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Cancer Costs More Than Doubled Over 40 Years as Deaths Fell 16%, JAMA Says

by on March 16, 2010

By Ellen Gibson March 16 (Bloomberg) — The U.S. government has spent $100 billion funding cancer research since then-President Richard Nixon declared the “ War on Cancer ” in 1971, says an editorial in the Journal of the American Medical Association . The death rate from all cancers fell by almost 16 percent from 1991 to 2006, the editorial said. Much of that decline came from anti-smoking campaigns and early disease detection, said the commentary by researchers at the American Cancer Society in Atlanta. While new drugs, led by Roche Holding AG ’s Avastin and Eli Lilly & Co. ’s Erbitux, are helping, the cost of medical care including these treatments is straining the U.S. health system, researchers at the Memorial Sloan-Kettering Cancer Center in New York said in a second commentary. Since 1990, cancer-related medical expenses have more than doubled to $90 billion, accounting for inflation, the second commentary said. The rate could be slowed by shifting to a system in which the cost of drugs, tests and other care are combined in a single- provider payment that would encourage doctors to “shop carefully for the services” patients need, the researchers wrote. “The expanding financial burden of cancer” including rising incidence rates “cannot be ignored,” wrote the commentary authors, led by Elena Elkin . This week’s special edition of the journal includes six editorials and commentaries assessing the country’s progress against cancer. Grouping Doctors The Sloan-Kettering researchers also suggested in their commentary that doctors and hospitals should be grouped into accountable-care organizations that would nudge physicians to act more cohesively, and could be rewarded by payers for providing care that delivers good results. Cancer remains the second-leading cause of death in the U.S., according to the American Cancer Society in Atlanta. In one survey cited in the journal, almost a quarter of respondents with health insurance said they used most or all of their savings during treatment for cancer. Avastin, the drug made by Roche of Basel, Switzerland, for breast, lung and colorectal cancer, can cost as much as $100,000 a year, according to UnitedHealth Group Inc. of Minnetonka, Minnesota, the biggest U.S. health insurer. Erbitux, the colon cancer treatment made by Indianapolis-based Lilly, can cost $40,000, said Les Funtleyder , a Miller Tabak & Co. LLC analyst in New York, in an e-mail today. High Bills Not only do high bills cause financial hardship for patients, they influence the choices doctors make, the authors said. In a separate survey noted in the editorial, 84 percent of oncologists said that concerns about patients’ out-of-pocket payments influenced their treatment decisions. The so-called war on cancer has led to $100 billion in cancer-research funding by U.S. agencies, according to a journal commentary written by Susan Gapstur , an epidemiologist at the American Cancer Society. These efforts resulted in a 1 percent annual drop in new cancer diagnoses between 1999 and 2006, her report said. There has been “remarkable progress” in the treatment of certain types of cancer, the report said, including breast cancer, Hodgkin’s disease , and testicular cancer . Almost 80 percent of children and adolescents diagnosed with cancer now survive at least five years, Gapstur said in a phone interview yesterday. Public Messages The main driver of progress has been public-health messages about tobacco use. The decrease in cigarette smoking in the U.S. over the past half-century accounts for 40 percent of the drop in cancer deaths in men since 1990, the year when the lung- cancer mortality rate for men peaked, Gapstur’s commentary said. “We’ve made progress, but people are still dying at too high a rate,” she said. “At the moment, we can’t put a dollar amount on when we stop. We have to continue our research efforts.” Early detection of colorectal and cervical cancers has reduced the mortality rates associated with those diseases. The challenge now, she said, is to improve early detection methods and enhance their usefulness. “For society, it’s less expensive to screen hundreds of people than to treat a single patient with cancer,” said Bert Vogelstein , co-director of the Johns Hopkins Ludwig Center in Baltimore, who is working to developing diagnostics to detect the genetic alterations that are seen in cancers. Aging Population There are a number of other challenges ahead, according to the report. An aging population means the number of cancer cases is likely to increase in the future, it said. Some cancers, including those of the liver , pancreas , and brain , are still linked to high mortality rates despite research efforts. As tobacco use wanes, the high rate of obesity in the U.S. could present a new public health challenge by raising cancer rates, Gapstur said. “Most epidemiologic studies have shown that obesity is a risk factor for cancer,” said Vogelstein in an interview yesterday. About 30 to 35 percent of all cancers can be attributed to nutrition, lack of physical activity, and obesity, Gapstur said. “Our concern is that, over time, that epidemic will have an impact on cancer mortality.” Gapstur’s essay notes that many articles have been written that are critical of the pace of progress in battling cancers and finding cures, especially in light of the “immense” economic costs. “We’ve been fighting this war on cancer since Nixon’s time, but we’ve only had the human genome for about a decade,” said Victor Velculescu , co-director of cancer biology at Johns Hopkins Kimmel Cancer Center . “It takes time to translate genetic info, but we’ve only just started getting it.” To contact the reporters on this story: Ellen Gibson in New York at egibson9@bloomberg.net ;

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Cancer Costs More Than Doubled Over 40 Years as Deaths Fell 16%, JAMA Says

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Ellen Brown: Funding Public Health Care With a Publicly Owned Bank: How Canada Did It

by Ellen Brown on January 25, 2010

The story goes that Churchill offered a woman 5 million pounds to sleep with him. She hedged and said they would have to discuss terms. Then he offered her 5 pounds. “Sir!” she said. “What sort of woman do you think I am?” “Madam,” he replied, “We’ve already established that. Now we’re just haggling over the price.” The same might be said of President Obama’s health care bill, which was sold out to corporate interests early on. The insurance lobby had its way with the bill; after that they were just haggling over the price. The “public option” was so watered down in congressional deal-making that it finally disappeared altogether. However, the bill passed both Houses by razor-thin margins, and the stunning loss on January 19 of the late Ted Kennedy’s Democratic seat to a Republican may force Obama to start over with his agenda. The good news is that this means there is still a chance of getting legislation that includes what Obama’s supporters thought they were getting when they elected him – a universal health care plan on the model of Medicare. That still leaves the question of price, but all industrialized countries except the United States have managed to foot the bill for universal health care. How is it that they can afford it when we can’t? Do they have some secret funding source that we don’t have? In the case of our nearest neighbor Canada, the answer is actually that they do. At least, they did for the first two decades of their national health service — long enough to get it up and running. Now the Canadian government, too, is struggling with a mounting debt to private banks at compound interest; and its national health service is suffering along with other public programs. But when Canada first launched its national health service, the funding came from money created by its own central bank. Canada’s innovative funding model is one that could still be followed by a President committed to deliver on his promises. The Canadian National Health Service Today Despite what you may have read in the corporate-controlled press, studies show that Canadians are generally happy with the care they receive; and they live an average of 2.5 years longer than Americans. They receive free health service for all diagnostic procedures, hospital and home care deemed medically necessary. People can choose the general practitioners they want; there are no deductibles on basic care; and co-pays are low or zero. Care continues despite changing jobs, and no one is excluded for having a pre-existing condition. Drug prices are negotiated by the government and are paid with public money for the elderly and homeless. For the rest of the population, cost-sharing schemes are arranged between private insurers and provincial governments, with most provinces requiring families to pay small monthly premiums (generally around $100 for a family of four). According to a 2007 study , the government pays for more than two-thirds of all Canadian health care costs. The US government, by contrast, pays for less than half of these costs. In 2007, the US spent a staggering 16% of GDP on health care compared to 10% in Canada. Health costs paid for out-of-pocket by Canadians amount to less than $300 per capita annually. But while that arrangement may look good to people in the U.S., it is only a shadow of Canada’s former system. The federal government’s contributions have decreased significantly , making up only slightly more than 20% of provincial medical care costs in 2002; and this money is largely borrowed by the Canadian government at interest. The portion not paid by the federal government must be borne by provincial governments through taxes. In its early years, however, Canada’s public health system was funded under a provision of the Bank of Canada Act allowing the Bank to create the money to finance federal, provincial, and municipal projects on a nearly interest-free basis. Money Created the Old-Fashioned Way – by the Government Rather than the Banks What was extraordinary about the Bank of Canada was not so much that it created money on its books as that it managed to wrest that power away from the private banking monopoly. All banks actually create the money they lend simply with accounting entries on their books. This was confirmed by Graham Towers , the first governor of the Bank of Canada, in hearings in 1935. Asked whether banks create “the medium of exchange,” he replied: That is right. That is what they are there for. . . . That is the banking business, just in the way that a steel plant makes steel. The manufacturing process consists of making a pen-and-ink or typewriter entry on a card in a book. That is all. The decision to fund government programs through a publicly-owned central bank was driven by a crisis much like that in the U.S. today. The country was in the throes of the Great Depression, and the money supply had radically contracted, causing businesses to close and unemployment to soar. Many Canadians blamed the private banks for making conditions worse by failing to extend loans. Prior to the 1935 Bank of Canada Act , private banks in Canada issued their own banknotes, which were regulated less by the government than by the Canadian Banker’s Association. The country’s largest private bank, the Bank of Montreal, served as the government’s de facto banker. By the eve of the Great Depression, interest on Canada’s public debt had reached one-third of government expenditures, and many officials believed that the government needed a central bank to come up with the money to pay its foreign debts. A Royal Commission was put together in 1933 which supported creating a Bank. A major debate then ensued over whether the central bank should be public or private. Much of the credit for the Canadian public banking model goes to a Canadian mayor named Gerald Gratton McGeer. He has been largely lost to history, and his book The Conquest of Poverty has been long out of print; but according to local historian Will Abrams , it was McGeer’s lengthy presentations to the Ottawa Common Banking Committee that clarified for bankers, economists and legislators how well a publicly-owned bank could work. McGeer’s model was based on the public banking system of Guernsey, an island state between Britain and France. The Guernsey government began issuing currency to pay for public works as far back as 1816. To this day, its system of publicly-issued money has allowed its inhabitants to maintain full employment and enjoy quality infrastructure, while paying modest taxes and without suffering from price inflation. The Bank of Canada became publicly-owned in 1938 under Prime Minister William Lyon Mackenzie King , a staunch supporter of McGeer’s vision for a public central bank. King maintained: Until the control of the issue of currency and credit is restored to government and recognized as its most conspicuous and sacred responsibility, all talk of the sovereignty of Parliament and of democracy is idle and futile. Once a nation parts with the control of its currency and credit, it matters not who makes that nation’s laws. Usury, once in control, will wreck any nation. What Can Be Done by a Government Issuing Its Own Currency Along with New Zealand, Australia and other progressive countries, Canada proceeded to fund infrastructure and social programs using national credit issued by its own central bank. The potential of this new credit tool for the Canadian economy was first demonstrated in World War II, in which Canada ranked fourth among the Allies for production of war goods. Under the Returning Veterans Rehabilitation Act of 1945, some 54,000 returning vets were given financial aid to attend university. The Department of Veterans Affairs provided another 80,000 vets with vocational training, and the Veterans’ Land Act helped 33,000 vets buy farmland. After the War, the Industrial Development Bank, a subsidiary of the Bank of Canada, was formed to boost Canadian businesses by offering loans at low interest rates. The Bank of Canada also funded many infrastructure projects and social programs directly. Under the 1950 Trans Canada Highway Act, Canada built the world’s longest road and the world’s longest inland waterway (a joint venture with the United States), as well as the 28-mile Welland Canal. People over 70, regardless of income or assets, received $40 a month from the government under the Old Age Security Act; and children under 15 got a tax-free allowance of $5-$8 a month. Canadians first began talking about a government-run health system during the Great Depression, but at that time the government felt it could not afford the service. Various provincial programs were launched in the 1940s, often to care for returning veterans. But it was not until 1957 that the Canadian federal health care system was actually initiated, with funding from the Bank of Canada. A Hospital Act was passed under which the federal government agreed to pay half its citizens’ bills at most hospitals; and a Diagnostic Services Act gave all Canadians free acute hospital care, as well as lab and radiology work. In 1966, the Hospital Act was expanded to cover physician services. In 1984, the Canada Health Act ensured that no medically-necessary care would include private fees or a charge to citizens. A Misguided Economic Policy Kills the Golden Goose For three decades, Canada paid for these projects through its own government-owned central bank, without sparking price inflation. Then in the late 1960s, a period of “stagflation” set in –rising prices accompanied by high unemployment. According to former Canadian Defense Minister Paul Hellyer , these elevated prices were the result of “cost-push” inflation, which could be traced to a combination of causes. Big labor unions, big government, and big corporations all negotiated top dollar for their contracts. In 1971, President Richard Nixon took the U.S. dollar off the gold standard, putting a strain on currencies in international markets. In 1974, the price of oil quadrupled, following a secret deal between Henry Kissinger and the OPEC countries in which the latter agreed to sell their oil only in U.S. dollars and to deposit the dollars in U.S. banks. Countries without sufficient dollar reserves had to borrow from these banks to buy the oil they needed, setting a debt trap that sprang shut when U.S. Federal Reserve Chairman Paul Volcker raised interest rates to 20% in 1980. These increased costs drove up prices worldwide; but in Canada, price inflation was blamed on the government drawing money from its own central bank. Under the sway of the classical monetarist theory promoted by U.S. economist Milton Friedman, the Canadian government abandoned its successful experiment in self-funding and began borrowing from private international lenders. These private banks created “credit” on their books just as the Bank of Canada had done; but they lent it to the government at compound interest, creating a soaring national debt. Today, interest on the debt is the Canadian government’s single largest budget expenditure — larger than health care, senior entitlements or national defense. The provision of government-paid services is gradually being undermined by a combination of cuts to funding and provision of private services. Canada’s health care system is suffering along with the rest of the economy, necessitating the cutbacks and long waits for elective procedures described by critics. But the achievements of an earlier debt-free era attest to the sustainability of a system of public health care funded with money issued through the government’s own central bank. Goosing the Economy Again The Bank of Canada was created to end the hardships of the depression and give the government full responsibility for the health of the economy. As it turned out, the Bank also funded the health of the Canadian people. The U.S. government could fund universal health coverage in the same way. Ideally, it would nationalize the Federal Reserve or set up a separate government-owned bank for this purpose. However, the same result could be achieved by borrowing from the privately-owned Federal Reserve, which always rebates the interest to the government after deducting its costs. The federal debt is never paid off but is just rolled over from year to year. Interest-free loans rolled over from year to year are the equivalent of debt-free government-issued money. Contrary to popular belief, adding to the money supply in this way would not be inflationary . Inflation results when “demand” (“money”) exceeds “supply” (goods and services). In this case the new money would be used to create new goods and services, so supply would be kept in balance with demand. The result would particularly not be inflationary today, when we are suffering from a deflationary crisis. As in the Great Depression, money is not available to buy products and fund programs because the money supply itself has collapsed. The solution is not to slash programs but to put more money into the economy; and that can be done by authorizing the government to create the funds it needs through its own bank.

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Ellen Brown: Funding Public Health Care With a Publicly Owned Bank: How Canada Did It

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Adam Hanft: The Haiti Tragedy: Why Is There Digital Silence?

January 18, 2010

Tragedies are capitalist conundrums. Whenever the world is gripped by an unfolding disaster, American corporations wrestle with their response strategies. Ignore it and you risk looking detached, or worse, callous. Particularly in an era when consumers expect big companies to make big gestures. But splash it over your website and you run another risk — coming across as grubby and opportunistic. Public skepticism isn’t what it used to be, though. Walmart’s heroic response to Katrina, in comparison to FEMA’s ineptitude, sparked excited commentary like this in the Washington Post : “…an unrivaled $20 million in cash donations, 1,500 truckloads of free merchandise, food for 100,000 meals and the promise of a job for every one of its displaced workers — has turned the chain into an unexpected lifeline for much of the Southeast and earned it near-universal praise at a time when the company is struggling to burnish its image.” So what has been the corporate response to the wrenching scenes out of Haiti? A quick scan of the websites of some of our most well-known brands indicates a surprising – if not shocking – minimalism It’s nothing even close to the post-Katrina period, when website after website devoted their home pages to messages of shared sorrow and invitations to contribute to the relief programs. The reason this is important to assess is that a company’s website is a wide-open front door into its heart and soul. Visibility is strategy. Responsiveness is diagnostic. What’s featured and what isn’t featured – and what the relative emphasis is – speaks volumes. And in our world of instant digital communication, in which websites can change in seconds, when a major American institution chooses to ignore a global catastrophe, without even a pro forma “Our hearts are with the people of Haiti” message, it makes you wonder about them. • Let’s start with our eleemosynary friends at Goldman Sachs , Bank of America , JP Morgan Chase and Morgan Stanley , whose CEOs testified before a bi-partisan Congressional Committee on the financial crisis last week. I don’t know what their response was during Katrina. But today, when they should be scrambling for any shred of goodwill, their websites are completely silent about the devastation, not even an insey weensey “Contribute to Haiti” button. You’d think (hope?) one of their PR flaks would have said “Hey guys, let’s burnish our brands a little while we’re in the withering glare.” But nothing. And the silence is devastating; they don’t even care enough pretend. • Wal-Mart hasn’t given its Haiti efforts any dramatic home-page placement. There’s just some small real estate below the fold that features a Red Cross logo and an invitation to “Join Walmart’s efforts to support those in need.” Click on the link, though, and you come to a page dedicated to the company’s efforts in Haiti. While not on a Katrina-like scale, they include a $400,000 monetary donation. Target goes bigger than its rival Walmart on their home page – with a big horizontal banner that sits right under their logo and top navigation. Click on it and you come to a page that details “How Target is Helping” and “How You Can Help.” • Media companies are obviously following the story intently, and their websites show it. But while their newscasts continually direct viewers to organizations who are accepting donations, it’s curious that their websites generally offer no opportunities for readers to contribute. Nor do they boast of their own philanthropic efforts; that’s probably to be expected, given that media companies are experiencing their own metaphorical earthquakes. NPR asks for donations, but PBS , the New York Times , the Wall Street Journal and USA Today don’t. CNN is running a paid ad unit from a non-profit World Vision, asking for contributions. (Yikes, does that mean they are profiting from the earthquake?) • Big consumer brands, usually quick to associate themselves with so-called CSR – Corporate Social Responsibility – efforts, are conspicuously mute. Surprisingly, that includes Starbucks and Nike , two brands that usually chase down socially conscious opportunities wherever they find them. Their websites are acknowledgement-free zones. The cone of silence extends to Coca-Cola , which is a fascinating case because their foundation donated a million bucks. But their website doesn’t hint at that; it remains plushly dedicated to their “Open Happiness” message. Clearly, they’ve resolved to keep their philanthropic and marketing efforts separate, perhaps deciding that the grim news out of Haiti would be inappropriate in juxtaposition to the bubbly promise of “Open Happiness”. A perfect example of the Capitalist Conundrum. As for Amazon, they yield some room above the fold, in the upper right portion of its homepage, asking for donations to “Mercy Corps to help victims of the Haiti earthquake.” • Most technology companies and telecom are too busy. IBM , HP, Verizon and Sony keep their mouths closed. Microsoft is an exception, with a message on the home page that links to an impressive page that notes the company has made an initial commitment of $1.25 million and that it has: “… activated its Disaster Response Team. Through Microsoft’s support, nonprofit partner NetHope has been able to set up an immediate response, with specific focus on establishing temporary telecommunications infrastructure to allow humanitarian agencies to communicate and provide relief to the affected victims.” • Google’s and Apple , as you might expect, are also exceptions. Google’s home page features a big link that reads “Information, resources, and ways you can help survivors of the Haiti earthquake.” The link takes you to a page that references Google’s $1 million contribution, but is largely devoted to a range of contribution options, including Unicef and CARE, as well as organizations that only accept SMS donations. Apple has a small message on their homepage, which takes to the iTunes store. There, the usual storefront is replaced an interruptive page which asks for donations to the Red Cross in amounts from $5 to $200, with all transactions processed through iTunes. Lastly, the site for the Vatican makes no reference to the earthquake. (Note to Holy See webmaster: Time to take down “Christmas 2009″ from your site messaging.) Bottom line: compared to Katrina or the 2004 tsunami – when the Internet was far less developed – most of corporate America has chosen to leave Haiti unacknowledged on their websites. They’ve chosen not to leverage their digital presences; which means no opportunities to contribute, and certainly no efforts to use their databases or social media to rally support. I don’t know if it’s disaster fatigue, or if the recession has downsized their digital departments, but our biggest companies have failed to rise even to the level of meretricious opportunism.

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Credit Card Companies Waive Fees For Select Haiti Charities

January 15, 2010

All four major credit card companies — Visa, MasterCard, American Express and Discover — have waived or rebated their processing fees on donations to select charities in support of the relief effort in Haiti, representatives of the companies say. Visa Inc. has announced that it will waive fees through the end of February on credit card donations made to a “select group” of 11 major U.S. charities that are providing support to Haitian relief efforts. The eligible charities are American Red Cross; AmeriCares; CARE USA; Direct Relief International; Habitat for Humanity; International Rescue Committee; Mercy Corps; Oxfam America; Save the Children; US Fund for UNICEF; and World Vision. Visa’s number of eligible groups has doubled since the last disaster. After only waiving fees for the American Red Cross in the aftermath of Hurricane Katrina, it did so for five charities after the 2004 tsunami. American Express has waived and rebated its processing fee for card donations between January 12 through the end of February for the 65 charities on the USAID-approved InterAction website . According to Christine Elliot, a corporate spokesperson for American Express, the company took similar actions for the tsunami of 2004 as well as for Hurricane Katrina. “The criteria for when we decide to waive these fees for charities is guided by the level of response from the Red Cross,” Elliot said. “We waive the fees when the Red Cross internally designates something a ‘catastrophic event,’ and we only waive them for the charities designated by USAID because we have confidence that they’ve done due diligence in determining what is a reputable organization.” Elliot said Doctors Without Borders, while not on the USAID list will also have its fees waived because of the group’s “longstanding relationship” with Amex. MasterCard Worldwide has waived its transaction fees on donations to five charities, as it did for Hurricane Katrina, the tsunami and 9/11. Discover has only agreed to forgive their fee for the American Red Cross. This is the first time Discover has done so, though the company raised millions of dollars for Hurricane Katrina and September 11 relief efforts through a cardmember matching program. None of the four major credit card companies would discuss waiving or reducing their fees for these or other charities past February. The Huffington Post estimates that American banks and credit card companies make huge profits — somewhere in the neighborhood of $250 million a year – by skimming their “transaction fees” off the top of charitable donations.

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Democratic Senators Rebel Over Health Care Compromise to Expand Medicare

December 12, 2009

By Nicole Gaouette and Jim Rowley Dec. 12 (Bloomberg) — A Democratic compromise over health- care legislation came under attack today from within the party as 10 senators voiced concern the plan would make it harder for the elderly to get medical care. The senators were responding to a proposal to expand the Medicare program, which serves Americans age 65 and over, to cover people as young as 55. The 10 lawmakers demanded changes in Medicare reimbursement rates, complaining that Medicare currently underpays states with more efficient medical care, driving up the number of physicians unwilling to treat patients in the program. The letter provided more fodder for Republicans who argue that the legislation doesn’t meet a central goal President Barack Obama has set for slowing the increase in health costs and expanding access to medical care. The Democrats’ letter came a day after a report by the Centers for Medicare and Medicaid Services that found the Senate bill would increase total spending on health care and may contain “unrealistic” promises to save money on Medicare. “We appreciate the rationale underlying the proposed Medicare expansion,” the lawmakers wrote in the Dec. 11 letter, “but fear that provider shortages in states with low reimbursement rates such as ours will make such a program ineffective, or even worsen the problems these states are experiencing.” Signers of Letter The letter to Senate Majority Leader Harry Reid was signed by Senator Maria Cantwell of Washington, Senator Russ Feingold of Wisconsin, Tim Johnson of South Dakota, Senator Patrick Leahy of Vermont, Senator Jeanne Shaheen of New Hampshire, Senator Tom Udall of New Mexico, Oregon senators Jeff Merkley and Ron Wyden , and Minnesota senators Amy Klobuchar and Al Franken . The current system pays providers for the number of services they provide, creating a situation in which Medicare pays more efficient states less for the same result, and “spends over one-third more for each beneficiary in some states compared to ours,” the Democratic senators wrote. “An expansion of the program would simply see the same issue expanded to Americans between the ages of 55-64,” they said. They urged Reid to make changes in the bill to reward providers for the quality, not quantity, of their care. Republican Criticism Republicans were quick to expand on the Democrats’ criticism. “Access is a crisis,” said Senator Lisa Murkowski , an Alaska Republican. Her state has the fastest growing elderly population in the country, Murkowski told reporters today. Yet in Anchorage, the state’s largest city, there are only 13 physicians willing to see new Medicare patients because of the low reimbursement rates, she said. According to a 2008 study by the Institute of Social Economic Research at the University of Alaska Anchorage, the city has 19,210 Medicare beneficiaries 65 and older. That number does not account for disabled in the program. The Senate bill “does nothing to expand access,” Murkowski said. “This is not acceptable to us.” Reid is prodding the Senate to pass legislation before the end of the month. The 10-year, $848 billion Senate bill is designed to cover 31 million uninsured Americans and curb medical expenses. Gaining the support of moderate Democrats is essential to meet the 60-vote benchmark needed to pass the bill. “Right now you are at the crucial hour,” Wyden of Oregon said about negotiations in an interview. “You’re facing 14, 15 days to the holiday.” Seeking Centrist Support The Medicare expansion, or buy-in, was meant to draw moderate support. It is part of a compromise to replace a government-run insurance plan that drew so much opposition it threatened to derail the legislation. Both Republicans and centrist Democrats said a public plan would provide unfair competition to insurers such as Hartford, Connecticut-based Aetna Inc . Almost immediately, however, centrist Democrats raised questions about the Medicare expansion. “As long as Medicare continues to underpay providers, Medicare patients are at risk of losing” doctors who will treat them, Senator Ben Nelson , a Nebraska Democrat said in an interview. Democratic leaders refused to share details of the compromise plan until the Congressional Budget Office has offered a cost estimate. They suggest there may be a fix for Medicare reimbursement rates in the larger proposal. Senator Charles Schumer of New York told reporters that he didn’t think the budget-office “numbers will be so out of the ballpark we will have to start all over again.” Reimbursement Disparities Asked whether the proposal deals with disparities in reimbursement between regions where medical costs are higher than others, Schumer declined to discuss specifics of the proposal, saying only “those are legitimate concerns that I think ought to be addressed.” “We may have to adjust things here and there to keep the deficit number down and keep the savings up,” he said. “It’s very, very possible there will have to be some readjustments” because “CBO tells you what you’re doing.” Yesterday Richard Foster , the chief actuary of the Medicare and Medicaid programs, said that under the Senate bill national health expenditures would grow about $234 billion from 2010-2019 under the bill, 0.7 percent more than if nothing were done. He attributed the increases to greater use of services by newly insured patients, the report said. The impact of several provisions aimed at curbing spending growth would be offset through 2019 by the higher costs of expanding coverage. Senator John Cornyn , a Texas Republican, released a statement saying the study proved Republican claims that the Democrats’ legislation would “drive up this country’s unsustainable level of health-care spending.” Democratic Senator Max Baucus of Montana, one of the bill’s chief architects, said the Medicare and Medicaid Services report shows the health-care overhaul would extend the life of Medicare and reduce premiums in the government health-insurance program for the elderly. To contact the reporters on this story: Nicole Gaouette in Washington at ngaouette@bloomberg.net ;

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Your Final Wish Isn’t Always Your Doctor’s Command: Ann Woolner

December 9, 2009

Commentary by Ann Woolner Dec. 9 (Bloomberg) — You think you’ve done the legal paperwork to avoid becoming another Terri Schiavo , who was trapped in a hopeless vegetative state while her family argued over whether to keep her going. You’ve specified ahead of time that you want nothing artificial to prolong your life, not even a forced-feeding tube, if doctors say you won’t recover from that state. Don’t rest assured. If that time comes, the documents you labored over won’t count for much if you wind up in the wrong place. More than 900 hospitals and health-care centers in the U.S. that treated 93 million patients last year are affiliated with the Catholic Church, whose American policy-making body won’t let your end-of-life wishes come true while you are in their care. Last month the U.S. Conference of Catholic Bishops resolved what had been a debate among clerics and ethicists over the morality of artificially feeding or hydrating patients who are stuck in a vegetative state, possibly for years. What had been a “presumption” in favor of tube feeding in 2001 became, in the revised policy, an “obligation.” “This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care,” the bishops announced in the latest version of their Ethical and Religious Directives for Catholic Health Care Services. If an incapacitated patient has a living will that instructs physicians, it “should always be respected and morally complied with, unless it is contrary to Catholic moral teaching,” the bishops said. A Big ‘Unless’ That’s a big “unless.” If family members insist that the patient’s directive be followed, they would have to move him to another facility, according to the Reverend Thomas Weinandy , executive director of the Conference of Bishops doctrine committee. For thousands of Americans, a Catholic hospital is the only one they have, says Compassion and Choices, a non-profit group that advocates for the terminally ill. Federal and state laws encourage people to think ahead of time about what medical treatment they would want, and under what circumstances, if they became incapacitated. Hospitals that accept federal funds are required to bring up the subject, and that’s when they advise incoming patients of their policies. You can spell out your wishes in an advance directive, and you can name a health-care proxy to speak for you on such matters. Criminal Battery “Where you actually have a medical directive, people are constitutionally entitled to have their wishes given effect,” says Ray Madoff , a law professor at Boston College focusing on end-of-life issues. The U.S. Supreme Court said so in the Nancy Cruzan case in 1990. But, Madoff asks, who’s going to enforce that right? Under older case law than Cruzan, if you are given a treatment you specifically declined, it is considered criminal battery under the law. Whether that applies to tubing for food and water, which some see as too basic to human existence to be considered medical treatment, isn’t as clear. In New York, state law requires an extra level of evidence that the patient didn’t want a feeding tube for it to be denied. An advance directive would accomplish that, and so would a health-care proxy with knowledge of the patient’s wishes. But I digress. Larger Issue The conflict between patient and medical personnel speaks to a larger health-care issue that reaches beyond Catholic institutions. The notion is growing that the institutional or individual conscience of a health professional trumps a patient’s wishes when they conflict, or at least makes them more difficult to carry out. Health professionals have been winning ever-stronger language in state and federal laws that forbid discrimination against them if their moral or religious beliefs prevent them from assisting or performing abortion or prescribing birth control. You will find some version of it in health-care bills Congress is considering. And while in most cases of conflict arrangements are made to transfer patients to health-care providers and professionals who will comply with their wishes, that isn’t always possible. Critical Decisions This tugs at a sacred tenet of American health care: that an informed and competent patient should be allowed to make critical decisions over his own body, even in advance. Increasingly, the patient’s moral and religious convictions are taking a back seat to the beliefs of people charged with caring for their health. So it was with the Bishops Conference, which ditched its more ambiguous stance to adopt principles taught by Pope John Paul II . Catholic hospitals can still follow patient directives that refuse other sorts of medical treatments. The more difficult question was whether food and water are medical treatments and therefore morally optional. And what if the patient could exist for years in a vegetative state? Or was it something so essential to a person’s humanity that it must be given to affirm the value of human life, indefinitely? Would it be euthanasia to refrain from tubing? It would, the bishops announced. “We believe we are upholding the dignity and value of every human life,” Weinandy said in a telephone interview. And yet, there are others who believe their dignity requires health-care providers to abide by their wishes to keep feeding tubes out of their bodies if they have no hope of ever resuming consciousness. At a time when the country is in desperate need to reduce health-care costs, surely we could start by agreeing that it’s a good idea for patients not to be given treatment they have specifically refused. ( Ann Woolner is a Bloomberg News columnist. The opinions expressed are her own.) Click on “Send Comment” in sidebar display to send a letter to the editor. To contact the writer of this column: Ann Woolner in Atlanta at awoolner@bloomberg.net

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Father Calls Insurance Company’s Decision To Drop Son’s Coverage "Attempted Murder"

October 15, 2009

As part of its Bearing Witness 2.0 project, the Huffington Post is rounding up a few of the best local stories of the day. Rather than continue to pay for Ian Pearl’s million dollar medical treatments, one insurance company has decided to end certain lines of coverage altogether, reports William Ehart of the Washington Times . Pearl, 37, suffers from Type II spinal muscular dystrophy, and has been using a wheel chair and connected to a breathing tube for most of his life. Patients with his type of muscular dystrophy rarely live past infancy, but Peal credits his vitality to the care he has received all his life. On December 1 his insurer, Guardian, is discontinuing a portion of its coverage, which will effectively kill him. Without his extensive coverage Pearl will be admitted to a state hospital under Medicaid, with less treatment. Pearl’s mother said that in a state hospital her son would be lucky to live more than a few weeks. Pearl’s plan, as of now, covers 24-hour home nursing, which Medicaid, and the vast majority of plans, do not. “This is attempted murder” said his father, Warren, “the insurance companies are cheating in order to have obscene profits.” Last year Guardian reported $437 million profits, up 50 percent from 2007. ****** The Los Angeles schools superintendent is standing by a decision that allows recently laid-off teachers to have priority for substituting jobs over veteran subs with more seniority, reports the Los Angeles Times , which puts substitutes’ health benefits at risk. In July, in the midst of a budget crisis, the Los Angeles Unified School District laid off 2,000 teachers and registered almost all of them to be substitutes, bumping ahead of veteran subs, a move roundly rejected by the local teachers union . ****** Leslie Park has lived in her South Minneapolis home for 21 years. But in May, after her mother fell victim to a shady mortgage deal with an adjustable rate, her home was sold by the local sheriff and she’s now in what is called the redemption period — a period of six to 12 months after the sale where the previous owner can continue to stay, with the potential to buy back the title, plus interest. The redemption period ends November 30, and Park is not optimistic that she’ll be able to buy he home back. Instead, reports Charles Hallman of the Minnesota Spokesman-Recorder , she has joined with four other women, dubbing themselves the Foreclosure Five, and, as part of the Minnesota Coalition for a People’s Bailout , are urging the state legislature to place a moratorium on foreclosures and make owners of foreclosed houses let the occupants stay and make their monthly payments. She, like many others, has pledged to fight: “They are not going to get me out of that house.” ****** A pilot program of the New York State Department of Labor is going to help job-seekers find employment using a mathematical algorithm that searches for phrases and paragraphs in an applicant’s resume, instead of just keywords, reports Ilya Marritz for WNYC . The formula was designed for people like Danielle Lazzaro, who lost her job four months ago and has had no luck posting her resume on internet job help sites like Careerbuilder or Monster.com. “I’ve been on the internet six to eight hours a day looking for a job,” she said, “I’ve pretty much made it my full time job looking for a job.” New Yorkers hope the new software, already used by corporations like Coca Cola and Accenture, as well as the state of Minnesota, will help cut down the growing unemployment numbers and help people find jobs. HuffPost readers: Seen a good local story? Heard about a heroic judge, neighbor, or doctor helping people stay in their homes? Tell us about it! Email jmhattem@gmail.com .

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Larry Gellman: Back to the Future — The Tension Over Tense

September 30, 2009

Have you ever noticed that most things people say they are worried might happen in the future are things that have already happened? Once the dreaded event has taken place, they start speaking in the future tense about it as though it hadn’t happened yet — but they’re worried that it might. That was this year’s Rosh Hashanah insight that got me through the day as we Chosen folks ushered in 5770 the other day. As a financial adviser I have seen it repeatedly over the years. Investors and the business news media always seem to consider the market to be risky after it has already been crushed. It is only near market tops that people tend to be comfortable owning stocks and are losing sleep because they don’t own enough hot issues. We saw panic at the bottom after the stock market crash in 1987 and again last March when people were so worried about how risky the market had become that they wanted to sell every stock they owned — including companies that were trading at valuations that were less than the cash they had in the bank. That, of course, was after their accounts had been crushed and the people sold their stocks without regard to price just so they could sleep at night. We saw the mirror image of that behavior during the late 1990′s during the tech bubble. “Conservative” investors fired their money managers for not owning enough high-flying stocks that had already gone up by 1,000 percent or more. Then they turned around and sued their new managers in the early 2000′s because they owned too many of the internet companies that the investors themselves ordered them to buy. It’s easy to poke fun but in fact human nature tends to lead us astray under a variety of circumstances. With investments, mob psychology takes over. People get greedy at the top and afraid at the bottom. At the end of the day, they almost always default in favor of sleeping at night. What is harder to understand is why people speak in the future tense about their worries months after the worst has already happened and the risk would seem to be gone. The same phenomenon seems to apply to the criticism and concerns expressed about President Obama. The very issues that many detractors say they are most worried about seem to be events that already happened long before Obama even took office. For example, critics say they are worried that Obamanomics will create huge federal deficits and destroy the economy. But during the eight years of George W. Bush’s presidency, what had been a budget surplus turned into $5 trillion in deficits and that doesn’t include the cost of the Iraq war and other expenses that were made off budget. To save the economy, Obama will certainly run $1 trillion-plus deficits in coming years, but Bush already did that in 2008. John McCain has admitted that had he been elected the deficit numbers would have looked pretty much the same. As far as destroying the economy is concerned, that was pretty much a done deal at this time a year ago — months before Obama was even elected. There is also a lot of hand-wringing and fear that Obama wants to redistribute wealth and take all the money from the rich and give it to the poor. But wasn’t it Bush who pushed through a $170 billion stimulus bill more than a year ago where checks of up to $1,200 were sent to the poorest Americans in a failed effort to avert a recession? Where were the cries of “socialism” and the teabagging parties back then? And wasn’t it Bush who redistributed billions of in the opposite direction with his tax cuts for the wealthy? The same is true regarding many concerns about health care reform — not the phony ones which are just based on lies. Outrage is routinely expressed about having a government-financed health care system in which the care itself would be rationed. But isn’t that what we already have with Medicare, Medicaid, and the V.A.? And isn’t health care already being rationed by our current system? I am covered by a “gold-plated” health plan but my premiums and co-pays go up every year and the procedures that are covered by my insurance keep going down. In recent years, I have been told more and more often that “your insurance doesn’t cover that procedure” and have seen an increasing number of doctors refuse to accept patients covered by certain insurers because their reimbursement levels have dropped so dramatically. Perhaps the most ironic line of this whole debate comes from the millions of Republicans who have cautioned Obama and the Democrats to “keep the government away from my Medicare.” There are many reasons to be concerned about the future of health care in our country and how we’re going to pay for it. But those who are most concerned about the government controlling coverage or about care being rationed in the future are waiting for a train that left the station years ago. My guess is that 95 percent of the things most people worry about either have already happened or will never happen. Having said that, there is no doubt that fear about the future can be a useful tool. But only if it is used to keep us out of trouble or to spur us on to imagine and work to create better outcomes and a better world. Today, however, fears and worries seem to mainly just whip up anger, hate, and demonization of our leaders and institutions. Hopefully during the coming year we will funnel more of our energy to finding constructive solutions to the many problems that confront us and waste less worrying about things that have already happened or never will. Steering the Ship of State and our personal lives is tough enough under the best of circumstances. It becomes impossible if we spend all our time looking in the rear view mirror.

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Short sales spread across real estate market

September 27, 2009

… and people, whether they are homeowners or real estate agents, just roll their eyes. The practice, … care of it. However, with so many distressed properties for sale, and other homes selling …

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Short Sales Spread across Real Estate Market, Leaving Frustration in Their Wake

September 25, 2009

… Short Sales Spread across Real Estate Market, Leaving Frustration in Their Wake RISMEDIA, … care of it. However, with so many distressed properties for sale, and other homes selling …

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Alzheimer’s, Dementia Rise Faster Than Expected in `Emergency,’ Study Says

September 21, 2009

By Elizabeth Lopatto Sept. 21 (Bloomberg) — Alzheimer’s disease and other dementias will afflict 35.6 million people in 2010, about 10 percent more than previously estimated because of a higher number of cases in developing countries than doctors realized, researchers said. The number of dementia sufferers may almost double every 20 years to 115.4 million in 2050, researchers at Alzheimer’s Disease International said in a report. The report’s authors had previously projected lower numbers in a 2005 article in the Lancet. Companies such as Johnson & Johnson , Eli Lilly & Co ., Baxter International Inc . and Bristol-Myers Squibb Co. are developing treatments to target the disease. The report recommends that the World Health Organization declare dementia a health priority, and that countries including the U.S. develop a plan for dealing with the greater numbers of dementia patients. “People, the government, the community need to understand that these numbers are an emergency,” said Daisy Acosta, the chairwoman of the London-based Alzheimer’s patients advocacy group. Lower and middle-income countries have the fastest increase in prevalence in the next 20 years, the report said. The poorest countries in Latin America will see the biggest increases of 134 to 146 percent. The new numbers are due to better data available since there weren’t many studies of Latin America, Africa, Russia, the Middle East, and Indonesia, the report said. Care Costs Rising Alzheimer’s disease and other dementias cost $315 billion a year, according to an estimate from Sweden’s Karolinska Institute cited by the paper. Dementia care costs are rising fastest in low and middle income countries, where per capita income is $11,905 or less, the report found. Patients and their families currently have few options. The drugs approved in the U.S. to treat Alzheimer’s ease symptoms for 6 to 12 months at most, according to the Alzheimer’s Association. If U.S. health officials and the WHO develop plans for dealing with the increase of dementia, other countries will follow suit, Acosta said. It has been difficult to get attention from global health organizations, because they often focus on reducing deaths rather than on treating disability, said Alzheimer’s Association Chief Executive Officer Harry Johns. “The very fact that people are older works against them,” Johns said. Many Alzheimer’s patients have spouses or children who provide their care, quitting their jobs to do so, he said. Between 15 percent and 32 percent of caregivers develop depression, as a result of the strains of providing for the needs of Alzheimer’s patients. WHO Priority “We already think dementia is a priority within WHO,” said Tarun Dua, a medical officer at the WHO’s department of mental health and substance abuse. WHO included Alzheimer’s disease as a priority condition when it launched the Mental Health Gap Action Program in October 2008 to bolster care for a range of ailments including mental health, neurology and substance abuse, she said. “The burden of these disorders is very high and the resources are scarce, especially in low and middle income countries,” Dua said in a telephone interview. About 5.2 million people in the U.S. have Alzheimer’s disease, according to the Chicago-based Alzheimer’s association. The first symptom of Alzheimer’s may be mild forgetfulness. As the condition progresses, it begins to interfere with patients’ lives as they forget how to brush their teeth, change their clothes, or recognize once-familiar people. “We’ll be spending the equivalent of the stimulus package every two years if we don’t address this,” Johns said. To contact the reporter on this story: Elizabeth Lopatto in New York at elopatto@bloomberg.net .

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Housing: Short sales spread across real estate market, leaving frustration in their wake: Offers may roll in, but banks often slow to respond,…

September 20, 2009

… and people, whether they are homeowners or real estate agents, just roll their eyes. The practice, … care of it. However, with so many distressed properties for sale, and other homes selling …

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Marshall Goldsmith: The Man Who Taught Me About Quality

August 31, 2009

As an executive coach, I have a unique compensation system — I only get paid if my clients get better. “Better” means my clients achieve positive, measurable change in behavior, not as judged by themselves but by their key stakeholders. This process usually takes about 18 months and involves an average of 16 stakeholders. My coaching approach has been described in several major publications, such as Forbes and The New Yorker . I have been asked many times where I came up with this “pay only for results” idea. The answer is from Dennis Mudd, who was my boss 46 years ago. Growing up in Valley Station, KY, my family was relatively poor. Dad operated a small, two-pump gas station. The roof on our home was very old and starting to leak badly. We had no choice but to get a new roof, although this would be a painful expenditure for us. Dad hired Dennis Mudd to put on the roof. In order for us to save some money, I worked as his assistant. Putting on a roof in the middle of the summer in Kentucky is incredibly hard work. I never have done another job (before or since) that required this degree of physical exertion. I was amazed at the care Mr. Mudd put into the laying of the shingles. He was patient with me as I made mistakes and helped me learn how to do the job right. After a while, my attitude toward this project changed from “grudging acceptance” to “pride in a job well done.” In spite of the heat and pain, I looked forward to working with Mr. Mudd every day. When the project was finally over, I thought the roof looked great. When Mr. Mudd presented my Dad with the invoice for our work, he said quietly, “Bill, please take your time and inspect our work. If you feel that this roof meets your standards, pay us. If not, there is no charge for our work.” It was very obvious he was very serious in his request. Dad carefully looked at the roof, thanked both of us for a job well done and then paid Mr. Mudd, who then paid me for my help. I will never forget watching Mudd when he asked Dad to only pay for results. He wasn’t kidding — he was dead serious, and my respect for Mudd skyrocketed. I was only 14 years old, but I will never forget this event. I knew the Mudd family. They didn’t have any more money that we did. I thought, “Mr. Mudd may not be rich, but he is not cheap. This guy has class. When I grow up, I want to be like Dennis Mudd.” Although I have received many honors for my work, I doubt I will ever match the dedication to quality and the integrity Mr. Mudd showed. In the past 32 years, I have not gotten paid on a few assignments and have never asked for money I felt was undeserved. Financially, how much has this hurt me? At the time, it caused me some pain and embarrassment, but I knew I was still going to have a very prosperous life. How much would not getting paid have hurt Mr. Mudd? A lot. Not paying him would have meant that his family would not be eating very well for the next couple of months. This sacrifice didn’t matter, though. His pride and integrity were more important than money. Mr. Mudd never gave any pep talks about quality or values. He didn’t use any fancy buzzwords such as “empowerment” or “customer delight.” He didn’t have to — his actions communicated his values better than any buzzwords he might have used. We can all learn a lot from this man. The next time you are working on a project, ask yourself, “What would happen to my level of commitment if I knew that I was only going to be paid if I achieved results?” How would your behavior change? Mr. Mudd taught me a lesson I will try to live up to for the rest of my life. What is important is not how much he impressed me. What is much more important is that he could look with pride at the person he saw in the mirror every day.

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How The Profit-Hungry "Medical-IndustrIal Complex" Hurts Health Care (VIDEO)

August 28, 2009

“Bill Moyers Journal” aired a new documentary on its show Friday about how the “medical-industrial complex” affects America’s health care. Based on the book “Money-Driven Medicine” by Maggie Mahar, the film looks at why our health care costs are so high and yet the care is so often lacking. Mahar, who has reported on health care for years, explains the situation as follows: What I learned, during those years, is that in our health care system, profits often trump patients. A great many people are selling and selling hard. By law, for-profit corporations are supposed to put their shareholders’ interests first: this means that they must strive to maximize profits. And this goes a long way toward explaining why U.S. healthcare is so expensive. Watch a clip from the film below. See the whole thing at Bill Moyers Journal .

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Stephen M. Davidson: Paying for Health Care Reform: Part 1

August 12, 2009

The critical question of how to pay for health care reform seems more difficult than it needs to be because Congress has chosen to rely on a reform strategy that depends on competition among traditional insurance companies. The assumption is that, to win and retain customers, insurers will find ways to keep their prices low in order to persuade individuals and families to buy their coverage. But indemnity insurers that pay providers fees for each service they provide do not have the means to do that without undermining the value of the coverage. Insurers have few tools for keeping costs down. They can reduce what they pay for services, but some providers are likely to cope by increasing volume. They can impose prior authorization and other administrative requirements to make it harder for patients to receive covered services and for providers to be paid for them. They can segment the market and discourage potential high users of service from buying their policies in the first place. Insurers use these tactics now. In fact, one of the goals of reform is to eliminate them so that more people can have coverage and obtain the care they need. Regulation can mitigate their effects. Requiring insurers to accept any applicant and to renew any policy can reduce inequities. Requiring them to use community rating to set prices can keep premiums affordable for many higher risk people. Requiring them to cover a comprehensive set of services will provide access to the services subscribers need. Enforcement will be a challenge, and insurers are likely to continue to raise prices each year — constrained only by competitors that are up against the same forces. A simpler solution is available that will achieve the main reform goals and avoid most of the problems from relying on price competition among insurers. In this first post, I describe where the money would come from. In the next one, I talk about how it would be used. Here is the idea: Require that everyone contribute an income-related amount (that is, more for higher-income people than for others) to a dedicated pool of funds for paying insurers and health plans. Then issue vouchers which entitle everyone to choose a health plan or insurance policy. Before dismissing this idea for the cardinal sin of raising taxes, consider these facts: If everyone is covered, per capita costs will be much lower than currently because everyone will be in the risk pool, including millions who will need few or even no services. Also, the currently uninsured who now rely on expensive hospital emergency departments could select community-based primary care physicians. And the vast sums now spent on administrative functions – by insurers to keep from spending money on care and by providers to cope with the vast variations in coverage – would no longer be needed. Furthermore, for people who are currently insured, this “tax” will not only be lower, but will substitute for the premiums they pay now. Employers would pay either a percent of payroll or an amount based on their taxable income. Since the rates will be determined by the size of one’s income, the burden should be manageable for everyone. People with pre-existing conditions and other risk factors will not pay more. Those who don’t earn enough to pay taxes would be covered, too. Cost-sharing amounts, if any, would be kept small so as not to be a barrier to utilization as they are for many in today’s system. Medicare beneficiaries would not need to worry about their coverage. On the other hand, if Medicare (and Medicaid) were folded into the program, the taxes currently supporting those programs would be unnecessary, too. The contributions will be set to create a fund large enough to cover the following year’s projected health care costs for everyone. A key feature is that the amount available to be spent on care would be known at the beginning of the year (instead after all the bills are added up at the end). Costs would rise only modestly. And the best part is that all would be covered and costs would rise only modestly. In my next post, I will discuss disbursing the funds and how the rest of the plan could work. Davidson, a Boston University School of Management professor, is author of the forthcoming book, In Urgent Need of Reform: The U. S. Health Care System.

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