable (as presently it is not inconceivable) that such enormous sums would attract dishonest custodians.

There's a second problem at the other end of life. For better or worse, we have an existing Medicare program which is working reasonably well. Changing it in any way encounters immediate resistance, and indeed changing anything else in the government arouses the suspicion that Medicare will be cut, pay for it.

The most generally accepted way of reducing Medicare costs is to increase the retirement age at least to age 70, and perhaps 75. For one thing, we must not allow a thirty-year vacation at the end of life to become a national entitlement, if only because eventually the rest of the world will figure out how to compete with such an unsustainable model

And finally, we must recognize that a growing proportion of the health costs of the nation are self-inflicted things like alcoholism and drug addiction, to say nothing of obesity and unwise nutrition

(expand the last three paragraphs)

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SECTION ONE: Health Savings Accounts and its Competitor, in Brief

Health Savings Accounts and its Competitor, in Brief

Torie

The first graph is a family of curves, showing what we are already spending per person for healthcare, compared with the revenue could be projected by investing the same amounts at several rates, and not spending any of it for health. The graph shows the revenue as it enters the system, at various interest rates, from birth to age 90. It's unrealistic because it assumes no cost for health, all of the money going for retirement income. But it's the theoretical maximum to be achievable for retirement alone at present, at the longevity predicted, by the time you reach it. It's pretty convincing we have enough money for retirement if we don't get sick. The second graph chooses 6.5% compounded quarterly as the present achievable maximum net after inflation, imagined as a more realistic maximum, and subtracts present levels of health expenditure at various ages, produced by the Secretary of Health. The third comparison is the recirculation of a $400 subsidy at birth, assuming the Affordable Care Act or its replacement is cost-neutral from age 25 to 65, adding the present level of withholding tax for Medicare during the working years, and no premiums thereafter. All of those graphs are designed to show what we have to work with, under various assumptions, all of them including the present cost of Medicare. The final two graphs show the addition of the first and last year of life subsidies at $400 at birth compounded at 6.5%, with and without current levels of spending (the addition of 3% revenue inflation is in theory offset by a 3% inflation of costs).