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The Uninsured:

The Uninsured: Keep Them That Way ? It's Safer National Congress On the Un and Underinsured Table of Contents . Introduction-Solutions Some Tables on Costs and Medical Care Received MCR Impact Infections Impact Cancer Death Rates, Deaths and Survivals

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The Uninsured:

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    1. The Uninsured: Keep Them That Way – It’s Safer National Congress on the Un and Underinsured December 11, 2007 Edward T. Gluckmann, M.S. President, Health Matters, Inc. 20/200 Visionary healthmatters@delhitel.net The opinions expressed are those of Mr. Gluckmann Less costly Economic opportunity Encourage new thinkingLess costly Economic opportunity Encourage new thinking

    2. The Uninsured: Keep Them That Way – It’s Safer National Congress On the Un and Underinsured Table of Contents Introduction-Solutions Some Tables on Costs and Medical Care Received MCR Impact Infections Impact Cancer Death Rates, Deaths and Survivals Two Consumer Revolutions, One Women, One Men Pillow Talk: A Foot Note On Aging Impact Alzheimer’s Research On Research How We Treat Those Who Treat Our Most Ill Stents, Devises Florida, Land Of Opportunity Different Visions Myths Deconstructed Can You Play This Game? Does He Or Does He Not? Political Ploys Cancer: First and Last Word Q & A Anybody?

    3. Solutions-change the thinking Solutions-eliminate profit and advertising Solutions-establish independent body-a public trust that approves only what can be platinum standard validated Solutions-convert the word medical in any title, activity or name to wellness and then make its parts comport to that goal Compensation is based on action to prevent first and treat later Criminalize all activity that benefits an individual, institution or entity that is or appears as a conflict Make them wash their hands Create a National Wellness Service

    4. “Best Health Care System in the World” “Today, the United States is undergoing a significant change in the language of medicine. “Words that once were said about the health care system reflexively, used to be assumed, increasingly cannot be said in public, or if uttered have to be seriously qualified. Unlike Carlin’s words, it is not that words about health care are profane or offensive, it is that they are increasingly untenable and unbelievable. Saying them suggests the speaker is out of touch with reality; they are the equivalent of former President George H. W. Bush’s shock at the supermarket checkout scanner.(5) They are a sign that the speaker fails to appreciate the experiences of the average American who interacts with the health care system.” JAMA, V. 297, No. 19, 2131-33,May 16, 2007—Ezekiel J. Emanuel, MD, PhD, (Department of Clinical Bioethics, The Clinical Center, National Institutes of Health), Note: Author’s references numbers are in (..). Italic are mine for emphasis. Bold is quote from another source. “What are we using here, just words.” Hoffa, played by Jack Nicholson A High Performance Health System for the United States: An Ambitious Agenda for the Next President, The Commonwealth Fund Commission on a High Performance Health System, November 2007 Missed the Point: American Medical Care Received (MCR) Is No Longer A Viable Place To Start A Discussion About How to Fix MCR In America Today’s presentation is designed to A) provoke crucial questions, B) establish a basis for a paradigm, tectonic shift in thinking, C) challenge acceptance of the common wisdom, eliminate platitudes, emotional appeals or myths passed off as fact. It seeks to open minds and dialogue to find correct and substantial solutions to what ails America. The Commonwealth Fund Agenda starts where America’s failures left off in the MCR model. It is replete with A) innocence, B) failures to address important issues; C) inaccuracies, myths and emotional content, coupled with common wisdom that is unsupported and challenged by many competent authorities, and D) clichés and fantasies in place of the realities of difficult issues and challenges. We call for a direct, non-flinching approach. MCR is a “mess”; is “dangerous” and the statistics are plain “damning”, yet the agenda recommendations, if ever implemented, would not enhance the value of MCR to Americans who are so desperate for health that can be attained in ways other than the one way that now exists. The agenda takes for granted that MCR can somehow be fixed. It can’t, at least not when starting from where it is without challenging the basic assumptions. In sum: the agenda rushes into a swamp where only fools would tread. It would impoverish, not enhance Americans as it would enrich others. Its approach is wrong and its direction is wrong in tone and wrong in its recommendations. This presentation will set out why the call should be for a “National Wellness Initiative”, one that: -supports prevention and avoidance, not early detection and eventual referral -creates an alternative wellness model to compete with the MCR model however it is recast -establishes consumer empowerment that is real and not one created by brokers and providers to market insurance -sets incentives for Americans to stay well, not waste time developing new provider payment mechanisms -develops a universally applied platinum, not false and selectively applied gold standard -replaces myths and emotional nine second sound bites with honest conversation with Americans, not with the invested elite -has unconditional cost controls instead of almost unlimited resources that will soon be wasted and open to profiteering -eliminates the fear, risk, diagnosed climate and direct-to-consumer demand generating advertising -eliminates any transaction of buying and selling health facilities, programs goods and services for profit -eliminates all potential conflict-of-interest transactions, not validating them by requiring full disclosure -creates funding for development and evaluation of natural processes, products, services and programs Universal MCR insurance can be considered after these conditions are instituted. Let’s start with the next slides to show why. It could be said that the recent A High Performance Health System for the United States: An Ambitious Agenda for the Next President, The Commonwealth Fund Commission on a High Performance Health System, November 2007 falls into this category. It misses the point: Americans no longer accept what is happening. There is a quiet revolution taking place at all levels. The underinsured are the fallout of those symptoms. And as with the medical model, instead of looking at the underlying causes, the manifestation is viewed as the problem. American Medical Care Received (MCR) Is No Longer A Viable Place To Start A Discussion About How to Fix MCR In America. If anything: it is the last place to start. This presentation is designed to A) provoke crucial questions, B) establish a basis for a paradigm, tectonic shift in thinking, C) challenge acceptance of the common wisdom, eliminate platitudes, emotional appeals or myths passed off as fact. It seeks to open minds and dialogue to find correct and substantial solutions to what ails America. The Commonwealth Fund Agenda starts where America’s failures end in the MCR model. It is replete with A) innocence, B) failures to address important issues; C) inaccuracies, myths and emotional content, coupled with common wisdom that is unsupported and challenged by many competent authorities, and D) clichés and fantasies in place of the realities of difficult issues and challenges. We call for a direct, non-flinching approach that starts elsewhere and ignores the manifestation of symptoms and looks for the causes. There is not a word about corruption, fraud, stock options, buying and selling for profit, not health or for even diagnostic and treatment purposes. There is not a word about Wall Street, investments, entrepreneurs gone a muck, the falseness of the competitive model in medicine that drives costs up, not down, the false idolatry and ideology of free enterprise, transparency and electronic solutions to problems without mentioning the GIGO reality, regulatory agencies under the thumb of those they regulate or the inability to do their jobs due to political and budgetary constraints. MCR is a “mess”; is “dangerous” and the statistics are plain “damning”, yet the agenda recommendations, if ever implemented, would not enhance the value of MCR to Americans who are so desperate for health that can be attained in ways other than the one way that now exists. The agenda takes for granted that MCR can somehow be fixed. It can’t, at least not when starting from where it is without challenging the basic assumptions. In sum: the agenda rushes into a swamp where only fools would tread. It would impoverish, not enhance Americans as it would enrich others. Its approach is wrong and its direction is wrong in tone and wrong in its recommendations. “What are we using here, just words.” Hoffa, played by Jack Nicholson A High Performance Health System for the United States: An Ambitious Agenda for the Next President, The Commonwealth Fund Commission on a High Performance Health System, November 2007 Missed the Point: American Medical Care Received (MCR) Is No Longer A Viable Place To Start A Discussion About How to Fix MCR In America Today’s presentation is designed to A) provoke crucial questions, B) establish a basis for a paradigm, tectonic shift in thinking, C) challenge acceptance of the common wisdom, eliminate platitudes, emotional appeals or myths passed off as fact. It seeks to open minds and dialogue to find correct and substantial solutions to what ails America. The Commonwealth Fund Agenda starts where America’s failures left off in the MCR model. It is replete with A) innocence, B) failures to address important issues; C) inaccuracies, myths and emotional content, coupled with common wisdom that is unsupported and challenged by many competent authorities, and D) clichés and fantasies in place of the realities of difficult issues and challenges. We call for a direct, non-flinching approach. MCR is a “mess”; is “dangerous” and the statistics are plain “damning”, yet the agenda recommendations, if ever implemented, would not enhance the value of MCR to Americans who are so desperate for health that can be attained in ways other than the one way that now exists. The agenda takes for granted that MCR can somehow be fixed. It can’t, at least not when starting from where it is without challenging the basic assumptions. In sum: the agenda rushes into a swamp where only fools would tread. It would impoverish, not enhance Americans as it would enrich others. Its approach is wrong and its direction is wrong in tone and wrong in its recommendations. This presentation will set out why the call should be for a “National Wellness Initiative”, one that: -supports prevention and avoidance, not early detection and eventual referral -creates an alternative wellness model to compete with the MCR model however it is recast -establishes consumer empowerment that is real and not one created by brokers and providers to market insurance -sets incentives for Americans to stay well, not waste time developing new provider payment mechanisms -develops a universally applied platinum, not false and selectively applied gold standard -replaces myths and emotional nine second sound bites with honest conversation with Americans, not with the invested elite -has unconditional cost controls instead of almost unlimited resources that will soon be wasted and open to profiteering -eliminates the fear, risk, diagnosed climate and direct-to-consumer demand generating advertising -eliminates any transaction of buying and selling health facilities, programs goods and services for profit -eliminates all potential conflict-of-interest transactions, not validating them by requiring full disclosure -creates funding for development and evaluation of natural processes, products, services and programs Universal MCR insurance can be considered after these conditions are instituted. Let’s start with the next slides to show why. It could be said that the recent A High Performance Health System for the United States: An Ambitious Agenda for the Next President, The Commonwealth Fund Commission on a High Performance Health System, November 2007 falls into this category. It misses the point: Americans no longer accept what is happening. There is a quiet revolution taking place at all levels. The underinsured are the fallout of those symptoms. And as with the medical model, instead of looking at the underlying causes, the manifestation is viewed as the problem. American Medical Care Received (MCR) Is No Longer A Viable Place To Start A Discussion About How to Fix MCR In America. If anything: it is the last place to start. This presentation is designed to A) provoke crucial questions, B) establish a basis for a paradigm, tectonic shift in thinking, C) challenge acceptance of the common wisdom, eliminate platitudes, emotional appeals or myths passed off as fact. It seeks to open minds and dialogue to find correct and substantial solutions to what ails America. The Commonwealth Fund Agenda starts where America’s failures end in the MCR model. It is replete with A) innocence, B) failures to address important issues; C) inaccuracies, myths and emotional content, coupled with common wisdom that is unsupported and challenged by many competent authorities, and D) clichés and fantasies in place of the realities of difficult issues and challenges. We call for a direct, non-flinching approach that starts elsewhere and ignores the manifestation of symptoms and looks for the causes. There is not a word about corruption, fraud, stock options, buying and selling for profit, not health or for even diagnostic and treatment purposes. There is not a word about Wall Street, investments, entrepreneurs gone a muck, the falseness of the competitive model in medicine that drives costs up, not down, the false idolatry and ideology of free enterprise, transparency and electronic solutions to problems without mentioning the GIGO reality, regulatory agencies under the thumb of those they regulate or the inability to do their jobs due to political and budgetary constraints. MCR is a “mess”; is “dangerous” and the statistics are plain “damning”, yet the agenda recommendations, if ever implemented, would not enhance the value of MCR to Americans who are so desperate for health that can be attained in ways other than the one way that now exists. The agenda takes for granted that MCR can somehow be fixed. It can’t, at least not when starting from where it is without challenging the basic assumptions. In sum: the agenda rushes into a swamp where only fools would tread. It would impoverish, not enhance Americans as it would enrich others. Its approach is wrong and its direction is wrong in tone and wrong in its recommendations.

    5. “Best Health Care System in the World” The statistics are “damning” The system a “mess” Country Per Capita ($) % of GNP USA 6,000 16.0 Switzerland 4,077 11.5 Norway 3,966 9.7 Germany 3,043 10.6 S. Korea 1,149 8.2 USA Ranking Life Expectancy 45th (behind Bosnia) Infant Mortality Rates (Per 1,000 live births) All 6.37 (behind Cuba) White 5.7 (two times the rate of Singapore/Sweden/Japan) What Cannot be Said on Television About Health Care, JAMA, V. 297, No. 19, 2131-33, Ezekiel J. Emanuel, MD, PhD, (Department of Clinical Bioethics, The Clinical Center, National Institutes of Health) Author’s reference numbers are in (..). “Many no longer believe the United States has the best health care system in the world.(7) The statistics are damning. The United States has the most expensive system, by far. In 2005 health care cost more than $6000 per person or in excess of 16% of the gross domestic product (GDP).(8) The nearest rival, Switzerland, spends $4077 per person per year, or 11.5% of its GDP (in purchasing power parity).(9) Norway spends $3966 (9.7% of GDP); Germany, $3043 (10.6% of GDP); and South Korea, a mere $1149 (8.2% of GDP).(9) However, Americans are increasingly aware that all of this money is not buying very much. Life expectancy in the United States is 78 years, ranking 45th in the world, well behind Switzerland, Norway, Germany, and even Greece, Bosnia, and Jordan.(10) The US infant mortality rate is 6.37 per 1000 live births, higher than almost all other developed countries, as well as Cuba. Even for white individuals, the numbers are not world class—5.7 infant deaths per 1000 live births—more than double the rate in Singapore, Sweden, and Japan.(9)” prescription drugs, rent/mortgage food, premiums For decades it was accepted that health care was special… To many, the specialness of health care meant that cost should not be a consideration in care….. The tipping point came when the media began reporting that the high cost of pharmaceuticals forced some elderly to choose between drugs and food.(18)…. Americans began to realize that, as the economists would say, spending on health care has opportunity costs. Indeed, experts in the social determinants of health emphasized that many of these other factors, from income to education, were integral and perhaps even more integral than health care services for improving health outcomes….. Today, saying that health care is so special that its cost is irrelevant serves to discredit the source…. Replacing the notion that cost is irrelevant is the notion of value. Just as consumers ask whether a car or a computer is worth the cost, Americans are enamored with technology, especially health technology….. Americans are beginning to be skeptical about whether new health care technologies are better. Today, the list of drugs and technologies for which new might not be better (and may be even worse) has expanded rapidly” But that phrase is new is better is more frequently countered…more frequently challenged, and less readily believed without qualification. Instead, many are more likely to read the restrictions, accept that the provisos have merit, and question the true value of the new interventions The tipping point probably came with the withdrawal of rofecoxib from the US market …. Unlike the other phrases, it is still possible to say on TV that “new drugs and health care technologies are improved Rate of increases and absolute costs force harsh decisions Opportunity costs: illness vs. wellness; medical care vs. housing, food, education Prevention vs. early detection? Health care consumers are beginning to ask whether a health care intervention is worth the cost…. “Many no longer believe the United States has the best health care system in the world.(7) The statistics are damning. The United States has the most expensive system, by far. In 2005 health care cost more than $6000 per person or in excess of 16% of the gross domestic product (GDP).(8) The nearest rival, Switzerland, spends $4077 per person per year, or 11.5% of its GDP (in purchasing power parity).(9) Norway spends $3966 (9.7% of GDP); Germany, $3043 (10.6% of GDP); and South Korea, a mere $1149 (8.2% of GDP).(9) However, Americans are increasingly aware that all of this money is not buying very much. Life expectancy in the United States is 78 years, ranking 45th in the world, well behind Switzerland, Norway, Germany, and even Greece, Bosnia, and Jordan.(10) The US infant mortality rate is 6.37 per 1000 live births, higher than almost all other developed countries, as well as Cuba. Even for white individuals, the numbers are not world class—5.7 infant deaths per 1000 live births—more than double the rate in Singapore, Sweden, and Japan.(9)” prescription drugs, rent/mortgage food, premiums For decades it was accepted that health care was special… To many, the specialness of health care meant that cost should not be a consideration in care….. The tipping point came when the media began reporting that the high cost of pharmaceuticals forced some elderly to choose between drugs and food.(18)…. Americans began to realize that, as the economists would say, spending on health care has opportunity costs. Indeed, experts in the social determinants of health emphasized that many of these other factors, from income to education, were integral and perhaps even more integral than health care services for improving health outcomes….. Today, saying that health care is so special that its cost is irrelevant serves to discredit the source…. Replacing the notion that cost is irrelevant is the notion of value. Just as consumers ask whether a car or a computer is worth the cost, Americans are enamored with technology, especially health technology….. Americans are beginning to be skeptical about whether new health care technologies are better. Today, the list of drugs and technologies for which new might not be better (and may be even worse) has expanded rapidly” But that phrase is new is better is more frequently countered…more frequently challenged, and less readily believed without qualification. Instead, many are more likely to read the restrictions, accept that the provisos have merit, and question the true value of the new interventions The tipping point probably came with the withdrawal of rofecoxib from the US market …. Unlike the other phrases, it is still possible to say on TV that “new drugs and health care technologies are improved Rate of increases and absolute costs force harsh decisions Opportunity costs: illness vs. wellness; medical care vs. housing, food, education Prevention vs. early detection? Health care consumers are beginning to ask whether a health care intervention is worth the cost….

    6. Number of Americans With Coverage By Type Type Level of Insurance (000,000) Total Full Under Un Med/Hosp/Drug 300 30 50 220 Dental 300 30 140 130 Health/Wellness 300 30 10 260 Dental insurance an affordable benefit Employer-sponsored plans have positive payback AVMA News, November 15, 2004 Definitions Medical/Hospital/Drug are sometimes referred to as Health Insurance. We will soon see that this is a a simple misnomer. Dental includes all forms of diagnoses and treatment of things found in the mouth-teeth, gums, jawbone, tongue Health/Wellness includes the avoidance and prevention of disease based on different principles, foundations and fundamentals than associating symptoms with a disease. Examples will be scattered about but the simple one we all know is that scurvy is not a disease but a deficiency in a natural vitamin. Today, scurvy would be a source of research seeking a drug that promised a cure. Use of vitamin C would be discouraged by omission. Similar story with Niacin, vitamin B-3 and cholesterol, C’est vrai? Scurvy (N.Lat. scorbutus) is a deficiency disease that results from insufficient intake of vitamin C, which is required for correct collagen synthesis in humans. The scientific name of vitamin C, ascorbic acid, is derived from the Latin name of scurvy, scorbutus. Scurvy leads to the formation of liver spots on the skin, spongy gums, and bleeding from all mucous membranes. The spots are most abundant on the thighs and legs, and a person with the ailment looks pale, feels depressed, and is partially immobilized. In advanced scurvy there are open, suppurating wounds and loss of teeth. Scurvy was at one time common among sailors, pirates and others who were on ships that were out to sea longer than perishable fruits and vegetables could be stored and by soldiers who were similarly separated from these foods for extended periods. It was described by Hippocrates (c. 460 BC–c. 380 BC). Its cause and cure have been known in many native cultures since prehistory. For example, in 1536, the French explorer Jacques Cartier, exploring the St. Lawrence River, used the local natives' knowledge to save his men who were dying of scurvy. He boiled the needles of the arbor vitae tree (Eastern White Cedar) to make a tea that was later shown to contain 50 mg of vitamin C per 100 grams.[1][2] However it was a Scottish surgeon in the British Royal Navy, James Lind who first proved it could be treated with citrus fruit in experiments he described in his 1753 book, A Treatise of the Scurvy. Some means some coverage, includes high front end deductible plan, basic coverage, excludes dental Fully means people who have resources to pay for any medical care bill. Would certainly include the 5% who own 80% of American assets. I assume the next 5% would also have no problem to cover bills if not insured. Partial means the standard HMO, PPO, POS, indemnity and other insurance, each of which has a list of covered, non-covered services, limitations, exclusions, etc. Dental coverage is less, yet maybe more important. Poor teeth means the person cannot eat properly, might have attitude issues due to appearance. Many processes and disease start here, in the mouth.Dental insurance an affordable benefit Employer-sponsored plans have positive payback AVMA News, November 15, 2004 Definitions Medical/Hospital/Drug are sometimes referred to as Health Insurance. We will soon see that this is a a simple misnomer. Dental includes all forms of diagnoses and treatment of things found in the mouth-teeth, gums, jawbone, tongue Health/Wellness includes the avoidance and prevention of disease based on different principles, foundations and fundamentals than associating symptoms with a disease. Examples will be scattered about but the simple one we all know is that scurvy is not a disease but a deficiency in a natural vitamin. Today, scurvy would be a source of research seeking a drug that promised a cure. Use of vitamin C would be discouraged by omission. Similar story with Niacin, vitamin B-3 and cholesterol, C’est vrai? Scurvy (N.Lat. scorbutus) is a deficiency disease that results from insufficient intake of vitamin C, which is required for correct collagen synthesis in humans. The scientific name of vitamin C, ascorbic acid, is derived from the Latin name of scurvy, scorbutus. Scurvy leads to the formation of liver spots on the skin, spongy gums, and bleeding from all mucous membranes. The spots are most abundant on the thighs and legs, and a person with the ailment looks pale, feels depressed, and is partially immobilized. In advanced scurvy there are open, suppurating wounds and loss of teeth. Scurvy was at one time common among sailors, pirates and others who were on ships that were out to sea longer than perishable fruits and vegetables could be stored and by soldiers who were similarly separated from these foods for extended periods. It was described by Hippocrates (c. 460 BC–c. 380 BC). Its cause and cure have been known in many native cultures since prehistory. For example, in 1536, the French explorer Jacques Cartier, exploring the St. Lawrence River, used the local natives' knowledge to save his men who were dying of scurvy. He boiled the needles of the arbor vitae tree (Eastern White Cedar) to make a tea that was later shown to contain 50 mg of vitamin C per 100 grams.[1][2] However it was a Scottish surgeon in the British Royal Navy, James Lind who first proved it could be treated with citrus fruit in experiments he described in his 1753 book, A Treatise of the Scurvy. Some means some coverage, includes high front end deductible plan, basic coverage, excludes dental Fully means people who have resources to pay for any medical care bill. Would certainly include the 5% who own 80% of American assets. I assume the next 5% would also have no problem to cover bills if not insured. Partial means the standard HMO, PPO, POS, indemnity and other insurance, each of which has a list of covered, non-covered services, limitations, exclusions, etc. Dental coverage is less, yet maybe more important. Poor teeth means the person cannot eat properly, might have attitude issues due to appearance. Many processes and disease start here, in the mouth.

    7. Americans Rate Medical Care Received American leadership needs to get the message: Americans do not buy the best, its different , newest lines anymore. In the survey of 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States, one third of U.S. adults called for rebuilding the system, the highest rate in any country surveyed. The U.S. also ranked last in saying only minor changes are needed in the health system. American leadership needs to get the message: Americans do not buy the best, its different , newest lines anymore. In the survey of 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States, one third of U.S. adults called for rebuilding the system, the highest rate in any country surveyed. The U.S. also ranked last in saying only minor changes are needed in the health system.

    8. California HMOs Meets National Member Care Standards Rating 55% 63% Based on reports for nine top HMOs that cover 90% of HMO covered population in CA State of California Website 10/2007 Quality HMOs - California Dreaming or California Reality. How does the government allow the title HMO, health maintenance organization with these findings. Should there not be an application of truth in advertising laws applied here? Obese? 60% no diet or exercise counseling Diabetic? 30% no control of sugar levels Consumers: 70% unfavorable ratings Responses by HMOs and the State: “will focus on areas that need improvement” “there is room for improvement” “can all do better” The California HMOs Realty Show-Who Will Survive? Meeting National Members Rate HMO Standards of Care Their HMO Aetna Health of California, Inc. ** * Blue Cross HMO/California Care ** ** Blue Cross of California HMO ** *** Cigna HMO ** ** Health Net of California, Inc. *** *** Kaiser Permanente/No. CA Region *** *** Kaiser Permanente/So. CA Region *** *** PacifiCare of California ** *** Western Health Advantage ** *** HMO Ratings At-a-Glance: Excellent ****; Good ***; Fair **; Poor * Quality can be measured/based on established standards or it can be based on general impressions, reactions and feelings by asking people, “What do you think?” When the JACHO says a hospital is in the top 10% or a survey of patients concludes patients are happy with what they got, the papers are filled with advertisements about the ratings. Or when marketing the new or latest or best cancer care, all that is done is create a market piece with a picture of some impressive machinery, a spotless building or patient room, more nurses, techs and physicians (all in white uniforms, stethoscope extra) than patients and for greater impact, a picture of a group of young, happy women, all looking rather slim, smiley with a few children (boy and girl preferred) with a few happy men-assumed to be the husbands and fathers who also are all slim and robust. Kind of makes you forget the mastectomy, chemo, radiation, wigs, weight loss, fatigue, medical bills. Why these folks are just having a ball. Have there been any ads about this rating sponsored by any HMO, hospital, medical group, AHIP, AHA, or the AMA? Would you be eager to join any of these HMOs? Now that you see what the ratings are for the most populated state (covers 90% of insured in Ca.), do you still want to throw a few hundred billion out there? The answer is determined on whether you are paying the bill or receiving the payment. Quality HMOs-California Dreaming Obese? 60% no diet or exercise counseling Diabetic? 30% no control of sugar levels Consumers: 70% unfavorable ratings Responses by HMOs and the State: “will focus on areas that need improvement” “there is room for improvement” “can all do better” Quality HMOs - California Dreaming or California Reality. How does the government allow the title HMO, health maintenance organization with these findings. Should there not be an application of truth in advertising laws applied here? Obese? 60% no diet or exercise counseling Diabetic? 30% no control of sugar levels Consumers: 70% unfavorable ratings Responses by HMOs and the State: “will focus on areas that need improvement” “there is room for improvement” “can all do better” The California HMOs Realty Show-Who Will Survive? Meeting National Members Rate HMO Standards of Care Their HMO Aetna Health of California, Inc. ** * Blue Cross HMO/California Care ** ** Blue Cross of California HMO ** *** Cigna HMO ** ** Health Net of California, Inc. *** *** Kaiser Permanente/No. CA Region *** *** Kaiser Permanente/So. CA Region *** *** PacifiCare of California ** *** Western Health Advantage ** *** HMO Ratings At-a-Glance: Excellent ****; Good ***; Fair **; Poor * Quality can be measured/based on established standards or it can be based on general impressions, reactions and feelings by asking people, “What do you think?” When the JACHO says a hospital is in the top 10% or a survey of patients concludes patients are happy with what they got, the papers are filled with advertisements about the ratings. Or when marketing the new or latest or best cancer care, all that is done is create a market piece with a picture of some impressive machinery, a spotless building or patient room, more nurses, techs and physicians (all in white uniforms, stethoscope extra) than patients and for greater impact, a picture of a group of young, happy women, all looking rather slim, smiley with a few children (boy and girl preferred) with a few happy men-assumed to be the husbands and fathers who also are all slim and robust. Kind of makes you forget the mastectomy, chemo, radiation, wigs, weight loss, fatigue, medical bills. Why these folks are just having a ball. Have there been any ads about this rating sponsored by any HMO, hospital, medical group, AHIP, AHA, or the AMA? Would you be eager to join any of these HMOs? Now that you see what the ratings are for the most populated state (covers 90% of insured in Ca.), do you still want to throw a few hundred billion out there? The answer is determined on whether you are paying the bill or receiving the payment. Quality HMOs-California Dreaming Obese? 60% no diet or exercise counseling Diabetic? 30% no control of sugar levels Consumers: 70% unfavorable ratings Responses by HMOs and the State: “will focus on areas that need improvement” “there is room for improvement” “can all do better”

    9. Comparison of Selected Benchmarks Before/After Expanded Insurance Before After . Total Cost $2,200,000,000,000 $2,604,000,000,000* Cost Per Insured $7,333 - $8,800** $8,000 - $9,600 GDP % 16% -18%* 20% - 22% Quality Rating*** 37th - 45th 37th - 45th Waste**** 20% - 70% 35% - 75% Deaths Due to Care***** 449,000 - 1,000,000 529,000 - 1,080,000 * Add $50 billion to cover price increases and correction of estimated costs. ** Depends on who is doing the count. But who is? Everyone! *** USA compared to the world for selected benchmarks. **** Estimated based on various indicators of waste. ***** Used conservative 80,000 additional deaths due to medical care received (MCR) No matter who pays, in the end the cost is $300,000,000,000 to cover 50,000,000 million underinsured befroe the food frenzy starts. Between 20 and 30 cents on every health care dollar we spend goes towards useless treatments and hospitalizations, towards CT scans we don’t need, towards ineffective surgeries—towards care that not only does nothing to improve our health Overtreated, Shannon Brownlee Evidence based guru says 85% wasted. Other evidence based pros say 70%-75%. Administrative overhead: Medicare 4%, private sector: 20-25% Assuming 725,000 deaths caused by medical care received (MCR) by 250,000,000 insured Americans, we can project another 87,000 dead when covered (meaning they get the care now claimed to not be received due to lack of coverage.). I used 80,000 for this slide. Quality ratings speak for themselves. But you can go to just about any WHO or recent literature on the subject of international ratings to confirm the quoted rankings. More to follow. Waste would include anything that is unnecessary, counterproductive or related to treatment for iatrogenic illness and disease, administration, fraud, costs of M & A, profits, advertisements, whistleblower and related litigation and plain old “Corruption.”No matter who pays, in the end the cost is $300,000,000,000 to cover 50,000,000 million underinsured befroe the food frenzy starts. Between 20 and 30 cents on every health care dollar we spend goes towards useless treatments and hospitalizations, towards CT scans we don’t need, towards ineffective surgeries—towards care that not only does nothing to improve our health Overtreated, Shannon Brownlee Evidence based guru says 85% wasted. Other evidence based pros say 70%-75%. Administrative overhead: Medicare 4%, private sector: 20-25% Assuming 725,000 deaths caused by medical care received (MCR) by 250,000,000 insured Americans, we can project another 87,000 dead when covered (meaning they get the care now claimed to not be received due to lack of coverage.). I used 80,000 for this slide. Quality ratings speak for themselves. But you can go to just about any WHO or recent literature on the subject of international ratings to confirm the quoted rankings. More to follow. Waste would include anything that is unnecessary, counterproductive or related to treatment for iatrogenic illness and disease, administration, fraud, costs of M & A, profits, advertisements, whistleblower and related litigation and plain old “Corruption.”

    10. Standard Leading Cause of American Death Rankings Rank/Cause Deaths (#) %/Total Death Rate All causes . . . . . . . . 2,443,387 100.0 847.31 1 Diseases of heart . . 696,947 28.5 241.72 2 Malignant neoplasms . 557,271 22.8 193.23 3 Cerebrovascular diseases . . . . . . 162,672 6.7 56.44 4 Chronic lower respiratory diseases. 124,816 5.1 43.35 5 Accidents (unintentional injuries) . 106,742 4.4 37.06 6 Diabetes mellitus . . . . . . . . . . 73,249 3.0 25.47 7 Influenza and pneumonia . . . . . . 65,681 2.7 22.88 8 Alzheimer’s disease. . . . . . . . . . . 58,866 2.4 20.49 9 Nephritis, nephrotic syndrome and nephrosis . . . 40,974 1.7 14.21 10 Septicemia . . . . . . . . . . . . . . 33,865 1.4 11.70 11 All other causes . . . (Residual) 522,304 21.4 181.10 In 22 years cancer will either be cured or vanish according to data showing over a 1% decrease in death rates per year over the last few years. Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes of death in selected age groups, by race and sex: United States, 2002, National Vital Statistics Reports, Vol. 53, No. 17, March 7, 2005 Other than stomach and a bit with the pancreas, everything else is stable. Lung however went thru the roof. 1930-1993 CANCER FACTS & FIGURES–1997, ACS [Rates per 100,000 population in specified group. Data for races other than white and black should be interpreted with caution because of misreporting of race on death certificates; see ‘‘Technical Notes.’’ The asterisk (*) preceding the cause-of-death codes indicates that they are not part of the International Classification of Diseases, Tenth Revision (ICD–10); see ‘‘Technical Notes’’] Deaths/Mortality (Data are for U.S. for year indicated) Number of deaths: 2,397,615 Death rate: 816.5 deaths per 100,000 population Life expectancy: 77.8 years Infant Mortality rate: 6.8 deaths per 1,000 live births Number of deaths for leading causes of death: Heart disease: 652,486 Cancer: 553,888 Stroke (cerebrovascular diseases): 150,074 Chronic lower respiratory diseases: 121,987 Accidents (unintentional injuries): 112,012 Diabetes: 73,138 Alzheimer's disease: 65,965 Influenza/Pneumonia: 59,664 Nephritis, nephrotic syndrome, and nephrosis: 42,480 Septicemia: 33,373 Source: Deaths: Final Data for 2004, table 12 Accidents, suicides and homicides are big in younger years and avoidable Heart, cancer etc are long in the making and appear later in life and are preventable. Where do you spend the $ new billions proposed to cover the under insured? Rank, cause, # of deaths, % of all deaths, death rate Death by accident is greatest of 10-14 year olds, cancer is #2, suicide #3, Congenital malformations, deformations and chromosomal abnormalities #4, and homicide is #5; Ages 1-4, accidents and homicide are # 1 and #3 respectively 15-19: accidents, homicide and suicide are # 1, 2 and 3 5-9 accidents, cancer, congenital et al and homicide are # 1, 2 3 and 4 respectively 20-24 accidents, homicides, suicides and cancer are #1, 2, 3, and 4 respectively; 25-34, same story 35-44 accidents, cancer, heart, suicide, HIV with homicide taking 6th place; 45-54 cancer, heart, accidents, liver, suicide; 55-64 cancer, heart, respiratory, diabetes, cerebrovascular, 65 and older: heart, cancer cerebrovascular, respiratory Cause of death (Based on the International Classification of Diseases, Tenth Revision, 1992), race, sex, and age Number2 Percentage of total deaths Rate2 In 22 years cancer will either be cured or vanish according to data showing over a 1% decrease in death rates per year over the last few years. Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes of death in selected age groups, by race and sex: United States, 2002, National Vital Statistics Reports, Vol. 53, No. 17, March 7, 2005 Other than stomach and a bit with the pancreas, everything else is stable. Lung however went thru the roof. 1930-1993 CANCER FACTS & FIGURES–1997, ACS [Rates per 100,000 population in specified group. Data for races other than white and black should be interpreted with caution because of misreporting of race on death certificates; see ‘‘Technical Notes.’’ The asterisk (*) preceding the cause-of-death codes indicates that they are not part of the International Classification of Diseases, Tenth Revision (ICD–10); see ‘‘Technical Notes’’] Deaths/Mortality (Data are for U.S. for year indicated) Number of deaths: 2,397,615 Death rate: 816.5 deaths per 100,000 population Life expectancy: 77.8 years Infant Mortality rate: 6.8 deaths per 1,000 live births Number of deaths for leading causes of death: Heart disease: 652,486 Cancer: 553,888 Stroke (cerebrovascular diseases): 150,074 Chronic lower respiratory diseases: 121,987 Accidents (unintentional injuries): 112,012 Diabetes: 73,138 Alzheimer's disease: 65,965 Influenza/Pneumonia: 59,664 Nephritis, nephrotic syndrome, and nephrosis: 42,480 Septicemia: 33,373 Source: Deaths: Final Data for 2004, table 12 Accidents, suicides and homicides are big in younger years and avoidable Heart, cancer etc are long in the making and appear later in life and are preventable. Where do you spend the $ new billions proposed to cover the under insured? Rank, cause, # of deaths, % of all deaths, death rate Death by accident is greatest of 10-14 year olds, cancer is #2, suicide #3, Congenital malformations, deformations and chromosomal abnormalities #4, and homicide is #5; Ages 1-4, accidents and homicide are # 1 and #3 respectively 15-19: accidents, homicide and suicide are # 1, 2 and 3 5-9 accidents, cancer, congenital et al and homicide are # 1, 2 3 and 4 respectively 20-24 accidents, homicides, suicides and cancer are #1, 2, 3, and 4 respectively; 25-34, same story 35-44 accidents, cancer, heart, suicide, HIV with homicide taking 6th place; 45-54 cancer, heart, accidents, liver, suicide; 55-64 cancer, heart, respiratory, diabetes, cerebrovascular, 65 and older: heart, cancer cerebrovascular, respiratory Cause of death (Based on the International Classification of Diseases, Tenth Revision, 1992), race, sex, and age Number2 Percentage of total deaths Rate2

    11. Leading Cause of American Death Rankings-Another View Rank/Cause Deaths (#) %/Total Death Rate All causes . . . . . . . . 2,443,387 100.0 847.31 1 MCR (Liberal) 783,936 32.0 2 Diseases of heart . . 696,947 28.5 241.72 3 Malignant neoplasms.. 557,271 22.8 193.20 4 MCR (Conservative) 424,000 17.0 5 Cerebrovascular diseases . . . . 162,672 6.7 56.44 6 Chronic lower respiratory dis. 124,816 5.1 43.35 7 Accidents (unintentional injuries).. 106,742 4.4 37.06 8 Diabetes mellitus . . . . . . . . . . 73,249 3.0 25.47 9 All other causes…………………… Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes of death in selected age groups, by race and sex: United States, 2002, modified to include liberal and conservative deaths caused by Medical Care Received (MCR), National Vital Statistics Reports, Vol. 53, No. 17, March 7, 2005 MCR = Medical Care Received. New ICD codes are forthcoming soon so that easier comparisons can be made year to year and internationally.Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes of death in selected age groups, by race and sex: United States, 2002, modified to include liberal and conservative deaths caused by Medical Care Received (MCR), National Vital Statistics Reports, Vol. 53, No. 17, March 7, 2005 MCR = Medical Care Received. New ICD codes are forthcoming soon so that easier comparisons can be made year to year and internationally.

    12. A Leading Cause of Death: Medical Care Received (MCR) ANNUAL PHYSICAL AND ECONOMIC COST OF MEDICAL INTERVENTION Condition Deaths Cost Author Adverse Drug Reactions 106,000 $12 billion Lazarou(1), Suh(49) Medical Error 98,000 $2 billion IOM(6) Bedsore 115,000 $55 billion Xakellis(7), Barczak(8) Infection 88,000 $5 billion Weinstein(9), MMWR(10) Malnutrition 108,800 -------- Nurses Coalition(11) Outpatients 199,000 $77 billion Starfield(12), Weingart(112) Unnecessary Procedures 37,136 $122 billion HCUP(3,13) Surgery-Related 32,000 $9 billion AHRQ(85) Totals: 783,936 $282 billion or 12.8% of $2.2 trillion The American Medical System Is The Leading Cause Of Death And Injury In The United States, Gary Null PhD, Carolyn Dean MD ND, Martin Feldman MD, Debora Rasio MD, Dorothy Smith PhD. (..) indicates reference numbers in original 9/11= 3,000 dead Old mantra: Weapons of Mass Destruction (WMD) 1/1-12/31/xx = 2,144 dead/day (hospital based only) New mantra: Comprehensive Universal Insurance (CUI). Which one is the true threat? Think Gary and crowd are exaggerating? We will show more conservative figures. 9/11= 3,000 dead Old mantra: Weapons of Mass Destruction (WMD) 1/1-12/31/xx = 2,144 dead/day (hospital based only) New mantra: Comprehensive Universal Insurance (CUI). Which one is the true threat? Think Gary and crowd are exaggerating? We will show more conservative figures.

    13. Hospital MCR Deaths Per Year By Type 12,000 - Unnecessary surgery 7,000 - Medication errors 20,000 - Other errors 80,000 - Nosocomial infections 106,000 - No error, adverse effects of medications Is US Health Really the Best in the World?, JAMA, July 26, 2000—V. 284, No. 4 483-85 Even the conservative figures are staggering.Even the conservative figures are staggering.

    14. Hospital MCR Deaths Per Year Medical Care Received (MCR) Caused Deaths Per Year 225,000 Is US Health Really the Best in the World?, JAMA, July 26, 2000, V. 284, No. 4 483-85 Iatrogenic My first though: How words can make a difference in our thinking. Substitute terrorist, lead poisoned kid toys, for iatrogenic, iatrogenic disorder is any pathological anomaly in which the dysfunctional symptoms in the patient owe their cause (iatrogenesis) to the actions of the practitioner. How would anyone react to substituting for iatrogenic the phrase “killed by medical care received (MCR)” ? My second thought: How could I make the figure larger? Yes, cover another 50,000,000 Americans. Does it matter if the figure is 225,000 or 783,936? Leading causes of death: Heart Disease runs about 900,000 Malignant Neoplasm runs about 600,000 Stroke runs less than these conservative Iatrogenic figures, as does diabetes, AIDS/HIV, car accidents, illicit drug deaths, etc. Sources used by author Barbara Starfield, M.D., MPH to develop the figures cited in the last two slides. 8. Leape L. Unnecessary surgery. Annu Rev Public Health. 1992;13:363-383. 9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644. 10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205.Iatrogenic My first though: How words can make a difference in our thinking. Substitute terrorist, lead poisoned kid toys, for iatrogenic, iatrogenic disorder is any pathological anomaly in which the dysfunctional symptoms in the patient owe their cause (iatrogenesis) to the actions of the practitioner. How would anyone react to substituting for iatrogenic the phrase “killed by medical care received (MCR)” ? My second thought: How could I make the figure larger? Yes, cover another 50,000,000 Americans. Does it matter if the figure is 225,000 or 783,936? Leading causes of death: Heart Disease runs about 900,000 Malignant Neoplasm runs about 600,000 Stroke runs less than these conservative Iatrogenic figures, as does diabetes, AIDS/HIV, car accidents, illicit drug deaths, etc. Sources used by author Barbara Starfield, M.D., MPH to develop the figures cited in the last two slides. 8. Leape L. Unnecessary surgery. Annu Rev Public Health. 1992;13:363-383. 9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644. 10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205.

    15. Medical Injury Is Significant Threat “In conclusion, our results clearly show that medical injuries in hospitals pose a significant threat to patients and incur substantial costs to society.” Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization, JAMA, 2003:290: 1868-1874 Just in case there was need for more information about quality and safety, we turn to this study “Because the PSIs flag few false-positive results… and a relatively large number of false-negative..resulting in conservative estimates.” PSI = Patient Safety Indicators only 18 were used in this study. Results support other studies. Again, conservative.Just in case there was need for more information about quality and safety, we turn to this study “Because the PSIs flag few false-positive results… and a relatively large number of false-negative..resulting in conservative estimates.” PSI = Patient Safety Indicators only 18 were used in this study. Results support other studies. Again, conservative.

    16. There is trouble at the most unlikely of places An ambulance just arrived at the famous “Pinata” Hospital The patient was heard screaming to the ER Nurse! “Please hurry, I’m losing my candy.” Is there a Pinata specialist in the house? No worry about payment. This condition is covered under the Sugar Game Act.Is there a Pinata specialist in the house? No worry about payment. This condition is covered under the Sugar Game Act.

    17. Is There An Extra Doctor In the House? “One analysis overcomes some of these limitations by estimating adverse effects in outpatient care and including adverse effects other than death.[11]. Adverse effects: 4%-18% Extra doc visits: 116,000,000 Extra prescriptions: 77,000,000 Extra ER Visits: 17,000,000 Extra Hospital Admissions: 8,000,000 Extra Long Term Admissions: 3,000,000 Extra Deaths: 199,000 Extra Cost: $77,000,000,000 Is US Health Really the Best in the World?, JAMA.2000; 284: 483-485 Barbara Starfield, MD, MPH, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health. Her reference in article [11] Epidemiology and medical error, Weingart SN, Wilson RM, Gibberd RW, Harrison B.. BMJ. 2000;320:774-777 Dr. Starfield was anticipating criticism about the validity of her number of hospital patients who died due to medical care received (MCR). Other reports estimated that between 4% and 18% of consecutive patients experience adverse effects in outpatient settings, with 116 million extra physician visits, 77 million extra prescriptions, 17 million emergency department visits, 8 million hospitalizations, 3 million long-term admissions, 199,000 additional deaths, and $77 billion in extra costs (equivalent to the aggregate cost of care of patients with diabetes) Adding the inpatient toll of 225,000 and the outpatient toll at 199,000, the total deaths are 424,000.Dr. Starfield was anticipating criticism about the validity of her number of hospital patients who died due to medical care received (MCR). Other reports estimated that between 4% and 18% of consecutive patients experience adverse effects in outpatient settings, with 116 million extra physician visits, 77 million extra prescriptions, 17 million emergency department visits, 8 million hospitalizations, 3 million long-term admissions, 199,000 additional deaths, and $77 billion in extra costs (equivalent to the aggregate cost of care of patients with diabetes) Adding the inpatient toll of 225,000 and the outpatient toll at 199,000, the total deaths are 424,000.

    18. Just Keep Me From The ER This Time 50 million unnecessary annual visits to the ER 95 per minute # by the time I finish? What is the cost? What is the benefit? National Center for Health Statistics Sung to the tune of Get Me To The Church On Time, My Fair Lady 5,700 more Cost per year $25,000,000,000 Benefit: keeps the economy going. Or does it? Cost during my talk $2,850,000 Is this the time to add 50,000,000 more? Oh the answer is: of course. They will stop using the ER as a family doctor. And the response is just as clear: no, they will not. When you are sick and your doctor is gone on vacation, sick, closed, off, you will seek care where you can get it, especially if disabled, impaired, in pain or fearful that you need something done fast. The kid just swallowed something. Do you wait. There is a nasty rash developing. An asthma attack, heart/chest pain, fell off a ladder, car accident, twisted an ankle, hit your hand with a hammer, ……..Sung to the tune of Get Me To The Church On Time, My Fair Lady 5,700 more Cost per year $25,000,000,000 Benefit: keeps the economy going. Or does it? Cost during my talk $2,850,000 Is this the time to add 50,000,000 more? Oh the answer is: of course. They will stop using the ER as a family doctor. And the response is just as clear: no, they will not. When you are sick and your doctor is gone on vacation, sick, closed, off, you will seek care where you can get it, especially if disabled, impaired, in pain or fearful that you need something done fast. The kid just swallowed something. Do you wait. There is a nasty rash developing. An asthma attack, heart/chest pain, fell off a ladder, car accident, twisted an ankle, hit your hand with a hammer, ……..

    19. Medical Care Received (MCR) Caused Deaths Per Year Hospital Based Deaths: 225,000 Non-Hospital Based Deaths: 199,000 Total Deaths: 424,000 Is US Health Really the Best in the World?, JAMA, July 26, 2000, V. 284, No. 4 483-85 Iatrogenic My first though: How words can make a difference in our thinking. Substitute terrorist, lead poisoned kid toys, for iatrogenic, iatrogenic disorder is any pathological anomaly in which the dysfunctional symptoms in the patient owe their cause (iatrogenesis) to the actions of the practitioner. How would anyone react to substituting for iatrogenic the phrase “killed by medical care received (MCR)” ? My second thought: How could I make the figure larger? Yes, cover another 50,000,000 Americans. Does it matter if the figure is 225,000 or 783,936? Leading causes of death: Heart Disease runs about 900,000 Malignant Neoplasm runs about 600,000 Stroke runs less than these conservative Iatrogenic figures, as does diabetes, AIDS/HIV, car accidents, illicit drug deaths, etc. Sources used by author Barbara Starfield, M.D., MPH to develop the figures cited in the last two slides. 8. Leape L. Unnecessary surgery. Annu Rev Public Health. 1992;13:363-383. 9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644. 10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205.Iatrogenic My first though: How words can make a difference in our thinking. Substitute terrorist, lead poisoned kid toys, for iatrogenic, iatrogenic disorder is any pathological anomaly in which the dysfunctional symptoms in the patient owe their cause (iatrogenesis) to the actions of the practitioner. How would anyone react to substituting for iatrogenic the phrase “killed by medical care received (MCR)” ? My second thought: How could I make the figure larger? Yes, cover another 50,000,000 Americans. Does it matter if the figure is 225,000 or 783,936? Leading causes of death: Heart Disease runs about 900,000 Malignant Neoplasm runs about 600,000 Stroke runs less than these conservative Iatrogenic figures, as does diabetes, AIDS/HIV, car accidents, illicit drug deaths, etc. Sources used by author Barbara Starfield, M.D., MPH to develop the figures cited in the last two slides. 8. Leape L. Unnecessary surgery. Annu Rev Public Health. 1992;13:363-383. 9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644. 10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205.

    20. A Hospital Is No Place To Be Sick Infections Acquired During Hospital Stays Kill More People Than Breast Cancer, Auto Accidents and AIDS Combined— Reports on the impact of 19,154 reported hospital acquired infections (HAI) in 2005 at 168 hospitals in Pennsylvania BENCHMARK HAI INVOLVED HAI NOT INVOLVED Average Length of Stay 20.6 (days) 4.5 (days) Extra Days 396,129 - 0 - Extra Hospital Charges $3.5 billion - 0 - Average Hospital Charges $185,260 $31,289 Hospital Patients Who Died 12.9% 2.3% This report recommends that everyone wash their hands! Other reports suggest that patients have friends stay with them in the hospital to protect them from human errors and complacency! Hospital-acquired Infections in Pennsylvania, Pennsylvania Health Care Cost Containment Council, November 2006, Data Reporting Period: January 1, 2005 - December 31, 2005, Pennsylvania Health Care Cost Containment Council, November 2006 Title is a quote of Samuel Goldwyn Look these figures over carefully. I did not make them up. The hospitals and their staff and attending physicians did that for us. HAI ALOS = 460% of non HAI ALOS Extra days with HAI reaches infinity Extra Hospital charges with HAI reaches infinity Extra Hospital charges = 592% of non HAI % of Hospital patients who died with HAI = 560% of non HAI 1847, Dr. Ignaz Philipp Semmelweis discovered that puerperal fever could be drastically cut by use of hand washing standards in obstetrical clinics. Others, including Pasteur have said wash your hands. Well it is a conservative profession; conservative to protect patients from things that are untested or fail to produce better care. A friend to protect us? And we were worried about Osama b! Actually, an intelligent, caring and effective friend can actually save lives. I attended my aging father along with other family members at a NYC hospital where the attending physicians were in addition to being outstanding in their fields of expertise, friends. But one night I found my father unshaven, unwashed and near delirious. His condition prevented him from getting to his food but the nurses said he did not want to eat. Without assistance, he started to starve to death. One physician suggested we get a private duty nurse as he acknowledged that there were not enough nurses on the floor (unit). So I had the painkiller patch removed as I remembered that narcotics affected eating and most other body functions, including the mind. Then I shaved and washed my dad. I fed him as did other members of the family, but not the crap the hospital served. We had food delivered or brought in. Two days later he was up and about and we made for the exit doors. Most physicians who are admitted as patients are armed with greater knowledgeable than most patients. Consitently they report the horror of errors, unresponsive staff, etc. Title is a quote of Samuel Goldwyn Look these figures over carefully. I did not make them up. The hospitals and their staff and attending physicians did that for us. HAI ALOS = 460% of non HAI ALOS Extra days with HAI reaches infinity Extra Hospital charges with HAI reaches infinity Extra Hospital charges = 592% of non HAI % of Hospital patients who died with HAI = 560% of non HAI 1847, Dr. Ignaz Philipp Semmelweis discovered that puerperal fever could be drastically cut by use of hand washing standards in obstetrical clinics. Others, including Pasteur have said wash your hands. Well it is a conservative profession; conservative to protect patients from things that are untested or fail to produce better care. A friend to protect us? And we were worried about Osama b! Actually, an intelligent, caring and effective friend can actually save lives. I attended my aging father along with other family members at a NYC hospital where the attending physicians were in addition to being outstanding in their fields of expertise, friends. But one night I found my father unshaven, unwashed and near delirious. His condition prevented him from getting to his food but the nurses said he did not want to eat. Without assistance, he started to starve to death. One physician suggested we get a private duty nurse as he acknowledged that there were not enough nurses on the floor (unit). So I had the painkiller patch removed as I remembered that narcotics affected eating and most other body functions, including the mind. Then I shaved and washed my dad. I fed him as did other members of the family, but not the crap the hospital served. We had food delivered or brought in. Two days later he was up and about and we made for the exit doors. Most physicians who are admitted as patients are armed with greater knowledgeable than most patients. Consitently they report the horror of errors, unresponsive staff, etc.

    21. A Hospital Is Just A Taxi With The Meter Running The . Excess . Event LOS Charges Mortality* Surgical Care Post-op Sepsis 10.89 $57,727 21.96% Dehiscence 9.42 $40,323 9.63% Medical Care Infection 9.58 $38,656 4.31% *Attributable Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization, JAMA, 2003: 290: 1868-1874 Quote attributed to Groucho Marx Another study saying about the same thing.Quote attributed to Groucho Marx Another study saying about the same thing.

    22. Rising Resistance Rising S. aureus (staph) 32% vs. methicillin S. aureus (staph) 98% vs. penicillin E. faecium 70% vs. cirpofloxian/ampicillin S. pneumoniae (strep) 37% vs. penicillin Everyday exposure to toxic pollutants, Scientific American, Feb/March 1998: 86-91 Look at the date of this early warning article. The body and its cells are pretty smart, have good memory and learn fast. Describing these wonderful characteristics, these skills with an ugly word-mutate-is demeaning and indicative of the attitude about medical care. This problem will get worse as we shall see. Look at the date of this early warning article. The body and its cells are pretty smart, have good memory and learn fast. Describing these wonderful characteristics, these skills with an ugly word-mutate-is demeaning and indicative of the attitude about medical care. This problem will get worse as we shall see.

    23. Staph Infections: Life Threatening CC/Symptoms: 94,000 MRSA Infections 19,000 MRSA Deaths Risk Factors: Most MRSA associated with health care Unnecessary, recent or long-term prescribing of antibiotics Antibiotics in food and water* Current or recent hospitalization or residing in a long-term care facility Invasive procedures/Bacterial mutations History: They do not wash their hands Takes time to wash Time is money No incentive to wash More illness, more income Diagnosis: Dirty Hands Treatment: Wash Hands Prognosis: Uncertain *Medical Drugs Pollute Water Supply, Maria P. Elliott and Edward T. Gluckmann, Green Times, V.27, No. 3, 2007 Pages 11-12 CDC Report, JAMA and New York Times, Infection Control Today, October 16, 2007 In late October, 2007, there was a scare about staph infections and resistance to drugs. A few people died, mostly high school kids. But there is no incentive to wash hands or do anything else that makes sense. Not even malpractice claims seems to move the system, so in the next slide we have a set of ideas to make simple meaningful changes. use—for decades, antibiotics have been prescribed for colds, flu, and other viral infections that do not require or respond to antibiotics. antibiotics are routinely given to cattle, pigs, and chickens Staph – Why Can’t They Wash Their Hands (7) Ablution is found in the Bahai Faith Ablution is found in Judaism Ablution is found in Hinduism (no Shahi Snan) Lavabo in Christianity (no mass needed) Misogi in Shintoism (no waterfall needed) Wudu in Islam (no ghusl) "royal bath complete washing forerunner of the modern sink Only reasonable conclusions about failure to wash their hands is the medical and hospital staff are: Fearful of performing this universal ritual Fearful of being ID as the Oz Wicked Witch of the North Without remorse and just do not care Without time and do not want to buy antiseptic soap Sure it will not help and believe it will dry their hands Personally unclean or feel so clean that it ill not help Unwilling to be responsible for orders given Some or all of the above bacteria that survive treatment with one antibiotic may develop resistance to the effects of that drug and similar medicines Antibiotics are awash in our water, world wide In late October, 2007, there was a scare about staph infections and resistance to drugs. A few people died, mostly high school kids. But there is no incentive to wash hands or do anything else that makes sense. Not even malpractice claims seems to move the system, so in the next slide we have a set of ideas to make simple meaningful changes. use—for decades, antibiotics have been prescribed for colds, flu, and other viral infections that do not require or respond to antibiotics. antibiotics are routinely given to cattle, pigs, and chickens Staph – Why Can’t They Wash Their Hands (7) Ablution is found in the Bahai Faith Ablution is found in Judaism Ablution is found in Hinduism (no Shahi Snan) Lavabo in Christianity (no mass needed) Misogi in Shintoism (no waterfall needed) Wudu in Islam (no ghusl) "royal bath complete washing forerunner of the modern sink Only reasonable conclusions about failure to wash their hands is the medical and hospital staff are: Fearful of performing this universal ritual Fearful of being ID as the Oz Wicked Witch of the North Without remorse and just do not care Without time and do not want to buy antiseptic soap Sure it will not help and believe it will dry their hands Personally unclean or feel so clean that it ill not help Unwilling to be responsible for orders given Some or all of the above bacteria that survive treatment with one antibiotic may develop resistance to the effects of that drug and similar medicines Antibiotics are awash in our water, world wide

    25. Program to Get Them to Wash Their Hands Teach hand washing (Medical School and Residency) Put hand washing questions on all board exams (Competency) Add to credentialing process (Washes hands: Often? Vigorously?) Have soap companies fund research and CME (Reduce costs) Develop a new CPT code (P4P, Positive Incentive) Report failure to wash to Homeland Security (Be Alert and Report!) Rate all providers who fail to wash hands. (Transparency) Fine providers for failure to wash hands (Negative Incentive) Provide universal insurance for 50,000,000 uninsured Americans? Fail! Hear my mother’s, “Edward, wash your hands.” over intercom.” (Equivalent of legal water-boarding.) System Failure versus Personal Accountability — The Case for Clean Hands, NEJM, V. 355, No. 2, :121-123, 7/13/2006 The caveat: None hand washers and facilities that do not provide soap and an educational program and disciplinary plan can be paid for any lucrative new source of income. Boston Scientific and Consultant Settle a Lawsuit, New York Times, November 17, 2007 “Boston Scientific had said that ECRI illegally disclosed its trade secrets. It also argued that ECRI interfered with its business relationships by inducing hospitals to violate sales contracts that require the hospitals not to disclose the prices they pay for Boston Scientific’s heart defibrillators and other devices. “The lawsuit had drawn attention to arguments that the secrecy in device pricing has contributed to rising costs.”The caveat: None hand washers and facilities that do not provide soap and an educational program and disciplinary plan can be paid for any lucrative new source of income. Boston Scientific and Consultant Settle a Lawsuit, New York Times, November 17, 2007 “Boston Scientific had said that ECRI illegally disclosed its trade secrets. It also argued that ECRI interfered with its business relationships by inducing hospitals to violate sales contracts that require the hospitals not to disclose the prices they pay for Boston Scientific’s heart defibrillators and other devices. “The lawsuit had drawn attention to arguments that the secrecy in device pricing has contributed to rising costs.”

    26. Change in the US Death Rates* by Cause, 1950 & 2003 Compared to the rate in 1950, the cancer death rate decreased slightly in 2003, while rates for other major chronic diseases decreased substantially during this period. Compared to the rate in 1950, the cancer death rate decreased slightly in 2003, while rates for other major chronic diseases decreased substantially during this period.

    27. Trends in the Number of Cancer Deaths Among Men and Women, US, 1930-2003 From 2002 to 2003, the number of recorded cancer deaths decreased by 778 in men, but increased by 409 in women, resulting in a net decrease of 369 total cancer deaths, the first such decrease since 1930, when nationwide mortality data began to be compiled. The decrease in the number of Americans dying from cancer is a result of declining cancer death rates outpacing the impact of growth and aging of the population. From 2002 to 2003, the number of recorded cancer deaths decreased by 778 in men, but increased by 409 in women, resulting in a net decrease of 369 total cancer deaths, the first such decrease since 1930, when nationwide mortality data began to be compiled. The decrease in the number of Americans dying from cancer is a result of declining cancer death rates outpacing the impact of growth and aging of the population.

    28. Five-year Relative Survival (%)* During Three Time Periods By Cancer Site All sites 50 53 65 Breast (female) 75 78 88 Colon 50 58 64 Leukemia 34 41 48 Lung and bronchus 12 14 15 Melanoma 80 85 92 Non-Hodgkin lymphoma 47 54 60 Ovary 37 41 45 Pancreas 3 3 5 Prostate 67 75 100 Rectum 49 55 65 Urinary bladder 73 78 82 *5-year relative survival rates based on follow up of patients through 2002. †Recent changes in classification of ovarian cancer have affected 1995-2001 survival rates. Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and Population Sciences, National Cancer Institute, 2005. The survival rates for all cancers combined and for certain site-specific cancers have improved significantly since the 1970s, due, in part, to both earlier detection and advances in treatment. Survival rates markedly increased for cancers of the prostate, breast, colon, rectum, and for leukemia. With new treatment techniques and increased utilization of screening, there is hope for even greater improvements in the not-too-distant future. *5-year relative survival rates based on follow up of patients through 2002. †Recent changes in classification of ovarian cancer have affected 1995-2001 survival rates. Source: Surveillance, Epidemiology, and End Results Program, 1975-2002, Division of Cancer Control and Population Sciences, National Cancer Institute, 2005. The survival rates for all cancers combined and for certain site-specific cancers have improved significantly since the 1970s, due, in part, to both earlier detection and advances in treatment. Survival rates markedly increased for cancers of the prostate, breast, colon, rectum, and for leukemia. With new treatment techniques and increased utilization of screening, there is hope for even greater improvements in the not-too-distant future.

    29. Another Warrior Fights Cancer 'Her determination to fight the disease is an inspiration to all of us.’ …President Bush 'I always admired Congresswoman … strong convictions and the tenacity..’ John W. Warner She underwent chemotherapy treatments and a mastectomy…in 2005. When the cancer returned, she underwent chemotherapy again... ..she died...after a 2-year battle with the disease. Congresswoman Dies After Cancer Fight, New York Times, October 10, 2007 The worst crime against humanity in my book is the statement, “I am determined to fight this cancer.” or “S/he is battling cancer” How? With a big stick? With a lot of toxins that destroy cells and the immune system? Being followed to see how s/he is doing? Yielding to others? Fighting with your HMO? Going into remission and then having cancer again? Having body parts removed to avoid the risk? Running with a crowd around the block? Sending a check to the same ole? Being aware of the disease? Worry about medical bills? How about: I am determined to tell others (women) to live healthy, follow health fundamentals, fight for research that is independent, demand that they are allowed to seek other treatments, and most importantly, to use the right to refuse medical treatment. All her determination, conviction and battle for naught! When do we wake up and say without anger, allegation, fault or remorse, “Cancer has us beat. We got to do something else.” Or we can continue to do what is not working, over and over again not working and meet Albert Einstein’s definition of insanity-To do something over and over and over and expect a different result. Or we can keep trotting out the survivors!The worst crime against humanity in my book is the statement, “I am determined to fight this cancer.” or “S/he is battling cancer” How? With a big stick? With a lot of toxins that destroy cells and the immune system? Being followed to see how s/he is doing? Yielding to others? Fighting with your HMO? Going into remission and then having cancer again? Having body parts removed to avoid the risk? Running with a crowd around the block? Sending a check to the same ole? Being aware of the disease? Worry about medical bills? How about: I am determined to tell others (women) to live healthy, follow health fundamentals, fight for research that is independent, demand that they are allowed to seek other treatments, and most importantly, to use the right to refuse medical treatment. All her determination, conviction and battle for naught! When do we wake up and say without anger, allegation, fault or remorse, “Cancer has us beat. We got to do something else.” Or we can continue to do what is not working, over and over again not working and meet Albert Einstein’s definition of insanity-To do something over and over and over and expect a different result. Or we can keep trotting out the survivors!

    30. This is actually a study report of a revolution that is happening without Steve Jobs. Main point: Less intervention, improved health. Why did not the doctors get it. Some might claim the color of money. I prefer to think they are just slow at change. Despite the findings, many physicians continued to argue that the therapy was good, not the cause of cancer and they would continue to recommend HRT to patients. Subsequent drops were reported in 2004, and I believe 2005. So the new defense of what was becoming clear was that the drop was due to fewer women undergoing mammography. An inadvertent slip that says early detection of disease might not be as valuable? Or that early detection of disease does not make for more survivors? So the argument that there are fewer cases of cancer really means fewer cases of detectable cancers. The fact is that cancer takes years to manifest at some detectable level, that many cancers are still not clearly, universally and consistently responsive to medical and surgical treatment. The actual date of the onset of cancer at the cellular level (that’s where it starts) is unknown in almost all cases and actual rates of new cancers and survival rates and length of survival are just a manipulation of statistical data that unfortunately sometimes used for bragging rights to lure fearful people into the medical “mess”. My cancer care unit is bigger, better than the one down the street. This is actually a study report of a revolution that is happening without Steve Jobs. Main point: Less intervention, improved health. Why did not the doctors get it. Some might claim the color of money. I prefer to think they are just slow at change. Despite the findings, many physicians continued to argue that the therapy was good, not the cause of cancer and they would continue to recommend HRT to patients. Subsequent drops were reported in 2004, and I believe 2005. So the new defense of what was becoming clear was that the drop was due to fewer women undergoing mammography. An inadvertent slip that says early detection of disease might not be as valuable? Or that early detection of disease does not make for more survivors? So the argument that there are fewer cases of cancer really means fewer cases of detectable cancers. The fact is that cancer takes years to manifest at some detectable level, that many cancers are still not clearly, universally and consistently responsive to medical and surgical treatment. The actual date of the onset of cancer at the cellular level (that’s where it starts) is unknown in almost all cases and actual rates of new cancers and survival rates and length of survival are just a manipulation of statistical data that unfortunately sometimes used for bragging rights to lure fearful people into the medical “mess”. My cancer care unit is bigger, better than the one down the street.

    31. Lung Cancer - Black Revolution Lower rate of lung cancer surgery among black patients due partly to communication problems, study finds Even with equal access, blacks are about half as likely as whites to undergo surgery that could save their lives Black men have higher death rates than white men for lung cancer Smoking explains virtually all the disparity between black men and white men in cancer mortality rates Dana-Farber Cancer Institute, Website, Christopher Lathan, MD, Spring/Summer 2006 Potentially curable, save their lives. So much for access issues due to a lack of insurance. But wait, there is more.Potentially curable, save their lives. So much for access issues due to a lack of insurance. But wait, there is more.

    32. Lung Cancer - Black Revolution Death rates for black men went up as smoking increased Smoking among black men peaked in 1990 CDC has registered sharp declines in black men smoking since 2001 When smoking declined: cancer rates dropped 1990 - 2000, the mortality rate dropped 11% If black men stopped smoking, their cancer rates would drop 66% Lung cancer rates as an index of tobacco smoke exposures: validation against black male non- lung cancer death rates, 1969-2000, Prev Med. 38(5):511-15 Main Point: by changing life style, better, safer and less costly approach to health Classic case of the profession trying to find solutions about problems it cannot handle but needs the business or finding a solution that is not applicable, somewhat along the line of Groucho’s remarks about politicians. Other points: Current age-adjusted cancer death rate for black men is 330.9 deaths per 100 000 men, compared to 239.2 for white men. Overall cancer mortality rates Year Black Males White males 1950 178.9 210 Current age-adjusted cancer death rates deaths per 100 000 men 2004 330.9 239.2 From 1990 - 2000, the mortality rate dropped 11 percent, as smoking declined. CDC has registered sharp declines in smoking rates among blacks since 2001 Other types of cancers also increased with the increase in smoking. So we provide insurance coverage and assume blacks do not have now: More tests, surgery, drugs, hospitalizations Or we start the drive for an effective National Stop Smoking Wellness Program Focus on self-help, empowerment, life style changes, end fraudulent and dangerous advertising directed at vulnerable groups. Anyone here remember the campaign to stop cigarette companies from targeting children, minorities, women? Guess what: those efforts are paying off with paying bills. Bruce Leistikow (2004) Lung cancer rates as an index of tobacco smoke exposures: validation against black male ~non-lung cancer death rates, 1969-2000. Prev Med. 38(5):511-15 Main Point: by changing life style, better, safer and less costly approach to health Classic case of the profession trying to find solutions about problems it cannot handle but needs the business or finding a solution that is not applicable, somewhat along the line of Groucho’s remarks about politicians. Other points: Current age-adjusted cancer death rate for black men is 330.9 deaths per 100 000 men, compared to 239.2 for white men.Overall cancer mortality rates Year Black Males White males 1950 178.9 210 Current age-adjusted cancer death rates deaths per 100 000 men 2004 330.9 239.2 From 1990 - 2000, the mortality rate dropped 11 percent, as smoking declined.CDC has registered sharp declines in smoking rates among blacks since 2001 Other types of cancers also increased with the increase in smoking. So we provide insurance coverage and assume blacks do not have now: More tests, surgery, drugs, hospitalizations Or we start the drive for an effective National Stop Smoking Wellness Program Focus on self-help, empowerment, life style changes, end fraudulent and dangerous advertising directed at vulnerable groups. Anyone here remember the campaign to stop cigarette companies from targeting children, minorities, women? Guess what: those efforts are paying off with paying bills. Bruce Leistikow (2004) Lung cancer rates as an index of tobacco smoke exposures: validation against black male ~non-lung cancer death rates, 1969-2000. Prev Med. 38(5):511-15

    33. Cancer Care More Aggressive Near Death: Study Doctors efforts are costly, futile attempt to extend lives Chemo up 6% Chemo up 34% in patients who died within two weeks Doctors should review their treatment regimens Doctors should in some cases focus on palliative care Hospice care reduces aggressive treatment; improves quality of life for terminally ill Study suggests more cancer patients receiving aggressive care at end-of-life, Dan-Farber Cancer Institute, June 4, 2003 Based on 28,777 Medicare patients who died in the 1990s Main point: access means more costs; not necessarily improved health, extension of a quality life. Dana-Farber is affiliated with Harvard Medical School. Study of lung, breast, colorectal, and other gastrointestinal tumors. Presented at the annual meeting of the American Society of Clinical Oncology in Chicago on June 1. lung, breast, colorectal, and other gastrointestinal tumors between 1993 and 1996 Cancer care for patients who are near death is becoming more aggressive, with doctors ordering chemotherapy and other medicines in often futile attempts to extend lives, according to a study by Harvard Medical School researchers. Doctors should review their treatment regimens and in some cases focus on palliative care for patients in the last days of their lives instead of on costly medicine, the researchers said. The researchers reviewed Medicare records for more than 215 million people who died of cancer in the 1990s. In 1999, 12% of cancer patients who died received chemotherapy in the last two weeks of their lives, about 2 percentage points higher than in 1993. The data were presented at the American Society of Clinical Oncology meeting in Atlanta. They found that during this four-year period, the use of chemotherapy among these patients increased from 27.9 percent to 29.5 percent. Among those, the proportion receiving chemotherapy within two weeks of dying grew from 13.8 percent to 18.5 percent. The researchers also observed an increase in the number of these patients who, during their last month of life, were seen in the emergency room (8.3 percent in 1993 to 10.7 percent in 1996) or admitted to an intensive care unit (7.1 percent to 9.4 percent). However, they also found that fewer patients were dying in acute care hospitals (33.2 percent, down from 35.8 percent) and more were using hospice care (40.5 percent up from 31.6 percent). Presented at the annual meeting of the American Society of Clinical Oncology in Chicago on June 1. Journal of Clinical Oncology, June 15, 2003 "There are indications of increasing utilization of aggressive interventions in cancer patients who are near death," say Craig Earle, MD, of Dana-Farber. "Interestingly, the availability of hospice services and related medical resources may reduce the chance that a patient will receive aggressive treatment at the end-of life. The appropriate distribution of resources for end-of-life care may improve the quality of care for many terminally ill patients." Based on 28,777 Medicare patients who died in the 1990s Main point: access means more costs; not necessarily improved health, extension of a quality life. Dana-Farber is affiliated with Harvard Medical School. Study of lung, breast, colorectal, and other gastrointestinal tumors. Presented at the annual meeting of the American Society of Clinical Oncology in Chicago on June 1. lung, breast, colorectal, and other gastrointestinal tumors between 1993 and 1996 Cancer care for patients who are near death is becoming more aggressive, with doctors ordering chemotherapy and other medicines in often futile attempts to extend lives, according to a study by Harvard Medical School researchers. Doctors should review their treatment regimens and in some cases focus on palliative care for patients in the last days of their lives instead of on costly medicine, the researchers said. The researchers reviewed Medicare records for more than 215 million people who died of cancer in the 1990s. In 1999, 12% of cancer patients who died received chemotherapy in the last two weeks of their lives, about 2 percentage points higher than in 1993. The data were presented at the American Society of Clinical Oncology meeting in Atlanta. They found that during this four-year period, the use of chemotherapy among these patients increased from 27.9 percent to 29.5 percent. Among those, the proportion receiving chemotherapy within two weeks of dying grew from 13.8 percent to 18.5 percent. The researchers also observed an increase in the number of these patients who, during their last month of life, were seen in the emergency room (8.3 percent in 1993 to 10.7 percent in 1996) or admitted to an intensive care unit (7.1 percent to 9.4 percent). However, they also found that fewer patients were dying in acute care hospitals (33.2 percent, down from 35.8 percent) and more were using hospice care (40.5 percent up from 31.6 percent). Presented at the annual meeting of the American Society of Clinical Oncology in Chicago on June 1. Journal of Clinical Oncology, June 15, 2003 "There are indications of increasing utilization of aggressive interventions in cancer patients who are near death," say Craig Earle, MD, of Dana-Farber. "Interestingly, the availability of hospice services and related medical resources may reduce the chance that a patient will receive aggressive treatment at the end-of life. The appropriate distribution of resources for end-of-life care may improve the quality of care for many terminally ill patients."

    34. Annualized Cost To Buy 20 Days $143,612 - Localized Cancer $145,861 - Regional Cancer $1,190,322 - Metastatic Cancer 70%-90% of lung cancer smoking related Smoking prevention and cessation programs are more promising Survival Benefit Minimal Despite Rising Cost of Lung Cancer Treatment in Elderly, Cancer, 2007 (reported in) MedScape Medical News, October 25, 2007 Costly Demand Creation In Cancer Another finding: life style again. Keeps popping up and drowned in prescription pad ink. Despite an increase in healthcare spending, the life expectancy for lung cancer patients showed only minimal improvement, increasing an average of 0.60 months (16-19 days)). The total lifetime expenditure for treating lung cancer increased by approximately $20,157 per patient per 0.05 life-years added (or about $1,250 per day), or $403,142 per year of life. Treatment for localized disease was found to be more cost effective and, when analyzed by disease stage, the cost per additional year gained for localized cancer was $143,614; for regional cancer it was $145,861 and for metastatic cancer it was $1,190,322. "Meanwhile, given that tobacco smoking is the etiological carcinogen accounting for 80% to 90% of lung cancer cases in men and 70% to 80% of lung cancer cases in women, smoking prevention and cessation programs are perhaps more promising.“ per dr w. Rebecca Woodward, PhD, from the National Bureau of Economic Research, in Cambridge, Massachusetts, and colleagues evaluated changes in the costs and benefits of treatment for elderly lung cancer patients between 1983 and 1997 using Surveillance, Epidemiology, and End Results (SEER) data. They assessed the direct costs for non–small cell lung cancer detection and treatment using data from Part A and Part B reimbursements from the Continuous Medicare History Sample File (CMHSF) and then linked the CMHSF and SEER data to calculate lifetime treatment costs. Quality and price transparency will curb U.S. healthcare spending by at least 1%, said roughly half of respondents in the Commonwealth Fund’s latest healthcare opinion leaders survey. Of those respondents, slightly more than 30% said disclosure would reduce spending by 1% to 5%, while 17% said reporting would cut spending by at least 5%. Costly Demand Creation In Cancer Another finding: life style again. Keeps popping up and drowned in prescription pad ink. Despite an increase in healthcare spending, the life expectancy for lung cancer patients showed only minimal improvement, increasing an average of 0.60 months (16-19 days)). The total lifetime expenditure for treating lung cancer increased by approximately $20,157 per patient per 0.05 life-years added (or about $1,250 per day), or $403,142 per year of life. Treatment for localized disease was found to be more cost effective and, when analyzed by disease stage, the cost per additional year gained for localized cancer was $143,614; for regional cancer it was $145,861 and for metastatic cancer it was $1,190,322. "Meanwhile, given that tobacco smoking is the etiological carcinogen accounting for 80% to 90% of lung cancer cases in men and 70% to 80% of lung cancer cases in women, smoking prevention and cessation programs are perhaps more promising.“ per dr w. Rebecca Woodward, PhD, from the National Bureau of Economic Research, in Cambridge, Massachusetts, and colleagues evaluated changes in the costs and benefits of treatment for elderly lung cancer patients between 1983 and 1997 using Surveillance, Epidemiology, and End Results (SEER) data. They assessed the direct costs for non–small cell lung cancer detection and treatment using data from Part A and Part B reimbursements from the Continuous Medicare History Sample File (CMHSF) and then linked the CMHSF and SEER data to calculate lifetime treatment costs. Quality and price transparency will curb U.S. healthcare spending by at least 1%, said roughly half of respondents in the Commonwealth Fund’s latest healthcare opinion leaders survey. Of those respondents, slightly more than 30% said disclosure would reduce spending by 1% to 5%, while 17% said reporting would cut spending by at least 5%.

    35. Sleep On This For A While “Poor sleep among the elderly, it turns out, is not because of aging itself, but mostly because of illnesses or the medications used to treat them.” The Elderly Always Sleep Worse, and Other Myths of Aging, NY Times, October 23, 2007 Other myths already covered under Myths and Pleas, but this is just another example of what we believe so strongly is true, just isn’t. One myth is that aging is normal, not that there is normal aging. Think about it. Other myths already covered under Myths and Pleas, but this is just another example of what we believe so strongly is true, just isn’t. One myth is that aging is normal, not that there is normal aging. Think about it.

    36. Dark Blue Is Medical Cost Increases Due To Aging! Source: The Long-Term Outlook for Health Care Spending, CBO, November, 2007 Top of graph, lighter blue = Effect of Cost Growth Faster Than GDP and Aging of Population Bottom of graph, darker blue = Effect of Aging of Population Left vertical = % of GDP, in 5% increments starting at 0% at th axis and going to 20% the aging of the population accounts for only a modest fraction of the projected growth in federal spending on Medicare and Medicaid. The main factor is excess cost growth—or the extent to which the increase in health care spending exceeds the growth of the economy. Bottom horizontal shows the years starting at 2007 and in increments of years. comparative-effectiveness research = compare not to placebo but other treatments The current financial incentives facing both providers and patients tend to encourage or at least facilitate the adoption of expensive treatments and procedures, even if the evidence about their effectiveness relative to other therapies is limited. For doctors and hospitals, those incentives stem from fee-for-service reimbursement. Such payments can encourage health care providers to deliver a given service in an efficient manner but also provide an incentive to supply additional services—as long as the payments exceed the costs. For their part, insured individuals generally face only a portion of the costs of their care and thus have only limited financial incentives to seek lower-cost treatments. Private health insurers have incentives to limit the use of ineffective care but are also constrained by a lack of information about what treatments work best for which patients.Source: The Long-Term Outlook for Health Care Spending, CBO, November, 2007 Top of graph, lighter blue = Effect of Cost Growth Faster Than GDP and Aging of Population Bottom of graph, darker blue = Effect of Aging of Population Left vertical = % of GDP, in 5% increments starting at 0% at th axis and going to 20% the aging of the population accounts for only a modest fraction of the projected growth in federal spending on Medicare and Medicaid. The main factor is excess cost growth—or the extent to which the increase in health care spending exceeds the growth of the economy. Bottom horizontal shows the years starting at 2007 and in increments of years. comparative-effectiveness research = compare not to placebo but other treatments The current financial incentives facing both providers and patients tend to encourage or at least facilitate the adoption of expensive treatments and procedures, even if the evidence about their effectiveness relative to other therapies is limited. For doctors and hospitals, those incentives stem from fee-for-service reimbursement. Such payments can encourage health care providers to deliver a given service in an efficient manner but also provide an incentive to supply additional services—as long as the payments exceed the costs. For their part, insured individuals generally face only a portion of the costs of their care and thus have only limited financial incentives to seek lower-cost treatments. Private health insurers have incentives to limit the use of ineffective care but are also constrained by a lack of information about what treatments work best for which patients.

    37. Early Detection, Survival and Marketing Claims made: -Cancer survival rates increased -2.3 million breast cancer survivors SCR: Best Cancer Treatment (Surgery, Chemo, Radiation) New Ventures Help Fight the Frustrations of Fighting Breast Cancer, New York Times, October 25, 2007 Survival rates are explained by identification of the disease in progress at an earlier point in its development. Decreasing rates of cancer are associated mainly with people changing their life styles, I e not smoking CONCLUSION Even our most conservative estimate indicates that reductions in lung cancer, resulting from reductions in tobacco smoking over the last half century, account for about 40% of the decrease in overall male cancer death rates and have prevented at least 146 000 lung cancer deaths in men during the period 1991 to 2003. A more realistic straight line projection of what lung cancer rates might have become suggests that, without reductions in smoking, there would have been virtually no reduction in overall cancer mortality in either men or women since the early 1990s. The payoff from past investments in tobacco control has only just begun. The aging of birth cohorts with lower smoking initiation rates and the anticipated future decrease in lung cancer mortality in women will help to sustain progress. It is unclear how long the recent decrease in the number of Americans dying of cancer will continue, given the size of the "baby boomer" generation, even though the 2004 preliminary mortality data covering over 90% of the total US deaths9 suggest that the decrease will continue in the near term. What is certain is that sustained progress in tobacco control is essential if we are to continue to make progress against cancer. How much of the decrease in cancer death rates in the United States is attributable to reductions in tobacco smoking? Tobacco Control 2006;15:345-347; doi:10.1136/tc.2006.017749 Here is the survivor number game played out with real people, not the unscientific stats and shifting measuring rods. We will learn more in a few slides… National Vital Statistics Reports, Vol. 55, No. 10, March 15, 2007 17 Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes of death in selected age groups, by race and sex: United States, 2003 All ages, all groups: for 2003 Malignant Neoplasm 191.5 556,902 deaths Survival rates are explained by identification of the disease in progress at an earlier point in its development. Decreasing rates of cancer are associated mainly with people changing their life styles, I e not smoking CONCLUSIONEven our most conservative estimate indicates that reductions in lung cancer, resulting from reductions in tobacco smoking over the last half century, account for about 40% of the decrease in overall male cancer death rates and have prevented at least 146 000 lung cancer deaths in men during the period 1991 to 2003. A more realistic straight line projection of what lung cancer rates might have become suggests that, without reductions in smoking, there would have been virtually no reduction in overall cancer mortality in either men or women since the early 1990s. The payoff from past investments in tobacco control has only just begun. The aging of birth cohorts with lower smoking initiation rates and the anticipated future decrease in lung cancer mortality in women will help to sustain progress. It is unclear how long the recent decrease in the number of Americans dying of cancer will continue, given the size of the "baby boomer" generation, even though the 2004 preliminary mortality data covering over 90% of the total US deaths9 suggest that the decrease will continue in the near term. What is certain is that sustained progress in tobacco control is essential if we are to continue to make progress against cancer. How much of the decrease in cancer death rates in the United States is attributable to reductions in tobacco smoking? Tobacco Control 2006;15:345-347; doi:10.1136/tc.2006.017749 Here is the survivor number game played out with real people, not the unscientific stats and shifting measuring rods. We will learn more in a few slides… National Vital Statistics Reports, Vol. 55, No. 10, March 15, 2007 17 Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes of death in selected age groups, by race and sex: United States, 2003 All ages, all groups: for 2003 Malignant Neoplasm 191.5 556,902 deaths

    38. Early Detection, Survival and Advertising Disfigurement/Pain/Realism/Death Cancer as bad as it is, emotionally had an end Lymphedema complication, forever affects quality of life +++++++++++++++++++++++++++++++++++++++++++ Optimistic survivors also realists Since their book was published, 2 of 3 co-authors died New Ventures Help Fight the Frustrations of Fighting Breast Cancer, New York Times, October 25, 2007 Top of slide relates to a women with cancer who wants to design clothes for women with this side effect of disfigurement. The bottom relates to 3 people whom had cancer. Now only one has. Cancer treatment is associated with side effects- Lymphedema-affects sizable number of breast cancer survivors-limbs swell with fluid One survivor says that at least with cancer you made it or not. Now she lives (?) with another condition. This survivor decided to design clothes to accommodate the sleeve compressor to reduce swelling. She found a younger gal who was glad to help as her grandmother had breast cancer and then lymphedema. Small world. Another survivor? As George Carlin said, Live long enough and everyone you know has cancer. Another survivor started a company to help survivors handle their bills. She now has been diagnosed with a second cancer. Three breast cancer survivors decided to share their experiences with other victims/survivors and wrote a book. 50% are already dead. Maybe it was just a case of shock when seeing the bills. Or maybe they never got to use the services of the other survivor. Korman has marketers, sometimes referred to translators, sales or public relations. Many times I get confused and think, “spinmeister” Imagine how you would react to Joseph Goebbels announcing every day the number of concentration prisoners as “The almost gone missing survivors.” to show the compassion of the third reich. Words are very powerful. As Jack Nicholson stated in several scenes in “Hoffa”, “What are we using here, just words?” Top of slide relates to a women with cancer who wants to design clothes for women with this side effect of disfigurement. The bottom relates to 3 people whom had cancer. Now only one has. Cancer treatment is associated with side effects- Lymphedema-affects sizable number of breast cancer survivors-limbs swell with fluid One survivor says that at least with cancer you made it or not. Now she lives (?) with another condition. This survivor decided to design clothes to accommodate the sleeve compressor to reduce swelling. She found a younger gal who was glad to help as her grandmother had breast cancer and then lymphedema. Small world. Another survivor? As George Carlin said, Live long enough and everyone you know has cancer. Another survivor started a company to help survivors handle their bills. She now has been diagnosed with a second cancer. Three breast cancer survivors decided to share their experiences with other victims/survivors and wrote a book. 50% are already dead. Maybe it was just a case of shock when seeing the bills. Or maybe they never got to use the services of the other survivor. Korman has marketers, sometimes referred to translators, sales or public relations. Many times I get confused and think, “spinmeister” Imagine how you would react to Joseph Goebbels announcing every day the number of concentration prisoners as “The almost gone missing survivors.” to show the compassion of the third reich. Words are very powerful. As Jack Nicholson stated in several scenes in “Hoffa”, “What are we using here, just words?”

    39. Early Detection, Survival and Sales Drive to find disease early that leads to.. Diagnostic epidemic that leads to.. Medicalization of everyday life that leads to.. 50% of Americans diagnosed as diseased that leads to.. More disease caused by tests, treatment and drugs that leads to.. Threat to Americans health that leads to.. America spends more than any other country that leads to.. America having: (Please check all that apply) ___ The best care in the world ___ A need to stop the hemorrhaging first ___ Some of the lowest world wide rankings ___ A need to spend an additional $300,000,000,000 What’s Making Us Sick Is an Epidemic of Diagnoses, New York Times, January 2, 2007 A case of more is less than less 50% are not diagnosed yet. The obvious goal is 100%. Many diagnosed, few are stricken. We spend more, encourages more capitalization and shareholder interest that requires increasing market flow (more billable patients). Rule of epidemiology: More you look, the more you find. Rule of medicine: The more you find, the more you bill. Rule of reality: Not much can be done. Rule of profit insurance/HMO: The more they bill, the more you deny. When you find something, you name it. It is a disease, an illness, a condition a syndrome. Each disease, illness, condition and syndrome is studied, reported and requires a way to treat, not necessarily cure and definitely not to prevent. Physicians do lots of things, but cure and prevention are not part of that process. They are trained to diagnose and treat, then write a prescription, make a referral, and follow up. The results of this disease orientation is evident: more spent, less results.A case of more is less than less 50% are not diagnosed yet. The obvious goal is 100%. Many diagnosed, few are stricken. We spend more, encourages more capitalization and shareholder interest that requires increasing market flow (more billable patients). Rule of epidemiology: More you look, the more you find. Rule of medicine: The more you find, the more you bill. Rule of reality: Not much can be done. Rule of profit insurance/HMO: The more they bill, the more you deny. When you find something, you name it. It is a disease, an illness, a condition a syndrome. Each disease, illness, condition and syndrome is studied, reported and requires a way to treat, not necessarily cure and definitely not to prevent. Physicians do lots of things, but cure and prevention are not part of that process. They are trained to diagnose and treat, then write a prescription, make a referral, and follow up. The results of this disease orientation is evident: more spent, less results.

    40. Early Detection, Survival and Collection 40% of summer camp kids on chronic prescription drugs Arthritis without joint pain Stomach damage without heartburn Million prostate cancers patients who have lived as long without being diagnosed as a cancer patient Biggest health threat is our health-care system Pre-diseased population > those who get the disease Labeling causes anxiety, sense of vulnerability …a particular concern in children What’s Making Us Sick Is an Epidemic of Diagnoses, New York Times, January 2, 2007

    41. Early Detection, Survival and Impact on Children Psychiatrists in several states get most drug money Psychiatrists who do take the money, tend to prescribe the most antipsychotic drugs to children These drugs are risky and not FDA approved for kids Psychiatrists know the dangers Antipsychotic drugs are a large expense for Medicaid Psychiatrists Top List in Drug Maker Gifts, New York Times, June 27, 2007 Leading cause of death among children: accidents, suicide and homicide. Info collected by state officials including attorney generals. Here is means a type of payment that has been described as a bribe that is conveyed by covers that include buying expertise, participating in studies, being a lead, expert, or whatever other mechanism the lawyers say might fly. Is water boarding torture? Does a bear ….. in the woods? These complicated questions make the physicians, in this case, psychiatrists look like they have their hand in the cookie jar, when in fact they do. Average payments doubled to psychiatrists, $45,692 from $20,835 in two years in VT, The Green Mountain State. Psychiatrists in Minnesota earned more on aggregate than other specialialties, ranging for $51 (get that license revoked) to $689,000 (winner of $$$$ doesn’t influence me award) And on average $33,750 for the runner ups: endocrinologists. Total drug payments were $2.25 million. Assuming VT is the same in all medical respects as any of the other 51 states and the D.C. in terms of patients, numbers of physicians, we can make a fast calculation that drug money spent is over $100,000,000. Any takers that this is overestimate? Leading cause of death among children: accidents, suicide and homicide. Info collected by state officials including attorney generals. Here is means a type of payment that has been described as a bribe that is conveyed by covers that include buying expertise, participating in studies, being a lead, expert, or whatever other mechanism the lawyers say might fly. Is water boarding torture? Does a bear ….. in the woods? These complicated questions make the physicians, in this case, psychiatrists look like they have their hand in the cookie jar, when in fact they do. Average payments doubled to psychiatrists, $45,692 from $20,835 in two years in VT, The Green Mountain State. Psychiatrists in Minnesota earned more on aggregate than other specialialties, ranging for $51 (get that license revoked) to $689,000 (winner of $$$$ doesn’t influence me award) And on average $33,750 for the runner ups: endocrinologists. Total drug payments were $2.25 million. Assuming VT is the same in all medical respects as any of the other 51 states and the D.C. in terms of patients, numbers of physicians, we can make a fast calculation that drug money spent is over $100,000,000. Any takers that this is overestimate?

    42. Early Detection, Survival and Causes of Disease Assumption is all diagnosis are beneficial. Early Detection = Prevention = Threat But at the extreme, the logic of early detection is absurd Biggest health threat is our health-care system Pre-diseased population > those who get the disease Labeling causes anxiety, sense of vulnerability …a particular concern in children What’s Making Us Sick Is an Epidemic of Diagnoses, New York Times, January 2, 2007 Think back to suicide, accidents, homicides Attitude can increase or decrease tendency to have accidents. Kids on drugs. Kids on drugs are us? Think back to suicide, accidents, homicides Attitude can increase or decrease tendency to have accidents. Kids on drugs. Kids on drugs are us?

    43. Early Detection, Survival, Harm Disease epidemic = Treatment epidemic Not all treatments have important benefits Some involve potential harm Some harm is not immediately known Being labeled “pre-diseased” or “at risk” but destined to remain healthy, treatment can only cause harm. What’s Making Us Sick Is an Epidemic of Diagnoses, New York Times, January 2, 2007

    44. Early Detection, Survival: Good 4 Business! Bad 4 Business? The epidemic of diagnoses has many causes. More diagnoses mean more money, stature for: - Drug and device manufacturers - Hospitals and physicians, - Disease-based advocacy organizations - Researchers - National Institutes of Health - Anyone promoting a disease What’s Making Us Sick Is an Epidemic of Diagnoses, New York Times, January 2, 2007 Good for medical business, bad for employers. Imagine an announcement being made that a simple cure for cancer and even more important, a simple way, almost no cost way to prevent cancers. 10% of this Congress would be out looking for work. Good for medical business, bad for employers. Imagine an announcement being made that a simple cure for cancer and even more important, a simple way, almost no cost way to prevent cancers. 10% of this Congress would be out looking for work.

    45. Where’s Proof Treatment Works, Works Safely Gold Standard-randomized double blind, placebo-controlled trials. Platinum Standard-monitor actual outcomes for all patients for 1,3,5,7,10 years. How many physicians, surgeons or hospitals can produce cost/benefit data (i.e. positive and negative outcomes vs. charges/fees)? Without the proof there is information, value or meaningful use by consumers! Any discussion about anything new in medicine requires the gold standard. Any effort to validate practice outcomes is the platinum standard. The medical physicians ignore the first when it comes to prescribing drugs, about 1/5 to 3/5 of the time Users'guides to the medical literature. III. How to use an article about a diagnostic test. B. What … - all 7 versions » R Jaeschke, GH Guyatt, DL Sackett - JAMA, 1994 - Am Med Assoc ... JAMA, Vol. 271, Issue 9, 703-707, March 2, 1994 ARTICLES. Users' guides to the medical literature. III. How to use an article about a diagnostic test. ... Cited by 739 - Related Articles - Web Search - BL Direct [PDF] Users’guides to the medical literature. III. How to use an article about a diagnostic test. A. Are … - all 2 versions » R Jaeschke, G Guyatt, DL Sackett… - JAMA, 1994 - thoracic.org ... Volume 271(5) 2 February 1994 pp 389-391 Users' Guides to the Medical Literature: III. How to Use an Article About a Diagnostic Test: A. Are the ... Cited by 642 - Related Articles - View as HTML - Web Search - BL Direct [CITATION] … Medicine Working Group. Users’ guides to the medical literature. III. How to use an article about … R Jaeschke, GH Guyatt, DL Sackett - JAMA, 1994 Users'guides to the medical literature. III. How to use an article about a diagnostic test. B. What … - all 7 versions » R Jaeschke, GH Guyatt, DL Sackett - JAMA, 1994 - Am Med Assoc ... JAMA, Vol. 271, Issue 9, 703-707, March 2, 1994 ARTICLES. Users' guides to the medical literature. III. How to use an article about a diagnostic test. ... Cited by 739 - Related Articles - Web Search - BL Direct [PDF] Users’guides to the medical literature. III. How to use an article about a diagnostic test. A. Are … - all 2 versions » R Jaeschke, G Guyatt, DL Sackett… - JAMA, 1994 - thoracic.org ... Volume 271(5) 2 February 1994 pp 389-391 Users' Guides to the Medical Literature: III. How to Use an Article About a Diagnostic Test: A. Are the ... Cited by 642 - Related Articles - View as HTML - Web Search - BL Direct [CITATION] … Medicine Working Group. Users’ guides to the medical literature. III. How to use an article about … R Jaeschke, GH Guyatt, DL Sackett - JAMA, 1994 Cited by 167 - Related Articles - Web Search [CITATION] … Working Group.(1994a) Users’ guides to the medical literature III: how to use an article about a … R Jaeschke, G Guyatt, DL Sackett - Journal of the American Medical Association Cited by 2 - Related Articles - Web Search Study: Drug company evidence sent to plans of of variable quality, New Analysis, Managed Healthcare Executive, September 2007 Study (3 year study by Tufts-New England Medical Center, U of Washington and Premera) says 17% of 115 submissions requested by Blue Cross Premera (Washington based) compared the new drugs with the most relevant or cost-effective alternatives. Economic analysis met Academy of Managed Care Pharmacy standards 46% of the time. Did not use “gold standard” as they mixed apples and oranges according to the VP of Premera’s pharmacy division. “>>>the dossier info supporting off-label indications was less substantial than for the labeled indications.” “There is not clear information that consumers can rely on to make effective purchasing decisions.” (COO, Randy Gebhardt, President/COO, Quantum Health, Inc.Any discussion about anything new in medicine requires the gold standard. Any effort to validate practice outcomes is the platinum standard. The medical physicians ignore the first when it comes to prescribing drugs, about 1/5 to 3/5 of the time Users'guides to the medical literature. III. How to use an article about a diagnostic test. B. What … - all 7 versions »R Jaeschke, GH Guyatt, DL Sackett - JAMA, 1994 - Am Med Assoc... JAMA, Vol. 271, Issue 9, 703-707, March 2, 1994 ARTICLES. Users' guides to the medicalliterature. III. How to use an article about a diagnostic test. ... Cited by 739 - Related Articles - Web Search - BL Direct [PDF] Users’guides to the medical literature. III. How to use an article about a diagnostic test. A. Are … - all 2 versions »R Jaeschke, G Guyatt, DL Sackett… - JAMA, 1994 - thoracic.org... Volume 271(5) 2 February 1994 pp 389-391 Users' Guides to the Medical Literature:III. How to Use an Article About a Diagnostic Test: A. Are the ... Cited by 642 - Related Articles - View as HTML - Web Search - BL Direct [CITATION] … Medicine Working Group. Users’ guides to the medical literature. III. How to use an article about …R Jaeschke, GH Guyatt, DL Sackett - JAMA, 1994Users'guides to the medical literature. III. How to use an article about a diagnostic test. B. What … - all 7 versions »R Jaeschke, GH Guyatt, DL Sackett - JAMA, 1994 - Am Med Assoc... JAMA, Vol. 271, Issue 9, 703-707, March 2, 1994 ARTICLES. Users' guides to the medicalliterature. III. How to use an article about a diagnostic test. ... Cited by 739 - Related Articles - Web Search - BL Direct [PDF] Users’guides to the medical literature. III. How to use an article about a diagnostic test. A. Are … - all 2 versions »R Jaeschke, G Guyatt, DL Sackett… - JAMA, 1994 - thoracic.org... Volume 271(5) 2 February 1994 pp 389-391 Users' Guides to the Medical Literature:III. How to Use an Article About a Diagnostic Test: A. Are the ... Cited by 642 - Related Articles - View as HTML - Web Search - BL Direct [CITATION] … Medicine Working Group. Users’ guides to the medical literature. III. How to use an article about …R Jaeschke, GH Guyatt, DL Sackett - JAMA, 1994Cited by 167 - Related Articles - Web Search [CITATION] … Working Group.(1994a) Users’ guides to the medical literature III: how to use an article about a …R Jaeschke, G Guyatt, DL Sackett - Journal of the American Medical AssociationCited by 2 - Related Articles - Web Search Study: Drug company evidence sent to plans of of variable quality, New Analysis, Managed Healthcare Executive, September 2007 Study (3 year study by Tufts-New England Medical Center, U of Washington and Premera) says 17% of 115 submissions requested by Blue Cross Premera (Washington based) compared the new drugs with the most relevant or cost-effective alternatives. Economic analysis met Academy of Managed Care Pharmacy standards 46% of the time. Did not use “gold standard” as they mixed apples and oranges according to the VP of Premera’s pharmacy division. “>>>the dossier info supporting off-label indications was less substantial than for the labeled indications.” “There is not clear information that consumers can rely on to make effective purchasing decisions.” (COO, Randy Gebhardt, President/COO, Quantum Health, Inc.

    46. Off-Label Prescribing: Thar’s AU, But No Standard, In Them Thar Hills Summary of Number of Drug Uses, By Off-label Status and Level of Supporting Evidence, United States, July 2005 through December 2006, IMS Health National Therapeutic and Disease Index, Estimated DRUG USES IN THOUSANDS, United States Generic Total Uncertain/ Evidence Evidence On-Label Off-Label Inadequate Inadequate Uncertain 112,033 42,692 37,387 7,380 30,007 72%* 28%* 87%** 17%** 70%** * % of total prescriptions = generic on-label + total off-label; ** % of total that are off-label; 5,305,000 or 12% off-label prescriptions were deemed OK. Off-Label Drug Use, Stanford School of Medicine, Stanford Prevention Research Center, Randall Stafford, MD, PhD., Week of 06/04/2007 Gold standard is demanded to maintain illusion of science, but discarded fast enough. Table 1: Number of Drug Uses, By Off-label Status and Level of Supporting Evidence, United States, July 2005 through December 2006, IMS Health National Therapeutic and Disease Index. Estimated DRUG USES IN THOUSANDS, United States Evidence Generic Total Uncertain or Rank Name On-Label Off-Label Inadequate Inadequate Uncertain 1 quetiepine 1350 4025 4025 0 4025 2 divalproex 905 3949 3689 3015 674 3 warfarin 7967 3439 3439 0 3439 4 prednisone 6536 2767 2594 1806 788 5 risperidone 1288 2588 2588 896 1692 6 escitalopram 14148 2218 2218 0 2218 7 alprazolam 4835 2231 2067 1663 404 8 promethazine 148 2022 2022 0 2022 9 digoxin 3189 1695 1695 0 1695 10 sertraline 11132 1537 1537 0 1537 11 zolpidem 2520 1482 1482 0 1482 12 lisinopril 19389 1569 1429 0 1429 13 lorazepam 1641 1278 1278 0 1278 14 bupropion 7826 1233 1233 0 1233 15 trazodone 1661 1223 1223 0 1223 16 metronidazole 1295 1045 1045 0 1045 17 albuterol 7522 5591 1033 0 1033 18 venlafaxine 7227 963 963 0 963 19 montelukast 5135 924 924 0 924 20 esomeprazole 6319 903 903 0 903 Off-Label Drug Use, Faculty Stanford School of Medicine, Stanford Prevention Research Center, June 4, 2007 For anyone living with the myth that electronic this and that will do the trick for cost or quality, Dr. Stanford’s recent study showed that EMR is a flop. GIGO! Now back to the action: over 42 million prescriptions where there is no, insufficient or uncertain evidence that the FDA approved drug had any science behind it. Oh, the art of medicine. 100,000 drug deaths. Please start to draw the lines between the dots. Table 1: Number of Drug Uses, By Off-label Status and Level of Supporting Evidence, United States, July 2005 through December 2006, IMS Health National Therapeutic and Disease Index. Estimated DRUG USES IN THOUSANDS, United States Evidence Generic Total Uncertain or Rank Name On-Label Off-Label Inadequate Inadequate Uncertain 1 quetiepine 1350 4025 4025 0 4025 2 divalproex 905 3949 3689 3015 674 3 warfarin 7967 3439 3439 0 3439 4 prednisone 6536 2767 2594 1806 788 5 risperidone 1288 2588 2588 896 1692 6 escitalopram 14148 2218 2218 0 2218 7 alprazolam 4835 2231 2067 1663 404 8 promethazine 148 2022 2022 0 2022 9 digoxin 3189 1695 1695 0 1695 10 sertraline 11132 1537 1537 0 1537 11 zolpidem 2520 1482 1482 0 1482 12 lisinopril 19389 1569 1429 0 1429 13 lorazepam 1641 1278 1278 0 1278 14 bupropion 7826 1233 1233 0 1233 15 trazodone 1661 1223 1223 0 1223 16 metronidazole 1295 1045 1045 0 1045 17 albuterol 7522 5591 1033 0 1033 18 venlafaxine 7227 963 963 0 963 19 montelukast 5135 924 924 0 924 20 esomeprazole 6319 903 903 0 903 Off-Label Drug Use, Stanford School of Medicine, Stanford Prevention Research Center, Randall Stafford, MD, PhD, Week of 06/04/2007Gold standard is demanded to maintain illusion of science, but discarded fast enough. Table 1: Number of Drug Uses, By Off-label Status and Level of Supporting Evidence, United States, July 2005 through December 2006, IMS Health National Therapeutic and Disease Index. Estimated DRUG USES IN THOUSANDS, United States Evidence Generic Total Uncertain or Rank Name On-Label Off-Label Inadequate Inadequate Uncertain 1 quetiepine 1350 4025 4025 0 4025 2 divalproex 905 3949 3689 3015 674 3 warfarin 7967 3439 3439 0 3439 4 prednisone 6536 2767 2594 1806 788 5 risperidone 1288 2588 2588 896 1692 6 escitalopram 14148 2218 2218 0 2218 7 alprazolam 4835 2231 2067 1663 404 8 promethazine 148 2022 2022 0 2022 9 digoxin 3189 1695 1695 0 1695 10 sertraline 11132 1537 1537 0 1537 11 zolpidem 2520 1482 1482 0 1482 12 lisinopril 19389 1569 1429 0 1429 13 lorazepam 1641 1278 1278 0 1278 14 bupropion 7826 1233 1233 0 1233 15 trazodone 1661 1223 1223 0 1223 16 metronidazole 1295 1045 1045 0 1045 17 albuterol 7522 5591 1033 0 1033 18 venlafaxine 7227 963 963 0 963 19 montelukast 5135 924 924 0 924 20 esomeprazole 6319 903 903 0 903 Off-Label Drug Use, Faculty Stanford School of Medicine, Stanford Prevention Research Center, June 4, 2007 For anyone living with the myth that electronic this and that will do the trick for cost or quality, Dr. Stanford’s recent study showed that EMR is a flop. GIGO! Now back to the action: over 42 million prescriptions where there is no, insufficient or uncertain evidence that the FDA approved drug had any science behind it. Oh, the art of medicine. 100,000 drug deaths. Please start to draw the lines between the dots. Table 1: Number of Drug Uses, By Off-label Status and Level of Supporting Evidence, United States, July 2005 through December 2006, IMS Health National Therapeutic and Disease Index. Estimated DRUG USES IN THOUSANDS, United States Evidence Generic Total Uncertain or Rank Name On-Label Off-Label Inadequate Inadequate Uncertain 1 quetiepine 1350 4025 4025 0 4025 2 divalproex 905 3949 3689 3015 674 3 warfarin 7967 3439 3439 0 3439 4 prednisone 6536 2767 2594 1806 788 5 risperidone 1288 2588 2588 896 1692 6 escitalopram 14148 2218 2218 0 2218 7 alprazolam 4835 2231 2067 1663 404 8 promethazine 148 2022 2022 0 2022 9 digoxin 3189 1695 1695 0 1695 10 sertraline 11132 1537 1537 0 1537 11 zolpidem 2520 1482 1482 0 1482 12 lisinopril 19389 1569 1429 0 1429 13 lorazepam 1641 1278 1278 0 1278 14 bupropion 7826 1233 1233 0 1233 15 trazodone 1661 1223 1223 0 1223 16 metronidazole 1295 1045 1045 0 1045 17 albuterol 7522 5591 1033 0 1033 18 venlafaxine 7227 963 963 0 963 19 montelukast 5135 924 924 0 924 20 esomeprazole 6319 903 903 0 903 Off-Label Drug Use, Stanford School of Medicine, Stanford Prevention Research Center, Randall Stafford, MD, PhD, Week of 06/04/2007

    47. $3,430 Billion Reasons Explain Rising Costs Mo./Year Company/Drug/Disease Allegations Settlement 9/2007 Sanofi-Aventis Violated False $190 /Anzemet/Cancer Claims Act Inflated Prices/Physicians Profits, Medicare/Medicaid 9/2007 Bristol Meyers Squibb/ Illegally Promoted $515 Abilify/Anti-psychotic use for Off-label Drug Use-Pediatric/ Dementia By Consulting Fees/Luxury Trips 9/2007 Zommer, Biomet Kickbacks/Surgeons $311 DePuy Orthopaedics (J&J) Smith & Nephew/ Replacement Hips & Knees 2006 Medtronics Consulting Fees/Free $ 40 Spinal Implants Travel/Other Perks 2007 Again Accused of Similar Charges-not Settled (yet) 2007 Purdue Frederick/ Misbranding/Misleading $634* OxyContin/Pain Killer Information re: Addictive Characteristics 2007 Schering Sales Corp./ Lied to Gov’t re: Pricing/ $435 and Parent Company/ Illegal Promotion for Temodat & Intron A/ Off-label Use-Cancers Glioblastoma multiforme 2004 Pfizer Inc./Neurontin Off–label Use for $430 Epilepsy Pain and Psychiatric Illness 2001 Tap Pharmaceutical Inflation of Prices $875 Products/Lupron/ Bribed Physicians Prostrate Cancer All figures (000,000) September: A Banner Month For Drug Industry Crime, NewsTarget.com When asked why he robbed banks, Willy Sutton said “That’s Where the Money Is” Willie was wrong! Willie would not find $3,430,000,000 in most banks. This is the tip of the iceberg. Nothing went to any victim. No part of these settlements went to improve patient safety. No physician was: reported, disciplined charged with accepting bribes, compromising patient care or censured for reflecting poorly on the profession. Wyeth, another drug company, agreed in 1999 to pay $3.75 billion to settle lawsuits over the fen-phen diet drug combination, which was linked to heart problems. Now liabilities are up to $21 billion. Excludes consideration of litigations related to: brand-generic disputes generic-generic manufacturers; patent litigation; restricted generic entry; Anti-trust Does not include stockholder claim settlements like After prosecuting the securities litigation claims against Bristol-Myers Squibb Co. (BMS) for over five years, Labaton Sucharow, Lead Counsel representing the class and Lead Plaintiff, the LongView Collective Investment Fund of the Amalgamated Bank, reached an agreement in principle to settle the claims for $185 million in addition to meaningful corporate governance reforms that will affect future consumers and investors alike. The class action settlement concludes a lengthy and arduous litigation that was set for trial in 2006. This a sampling of settlements that involved alleged harm to patients that literally run into the billions. Is this the place you want to lay your bets? In the OxyContin case, the term pain killer took on new meaning as many users were in fact killed by the drug or by people on the drug. The exposure of the policies of the company were first made by a law enforcement official who connected the dots to rising crime, deaths and addiction in his formerly quiet community. Former company executives also paid fines of several millions of dollars according to New York Times reports. No one acknowledged any wrong doing. Criminal charges were not started against the company, but against many youthful offenders for drug addiction, robberies and murder As Sutton also said, “It is a rather pleasant experience to be alone in a bank at night.” Would Sutton feel uncomfortable in this crowd? September: A Banner Month For Drug Industry Crime, NewsTarget.com, Herb Newborg, November 1, 2007 All content posted on this site is commentary or opinion and is protected under Free Speech. Truth Publishing LLC takes sole responsibility for all content. Truth Publishing sells no hard products and earns no money from the recommendation of products. Newstarget.com is presented for educational and commentary purposes only and should not be construed as professional advice from any licensed practitioner. Truth Publishing assumes no responsibility for the use or misuse of this material. For the full terms of usage of this material, visit www.NewsTarget.com/terms.shtml Wyeth, another drug company, agreed in 1999 to pay $3.75 billion to settle lawsuits over the fen-phen diet drug combination, which was linked to heart problems. Now liabilities are up to $21 billion. Excludes consideration of litigations related to: brand-generic disputes generic-generic manufacturers; patent litigation; restricted generic entry; Anti-trust Does not include stockholder claim settlements like After prosecuting the securities litigation claims against Bristol-Myers Squibb Co. (BMS) for over five years, Labaton Sucharow, Lead Counsel representing the class and Lead Plaintiff, the LongView Collective Investment Fund of the Amalgamated Bank, reached an agreement in principle to settle the claims for $185 million in addition to meaningful corporate governance reforms that will affect future consumers and investors alike. The class action settlement concludes a lengthy and arduous litigation that was set for trial in 2006. This a sampling of settlements that involved alleged harm to patients that literally run into the billions. Is this the place you want to lay your bets? In the OxyContin case, the term pain killer took on new meaning as many users were in fact killed by the drug or by people on the drug. The exposure of the policies of the company were first made by a law enforcement official who connected the dots to rising crime, deaths and addiction in his formerly quiet community. Former company executives also paid fines of several millions of dollars according to New York Times reports. No one acknowledged any wrong doing. Criminal charges were not started against the company, but against many youthful offenders for drug addiction, robberies and murder As Sutton also said, “It is a rather pleasant experience to be alone in a bank at night.” Would Sutton feel uncomfortable in this crowd? September: A Banner Month For Drug Industry Crime, NewsTarget.com, Herb Newborg, November 1, 2007 All content posted on this site is commentary or opinion and is protected under Free Speech. Truth Publishing LLC takes sole responsibility for all content. Truth Publishing sells no hard products and earns no money from the recommendation of products. Newstarget.com is presented for educational and commentary purposes only and should not be construed as professional advice from any licensed practitioner. Truth Publishing assumes no responsibility for the use or misuse of this material. For the full terms of usage of this material, visit www.NewsTarget.com/terms.shtml

    48. $4.85 Billion Settlement Is Victory For Drug Company 2001 JAMA article warns of Vioxx risks 9/2002: Vioxx increased risk of heart attacks/strokes Merck spends more than $1.2 billion on Vioxx-related legal fees 9/2004 Vioxx withdrawn by Merck 8/2005: First verdict: $253,500,000 (Reduced to less than $25,000,000) 2006/2007, Merck defeats 8 of 10 plaintiffs in CA, FL, NJ, IL, LA 11/2007 Merck settles 27,000 Vioxx suits for $4.85 billion Settlement = 9 months profits Wall Street reacted favorably Merck still facing civil and criminal action by several states and feds Merck Agrees to Settle Vioxx Suits for $4.85 Billion, New York Times, November 9, 2007 Analysts See Merck Victory in Vioxx Settlement, New York Times, November 10, 2007 Merck withdrew Vioxx from the market in September 2004, after a clinical trial proved that it increased the risks of heart attacks and strokes. But internal company documents showed that Merck's scientists were concerned about the risks of Vioxx several years earlier. And a large clinical trial that ended in 2000 also showed that Vioxx was much riskier than naproxen, an older painkiller sold under the name Aleve. November 10, 2007 Analysts See Merck Victory in Vioxx Settlement $4.85 billion, represents only about nine months of profit for Merck, whose stock rose 2.3 percent on news of the agreement Payments averaging about $120,000 each before legal fees and expenses, patients or surviving families get maybe $70,000 on average Lawyers stand to earn $2 billion Dr. Eric Topol, a cardiologist who in 2001 was co-author of a paper in The Journal of the American Medical Association warning of the risks of Vioxx, said he believed that the payment amounted to little more than a slap on the wrist for Merck. Wyeth, another drug company, agreed in 1999 to pay $3.75 billion to settle lawsuits over the fen-phen diet drug combination, which was linked to heart problems Merck withdrew Vioxx from the market in September 2004, after a clinical trial proved that it increased the risks of heart attacks and strokes. But internal company documents showed that Merck's scientists were concerned about the risks of Vioxx several years earlier. And a large clinical trial that ended in 2000 also showed that Vioxx was much riskier than naproxen, an older painkiller sold under the name Aleve. November 10, 2007 Analysts See Merck Victory in Vioxx Settlement $4.85 billion, represents only about nine months of profit for Merck, whose stock rose 2.3 percent on news of the agreement Payments averaging about $120,000 each before legal fees and expenses, patients or surviving families get maybe $70,000 on average Lawyers stand to earn $2 billion Dr. Eric Topol, a cardiologist who in 2001 was co-author of a paper in The Journal of the American Medical Association warning of the risks of Vioxx, said he believed that the payment amounted to little more than a slap on the wrist for Merck. Wyeth, another drug company, agreed in 1999 to pay $3.75 billion to settle lawsuits over the fen-phen diet drug combination, which was linked to heart problems

    49. Regrettable Human Error September 2006 F.D.A. reconvenes safety panel and OKs continued use of drug Company study showing adverse impact of drug not revealed to F.D.A. Company says failure to report findings was due to: Click here to return to Regrets October 2007 Researchers stopped a study of drug because 50% more likely to die vs. alternatives Drug increased the risks of kidney failure, heart attack and stroke Causes 10,000 to 11,000 kidney failures a year (Click here to return to Regrets) Stop and save more than $1 billion a year in dialysis costs November 2007 Bayer AG announced agreed to withdraw its controversial heart surgery drug F.D.A. could not identify any population where the benefits outweigh the risks Bayer says drug is beneficial when used as directed (Click here to return to Regrets) Heart Surgery Drug Pulled From Market, New York Times, November 6,2007 Main point: Less medicine and drugs better for any patients. The F.D.A. convened a panel of experts in September of last year to review the safety of the drug, and the panel concluded that Trasylol should remain on the market. But within days of the panel’s meeting, the agency discovered that Bayer had sponsored yet another study of Trasylol suggesting that the drug increased the risks of death and stroke. The company had failed to disclose the results of its study to the agency or the advisory panel. Indeed, Bayer scientists had defended Trasylol at the panel’s hearing but had not mentioned their own study or its worrisome findings. A company investigation later concluded that the findings had been withheld as a result of “regrettable human error.” About 200,000 patients around the world received Trasylol last year, 110,000 of them in the United States, Bayer said. The drug, known generically as aprotinin, has had F.D.A. approval since 1993 Looks like 10% dialysis per year Quick calculation: 1993 100; 1994 200; 1995 500; 1996, 750; 1997 1000 1998-2000 5,000; 2001-2007 60,000 new iatrogenic kidney failures Total 1993-2007 = 67550 unnecessary dialysis patients A cost-effectiveness analysis of hepatitis B vaccine in predialysis patients HEALTH SERVICES RESEARCH,  April, 1993  by Eugene Z. Oddone,  Patricia A. Cowper,  John D. Hamilton,  John R. Feussner Hemodialysis patients and staff remain at risk for infection from hepatitis B virus (HBV). The problem of HBV infection in hemodialysis is compounded by the large proportion of patients who become chronic carriers of the virus, increasing the possibility of spread to their contacts. (Szmuness, Prince, Grady, et al. 1974). Then there is the cost of liver transplants and strain to find more transplantable livers. “…half again as likely..” is that the same as “50% more likely?” The F.D.A. convened a panel of experts in September of last year to review the safety of the drug, and the panel concluded that Trasylol should remain on the market. But within days of the panel’s meeting, the agency discovered that Bayer had sponsored yet another study of Trasylol suggesting that the drug increased the risks of death and stroke. The company had failed to disclose the results of its study to the agency or the advisory panel. Indeed, Bayer scientists had defended Trasylol at the panel’s hearing but had not mentioned their own study or its worrisome findings. A company investigation later concluded that the findings had been withheld as a result of “regrettable human error.”Main point: Less medicine and drugs better for any patients. The F.D.A. convened a panel of experts in September of last year to review the safety of the drug, and the panel concluded that Trasylol should remain on the market. But within days of the panel’s meeting, the agency discovered that Bayer had sponsored yet another study of Trasylol suggesting that the drug increased the risks of death and stroke. The company had failed to disclose the results of its study to the agency or the advisory panel. Indeed, Bayer scientists had defended Trasylol at the panel’s hearing but had not mentioned their own study or its worrisome findings. A company investigation later concluded that the findings had been withheld as a result of “regrettable human error.” About 200,000 patients around the world received Trasylol last year, 110,000 of them in the United States, Bayer said. The drug, known generically as aprotinin, has had F.D.A. approval since 1993 Looks like 10% dialysis per year Quick calculation: 1993 100; 1994 200; 1995 500; 1996, 750; 1997 1000 1998-2000 5,000; 2001-2007 60,000 new iatrogenic kidney failures Total 1993-2007 = 67550 unnecessary dialysis patients A cost-effectiveness analysis of hepatitis B vaccine in predialysis patients HEALTH SERVICES RESEARCH,  April, 1993  by Eugene Z. Oddone,  Patricia A. Cowper,  John D. Hamilton,  John R. Feussner Hemodialysis patients and staff remain at risk for infection from hepatitis B virus (HBV). The problem of HBV infection in hemodialysis is compounded by the large proportion of patients who become chronic carriers of the virus, increasing the possibility of spread to their contacts. (Szmuness, Prince, Grady, et al. 1974). Then there is the cost of liver transplants and strain to find more transplantable livers. “…half again as likely..” is that the same as “50% more likely?” The F.D.A. convened a panel of experts in September of last year to review the safety of the drug, and the panel concluded that Trasylol should remain on the market. But within days of the panel’s meeting, the agency discovered that Bayer had sponsored yet another study of Trasylol suggesting that the drug increased the risks of death and stroke. The company had failed to disclose the results of its study to the agency or the advisory panel. Indeed, Bayer scientists had defended Trasylol at the panel’s hearing but had not mentioned their own study or its worrisome findings. A company investigation later concluded that the findings had been withheld as a result of “regrettable human error.”

    50. How Many Errors Were Not Detected? In terms of patient safety, adults in the U.S. report the highest rates of lab test errors and among the highest rates of medical or medication errors. Patient-reported errors were highest for those seeing multiple doctors or with multiple chronic illnesses. One-third of U.S. patients with chronic conditions reported a medical, medication, or test error in the past two years.In terms of patient safety, adults in the U.S. report the highest rates of lab test errors and among the highest rates of medical or medication errors. Patient-reported errors were highest for those seeing multiple doctors or with multiple chronic illnesses. One-third of U.S. patients with chronic conditions reported a medical, medication, or test error in the past two years.

    51. Non-Hospital Drug Adverse Effects Reported To the FDA in 1998 and 2005 Event 1998 2005 Increase All Drugs Serious, adverse 34,966 89,842 260% Serious, fatal 5,519 15,107 270% 13 new biotech products 580 9,181 1,580% These data show a marked increase in reported deaths and serious injuries associated with drug therapy over the study period. The results highlight the importance of this public health problem and illustrate the need for improved systems to manage the risks of prescription drugs. Serious Adverse Drug Events Reported to the Food and Drug Administration, 1998-2005, Arch Intern Med,  2007;167:1752-1759 The increase was influenced by relatively few drugs: 298 of the 1489 drugs identified (20%) accounted for 407,394 of the 467,809 events (87%). Reported serious events increased 4 times faster than the total number of outpatient prescriptions during the period.The increase was influenced by relatively few drugs: 298 of the 1489 drugs identified (20%) accounted for 407,394 of the 467,809 events (87%). Reported serious events increased 4 times faster than the total number of outpatient prescriptions during the period.

    52. A Drug Shark’s Tale Lipitor patent runs till 2010 Generic for Zocor, a Lipitor competitor, is now available Pfizer’s response: Tell Wall Street: Will spend two times more for ads Argue that a non-gold standard study shows value Attack insurers Hire a BIG name, hit man for ads Maker of Lipitor Digs In to Fight Generic Rival, New York Times, November 3, 2007 Main point: naicin works safer, better and less costly than drugs to control cholesterol. Has a bad side affect if overdosed. You temporarily blush (flush in doctorese). Anything rather than see stockholder value fall. Merck held patent on Zocor, a statin for lowering cholesterol Patent ran out Generic, simvastatin, now available and being used Lipitor market share dropped from 40% to 30% Pfizer now spends $147 million on ads for Lipitor, its brand name statin America’s cost all drugs/year $270 billion (18% of total bill); Statins: $ $22 billion; 16,000,000 Americans take statins Cost per day: Lipitor: $2.50-$3.00 : Generic $0.10-$1.00 Potential savings for nation: $ 2 billion Potential savings for patient: $730-$876 Pfizer is drug company with patent. Wall Street wants to know profits and impact on price of stock, not impact on nation’s financial and physical health Lower price might increase demand, but lower costs is difference in patient using drug as directed Study is not the gold that physicians claim they need Even a Pfizer doctor involved in the British study, Dr. Berkeley Phillips, said in an interview with the online publication WebMD that it did not prove that Lipitor worked better than simvastatin. “We can’t say from this study that switching is bad or that one statin is better than another,” Dr. Phillips said. “You would need a randomized clinical trial to say that.” Study claims 30% more heart attacks after switching Attack on insurers by Dr. Louis W. Sullivan, a former secretary of Health and Human Services Ad hit man Dr. Robert Jarvik, the inventor of the artificial heart Main point: naicin works safer, better and less costly than drugs to control cholesterol. Has a bad side affect if overdosed. You temporarily blush (flush in doctorese). Anything rather than see stockholder value fall. Merck held patent on Zocor, a statin for lowering cholesterol Patent ran out Generic, simvastatin, now available and being used Lipitor market share dropped from 40% to 30% Pfizer now spends $147 million on ads for Lipitor, its brand name statin America’s cost all drugs/year $270 billion (18% of total bill); Statins: $ $22 billion; 16,000,000 Americans take statins Cost per day: Lipitor: $2.50-$3.00 : Generic $0.10-$1.00 Potential savings for nation: $ 2 billion Potential savings for patient: $730-$876 Pfizer is drug company with patent. Wall Street wants to know profits and impact on price of stock, not impact on nation’s financial and physical health Lower price might increase demand, but lower costs is difference in patient using drug as directed Study is not the gold that physicians claim they need Even a Pfizer doctor involved in the British study, Dr. Berkeley Phillips, said in an interview with the online publication WebMD that it did not prove that Lipitor worked better than simvastatin. “We can’t say from this study that switching is bad or that one statin is better than another,” Dr. Phillips said. “You would need a randomized clinical trial to say that.” Study claims 30% more heart attacks after switching Attack on insurers by Dr. Louis W. Sullivan, a former secretary of Health and Human Services Ad hit man Dr. Robert Jarvik, the inventor of the artificial heart

    53. Some More Tales FDA cannot guarantee the safety of the nation's drug supply Foreign companies manufacture 80% of all ingredients used by American drug makers FDA’s records are poor FDA cannot even say what it inspected F.D.A. Is Unable to Ensure Drugs Are Safe, Panel Is Told, NYT, November 2, 2007 $20,157 buys a patient less than one month of increased survival Results are not surprising: “There is no early detection screen of proven worth as yet,.." “There are no good predictors to identify lung cancer at an early stage,.” “..so you would not expect an increase in early diagnosis to affect improvement in survival.“ (Stephen Spiro, MD, head, department of thoracic medicine, University College London Hospitals National Health Service Trust, UK) Survival Benefit Minimal Despite Rising Cost of Lung Cancer Treatment in Elderly, Medscape Medical News, October 25, 2007 Another slip of the lip. No early detection screens…o proven value. Proven?? New concept. Let’s assume there were good predictors and good early detection screens. That would be the date that the disease was diagnosed, not the date it started. Diagnosis dates are artificial and have little significance unless there are in fact an affordable, relatively easy regimen that assured a consistent and significant positive outcome with few adverse side affects. Otherwise it is just a game called “Other People’s Money” FDA Safety Failures: “The Food and Drug Administration cannot guarantee the safety of the nation's drug supply because it inspects few foreign drug manufacturers and the inspections it does carry out abroad are less rigorous than those performed in this country, witnesses told a Congressional subcommittee yesterday. “While foreign companies manufacture as much as 80 percent of all ingredients used by American drug makers, the drug agency's record keeping is so poor that it cannot say which of those have not been inspected, according to the testimony before the House Energy and Commerce Subcommittee on Oversight and Investigations.” Lung cancer: “..although the cost per patient has increased by $20,157, survival has increased by less than 1 month. "The results of the study are not all that surprising, commented Stephen Spiro, MD, head of the department of thoracic medicine at University College London Hospitals National Health Service Trust, in the United Kingdom. There is no early detection screen of proven worth as yet," he told Medscape Oncology. "There are no good predictors to identify lung cancer at an early stage, so you would not expect an increase in early diagnosis to affect improvement in survival." Woops. Out of the mouth of babes. Early detection does not yet improve survival (outcomes)?Another slip of the lip. No early detection screens…o proven value. Proven?? New concept. Let’s assume there were good predictors and good early detection screens. That would be the date that the disease was diagnosed, not the date it started. Diagnosis dates are artificial and have little significance unless there are in fact an affordable, relatively easy regimen that assured a consistent and significant positive outcome with few adverse side affects. Otherwise it is just a game called “Other People’s Money” FDA Safety Failures: “The Food and Drug Administration cannot guarantee the safety of the nation's drug supply because it inspects few foreign drug manufacturers and the inspections it does carry out abroad are less rigorous than those performed in this country, witnesses told a Congressional subcommittee yesterday. “While foreign companies manufacture as much as 80 percent of all ingredients used by American drug makers, the drug agency's record keeping is so poor that it cannot say which of those have not been inspected, according to the testimony before the House Energy and Commerce Subcommittee on Oversight and Investigations.” Lung cancer: “..although the cost per patient has increased by $20,157, survival has increased by less than 1 month. "The results of the study are not all that surprising, commented Stephen Spiro, MD, head of the department of thoracic medicine at University College London Hospitals National Health Service Trust, in the United Kingdom. There is no early detection screen of proven worth as yet," he told Medscape Oncology. "There are no good predictors to identify lung cancer at an early stage, so you would not expect an increase in early diagnosis to affect improvement in survival." Woops. Out of the mouth of babes. Early detection does not yet improve survival (outcomes)?

    54. Alzheimer’s=Disease=Research=Drugs Scientists reported progress… blood test…90 percent accurate in distinguishing …80 percent accurate in predicting… Outside experts called the results …promising but preliminary At present, treatments for Alzheimer’s disease are not very effective… …when drugs are developed that slow or halt … Alzheimer’s sent out signals to the body’s immune system…communication between cells paid for by… and Satoris, a company co-founded…to commercialize the test. Progress Cited in Alzheimer’s Diagnosis, NY Times, October 15, 2007 One self serving study and report: 90%, 80% accurate or 10%, 20% error? How will Mom or Dad feel to know that they have this dreaded disease earlier than later even though nothing can be done about it? Think how happy they will be to find out it was all a big mistake, assuming of course they do not forget. 80% is inverse of 20% or 1 of 5 Promising, a phrase often used to get funding, but from where? The key finding is the fifth bullet-the body’s attempt to fix itself. The body’s immune system is tying to work and is unable to meet the challenge. Question: what does the immune system and the body’s cells need to overcome the challenge? The report is self-serving; conflict of interest. Right again. Your global/local drug company. Again the sad news, treatments for disease are not very effective. Consideration of making an effort at prevention does not exist. No need to worry about funding for that.One self serving study and report: 90%, 80% accurate or 10%, 20% error? How will Mom or Dad feel to know that they have this dreaded disease earlier than later even though nothing can be done about it? Think how happy they will be to find out it was all a big mistake, assuming of course they do not forget. 80% is inverse of 20% or 1 of 5 Promising, a phrase often used to get funding, but from where? The key finding is the fifth bullet-the body’s attempt to fix itself. The body’s immune system is tying to work and is unable to meet the challenge. Question: what does the immune system and the body’s cells need to overcome the challenge? The report is self-serving; conflict of interest. Right again. Your global/local drug company. Again the sad news, treatments for disease are not very effective. Consideration of making an effort at prevention does not exist. No need to worry about funding for that.

    55. Alzheimer’s: Prevention Forgotten Not one word about a cure! Not one word about prevention! Not one word about what the body is missing! Not one word about using the cells communications! Not one word about the role of the immune system! Progress Cited in Alzheimer’s Diagnosis, NY Times, October 15, 2007 Welcome to the world of medicine! Alzheimer’s, a relatively new disease. Auto immune? Where did it come from? Why now? No cure, just another test. Prevention as part of a physician’s practice except to some extent among family practice and PCPs doesn’t exist. Prevention in medicine, as a general rule: does not exist. If it does-a total failure. What is missing? We will get there next. The cell, the place where disease starts. One disease. One drug. The world of the medical drug pushers, peddlers, prescribers (sounds so much better). For an example of what is missing in another area, inflammation, let’s go to the next slideWelcome to the world of medicine! Alzheimer’s, a relatively new disease. Auto immune? Where did it come from? Why now? No cure, just another test. Prevention as part of a physician’s practice except to some extent among family practice and PCPs doesn’t exist. Prevention in medicine, as a general rule: does not exist. If it does-a total failure. What is missing? We will get there next. The cell, the place where disease starts. One disease. One drug. The world of the medical drug pushers, peddlers, prescribers (sounds so much better). For an example of what is missing in another area, inflammation, let’s go to the next slide

    56. Four Red Dots? Science 313: 670-673 (August 4, 2006) Dar Vader, Mt. Rushmore, your neighborDar Vader, Mt. Rushmore, your neighbor

    57. Research: Finding What Is Known Place: Rockefeller University’s Leonard Wagner Laboratory of Molecular Genetics and Immunology Problem: The IgG paradox! IgG antibodies can prevent or cause autoimmune disorders (lupus, arthritis, asthma) Findings: Terminal sialic acid on the Fc portions of the IgG molecule stopped inflammation Explanation: IgG can shift from a state that is quite inflammatory to a state that is actively anti-inflammatory by just changing a sugar Solution: Want to develop another drug Issue: Natural remedy already exists Science 313: 670-673 (August 4, 2006) Harper’s Biochemistry, 25th Edition, Chapter 56, Page 675, McGraw-Hill, 2000 Could one day lead to a whole new class of therapeutics. “We have the opportunity to make a much better form of IVIG that will work 100 times better and be a pure molecule — to build a much better class of therapeutics based on a property that already exists in nature.” Suggest researchers go to *Harper’s Biochemistry, 25th Edition, Chapter 56, page 675, McGraw-Hill Sialic acid is a glycoprotein (sugar) whose properties are clearly identified. This sugar is readily available in supplements. No need to spend another six years to find a whole new class of therapeutics. But that is the way of medicine. Pick a disease, find a promise, get drug company funding, be a star. Could one day lead to a whole new class of therapeutics. “We have the opportunity to make a much better form of IVIG that will work 100 times better and be a pure molecule — to build a much better class of therapeutics based on a property that already exists in nature.” Suggest researchers go to *Harper’s Biochemistry, 25th Edition, Chapter 56, page 675, McGraw-Hill Sialic acid is a glycoprotein (sugar) whose properties are clearly identified. This sugar is readily available in supplements. No need to spend another six years to find a whole new class of therapeutics. But that is the way of medicine. Pick a disease, find a promise, get drug company funding, be a star.

    58. An Educated Consumer Is Our Best Customer Once paid $11.60 per month for Blue Cross In one week, received three pieces of mail: 43 pages about Medicare drug plan options Letter from company: What happens if selected plan is dropped Letter from a politician saying how great drug plan is Had to research 30 plans to get doctor/hospital, drug and cost info Times Herald-Record, Letter to Editor, November 8, 2007, Page 27 Our thanks to Sy Sims, the clothing retailer. Transparency at work. Just your ordinary American thrilled with transparency. I think there is a story about a king who had transparent clothes.Our thanks to Sy Sims, the clothing retailer. Transparency at work. Just your ordinary American thrilled with transparency. I think there is a story about a king who had transparent clothes.

    59. We Are Rated By How We Treat The Least Among US 1974 - 1975 House Staff physicians go on strike at 25 hospitals Demands include end of abusive work schedules Demands for more nursing, lab, messenger staff Most strikes settlements are inconclusive Some reductions in work hours and temporary staff improvements 1984 - one patient dies after ER admission at New York Hospital Grand Jury finds overworked and under supervised house staff New laws and professional GME guidelines are established GME groups concerned that training and patient care suffer Intern and Resident Organizations in the United States: 1934-1977, Robert G. Harmon, M.D., The Milbank Memorial Fund Quarterly. Health and Society, V. 56, No. 4 (Autumn 1978), pp. 500-530, supplemented by the presenter (In this case how it treats those who treat the sick, along with the sick) The Symptoms: Month/Year Hospital Strike/days Reason[s] Nov1974 Freedman’s 12 Excess hours/working conditions March1974 21 Hospitals 4 Excess hours/working conditions 1974 L.A. 7 Patient care/equipment 1975 Cook County strike Excess hours/patient care 1981 New York Strike Continued recognition 1984* New York 6 hours No attending, tired house staff All for naught as the struggle for decent hours and improved staffing falls on deaf and defiant ears. Then Libby Zion, 18 years old dies in 6 hours after admission via ER Milbank Memorial Fund Intern and Resident Organizations in the United States: 1934-1977 Robert G. Harmon, The Milbank Memorial Fund Quarterly. Health and Society, Vol. 56, No. 4 (Autumn, 1978), pp. 500-530, doi:10.2307/3349574 Libby “Fell On The Sword” For Hospital Patients The grand jury inquiry regarding her death found: The house officers on the floor had been at work for 18 hours. There were no attending physicians in the ER or in her unit. The New York State Department of Health made 19 recommendations but withdrew many because they would cost billions of dollars. Here is one: "Individual residents who have responsibility for patient care in areas other than ER shall have a work week that shall not exceed 80 hours per week over a 4-week period. They should also not be scheduled to work more than 24 consecutive hours." Do today's medical residents really have it better? Cleveland Clinic Journal of Medicine, Frank Michota, MD Read the fine print: 40/168 = 24%; 60/168 = 36%; 80/168 = 48%; 80 hours per week over a 4 week period. How about 110 hours for two weeks and reduced hours the other two. How about the last day of the 4 weeks at just 80 hours? Who wants the 110 hour physician? Who even wants the 80 hour variety? Who wants the intern at the 23rd hour? Or even the 18th? Billions to fix the way care is delivered? Not on your life. And what about the ER. The one place where being alert and awake might help. (In this case how it treats those who treat the sick, along with the sick) The Symptoms: Month/Year Hospital Strike/days Reason[s] Nov1974 Freedman’s 12 Excess hours/working conditions March1974 21 Hospitals 4 Excess hours/working conditions 1974 L.A. 7 Patient care/equipment 1975 Cook County strike Excess hours/patient care 1981 New York Strike Continued recognition 1984* New York 6 hours No attending, tired house staff All for naught as the struggle for decent hours and improved staffing falls on deaf and defiant ears. Then Libby Zion, 18 years old dies in 6 hours after admission via ER Milbank Memorial Fund Intern and Resident Organizations in the United States: 1934-1977 Robert G. Harmon, The Milbank Memorial Fund Quarterly. Health and Society, Vol. 56, No. 4 (Autumn, 1978), pp. 500-530, doi:10.2307/3349574Libby “Fell On The Sword” For Hospital Patients The grand jury inquiry regarding her death found: The house officers on the floor had been at work for 18 hours. There were no attending physicians in the ER or in her unit. The New York State Department of Health made 19 recommendations but withdrew many because they would cost billions of dollars. Here is one: "Individual residents who have responsibility for patient care in areas other than ER shall have a work week that shall not exceed 80 hours per week over a 4-week period. They should also not be scheduled to work more than 24 consecutive hours." Do today's medical residents really have it better? Cleveland Clinic Journal of Medicine, Frank Michota, MD Read the fine print: 40/168 = 24%; 60/168 = 36%; 80/168 = 48%; 80 hours per week over a 4 week period. How about 110 hours for two weeks and reduced hours the other two. How about the last day of the 4 weeks at just 80 hours? Who wants the 110 hour physician? Who even wants the 80 hour variety? Who wants the intern at the 23rd hour? Or even the 18th? Billions to fix the way care is delivered? Not on your life. And what about the ER. The one place where being alert and awake might help.

    60. Even The Pros Have Trouble With Handoffs! Improved patient care conditions are less evident than improved house staff conditions.(1) But do these benefits mean that today's interns and residents have it better? Are they learning more? Probably not.(2) In addition to problems with handoffs, house staff are particularly vulnerable to medical errors owing to teamwork failures, especially lack of supervision. Graduate medical education reform should focus on strengthening these aspects of training…(3) Serious consequences: 33% or 889 cases resulted in deaths.(4) (1) Intern and Resident Organizations in the United States: 1934-1977, Robert G. Harmon, M.D., The Milbank Memorial Fund Quarterly. Health and Society, Vol. 56, No. 4 (Autumn, 1978), pp. 500-530 (2) Do today's medical residents really have it better? Cleveland Clinic Journal of Medicine, Frank Michota, MD (3) Medical Errors Involving Trainees, A Study of Closed Malpractice Claims From 5 Insurers, Arch Intern Med, 2007;167:2030-2036. (4) Lack of communication tied to errors: report, Modern Healthcare’s Daily Dose, October 10, 2007 How about exhausted? Overworked, cheap labor? Errors due to becoming a walking zombie. Notice slipped in is a little remark about no supervision of these trainees. Do you still want to believe that malpractice is a cause of increasing costs? Or are you getting the idea that this system is broke and litigation is one way to recover from the damage it does everyday. When I was the executive director of the largest house staff union in America, we had a four day strike in 1975 for patient care: demanding more nurses, lab techs, and shorter work schedule hours. We were told, “This is how it was, now is and always will be.” 110 hours per week. One odd conclusion that came out of that strike when the over 2,200 house staff doctors took a walk was a report by the New York City Health Department authored by the Assistant Commissioner, Lowell Bellin, M.D. about the impact on patient care. It went nowhere because it would have destroyed a myth about non-municipal teaching hospitals-that they produce higher quality care because of the teaching/learning environment. Right: the report showed that mortality decreased in the city as major hospitals were emptied of patients! Years later a death of a daughter at a New York hospital led the father to seek redress through a malpractice claim-based on two facts: the attending physicians were no where to be found and the house staff involved in the care of this young woman were exhausted. A mistake was made due to exhaustion. A young woman died. 50,000,000 new potential inpatients. If we believe the common wisdom, they are all sick and in need of medical and hospital care because they now do not have insurance. That is another 2.5 -4 million admissions ready to be billed, maybe at the inflated HAI rates. A side note: 1/3 of the house staff errors involved a patient death. Norcini and colleagues (8) found that the knowledge level of U.S. medical graduates is getting worse and that of foreign medical graduates is getting better. 8. Norcini JJ, Shea JA, Benson JA. Changes in the medical knowledge of candidates for certification. Ann Int Med 1991; 114:33-35.How about exhausted? Overworked, cheap labor? Errors due to becoming a walking zombie. Notice slipped in is a little remark about no supervision of these trainees. Do you still want to believe that malpractice is a cause of increasing costs? Or are you getting the idea that this system is broke and litigation is one way to recover from the damage it does everyday. When I was the executive director of the largest house staff union in America, we had a four day strike in 1975 for patient care: demanding more nurses, lab techs, and shorter work schedule hours. We were told, “This is how it was, now is and always will be.” 110 hours per week. One odd conclusion that came out of that strike when the over 2,200 house staff doctors took a walk was a report by the New York City Health Department authored by the Assistant Commissioner, Lowell Bellin, M.D. about the impact on patient care. It went nowhere because it would have destroyed a myth about non-municipal teaching hospitals-that they produce higher quality care because of the teaching/learning environment. Right: the report showed that mortality decreased in the city as major hospitals were emptied of patients! Years later a death of a daughter at a New York hospital led the father to seek redress through a malpractice claim-based on two facts: the attending physicians were no where to be found and the house staff involved in the care of this young woman were exhausted. A mistake was made due to exhaustion. A young woman died. 50,000,000 new potential inpatients. If we believe the common wisdom, they are all sick and in need of medical and hospital care because they now do not have insurance. That is another 2.5 -4 million admissions ready to be billed, maybe at the inflated HAI rates. A side note: 1/3 of the house staff errors involved a patient death. Norcini and colleagues (8) found that the knowledge level of U.S. medical graduates is getting worse and that of foreign medical graduates is getting better. 8. Norcini JJ, Shea JA, Benson JA. Changes in the medical knowledge of candidates for certification. Ann Int Med 1991; 114:33-35.

    61. House Staff Training Fatigue Errors Number of Extended Duration Shifts/Month Event Base/None One-Four Five Reported-Fatigue Related Significant: Medical Error 100% 300% 700% Adverse Event 100% 700% 800% Preventable Adverse Event 100% 100% 300% Interns were also more likely to fall asleep during lectures, rounds, and clinical activities, even surgery…In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures, National Institute for Occupational Safety and Health within the US Centers for Disease Control (Grant R01OH07567) and the Agency for Healthcare Research and Quality (AHRQ) (Grant R01 HS12032) Medicine has gotten to the point where it has lost all sight of its goals as it doubles its efforts. Translated from the distant, non-emotional language of medicine: tied interns are making mistakes that include killing patients. The important public policy implication is the safety of people who become patients. Another public policy question is there justification to pay for this carnage? Will universal insurance keep interns awake? This is the way it has always been is not an answer, nor is it true. Medical internship training has been around for less than 70 years. Residency training slightly less. And even if it always was that way, is that any answer worthy of response? Our truckers (bus drivers, pilots, engineers, school bus drivers) always drink and take uppers to stay awake. It has always been that way! How to make good wellness, health and support practitioners is to get them out of hospitals and into other settings for training and continuing education. Except for some truly hospital based specialists, (maybe pathologists?, certainly no longer, all surgeons, radiologists,) most medical care is delivered in non-institutional settings. And with the slow advancement of the hospitalist and emergency room specialists, getting away from the high tech, less patient to physician interaction will put physicians back where they should be: in front of patients to prevent and when necessary to diagnose and treat disease. Medicine has gotten to the point where it has lost all sight of its goals as it doubles its efforts. Translated from the distant, non-emotional language of medicine: tied interns are making mistakes that include killing patients. The important public policy implication is the safety of people who become patients. Another public policy question is there justification to pay for this carnage? Will universal insurance keep interns awake? This is the way it has always been is not an answer, nor is it true. Medical internship training has been around for less than 70 years. Residency training slightly less. And even if it always was that way, is that any answer worthy of response? Our truckers (bus drivers, pilots, engineers, school bus drivers) always drink and take uppers to stay awake. It has always been that way! How to make good wellness, health and support practitioners is to get them out of hospitals and into other settings for training and continuing education. Except for some truly hospital based specialists, (maybe pathologists?, certainly no longer, all surgeons, radiologists,) most medical care is delivered in non-institutional settings. And with the slow advancement of the hospitalist and emergency room specialists, getting away from the high tech, less patient to physician interaction will put physicians back where they should be: in front of patients to prevent and when necessary to diagnose and treat disease.

    62. Stents: Sugar or Diet No clear comparative evidence studies to show which treatment is best, best over time, best in terms of disease type, level, and cost and how each treatment compares to other treatments, including prescription drugs, angioplasty alone, by-pass surgery, and changes in nutrition, supplements and other life style modifications. (Edward Gluckmann, Health Matters, Inc.) “It’s striking that we do so little to evaluate what we’re getting in return for it,” (CBO Director Peter Orszag) A Heart Stent Gets a Reprieve From Doctors, New York Times, November 13, 2007; Aging population isn’t the real threat, says CBO, Modern Healthcare’s Daily Dose, November 13, 2007 “The type of funding may have determinant effects on the design of studies and on the interpretation of findings: funding by the industry is associated with design features less likely to lead to finding statistically significant adverse effects and with a more favorable clinical interpretation of such findings. Disclosure of conflicts of interest should be strengthened for a more balanced opinion on the safety of drugs.” Adverse Effects of Inhaled Corticosteroids in Funded and Non-funded Studies, Arch Intern Med.  2007;167:2047-2053 For the Record: In Tests of Inhalers, Results May Depend on Who Pays, New York Times, November 13, 2007 CBO = Congressional Budget Office There just is not enough information to evaluate medical care in all its forms and modalities to see if they are cost effective and even less to evaluate their cost effectiveness against wellness approaches. The question is not disclosure but gold standard independent testing, evaluation and reporting. Who wants to waste time reading biased reports that somehow get the good housekeeping seal of approval because the conflict and influence is stated. When these studies are referenced later, there is no assurance that potential conflicts when disclosed will not have the opposite effect: lookey here doctor, we paid dr ghost writer a bundle and he came around. A review of more than 500 studies has found that independently backed studies of the inhalers, formally known as inhaled corticosteroids, are up to four times as likely to find adverse effects as studies paid for by drug companies. And the drug company studies downplayed the adverse affects found.CBO = Congressional Budget Office There just is not enough information to evaluate medical care in all its forms and modalities to see if they are cost effective and even less to evaluate their cost effectiveness against wellness approaches. The question is not disclosure but gold standard independent testing, evaluation and reporting. Who wants to waste time reading biased reports that somehow get the good housekeeping seal of approval because the conflict and influence is stated. When these studies are referenced later, there is no assurance that potential conflicts when disclosed will not have the opposite effect: lookey here doctor, we paid dr ghost writer a bundle and he came around. A review of more than 500 studies has found that independently backed studies of the inhalers, formally known as inhaled corticosteroids, are up to four times as likely to find adverse effects as studies paid for by drug companies. And the drug company studies downplayed the adverse affects found.

    63. Devices, Implants And Either This Guy Is Dead Or My Watch Stopped! Nation’s largest maker of implanted heart devices to docs: stop using a crucial component of our most recent defibrillator models. These devises caused malfunctions in hundreds of patients and may have contributed to five deaths. 235,000 patients have these devices that can make them misread heart-rhythm data. Cost $30,000/device Cost per year = $7,050,000,000 Patients Warned as Maker Halts Sale of Heart Implant Part, New York Times, October 15, 2007 Groucho Marx in Monkey Business, 1931. In less than ten words! What would Shakespeare's line be today? “De-fault is not in the stars, it is in your de-vice!” Best effort gets a free (previously owned) heart implant device autographed by the head pathologist. You can buy a car for that price, or two weeks gas to run it. 5/235,000 = small %, anyone want to go wit those odds? Go with them if it were your heart? $30,000 x 235,000 = big bucksGroucho Marx in Monkey Business, 1931. In less than ten words! What would Shakespeare's line be today? “De-fault is not in the stars, it is in your de-vice!” Best effort gets a free (previously owned) heart implant device autographed by the head pathologist. You can buy a car for that price, or two weeks gas to run it. 5/235,000 = small %, anyone want to go wit those odds? Go with them if it were your heart? $30,000 x 235,000 = big bucks

    64. Florida: Land Of Opportunity The wheelchair billed for $5 million Millions billed by an air conditioning repairman for specially formulated asthma medication High level of AIDS billing with no clinical explanation Criminal entrepreneurship funded by public Fraud penalties much less severe than they are for narcotics trafficking Fraud and Florida's multimillion-dollar wheelchair, Reuters, October 22, 2007 Willie Sutton must be rolling in his grave. And you thought your car and home were expensive. Asthma-speaks for itself. Investigators found that the repairman used a broom closet to keep some of his gear, including a bucket of tar! AIDS billing is out of sight in Florida. No clinical explanation. Back to crime. No conflicts of interest here. Make money. Be an entrepreneur. 50,000,000 more fish to reel in? Are you sure America’s crooks are ready? So what if they get caught. Why sell illegal drugs when you can just fraudulently bill for the prescription type? Willie Sutton must be rolling in his grave. And you thought your car and home were expensive. Asthma-speaks for itself. Investigators found that the repairman used a broom closet to keep some of his gear, including a bucket of tar! AIDS billing is out of sight in Florida. No clinical explanation. Back to crime. No conflicts of interest here. Make money. Be an entrepreneur. 50,000,000 more fish to reel in? Are you sure America’s crooks are ready? So what if they get caught. Why sell illegal drugs when you can just fraudulently bill for the prescription type?

    65. Visions of Medical Care-Ideal “Group medicine is not a financial arrangement ..“  “..(do) we take sufficient care to make a thorough physical examination..?”  “..some loss in appreciation of the individuality of the patient..”  “the main purpose to be served by the Clinic is the care of the sick.“ Operate ..intended not to create wealth but to provide a financial return sufficient for present and future needs.  30% of less fortunate patients received hand written bills marked paid in full. (They weren’t paid. They were just written off!) No one charged more than 10% of his or her annual income, no matter how expensive the treatment. Every dollar on bills over $1,000 went to help other sick people Mayo Clinic Foundation Website and The Value of Sharing, The Story of the Mayo Brothers, by Spencer Johnson, M.D. (Education includes a psychology degree from the University of Southern California, an M.D. from the Royal College of Surgeons and medical clerkships at Harvard Medical School and the Mayo Clinic) Dirty commie! William J. Mayo, M.D.Dirty commie! William J. Mayo, M.D.

    66. Visions of Medical Care-Investment Opportunity HCA buyers got $175 million in fees The group that bought HCA, will receive $175 million in transaction fees, and other fees down the road. Thomas Frist, Jr., a relative of the former Republican Party (Congressional leader) and members of his family, and top-level HCA executives, will also get $15 million annually under a management contract with HCA, which includes possible increases based on the new company’s profits. The buyout was for $33 billion. Several executives are guaranteed board seats as part of their employment agreements. Modern Health’s Daily Dose, a daily e-mail report on current healthcare events. The exact date is not crucial. This is a sample of many such reports that run into the billions nationwide over the course of any year. What does any of this buying and selling have to do with medical care? Notice the connection to politics. What does any of this buying and selling have to do with medical care? Notice the connection to politics.

    67. Visions of Medical Care-Wellness (First) A Drug Maker’s Views of What Ails American Health Care Holstein: “What should Americans be doing to fix the system?” Vasella: “One aspect is better patient education and better nutrition…we should look at how to give incentives to people to avoid disease-prone behaviors… Saturday Interview of Daniel L. Vasella, chief executive of Novartis by William Holstein, New York Times, September 8, 2007 Did he say expand insurance to the uninsured? Vasella: “One aspect is better patient education and better nutrition. People continue to eat as they did during the times when they were working in the fields. That is a dramatic mistake. Secondly, we should look at how to give incentives to people to avoid disease-prone behaviors such as smoking, alcohol consumption and being overweight.” Did he say expand insurance to the uninsured? Vasella: “One aspect is better patient education and better nutrition. People continue to eat as they did during the times when they were working in the fields. That is a dramatic mistake. Secondly, we should look at how to give incentives to people to avoid disease-prone behaviors such as smoking, alcohol consumption and being overweight.”

    68. Myths Deconstruction Another way of saying, we are doing nothing to save money. If all these claims actually worked, medical care would be free. Total costs would be going down. They are not. Maybe for one patient here and there, but not overall. (See above.) Almost without exception, buying and selling (M & A) or just gross transfers from one investment group to another is a business transaction loaded with costly stock options, profit/loss considerations, market positioning, golden parachutes, lucrative broker and other fees and has nothing to do with improving care or quality. Putting an investigation or litigation behind without any acceptance of wrong doing is just another way of saying: We got caught (acceptable business risk) with our hands in the cookie jar, and we got away with it (as we thought we would) by buying off prosecution with pennies on the dollar settlement, (another acceptable business cost). Now we can get on to make more money claiming to care about saving lives while agreeing to keep our hands out of the cookie jars, (but just for a while) and making more money.

    69. Myths Deconstruction Cost shifting is just that, the shifting of costs from the insurer, to the insured and among the insured and underinsured. It costs more not less. Consumer empowerment started in the 1970’s and failed then. Everyone speaks for the consumer, yet no one really does. Consumers have few choices and options. Most consumers have time to surf the Internet, but few understand the implications of what is going on when told they have cancer, or have had a serious heart attack or experiencing a stroke. Ditto Alzheimer’s, autism, emotional and mental turmoil. People with diabetes, are overweight, or obese are facing information that is contradictory, unproven and often not supported in a variety of ways, not least of which, is that the recommendations of what to do and what will be done have no consistent pattern of working. Proof: Look around. Read the statistics. See America’s world comparative rankings.

    70. “DOES ANYBODY HERE KNOW HOW TO PLAY THIS GAME?” Health insurance companies cited ..for violation of Medicare standards...(said) they were addressing the deficiencies and would improve service to patients, who will be able to switch plans in the last six weeks of the year. ...WellPoint, one of the nation’s largest insurers, said the company had hired additional employees to answer telephones and pay claims filed by or for Medicare beneficiaries..WellPoint was reducing its claims backlog and telephone waiting times and expected to be in compliance with federal standards by the end of this month. Coventry Health Care, which recently had a civil penalty of $264,000 assessed for violation of Medicare marketing standards, said it had taken steps to prevent a repetition of the problems. After Audit, Insurers Vow to Improve Medicare Service, New York Times, 10/10/2007 Casey Stengel, former NY Yankee and then current NY Mets Manager This for the reformers: you biuld a box and they will find a way in or out depending where the money is and what Wall Street says. Whereas the denial will enlighten and calm people who enrolled in this version of Medicare. The problem is getting caught and having to pay pennies on the dollar. Ever know a commissioned salesperson who could not tell you how the commission payment incentive program works and how to maximize it for personal gain. Does anyone think a company is going to offer a revised incentive plan that will not work for that company and its salespersons? Casey Stengel, former NY Yankee and then current NY Mets Manager This for the reformers: you biuld a box and they will find a way in or out depending where the money is and what Wall Street says. Whereas the denial will enlighten and calm people who enrolled in this version of Medicare. The problem is getting caught and having to pay pennies on the dollar. Ever know a commissioned salesperson who could not tell you how the commission payment incentive program works and how to maximize it for personal gain. Does anyone think a company is going to offer a revised incentive plan that will not work for that company and its salespersons?

    71. “DOES ANYBODY HERE KNOW HOW TO PLAY THIS GAME?” ..a spokeswoman for Coventry, said the company had retrained its agents and changed the timing of commission payment to discourage inappropriate sales. ..(a) public policy director at CareOregon, based in Portland, said her company was “very serious” about correcting deficiencies and was revising its procedures. ..CareOregon, which serves low-income people enrolled in both Medicare and Medicaid, questioned the wisdom of one recommendation, involving notices to beneficiaries about the denial of claims. “To send all these notices could confuse and scare our patients,.. After Audit, Insurers Vow to Improve Medicare Service, New York Times, October 10, 2007 Whereas the denial letters will enlighten and calm people who enrolled in this version of Medicare or are enrolled for Medicaid. Even better getting a cancellation of insurnace notice in the middle of chemo Health insurer tied bonuses to dropping sick policyholders, L.A> Times, 11/09/2007 One of the state's largest health insurers set goals and paid bonuses based in part on how many individual policyholders were dropped and how much money was saved. Health Net fined for lying about bonus program Health Net has been fined $1 million by California regulators for lying about an internal employee bonus program tied to policy cancellations during a state investigation. The Woodland Hills, Calif.-based insurer paid an analyst $20,000 in bonuses based in part for meeting or exceeding company goals for canceling individual insurance polices. The company avoided paying $35.5 million in medical claims between 2000 and 2006 by revoking more than 1,000 individual policies. The bonus program was disclosed in court documents and is illegal under state law. Modern Healthcare’s Daily Dose, November 16, 2007; Woodland Hills-based Health Net Inc. avoided paying $35.5 million in medical expenses by rescinding about 1,600 policies between 2000 and 2006. During that period, it paid its senior analyst in charge of cancellations more than $20,000 in bonuses based in part on her meeting or exceeding annual targets for revoking policies, documents disclosed Thursday showed. Health insurer tied bonuses to dropping sick policyholders Whereas the denial letters will enlighten and calm people who enrolled in this version of Medicare or are enrolled for Medicaid. Even better getting a cancellation of insurnace notice in the middle of chemo Health insurer tied bonuses to dropping sick policyholders, L.A> Times, 11/09/2007 One of the state's largest health insurers set goals and paid bonuses based in part on how many individual policyholders were dropped and how much money was saved.Health Net fined for lying about bonus program Health Net has been fined $1 million by California regulators for lying about an internal employee bonus program tied to policy cancellations during a state investigation. The Woodland Hills, Calif.-based insurer paid an analyst $20,000 in bonuses based in part for meeting or exceeding company goals for canceling individual insurance polices. The company avoided paying $35.5 million in medical claims between 2000 and 2006 by revoking more than 1,000 individual policies. The bonus program was disclosed in court documents and is illegal under state law. Modern Healthcare’s Daily Dose, November 16, 2007;

    72. “DOES ANYBODY HERE KNOW HOW TO PLAY THIS GAME?” When Dealing With The Insane, It Is Best To Pretend To Be Sane Senator Max Baucus, Democrat of Montana, chair, Finance Committee: “The unscrupulous tactics of some plans have led me to be skeptical about how well this market works for seniors.” And Representative Pete Stark, California Democrat, chair of the Ways and Means Subcommittee on Health: that the Bush administration had been reluctant to “regulate or offend these large companies.” But Kerry N. Weems, acting administrator of the Centers for Medicare and Medicaid Services: “contract compliance and beneficiary protection” had been among his top priorities since he took office last month. Karen M. Ignagni, president of America’s Health Insurance Plans said the audits did not reflect the fact that private plans “generally offer better benefits” than original Medicare.” The answer is yes. They all know how to play this game. After Audit, Insurers Vow to Improve Medicare Service, New York Times, October 10, 2007 Herman Hesse What are we using here, just words? Herman Hesse What are we using here, just words?

    73. Does He Or Does He Not? A Senator says his disease had progressed a very tough disease,” “it could progress rapidly..” “It’s possible the diagnosis is wrong,” Bruce Miller, Neurologist, UC “….tests can monitor the progression of the disease “In some cases I’ve followed patients for many years…” Norman Relkind, Neurologist, Cornell Medical Center And they need regular medical visits to monitor the progression of the disease The larger question for society…will be figuring out how and by whom decisions should be made about other people’s mental capacity to work, vote and make choices for themselves. Often, he said, doctors will have to be involved (Dr. Karlawish, Medicine & Medical Ethics, U of P) Senator’s Illness Requires Monitoring, New York Times, October 7, 2007 News reports show the chaos that reigns in medicine. One physician says you can live a normal life a long time, another says short, another is so sure of his colleagues, he says: maybe wrong diagnosis? Monitor the disease? Watch the progress of the disease? Follow patients? Read those words of big brother. The monitoring will be regular. Homeland Security, Stalin and Hitler would be proud. Nice move: built in job security-doctors will have to be involved (my emphasis). Talk about alleged stagehand featherbedding. Why not his family, friends, co-workers, a priest, rabbi, , monk, lawyer, the courts, flip a coin. Not cure. Not even treat with anything. Monitor, watch, follow…. All at some cost to the patient’s mental health and pocketbook. Why not suggest: get a life, do some fun things, at your age-smoke a joint, have a beer, smoke that fine stogie, take a trip, volunteer at a summer camp, cook a really unhealthy but great tasting meal, paint a picture, do a puzzle, design a boat, plane, car, read all the books you had no time for, write a book-call it, I forgot more than you’ll ever know, see a movie, take a walk, eat great healthy food, try some supplements that have been shown to help memory and the brain, move a lot, take some yoga and breathing exercises, try meditation and acupuncture, drink pure water, take some mental attitude improvement courses, support humanity and the environment, explore a hobby, volunteer somewhere or do whatever else makes you smile. We can’t do anything except run up billing hours, expose you to a lot of unnecessary tests and drugs. Spend the rest of your life without worrying about your next stressful appointment to be monitored, followed, etc. News reports show the chaos that reigns in medicine. One physician says you can live a normal life a long time, another says short, another is so sure of his colleagues, he says: maybe wrong diagnosis? Monitor the disease? Watch the progress of the disease? Follow patients? Read those words of big brother. The monitoring will be regular. Homeland Security, Stalin and Hitler would be proud. Nice move: built in job security-doctors will have to be involved (my emphasis). Talk about alleged stagehand featherbedding. Why not his family, friends, co-workers, a priest, rabbi, , monk, lawyer, the courts, flip a coin. Not cure. Not even treat with anything. Monitor, watch, follow…. All at some cost to the patient’s mental health and pocketbook. Why not suggest: get a life, do some fun things, at your age-smoke a joint, have a beer, smoke that fine stogie, take a trip, volunteer at a summer camp, cook a really unhealthy but great tasting meal, paint a picture, do a puzzle, design a boat, plane, car, read all the books you had no time for, write a book-call it, I forgot more than you’ll ever know, see a movie, take a walk, eat great healthy food, try some supplements that have been shown to help memory and the brain, move a lot, take some yoga and breathing exercises, try meditation and acupuncture, drink pure water, take some mental attitude improvement courses, support humanity and the environment, explore a hobby, volunteer somewhere or do whatever else makes you smile. We can’t do anything except run up billing hours, expose you to a lot of unnecessary tests and drugs. Spend the rest of your life without worrying about your next stressful appointment to be monitored, followed, etc.

    75. Politician’s Emotional Statement and Some Facts: Dialogue Dispute vs Dishonest Discourse -A Case Study Politician’s emotional statement: I am alive because I am free to choose my doctor (free enterprise), where as in other countries (socialized medicine) I cannot. He claims these facts support his position: USA prostrate cancer survival rate is 82% and UK prostate cancer survival rate is 44%. But the facts involved are: The 44% figure is bogus, called “crude’ by the politician’s own consultant and disavowed by the Commonwealth Fund, the original source. Giuliani’s Prostate Cancer Figure Is Disputed, New York Times, October 31, 2007 USA localized prostate cancer (at time of diagnosis) survival rates [1] are nearly 100% for five years, 93% for 10 years (32% for distant spread) and, 77% for 15 years where as the UK prostrate cancer survival rates 74.4% for five years. The 44% figure was seven years old , acknowledged by the politician’s consultant as “crude” and the Commonwealth said was used incorrectly. “And simply because (when) you find it (prostrate cancer) earlier, you will always have longer survival after the disease is diagnosed.” 44% quoted from an article the politician’s consultant wrote for City Journal, a publication of the Manhattan Institute, a conservative research organization. The self referential citation is , characterized by the politician’s camp as “…an article in a highly respected intellectual journal written by an expert at a highly respected think tank which the… read..” 44% actually came from a seven year old report by the Commonwealth Fund, a nonprofit group in New York specializing in health care policy issues, 44% was acknowledged as seven years old and ‘crude’ by the consultant The Commonwealth Fund said: “.. (the consultant) had misused its research by calculating a five-year survival rate based on data on prostate cancer incidence and mortality rates in the United States and Britain. “Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” The consultant dismissed the statement of the Commonwealth Fund by saying the group had “an ideological bias.” Physicians and Epidemiologists Respond: “.. unfair to compare prostate cancer statistics in Britain with those in the United States because in the United States the cancer is more likely to be diagnosed in its early stages..” “Certainly, if you intensively screen for prostate cancer, you will find early disease, “And simply because (when) you find it earlier, you will always have longer survival after the disease is diagnosed.” Politician says will continue to use that figure. To measure 10-year survival rates, we must have records of patients diagnosed more than 10 years ago. According to the most recent data, for all men with prostate cancer, the relative 10-year survival rate is 93% and the 15-year survival rate is 77%. Modern methods of detection and treatment mean that prostate cancers are now found earlier and treated more effectively. If you are diagnosed this year, your outlook is likely to be better than the numbers reported above. ACS, website, 10/31/2007 NOT RELATED YET? 37 cents of every healthcare dollar spent in America is wasted. Feds must get serious about prosecution, Modern Healthcare Daily’s Dose, October 30,2007 USA localized prostate cancer (at time of diagnosis) survival rates [1] are nearly 100% for five years, 93% for 10 years (32% for distant spread) and, 77% for 15 years where as the UK prostrate cancer survival rates 74.4% for five years. The 44% figure was seven years old , acknowledged by the politician’s consultant as “crude” and the Commonwealth said was used incorrectly. “And simply because (when) you find it (prostrate cancer) earlier, you will always have longer survival after the disease is diagnosed.” 44% quoted from an article the politician’s consultant wrote for City Journal, a publication of the Manhattan Institute, a conservative research organization. The self referential citation is , characterized by the politician’s camp as “…an article in a highly respected intellectual journal written by an expert at a highly respected think tank which the… read..” 44% actually came from a seven year old report by the Commonwealth Fund, a nonprofit group in New York specializing in health care policy issues, 44% was acknowledged as seven years old and ‘crude’ by the consultant The Commonwealth Fund said: “.. (the consultant) had misused its research by calculating a five-year survival rate based on data on prostate cancer incidence and mortality rates in the United States and Britain. “Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” The consultant dismissed the statement of the Commonwealth Fund by saying the group had “an ideological bias.” Physicians and Epidemiologists Respond: “.. unfair to compare prostate cancer statistics in Britain with those in the United States because in the United States the cancer is more likely to be diagnosed in its early stages..” “Certainly, if you intensively screen for prostate cancer, you will find early disease, “And simply because (when) you find it earlier, you will always have longer survival after the disease is diagnosed.” Politician says will continue to use that figure. To measure 10-year survival rates, we must have records of patients diagnosed more than 10 years ago. According to the most recent data, for all men with prostate cancer, the relative 10-year survival rate is 93% and the 15-year survival rate is 77%. Modern methods of detection and treatment mean that prostate cancers are now found earlier and treated more effectively. If you are diagnosed this year, your outlook is likely to be better than the numbers reported above. ACS, website, 10/31/2007 NOT RELATED YET? 37 cents of every healthcare dollar spent in America is wasted. Feds must get serious about prosecution, Modern Healthcare Daily’s Dose, October 30,2007

    76. “No, no, you're not thinking; you're just being logical.” Niels Bohr From your lips to g-d’s ear: Quality and price transparency will curb U.S. healthcare spending by at least 1%, said roughly half of respondents in the Commonwealth Fund’s latest healthcare opinion leaders survey. Of those respondents, slightly more than 30% said disclosure would reduce spending by 1% to 5%, while 17% said reporting would cut spending by at least 5%. The October online poll is the Commonwealth Fund’s fourth and final industry opinion leader’s survey for 2007. Roughly 240 healthcare insiders, academics and public policymakers participated, or a response rate of 21%. Eighty-five percent of respondents called greater transparency an important catalyst for performance improvement. Three-fourths agreed that disclosure was important to encourage insurers to reward or recognize quality and efficiency, and 66% said the same for transparency’s role helping patients make informed decisions. From your lips to g-d’s ear: Quality and price transparency will curb U.S. healthcare spending by at least 1%, said roughly half of respondents in the Commonwealth Fund’s latest healthcare opinion leaders survey. Of those respondents, slightly more than 30% said disclosure would reduce spending by 1% to 5%, while 17% said reporting would cut spending by at least 5%. The October online poll is the Commonwealth Fund’s fourth and final industry opinion leader’s survey for 2007. Roughly 240 healthcare insiders, academics and public policymakers participated, or a response rate of 21%. Eighty-five percent of respondents called greater transparency an important catalyst for performance improvement. Three-fourths agreed that disclosure was important to encourage insurers to reward or recognize quality and efficiency, and 66% said the same for transparency’s role helping patients make informed decisions.

    77. Cancer: A First and Last Word “Because no cancer cell exists, the respiration of which is intact, it cannot be disputed that cancer could be prevented if the respiration of the body cells would be kept intact.” “For cancer formation there is necessary not only an irreversible damaging of the respiration but also an increase in the fermentation.” (Fermentation is a way that cells with impaired respiration try to survive by converting body sugars [glucose] into a weak form of ATP energy.) “The most important fact in this field is that there is no physical or chemical agent with which the fermentation of cells in the body can be increased directly: for increasing fermentation, a long time and many cell divisions are always necessary.” “The mysterious latency period of the production of cancer is, therefore, nothing more than the time in which the fermentation increases after a damaging of the respiration.” “There would be no cancers if there were no fermentation of normal body cells.” “Carcinogenesis by x-rays is obviously nothing else than destruction of respiration by elimination of the respiring grana.” You kill cancer cells with radiation but you weaken healthier cells at the same time, so “…the descendents of the surviving normal cells may in the course of the latent period compensate the respiration decrease by the fermentation increase and thence become cancer cells.” The Prime Cause and Prevention of Cancer, Revised Lindau Lecture, 1966, Otto Warburg, M.D., PhD (Chemistry), Noble Laureate, 1931, 1944; Director, Max Planck Institute for Cell Physiology, Berlin-Dahlem, Germany 1931 Noble Laureate Explains Cancer. Putting These Comments Together With Smoking Does Not Cause Cancer And It Becomes Clear That The Loss Of Oxygen Is The Villain, Not the Smoking! All truth passes through three stages: First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as self-evident. George Carlin “No, no, you're not thinking; you're just being logical.” Niels Bohr Some people smoke and get lung and other cancers. Other people smoke and do not get lung or other cancers. Some people who do not smoke get lung and other cancers. Other people who do not smoke do not get lung or other cancers. It is not the smoke: it’s the breathing of sufficient oxygen that can be transferred into the body that is the key factor along with quality nutrition, proper rest and movement, quality water and a healthy, robust attitude that count. 1931 Noble Laureate Explains Cancer. Putting These Comments Together With Smoking Does Not Cause Cancer And It Becomes Clear That The Loss Of Oxygen Is The Villain, Not the Smoking! All truth passes through three stages: First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as self-evident. George Carlin “No, no, you're not thinking; you're just being logical.” Niels Bohr Some people smoke and get lung and other cancers. Other people smoke and do not get lung or other cancers. Some people who do not smoke get lung and other cancers. Other people who do not smoke do not get lung or other cancers. It is not the smoke: it’s the breathing of sufficient oxygen that can be transferred into the body that is the key factor along with quality nutrition, proper rest and movement, quality water and a healthy, robust attitude that count.

    78. Solutions-change the thinking Solutions-eliminate profit and advertising Solutions-establish independent body-a public trust that approves only what can be platinum standard validated Solutions-convert everything that starts with or contains the word medical into wellness and then make its parts comport to that goal Compensate based on results to prevent first and treat later Criminalize all activity that benefits an individual, institution or entity that is or appears as a conflict Make them wash their hands Create a National Wellness Service We start and end here. We start and end here.

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