The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
... William Penn's Quaker Colonies
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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.
Before the First World War, it was common for prosperous families to have two houses, like migrating birds. There was the big house in center city and a second place to go in the summer to get away from typhoid and malaria. In the early days before municipal water departments, sources of clean water for home use and sewage disposal often dictated the location of such annual migrations. In time, a wider variety of destinations appeared. Summer arrangements might be a summer cottage on a lake or a mansion in Bar Harbor. Friendly local Indians and good land for fresh vegetables or milk cows made an attraction. Usually, there was some sort of recreational attraction, perhaps a summer hotel where the family went every summer, located along a railroad for easy commuting. Along the East Coast, it was common to own a beach house along the Jersey shore, and for fashionable people, it was common to have a summer place along the Main Line. Germantown was the first summer colony, started by the Allen family and soon followed by the Chews at Cliveden, who also had a house on Third Street next door to George Washington, and to Powell, the Mayor of the city. There were Germans in Germantown, of course, but they were not in the same circle, any more than the "permanent residents" of the New Jersey barrier islands mix in with the "summer folk", today. If you look at the big houses along Spruce and Pine Streets, you will see little neighboring houses in the next-door alleys. Sometimes these little houses had three rooms on three floors and were called "Father, Son, and Holy Ghost" houses. Sometimes these houses were for servants, sometimes for local tradesmen.
The implication was that if you had two houses, you must be rich. That's sort of true, but lots of families in Philadelphia had lived in the region for many generations, and had accumulated lots of real estate for the various cousins of a shrinking family. In a sense, a greater portion of Philadelphia savings was locked into this real estate, than in other cities. And there were quicks. One of the traditions of the Philadelphia political machine was to have a dinky little house in some working-class district, but a very large and opulent place at the shore, perhaps in Longport, N.J. It probably isn't necessary to describe the reasons for this.
It later turned out that the geographical size of the city was to make a significant difference. In a small village, there is little difference between the town and the countryside, but after a while, significant differences in taxes appear, particularly when our system of government begins to encourage federal, state and local taxes to become the legal or traditional province of a particular level of government. The tendency was for taxes to focus on government services from which people would be reluctant to flee. If people lived in the city for the schools, school taxes were applied to real estate. The federal system of dependence on income taxes, on the other hand, reflected an indifference to where you happened to live. This started a cat and mouse game among municipalities, states and counties, which unfortunately contributed to the direction of tax flight, when there appeared to be a reason to flee.
Depression of the 1930s
During the Depression of the 1930s, that new threat appeared. Maintaining two houses soon seemed a needless extravagance, and it made sense to sell one of them. At that point, a choice had to be made, and the advent of the automobile made it entirely practical to live in the suburbs and commute to the city. A small town found it made little difference, but a medium-sized city gave the suburbs an attractiveness. In the case of Philadelphia, the city-county consolidation widened the geographical reach of city taxes, before taxes and land values reached the inviting cliff where they abruptly fell to rural levels. By that time, clean water and friendly Indians were less important than taxes and upkeep. Some people had very bad luck in the Market, sold the big house, and moved into the little house behind it. More often than not, the big, house was converted into apartments or just plain torn down, or else it fell into shabbiness and the whole neighborhood deteriorated. After twenty years, everything got so bad in Society Hill, that you could buy any one of the mansions for $1500. It was a spiral, of course, and although you could buy a house for $1500, and resell it twenty years later for a million, during the intervening twenty years it was worth your life to go out on the street at night. Or so it seemed until Richardson Dilworth built a brand-new mansion on 6th Street, and Society Hill started its revival. So, with this little bit of real estate history, you ought to be able to summon up the tolerance to smile, when a senior partner of a law firm at a party tells you, "Philadelphia declined because everybody had two houses, and sold one of them." Not exactly everybody, but mostly everybody in the leadership did.
Richardson Dilworth
In fact, that was seemingly true for everybody, because the cohesiveness of Philadelphia culture led the followers to follow. But there was the next stage, after that. Bargain hunters found their bargains, word spread among immigrants from the South, and mansions turned into slums. To some extent, this migration was balanced by a white migration to the South, seeking cheap land and fleeing expensive union labor. Before long, air conditioning made this a natural, bearable counter-migration. In colonial days, just about everybody had a summer house for mainly health reasons, but now there was a new force causing people to relocate entirely in the suburbs. The tax cliff created by the city-county consolidation artificially raised city land values in anticipation of expanding settlement. It suddenly became cheaper to relocate or rebuild an entire facility just over the city/county line, in accordance with newer concepts of one-story buildings instead of three-story factories near a waterfall. And then a new way of life grew up around this necessity, with only the leaders returning to the city for banking, clubs, and opera "during the season". Invisibly, sanitation and air conditioning had removed the economic reason behind the former social structure, but permanent Philadelphia residents continued its customs while the Gilded Age was invisibly making it all a little silly. But hit it with depression, ruin the industrial base supporting it, and then watch it disintegrate. Housing patterns didn't cause the problem, but new ones certainly made it hard to recover the good old ways, once they disappeared.
Every tennis racquet has a "sweet spot", a place within the stringed area that hits the ball just exactly right with minimum effort, and for that matter, does so with a minimum of noise. If your aim is good, the shot is much improved by whacking it with the sweet spot. In health savings accounts, the sweet spot is that combination of fixed choices over which you have no control, like your age, and independent choices over which you do have some control, like the amount you deposit into the account, or the shrewdness with which you choose your agent. There's a somewhat different sweet spot for males and females, and it will vary with the state of the stock market, or international warfare, during the era in which you had the highest earning potential. In other words, the cost of sickness is the only chance catastrophe we are aiming to protect against. For that narrow purpose, the uncontrollable factor which makes the most difference is
The age at which you started your spending account. Compound interest requires time to work; persons who start their accounts late in life no longer have to pay for their earlier expenses, but they must have some traditional insurance protection during the transition to full dependence on the account, or else some other form of savings. That's why you need catastrophic insurance coverage, but in the early stages of getting established, even that could be inadequate, and nothing can be offered unless the government offers to subsidize it. In order to find a way to capture twenty extra years of compound interest, it is tempting to begin depositing at birth, which is presently prevented by the HSA rule that you must be working to start an HSA. But children have health costs to be managed. In particular, 3% of all health costs are reported to occur in the first year of life. If Congress will allow it, we have a plan in later sections for doing it expeditiously.
Subsidies for the Unemployable, Such as Children. Please do not compare subsidy with lack of subsidy, because the subsidy is always cheaper in the short run. . Furthermore, subsidies are created by the government, and are therefore under pressure to demonstrate equity. Protection in extreme cases must rely on reasoning which placates the "Equal Protection" clause of the Fourteenth Amendment. All forms of insurance contain some incentive not to invest but to squander, and channeling that choice is part of insurance design. Here it attempts to balance a singular opportunity to select the best possible investment opportunity, with the unique ability to spend the proceeds on anything you choose after your health cost has been met. Unfortunately, we have already gone so far with borrowing for health, that many people are of a mind to believe balance can't be achieved. We could go on with this, but a quick summary is there are thousands of possible sweet spots, most of which are partly beyond anyone's control or ability to predict. There are even some circumstances where an individual would be better off putting reliance on Obamacare, trusting the government to bail him out with subsidies; if the nation decided to give equal subsidies for every payment alternative, however, most of these short-term advantages would disappear. The best we can suggest for people who dislike both HSA and Obamacare is, go see your congressman. In this book, we merely suggest that most people would be better off with HSA.
Trying not to be repetitious, there's nothing you can do about your age and sex, or previous state of health. You should have stopped smoking twenty years ago, but you can't help it now if you didn't. Twelve million people already have HSAs; if you aren't one of them, the best you can do is start one now. It's very difficult to imagine a situation in which a late start would inflict harm which subsidy couldn't help. On the other hand, if you make a bad choice of agency, make sure you are allowed to switch to a better one if you can find it. Some brokers charge too much, some of them pick poor investments to get a kickback. Some demand too large a front-end investment, although that may do you a favor in the long run. Essentially, your own choices affect the result, and your main recourse is to invest more than you planned. For the most part, the more you invest the better. If you invest as much as you can and it still isn't enough, you made an investment mistake. It's only a real catastrophe if you then get sick, and Congress didn't provide for those few who inevitably make such a double blunder. In that case, it will have required three misjudgments for a serious mistake to emerge, because even this mishap will be adjusted by aggregate subsidies costing less than the program is able to diminish overall costs -- a very likely outcome.
Interest Rates. Unless you are within a few years of death, or within a few weeks of a stock market crash, in the long run, you are generally better off with stocks than with bonds or money market funds. According to Ibbotson who published the results of all asset classes for a century, the stock market has averaged 11-12% total return for the past century. However, if you maintain internal reserves against a depression, you will probably only receive about 8% as an investor, of which 3% is due to inflation, so figure on a steady 5% after-tax, after-inflation return over the long haul. Use 8% as your shopping guide, resign yourself to 3% inflation loss, and content yourself with complaining about the 4% attrition seemingly imposed by the financial industry. You will find our charts use 5% tax-free as a standard, but show a family of curves up to 12%, just in case someone figures out a better system for harvesting the return. For 3-5 year depressions ("black swans" occur about every thirty years), we show curves of lower returns. Notice endowments and professional investors also figure on 5% overall from a 60/40 mixture of stocks and bonds, because they have a payroll to meet, but you may not. A conservative investor can feel comfortable with a 5% "spending rule", but that assumes a long horizon and the need to make expenditures. Some people have a short horizon and may be able to gamble on a pure stock portfolio because they have some other way to meet medical expenses up to the deductible on their catastrophic high-deductible insurance. But they better know they are gambling, and may, therefore, encounter a black swan they can't cope with. Such people probably need financial advice, because it is also possible to be too conservative if your deductible is comfortably covered. Fear of underfunding may cause the account to become overfunded, but that is scarcely a tragedy because you can withdraw your money without penalty after age 66. In fact, a policy of deliberately overfunding the account at all times never has any great downside, and lets everyone sleep better.
Age at Beginning an Account. If you begin to use an HSA during late working years, you have the consolation that you no longer need to plan for paying for the first forty or fifty years of your own health. However, the years of heavier medical expenses begin around age 45, by which time you have already paid for most of your Medicare payroll deduction, which is about a quarter of Medicare costs. The older you get, the more you have paid with a payroll deduction, but fewer years are left for compound interest to accumulate within the account. Balanced against this is the likelihood you are entering your highest earning years, which carried too far, may tempt you into unwise early retirement. You may need some accounting advice about what is best and still feasible. And you may need legal advice if the laws change.
Younger working people have contributed less to payroll deductions but have longer to earn compound interest in their HSA. People seem to have figured this out, and the largest group of new subscribers are in their twenties and thirties. This is the group with most to gain by proposing a buy-out of Medicare. A quarter of Medicare is paid for with payroll deductions, another quarter by Medicare premiums after you reach 66. If Congress could be persuaded to drop these contributions, what would be left is the half the government pays by borrowing from foreign sources. If you, in turn, agreed to pay off this indebtedness, the government might be tempted to match it by foregoing part or all of your payroll deductions and premiums. Since one about balances the other, the compound interest you earn on your deposits is pure profit. From the government's viewpoint, it might seem a great relief to know the debt would stop growing. Older people are generally so deeply committed to Medicare they would resist, but younger people -- and the Treasury Department -- would find it quite a bargain. Once again, financial advice from somebody good at math is highly advised. When the politics of this matter settle down, it should become possible to state a particular age, below which a Medicare buy-out is safely advisable for anyone. It's almost always in the Government's favor, so independent advice is only prudent. In summary, starting an HSA at almost any age is safe and wise. A Medicare buy-out is wise below a certain age, yet to be determined. In other circumstances, a buy-out is wise if personal finances are comfortable, but right now it would take financial advice to do it. And, of course, a friendly politician to convince Congress to make it legal.
There are two more steps to this transition. But before getting to them, it seems best to run dual systems while you phase one out and phase the other in. It may even prove to be best to run two systems indefinitely. Three principles emerge:
I. It would be pretty hard to run dual systems without also running subsidies for both. This would be part of Equal Justice Under the Law. It's hard to run dual subsidies until you know what the final rules would be. Some subsidies may be difficult to match, and require equivalent subsidies, which are harder to devise.
II. Dual systems and patchwork fixes always provide loopholes for someone seeking to take advantage. Some agency must be designated to keep this in line, using the principle of each system being charged with watching the other one. When you deal with one-seventh of the GDP, tremendous scams are entirely possible. A system of balanced whistle-blowing could effect great savings without the same surveillance costs.
III It isn't necessary to pay for everything. The reader will, of course, have noticed that paying for all of the medical care would save perfectly stupendous amounts of money. But paying for half of it would also save stupendous amounts. And even paying for only a quarter or a third of everything medical would save the economy two or three percent of Gross Domestic Product. That wouldn't be a failure, it would be a tremendous success.
In fact, it might be all the change the economy could withstand for a few years.
The Intergenerational Roll-Over.
The Coming Shift From InPatient to Outpatient Care.
There are two exceptional situations which might also be considered for universal coverage, even mandatory coverage if you insist. They are the first year, and the last year, of life. Some people get Tuberculosis, some people get cancer, some people live to be a hundred. But absolutely everybody is born, and everybody dies. Those are the two most expensive years of most people's lives, they almost always occur in hospitals, and nobody can fake them. The hospitals and Medicare keep careful records, so we know what they cost, both individually and on average. If we reimbursed the average cost to whoever paid it, the administrative expense would be small. The reason for doing this maneuver would be to take these costs out of the catastrophic insurance cost, both smoothing it out, and reducing it by 15%. There would be a transitional cost, because of the differing number of years before death appears. On the other hand, it would take a number of years before the births came up to average. But two major health costs would be universally covered.
The purpose of healthcare financing is to redistribute the pain of paying for it. Otherwise, the patient doesn't want to be sick or die; illness itself is a disincentive to abuse. The concern about abuse mainly arises when someone else pays for it. The indigent patient doesn't want to be sick, either, but somehow that's different. Not only does the public resent the cost, but the public also resents the need for the cost, as well.
Two of the central figures in devising Obamacare -- supposedly free healthcare for everyone -- have framed the issue as to whether it is better to die in America or somewhere else. Just about no one wants to die anywhere, at any time I notice. The mortality figures are too fuzzy to judge whether the extra cost is worth the money, but essentially there isn't enough provable difference among developed nations to assert most care lengthens the lifespan of the patients. Especially for cancer patients. Apparently, the diffusion speed of new knowledge makes it impossible to tell how much it helped. Or else the amount of new knowledge isn't sufficient to show up in such crude data. By that standard, medical care is just as "good", one place or another, one insurance system or another. It just costs more, that's all. When some research laboratory finds a cure for cancer, health care still won't seem to have proved it helped.
But life expectancy will increase; in the long run, costs will come down. It can be very confidently assumed that those who invest their savings early in life will enjoy a more prosperous retirement than those who depend on entitlements.
Not many practicing fee-for-service physicians are invited to address the White House staff on the economics of medicine. But two years ago George Ross Fisher, MD, of Philadelphia, Pa., received a White House invitation to speak about the burning medical issue of the day cost containment.
Now considered to be a prominent spokesman for the Physician viewpoint on this topic, Dr. Fisher started on the road to the White House podium when he wrote a book called The Hospital that ate Chicago which was published in 1980. In May 1981 Dr. Fisher’s book got a rave review in The Wall Street Journal’s sister publication, Barron’s a review that caught some White House staff members’ eyes and earned him his invitation.
When the various business coalitions on health held their first national meeting in Chicago last year, Dr. Fisher was the featured luncheon speaker. Before and since then he has outlined his ideas for many influential audiences around the country. For physicians, a key aspect of Dr. Fisher’s thinking is his belief that substantial economics and efficiencies can be made in the nation’s health care system without abandoning the many huge advantages and efficiencies of fee-for-service medical practice. Since he is both informed and articulate, his writings and speeches make a deservedly positive impression.
A member of Pennsylvania delegates to American Medical Association (AMA) House of Delegates for the past five years, Dr. Fisher is also the only AMA delegate in the country to have won an independent position as spokesman for ideas congenial to many, probably most, of the nation’s practicing physicians. Curiously, the AMA seems to have little idea of Dr. Fisher’s eminence and importance in the national debate.
Born in Erie, Pa., in 1925, the slim,erect and vigorous endocrinologist, who is a graduate of Yale and Columbia University's College of Physicians and Surgeons, is self-taught in medical economics, largely as a result of years of service on the economics committee of the Central City Branch of the Philadelphia Medical Society. He is married to another physician, Dr. Mary Stuart Fisher, who is a radiologist at Temple University Medical School. Among their four children is daughter Margaret, who will receive her MD degree next month along with her husband Jonathan Rosenthal.
Dr. Fisher originally wrote The Hospital that Ate Chicago in mid-1979 with the expectation that Sen. Edward Kennedy would be the Democratic candidate for president in 1980 and that national health insurance would be that year’s prime issue. His purpose in writing the book was to demonstrate the enormous cost and numerous inefficiencies inherent in the nation’s partisan approach to national health insurance plus Medicaid and Medicare have already imposed costs and inefficiencies that would be multiplied if the Kennedy nostrum became law.
At the cost of oversimplification, two weakness of the present system of financing medical care in this country is central to Dr. Fisher’s analysis. One is the prevalence of employer-paid private health insurance. This makes many people indifferent to the cost of their health care, especially if it is delivered in a hospital where care is most generously financed.
There is little or no patient resistance to ever more expensive care, practically if delivered in a hospital where insurance will pick up the entire bill.
The second central weakness, Dr. Fisher believes, is that because most hospitals are nonprofit institution they do not have the incentives for taut, economics operations like those profit-making institutions. Instead, they dissipate their surpluses either in above-market salaries for their paid personnel or in ceaseless efforts to grow bigger and more complicated. Where profits are not an index of efficiency and competence, Dr. Fisher remarks, mindless growth tends to replace that index.
From these and related premises, Dr. Fisher tends to favor reforms in health insurance which will give patients incentives to ponder costs among their health-care alternatives. Thus he is an advocate of taxing private health-care insurance benefits beyond some minimum level. The best insurance, he believes, is catastrophic insurance, i.e., health-care-insurance with a large deductible, since most people are healthy and can afford the relatively small bills for medical care the average person racks up in an average year.
He also believes that the charitable functions of nonprofit hospital ought to be separated from their normal operations; he is an advocate of nonprofit hospital turning their hospital and other heal-care activities into for-profit subsidiaries which would be run on a businesslike basis to deliver health care of a high quality as efficiently and index pensively as possible. He notes with satisfaction that since he articulated this notion, some hospital pioneers have begun doing precisely what he recommended.
Since writing his book, Dr. Fisher has developed two other ideas for which he has been seeking support.
One idea, which he got the AMA House of Delegates to support last year, is called health-related IRA penalty exclusions. It asks Congress to amend the individual retirement account(IRA) laws to permit a waiver of the present 10 percent penalty for withdrawal of funds prior to owner reaching age 59 ½. Such a waiver, Dr. Fisher argues, should be permitted under two health-related conditions. One would be in the case of illness required expensive treatment when an invasion of the IRA savings would be permitted to meet limited and defined health expenditures causing economic hardship. The second would permit diversion of investment income from an IRA to escape penalty if it issued to pay health insurance premiums.
Enactment of a law permitting this change in the Ira would mean that the IRA would assist not only in making up for inadequacies of Social Security pensions but also help make up for looming inadequacies of Medicare. The Medicare trust funds are rapidly approaching the bankruptcy that would have affected Social Security of it were not for the radical change and tax increases of recent years.
Dr. Fisher’s second brainstorm is what he calls assigned risk pools for health insurance. Dr. Fisher put the need for this change in these words when he addressed the AMA Council on Medical Services last January: “An uncomfortably large number of Americans presently feel unable to obtain health insurance, either because they have unsuccessfully tried to obtain it, or because they feel they would not know where to if they had to… It cannot be doubted that it would lessen future pressures for nationalized insurance if the public knew that anyone who wished to buy health insurance would not have been refused even though not everyone took advantage of the opportunity.â€
In Dr. Fisher’s opinion, this risk scheme would assign applicants to all health insurance firms in a state in specified rotation, so that all insurers would share in the burden. He worries about the assigned risk fee getting so low that people would voluntarily abandon their existing health insurance to go on the assigned risk plan, and for that purpose, he would require that the standard premium of the insurance company. He would also favor making the assigned risk assurance a plain with a deductible of serial thousand dollars linked to a clause making preexisting illness non-coverable for some defined period.
Though Dr. Fisher is a staunch advocate of fee-for-service medicine and does not hide his distaste for such schemes as mandatory fee assignment for physicians, e does not accept the conventional conservative position on all medical issues. He was a strong advocate of the professional standards review organizations (PSROs) because he felt they helped remove the one economic advantage health maintenance organization (HMOs) had over fee-for-service medicine.
That typical HMO advantage he points out is that an HMO hospitalizes its members far less often than does a comparable group of fee-for-service doctors. Dr. Fisher argues that the Philadelphia PSRO helped Blue Cross in that city reduce hospital days per thousand members from 1,085 to 760 in less than a decade. Persistence of such PSRO pressure for eight more years would lower Philadelphia Blue Cross members’ hospitalization to the 550-days-a-year level of Kaiser-Permanente in California, he says.
This summary of Dr. Fisher’s views cannot give a full idea of the subtlety, sophistication, and wit of his writing and thinking. In “the Hospital that Ate Chicago,†Dr. Fisher included a series of fantasy chapters which use fictional scenes to suggest what actually happens in the relations among the various groups impinging on hospitals and hospitals’ decisions.
Dr. Fisher has also gained expertise in the arcane but very important area of the higher mythology known as hospital accounting, particularly as that mythology tends to encourage the building of bigger and more expensive hospitals whether or not they are needed. And Dr. Fisher explains how the momentous misjudgment of the founders of Blue Cross/BlueShield in having both organizations be nonprofit groups made it possible for government officials to expropriate both Organizations from the hospital and physician organizations whose initial investments and scarf ices created first Blue Cross and Blue Shield.
Dr. Fisher has managed t develop is a high level of understanding and exposition of medical economics while continuing a demanding practice as a board-certified internist and endocrinologist on the teaching staff of the medical school of both the University of Pennsylvania and homes Jefferson University. There may be other remarks physicians in the United States, but they must be few a far between.
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.
