CHAPTER 2
A
“Economy is a savings - bank, into which men drop pennies, and get dollars in return.” – J. Billings
“The art of medicine consists in amusing the patient while nature cures the disease.” - Voltaire
§ 2.1.0 PLACEBO EFFECTS AND FAITH
§ 2.1.1.1 – PROBLEM: The Placebo effect is found throughout medicine. Essentially, a percentage, between 10 - 40%, of people will recover from ailments if provided an inert treatment, such as a pill made entirely of sugar.
§ 2.1.1.2 - The old medicine men and witch doctors knew that faith alone could heal some ailments suffered by some people, some of the time. Even briefly, the study of the effects of faith upon medical practice ought to be studied by all providers, without regard for any specific religion, but, rather, the underlying practice of faith.
§ 2.1.4.1 – RECOMMENDATIONS: While not ethical to practice, imagine the savings by providing “sugar pills” for non-life-threatening ailments for which the available medication is very expensive for patients most likely to benefit from the “suggestion”. If it were to be efficacious in the most conservative 10 percent, medical costs could be reduced $30 billion a year. This shows the power of faith in the healing arts. I propose that modest introduction of faith-based programs might cost $1 billion per year and would be projected to save $6 billion per year.
§ 2.2.0 REDUCE FELT NEED TO PRACTICE DEFENSIVE MEDICINE
§ 2.2.1.1 - PROBLEM: One of the single biggest contributors to the escalating costs of medical practice is the felt need by providers to practice defensive medicine. Where Medicare provider liability was curtailed, 9 percent of health care spending was eliminated. Of course, the old thinking hadn’t changed nor was total tort law reform fully curtailed, so only partial confidence in the experiment was achieved. Still 9 percent of $2,500 billion is $225 billion.
STUDY DEFENSIVE MED CO$T %
#1 $10 billion / YEAR 00.40%
#2 $225 billion / YEAR 09.00%
#3 $250 billion / YEAR 10.00%
#4 $300 billion / YEAR 12.00%
§ 2.2.1.2 - I estimate practicing defensive medicine costs about 14 percent or $350 billion a year. I have a goal of reducing defensive medicine by $225 billion (9 percent) a year (we can’t reduce it entirely, for when a litigious patient insists on a procedure that’s not totally unreasonable, it is often performed). Defensive medicine can only be reduced by adopting / combining each one of following six things:
* Tort Law Reform *
* Confidential Learning from Errors *
* Vigorous but Fair Enforcement *
* Efforts to Acknowledge & Reduce Medical Errors *
* Mens Rea Risk Aversive Practice Shift *
* Jury Dynamics *
§ 2.2.2.1 – ANALYSIS: GOLDEN FLEECE AWARD: Most (93 percent) physicians admit to practicing defensive medicine (a doctor places orders not medically necessary, so, if sued, a defense attorney can argue all efforts were made). While 100,000 people die each year from medical errors, only 5 percent of doctors are willing to say that “medical errors” is a problem. Either doctors prevaricate to avoid lawsuits, they truly are unaware of any problem, or they believe that medical errors do not affect outcomes. I suspect that the first explanation is valid by itself. I suspect that many providers become immune to the consequences of medical errors, they know sometimes they happen and one just moves on, or, better still, ignores errors, fueling the second explanation.
§ 2.2.3.1 – RECOMMENDATION: The Public Health Service (PHS), the CDC-P, and Federal Health Clinics (FHCs) must provide mandatory education, confidential discussion facilitation, and surveys to identify how to reduce defensive medicine and medical errors. The costs of defensive medicine that is fueled by malpractice is ten times the cost of mere malpractice. Yet, if malpractice is not addressed, there is no way that defensive medicine can be addressed.
§ 2.3.0 TORT LAW REFORM
“Lawsuit: A machine which you go into as a pig and come out of as a sausage.” - Ambrose Bierce
§ 2.3.1.1 – PROBLEM: Being sued frightens providers. They do anything to avoid it, ordering unnecessary tests,
providing marginally justified medicines that patients demand. Where malpractice costs are only about one percent of the cost of health care, they are the single biggest denominator behind the practice of defensive medicine, which costs 11 times more than tort law itself.
§ 2.3.2.1 – ANALYSIS: Tort law allows one who sustained an injury from another to sue in court and be awarded compensation for damages, pain and suffering, and punitive damages. Lawyers, depending upon custom and state regulation, charge 25 percent of a settlement when awarded out of court or 40 percent of an award when the case goes to trial. Plus, they charge for costs.
§ 2.3.2.2 - Previous attempts at tort law reform still resulted in provider’s liability in other states and federal courts, they were not combined with efforts to mold a new mens rea, reduce medical errors, reduce the practice of defensive medicine; nor did they address jury dynamics. I suggest that under the 14th Amendment, the US Congress can mandate reform to states’ tort laws.
§ 2.3.2.3 - Fierce competition between too many struggling attorneys results in more suits. The
§ 2.3.2.4 - Tort law reform could be seen as threatening attorneys’ livelihood and, frankly, justice. Physicians and conservatives align in seeing tort law reform as necessary for protection from costly lawsuits. This clash of special interests has stalled effective health care reform for 50 years. We must push ourselves through this issue and address it face on IF we are to reduce spending $350 billion and the practice of defensive medicine.
“Good lawyers know the law; great lawyers know the judge.” - Author Unknown
§ 2.3.4.1 – RECOMMENDATIONS: Special health care courts ought to be designed that specifically address such cases. These special courts would allow greater efficiency in addressing health care concerns. The added cost of these courts might approach $1 billion a year. These courts would be able to practice with greater efficiency.
§ 2.3.4.2 - The ABA must improve monitoring professional behaviors in malpractice cases. Most Americans perceive lawyers pursue medical malpractice suits for money rather than justice.
§ 2.3.4.3 - Judges ought to provide actual costs, histories jurisdictionally and nationally as guidance in making awards to
juries that have found in favor of the plaintiff.
§ 2.3.4.4 - Judges should authorize cost changes from insurance the defendant buys at the time of the award. This ought to include early death benefits.
§ 2.3.4.5 - The actuarial approach (NH = $100,000 / year, so, 5 percent of $2 million provides $100,000 in perpetuity) versus the “irrational” approach ($100,000 x 78 years equals $7.8 million) must be used in awarding damages. This would reduce provider malpractice. OB-GYN services would be more available, especially in underserved regions.
§ 2.3.4.6 - Medical malpractice plaintiffs often have pain and suffering. P & S ought to be continued. Providing
information to juries that have found in favor of the plaintiff the normative patterns of awards ought to be
sufficient for curtailing unusual awards.
§ 2.3.4.7 - When a patient dies, actuarially-based damages placed in escrow ought to be returned to insurance
companies, saving it and providers money. Payments ought to be paid immediately; if appealed, it should be placed in escrow, accumulating interest for the side ultimately found to be the “winner”.
§ 2.3.4.8 - Punitive damages should be placed in a COMMUNITY CHEST providing funds, in perpetuity, to improve the
community. The logic of concluding that the defendant merits a punitive damages award escapes me. The entire community suffers from a single injustice and community chests would benefit the entire population.
§ 2.3.4.9 - Lawyers’ fees ought to be awarded and approved by juries and judges, based on quality of litigation, within a
legislated range. They ought to not necessarily be based upon the awards to the defendant.
§ 2.3.4.10 - Attorney’s fees must not attach to punitive damage awards above a modest amount (say, $25,000).
§ 2.3.4.11 - Legal, court, and interest costs of the opposite side ought to be paid by the losing side.
§ 2.3.4.12 - Companies that stall, hoping to bankrupt accusers, ought to pay greater court costs and compensation to the
opposing side if they lose.
§ 2.3.4.13 -Class action suits challenge potential injustices upon classes of people by another (e.g., a drug company
might produce a medicine that prevents one disease but results in headaches in 2 percent of users. A crafty attorney advertises to capture claimants and files suit. The jury makes an award for each one of the 100,000 “victims” and the attorney currently receives 40 percent, plus costs). Reform of class action suits is needed so that attorney fees are within reason. I recommend that a Citizens Panel be formed to determine appropriate actions.
§ 2.3.4.14 - The short-term cost of implementing tort law reform might approach $10 billion over the next 10 years (about
$1 billion per year. The savings, mostly in the form of reduced litigation and malpractice awards, would be
$2.5 billion a year.
§ 2.3.5.1 – OUTCOMES: These modifications in tort law would result in -
§ 2.3.5.1.1 - Fewer Lawsuits would reduce court demands. The use of Electronic Medical Records (EMR) would
increase provider accountability, confidence in records presented to court, and might increase lawsuits in the short term.
§ 2.3.5.1.2 - Saved Money from Malpractice Awards will total $2.5 billion a year but will cost $1 billion a year for the next
10 years.
§ 2.3.5.1.3 - Reduced Practice of Defensive Medicine will save an estimated $225 billion per year (65 percent of
defensive medicine practices). It will never be completely eliminated.
§ 2.3.5.1.4 - Increased “Community Chest” Funds – I estimate that about $20 billion a year will be awarded to
“community chests” in punitive damages. I suggest the principal remain untouched but interest earnings become available for civic projects.
§ 2.3.5.1.5 - Congress would have to act against the wishes of the
§ 2.4.0 REDUCING MEDICAL ERRORS
§ 2.4.1.1 – PROBLEM: GOLDEN FLEECE AWARD: Medical errors kill 10 times more people than guns. I’ve read reports that between 12,000 and 250,000 Americans die each year from medical errors (depending on the definition of medical errors and biases of the authors). Conservatively, 100,000 people die and another 2.1 million are injured due to medical errors. An amazing 95 percent of doctors don’t think medical errors are a problem. Costs of $220 billion a year are incurred from medical errors. It may be the fifth leading cause of death in the
I have a goal of reducing the costs of medical errors by $165 billion a year over the next 10 years.
“The person I like most is the one who points out my defects.” - Umar (radi Allahu anhu)
§ 2.4.2.1 – ANALYSIS: CRUX OF THE PROBLEM - If a doctor flippantly doesn’t give someone’s dad the right diagnosis / treatment, and dad dies, most of us agree that we would not want that doctor to walk away with impunity. However, by “forcing” justice, that doctor will be more likely to hide / ignore / deny the error and will be less likely to learn from that error, nor will the doctors next to him learn from that error. By hiding, rather than broadcasting mistakes, errors are likely to continue.
§ 2.4.2.2 - If one’s dad died from a medical error, anger would follow. If one found out that the hospital conducted a CII, one might see that the hospital took dad’s life seriously and it was truly trying to learn from that error. One would be much less likely to consider filing suit.
§ 2.4.4.1 - RECOMMENDATIONS: Critical Incident Investigations (CIIs) ought to be carried out for all medical errors
new or demanding attention. These must be confidential and privileged, if not criminal cases. They ought to be conducted by medical investigators whose mission is to reveal truth and recommend changes for reducing the probability of re-occurrence of that error in the future.
§ 2.4.4.2 - Confidential and privileged facilitated discussions at FHCs ought to be conducted.
§ 2.4.4.3 - Some situations call for punishment. I defer to ethicists, attorneys, courts, and providers, in determining when
punishment is merited and what evidence ought to then be made available for investigations by professional organizations, licensing boards, civil attorneys, or prosecutors. Since I elsewhere advocate confidentiality of discussions of medical errors at FHCs, perhaps documents of those discussions and subpoenas of attendees might not be available.
§ 2.4.4.4 - I believe that all medical errors ought to be anonymously posted on the internet. Perhaps the PHS could operate a web site into which every health care provider in the
§ 2.4.4.5 - While these discussions and data are confidential and privileged, anonymous compiled data ought to compare hospitals / providers’ efficacy and these data ought to be available on the internet. Trust me, if a doctor has rankings averaging 2 stars out of 10 by 1,500 patients, most of us will drive to the next town. These rankings ought to follow a provider, accumulating across states and years.
§ 2.4.4.6 - Improved regulation by licensing boards and professional organizations may reduce errors. I believe that
higher national standards ought to be adopted by all state licensing boards, thus permitting providers to move to another state without interference of months in applying for licensure elsewhere.
§ 2.4.4.7 - An adequate number of providers will decrease the “need” to overlook repeated errors of less competent providers. Further, more providers means less stress and less likelihood of the commission of errors.
§ 2.4.4.8 - A thorough review of the equality of foreign and US health sciences education ought to be made, across fields such as radiology, orthopedics, nursing, pharmacy, and psychology.
§ 2.4.4.9 - Cost sharing of malpractice insurance incentivizes quicker learning from medical errors. Say, a provider shares in having to pay 5% of the cost of awards and settlements. A system would be developed through which providers found to deviate from best practices on multiple occasions would be assessed progressively increasing proportions of the costs of awards and settlements.
§ 2.4.4.10 - Federal limits ought to exist on provider hours. Medical interns can spend days at the hospital whereas truck
drivers are required to sleep and rest so many hours a day. Nurses are more likely to commit errors on 12 hour shifts.
§ 2.4.4.11 - Temporary providers make lots more errors, not knowing the system, staff, or patients. As such, the use of temporary providers ought to be kept to a minimum.
§ 2.4.12.1.1 - PROBLEM: Electronic Medical Records reduce errors.
§ 2.4.12.2.1 – ANALYSIS: Pharmacy IT has reduced medication errors in hospitals using this system by 86 percent.
§ 2.4.12.4.1 – RECOMMENDATIONS: All patient records, “recommended” tests, medications and dosages (especially
for pediatric, elderly, those with liver damage, metabolic changes, etc.), and procedures developed from statistical decision-making programs must be automatically presented, in essence, discussing options with the physician.
§ 2.4.12.4.2 - Each doctor’s order must be screened by a program that analyzes for contra-indications, interactions,
allergies, or inappropriateness based on patient historical factors or recent testing or observations, providing stop alerts that can be consciously over-written.
§ 2.4.12.4.3 - Verbal orders must be immediately followed-up by the prescriber with electronic record.
§ 2.4.12.4.4 - Reminder systems would be automatically presented so that nursing personnel are warned in advance of
upcoming procedures. A picture of medication capsules with a copy of the prescription and dose would be
presented.
§ 2.4.12.4.4 - I project front-end development of a comprehensive, interactive system to cost $30 billion. Beyond that,
providers would likely incur costs of $10 billion for updated computing systems.
§ 2.4.12.4.5 - Real time monitoring by government agencies of EMRs might more accurately and efficiently identify errors, patterns, save lives, and reduce costs.
§ 2.4.12.4.6 - A credible internet-based Journal of Null Results would increase access to information that could merit further investigation or which calls into question the findings from published studies that are erroneous.
§ 2.4.12.4.7 - One study reported that 1 patient in 5 in the ICU was misdiagnosed! More studies ought to be conducted to reduce this error rate. Allowing providers immediate access to all EMR ought to reduce misdiagnosis rate significantly and ought to reduce the length of time which patients spend in the ICU being diagnosed.
§ 2.4.12.4.8 - The costs of programs to reduce medical errors could approach $80 billion over the next 20 years ($4 billion a year). I estimate savings to be $165 billion a year or $3.3 trillion over the next 20 years.
§ 2.5.0 USE EVIDENCE BASED PRACTICES
§ 2.5.1.1 – PROBLEM: The use of evidence-based practices results in better outcomes and reduced costs.
§ 2.5.2.1 – ANALYSIS: All health care providers ought to be using evidence-based practices. Evidence-based practices are generally safer and provide greater efficacy.
§ 2.5.4.1 – RECOMMENDATIONS: The degree to which they are adhered ought to be reviewed by state licensing boards. Neglect of evidence-based practices might be grounds for training or license suspension.
§ 2.5.4.2 - The nice thing about living in the information age is that providers can have immediate access to best practice information AND regulators who assure our safety can immediately evaluate lists of procedures to assure safety and recommendations for compliance to best practices.
§ 2.5.5.1 – OUTCOMES: I have not found research that soundly estimates savings. I would hypothesize that a 5 percent savings might be reasonable, approaching $125 billion a year, by simply using evidence based practices.
§ 2.6.0 FEDERAL TAX LAW COMPLIANCE TOO COSTLY AND WASTEFUL!
§ 2.6.1.1 – PROBLEM: Compliance with federal tax law is too costly and wasteful!
§ 2.6.2.1 – ANALYSIS: At 20 percent compliance cost to generate revenue of $2 trillion a year, Americans spend $400 billion ($1,333 per person) on tax compliance. This is especially burdensome on the middle class.
§ 2.6.2.2 - GOLDEN FLEECE AWARD: The current federal tax code has evolved into a boon-doggle that assures employment of millions who don’t produce anything but spinning wheels designed to save as much in tax dollars as their fee is for saving that tax bill.
§ 2.6.2.3 - These brilliant people, instead of plugging in numbers and devising schemes to reduce others’ payments of taxes, could produce, generate a product, and help lead this nation to greater prosperity.
§ 2.6.4.1 – RECOMMENDATIONS: I suggest that the tax code be simplified over the next 3 years, so that $300 billion in tax compliance costs will be reduced per annum. I propose that $75 billion per year of this savings be utilized for health care. I propose that $75 billion per year be utilized to pay for re-tooling these professionals into fields that are likely to lead to US economic prosperity for each of the next 5 years. $150 billion per year can be distributed to taxpayers.
§ 2.7.0 FRAUD, WASTE & ABUSE
§ 2.7.1.1 – PROBLEM: The Senate Finance Committee estimates that $10 billion in public health programs consisted
of inappropriate payments.
§ 2.7.2.1 – ANALYSIS: Fraud, waste, and abuse is always wrong, but, when public systems pay providers below cost,
the deficiency hurts providers financially, and some, by need or greed, are driven to commit acts they might never otherwise do. While a counter argument might be, “you knew what the payment levels were like prior to signing the forms”.
On the other hand, as a taxpayer, we never want to see outright corruption, such as the
§ 2.7.4.1 – RECOMMENDATIONS: The Senate Finance Committee report requires reporting of gifts to physicians with
several reasonable exceptions, such as drugs for use by patients and items worth less than $10. It seemed odd that “profits from publicly traded companies” was included there. Any receipt of profits by companies ought to be reported, certainly whenever the appreciation or dividend is greater than $10. Physicians and health care providers might place their health related investments in a blind trust and thus avoid the need for reporting. A provider with a vested interest in a small, publicly traded company in which she owns 20 percent may be at increased risk of ethical conflicts and referring patients for profit.
§ 2.8.0 MORE WANTS EVEN MORE
§ 2.8.1 The
that our MRIs are used 1/3rd of that of OECD MRIs. You would be wrong. More MRIs leads to more use and reliance on MRIs. In Economics 101, we talked about supply and demand. Well, if the number of MRI machines available is too high, then the reimbursed price ought to be coming down. Instead, it goes up to pay for more MRI machines and procedures than are truly necessary. Use of purchasing co-operatives can save over $5 billion per year. Interestingly, GE, the largest marker of MRI machines, is the largest corporate lobbyist.
§ 2.9.0 LOCAL DIFFERENCES IN MEDICARE SPENDING
§ 2.9.1 Some communities spend significantly more on Medicare PP than other communities, some spending twice as
much as average. About 17 percent of communities account for highly disproportionate patterns of spending on Medicare. If only one-third of the excess in these communities from the national average were to be saved, Medicare would reduce expenses by $15 billion per year. The question that I have is why do these high cost communities cost so much more and low cost communities cost so much less? Are there consistent differences in risks? Are there regional differences is cost of living that contribute? Are patients more demanding? Are physicians more aggressive in treatment? Are there better outcomes? I propose a study be conducted that examines the differences in these and other factors across US communities.
CHAPTER 3
PREVENTION PROGRAMS
“Dig your well before you’re thursty.” – Hindu Proverb
§ 3.1.0 PREVENTION’S ROI
§ 3.1.1 Programs targeting enhanced wellness and reduced health care costs have been found to net returns of $1.75 to $6.00 per $1.00 invested. Thus, for most prevention programs, investments are well worthwhile.
§ 3.2.0 PREVENTION INFORMATION
“It is a wise mans part, rather to avoid sickness, than to wishe for medicines.” - (Sir / Saint) Thomas Moore
§ 3.2.1 Federal Health Centers (FHC), totaling 2,500, ought to provide coordinated prevention, outreach programs, and basic treatment, especially in rural communities and inner-cities. These FHCs will cost about $15 billion a year to operate and will conservatively save $15 billion a year.
§ 3.2.2 Providers must invest a moment with each patient near the end of the visit, assuring compliance ability, assessing comprehension of diagnosis, treatment, and expected behaviors. If the patient does not demonstrate comprehension, that’s great, we might’ve saved a life! S/he requires retraining, family intervention, or home health care referral.
§ 3.2.3 Prevention video streams by CDC / NIH / PHS / FDA ought to be presented on relevant risk factors at the end of each PCP visit. These programs may cost $100 million a year and will conservatively save $300 million a year.
§ 3.2.4 Readable, informative, and attractive pamphlets ought to be available at all health providers. The availability of these pamphlets may cost $300 million a year and will conservatively save $300 million a year.
§ 3.3.0 INFORMATION WHEN TRAVELING
“Every human being is the author of his own health or disease.” - Sivananda
§ 3.3.1 When a passport is issued, an electronic referral ought to be made for the citizen to visit an FHC or review internet prevention and risk reduction information at a CDC / PHS / State Department web site. It ought to be completed and the person “checked-off” prior to leaving on their travel. Custom’s officials and TSA employees ought to have sets of questions, updated, by region, to screen for diseases among people visiting the
§ 3.4.0 SAFETY, CPR, FIRST AID, LIFE SAVING, & EQUIPMENT
“Prevention is better than cure.” – Anonymous
§ 3.4.1 All children (as well as programs being open to parents) ought to complete a mini-course on safety each year (trauma is one of the 5 most costly conditions and one of the most common causes of injury and death among children). We must prevent, wherever possible, and train for primary intervention. Fire and police safety programs for children must be provided periodically. A fire prevention and floor / evacuation plan ought to be encouraged by teachers, providers, and first responders and reviewed by parents.
§ 3.4.2 All school students; staff and perhaps some residents of medical, government, military, educational, and corrections institutions; ought to complete CPR and First Aid, including use of external heart defibrillators (EHDs); without cost. Free Advanced First Aid and Life Saving ought to be offered.
§ 3.4.3 I estimate that the cost of life saving classes would be $3 billion per year. If only 1% of traumatic events or heart attacks are met with knowledgeable hands, the 12,000 lives saved each year ought to exceed $24 billion per year in value.
§ 3.4.4 Prevention Equipment is critical. First Aid kits, smoke detectors, carbon monoxide detectors, fire extinguishers, EHDs, batteries, car safety kits, a loud whistle for people walking at night time or in dangerous communities, even cell phones and Global Positioning Systems ought to be accessible to first responders, available in public places, and available in every American home. People at elevated risk of heart attack ought to have an EHD in their home / car. Home monitoring equipment might also be provided tax rebate status, especially for seniors, those with chronic medical conditions, or those in neighborhoods in which there is a heightened per capita risk of crime. Children might have GPSs or cell phones with GPS ability to which parents and LEOs can access for the purpose of preventing or intervening early in crime. The purchase of this equipment might result in tax rebates of $3 billion per year and tax deductions of $12 billion per year ($2.4 billion in deferred federal revenue). Reductions in crime, trauma related treatments, loss of property, and costs of death would exceed $15 billion per year.
§ 3.5.0 DENTAL DISEASE PREVENTION
§ 3.5.1 For each dollar invested in fluoridation, $38 is saved in subsequent dental services. Teaching how to floss and brush is worthwhile.
§ 3.5.2 With the costs of dental services about $100 billion per year and revenues per dentist averaging $700,000, a
well coordinated effort must be made at dental disease prevention. I proposed that FHCs and CDC coordinate dental disease prevention programs. I propose that these would cost $3 billion per year. These prevention efforts ought to reduce the need for dental services by $3 billion per year.
§ 3.6.0 HEALTH AND
“Those who think they have not time for bodily exercise will sooner or later have to find time for illness.”
§ 3.6.1 Every day you swipe your medical card at an HFC, you get a credit (say $5) toward your Life Savings Account (LSA) from which a monthly fee is paid to the HFC. This would immediately reward HFC use. HFCs would have to meet a certain threshold in order to qualify for this program and a “reasonable range” would be determined (e.g., $2,500 a month in
§ 3.6.2 HFCs improve mental and physical health, reduce health costs, and ought to reduce other societal costs (drugs, gangs, sick leave, lost productivity).
§ 3.6.3 Federal Health Clinics in underserved communities might provide HFCs, where other fitness options are not available for residents.
§ 3.6.4 If Joe takes his family on Saturday morning to the HFC, they would be credited $5 each, $20 total, to their accounts. The credit ought to be tied to length of visit (a one minute visit should not count – perhaps 45 minutes or more). Likewise, if Joe returns Saturday afternoon and evening, he would only receive the credit once per day.
§ 3.6.5 I project that the cost of this program, essentially providing a credit of $5 per day per person who attends a HFC, would be approximately $150 billion per year. That is a great cost. It goes without saying that exercising at fitness centers will improve health, reduce disease, and reduce health care costs. As the balance above HFC costs would go to individuals’ LSAs, the government would not need to contribute as much money to insurance for the poor to middle class, thus, saving some money to pay for this benefit.
§ 3.6.6 Many Americans already have access to fitness centers. Almost all children have access to physical education programs. Students, faculty, and staff of most colleges have access to fitness centers. Many patients or residents of psychiatric facilities, training centers, SO facilities, military installations / bases, large or special government facilities have access to fitness centers.
§ 3.7.0 GUN SAFETY
§ 3.7.1 While childhood deaths from guns has declined (from 5,000 to 3,000 yearly), it’s still higher than other OECD nations. I urge:
§ 3.7.2 Safety courses ought to be mandatory for all who purchase, own, or handle a firearm. These courses might be offered by the NRA or a similar rifle safety organization. A refresher course ought to be available every so many years.
§ 3.7.3 Trigger locks ought to be mandatory when purchased. While the use of trigger locks on guns in storage saves
lives, it also can interfere with a gun owners ability to protect him / herself if someone is breaking in the home.
§ 3.7.4 Standardized background checks, in all settings, using all federal, inter-pool, and intra-state criminal and mental health databases ought to be required. The government need not know what guns or ammunition a person purchases nor would it need to report to the gun shop specific feedback on an applicant beyond approved or declined. Those with a conviction for a felony, membership in a gang or organization that violates the Patriot Act or RICO Act, a violent offense, someone involuntarily committed for psychiatric treatment would not be permitted to purchase a firearm (say, for 10 years, once residing in the community, with no recidivistic events on file).
§ 3.7.5 Those with a recent diagnosis of a severe medical condition or a MI for which involuntary inpatient treatment was not ordered ought to undergo a safety interview to assure that the person will not be using the firearm for suicide or homicide.
§ 3.7.6 Restrictions:
§ 3.7.6.1 - Safe hunters must have access to guns.
§ 3.7.6.2 - Because of the constitution’s “well regulated militia” clause, I recognize that people ought to be allowed to own
firearms and, someday, we might need to rely on some people who have more lethal weapons.
§ 3.7.7.1 - I estimate that these programs will cost $600 million per year to implement and will save $300 million per year.
§ 3.8.0 DRIVER’S SAFETY
§ 3.8.1 I am flabergast by the inaction of American society regarding automobile safety. Seat belts save lives and their not being used must be penalized. Each year, there are 6 million auto accidents that kill 45 thousand people (10 times the number killed in the Wars in
§ 3.8.2.1 - Teens are easy to distract (radio, phones, i*pods, other passengers), often lack skills to drive in bad weather
or night time. Partial licenses might be extended two years.
§ 3.8.2.2 - Licensure requirements might include 200 hours of documented driving with adults.
§ 3.8.2.3 - Advanced safety / skill development courses consisting of twelve Saturday mornings and several evenings in
which students and a teacher individually rehearse dangerous scenarios. Building skills will lessen accidents, save lives, and reduce costs. It must be required. I estimate that costs will be $1,000 per teen or about $5 billion per year total. I estimate teens and parents will pay half of these costs, $500 per teen or about $2.5 billion per year, with federal programs covering the balance. I estimate that savings will exceed $20 billion per year and save tens of thousands of lives each year.
§ 3.8.3.1 - Tractor trailer drivers often drive the same route for years, getting tired.
§ 3.8.3.2 - Some consume stimulants to mitigate fatigue.
§ 3.8.3.3 - Truck accidents are more deadly and costly.
§ 3.8.3.4 - The criminal justice system ought to impose severe penalties for drivers with past offenses.
§ 3.8.3.5 - DUI, possession, or DIP might preclude training, licensure, or forfeit license.
§ 3.8.3.6 - Companies that hire dangerous drivers must be subject to more severe penalties.
§ 3.8.3.7 - All potential employees or contractors must submit to a records investigation.
§ 3.8.3.8 - Full reimbursement of accident clean-up costs to states and locales is mandatory.
§ 3.8.3.9 – The costs of these programs may exceed $500 million per year and will save $20 billion per year.
§ 3.8.3.10 - As the US population grows and we consume more products and many of these products are no longer local,
they must be delivered to us. Americans used to use trains and, to some extent, still do when fiscally sound. An Elevated-Rail system would increase efficiency, reduce transportation costs, and reduce the risk of car – truck accidents on the interstates that very frequently lead to death.
“Health consists with Temperance alone.” - Alexander Pope
§ 3.8.4.1 - Nearly 1 million arrests each year are for DUI. DUI related offenses must be treated very harshly. I think that
a first offense ought to include $10,000 in fines and 3 months in prison (in which they pay housing / board costs). Vehicular homicide might result in charges of first degree murder, especially when the defendant had a previous DUI. The total costs approach $20 billion, including $10 billion for prisons, $1 billion for courts, $2.5 billion for NIH, and $6.5 billion for law enforcement. The total revenues would equal $10 billion in fines, $2.5 billion NIH assessment, and $4.5 billion housing fee, totaling $17 billion per year. The net cost of a DUI program would be $3 billion per year.
§ 3.8.5.1 - Involvement in an accident or multiple moving violations increases risk of further accidents. As such, people
with a moving violation or accident ought to be monitored for further offenses. If another offense should occur, or if the first offense was serious, then the individual ought to obtain a “Probationary License”, complete a driver’s safety course, and pay increased licensing fees. The “defendant” would pay for all program costs averaging $1,500 each and totaling $4.5 billion per year. This program would be likely to save $20 billion per year.
§ 3.8.6.1 - Age, disease, and medicines may slow thinking and reactions, while increasing accidents, injuries, and death.
§ 3.8.6.2 - Driving after a stroke can be scary for the driver. Everyone who has experienced the freedom allowed by
driving wants to hold onto it. Following a serious medical incident, people ought to attend a safe driving class, in order to assess their safety, help them to develop alternative, coping skills and acquire confidence. For those individuals who can not acquire new, safe skills, perhaps after a second class, forfeiture of license must be mandatory.
§ 3.8.6.3 - Everyone after, say 70, ought to take a driver’s license exam every three years to assure safety so
that they are not at increased risk of an automobile accident. The individuals might be required to pay an
assessment fee of $50. If they fail, they will either forfeit their license or complete a safe driving class. Such safe driving classes might be offered by not-for-profit groups such as AARP or AAA. I propose that the reduction in costs from accidents would exceed $12 billion per year.
§ 3.9.0 TARGETED PREVENTION EFFORTS
“To cease smoking is the easiest thing I ever did. I ought to know because I've done it a thousand times.” - Mark Twain
Increase exercise Pay for weight loss program
Decrease over-eating Decrease unhealthy eating
Teach stress management Reduce smoking
Reduce depression Reduce anxiety
Reduce DUI Reduce drug use
Reduce gangs Get treatment early
Get pets Approve preventive measures
Annual Physical Exam Ask Questions of your Physician
Be Safe Comply with your Physician’s Orders
A quarterly stress management session or physical massage might reduce re-occurrence of heart attacks.
Full payment for preventive medical procedures such as Gastric Bypass Surgery (GBS), stress management, smoking cessation, substance / alcohol abuse counseling, weight loss programs, nutritional counseling, compliance enhancement techniques all ought to be expeditiously reviewed and, where proven efficacious, instituted immediately. Individuals should not have to pay co-payments for preventive services.
Insurance companies make money by spending lots of money on disease intervention. Spending money on prevention reduces insurance company’s future spending and future profit margins. So, they don’t want to spend money on prevention. For the most part, prevention programs result in later deaths that, in the long run, are less costly than “natural causes”. Social Security payments would be increased if prevention programs were efficacious.
§ 3.10.0 NATIONAL SCIENCE FOUNDATION (NSF)
§ 3.10.1 The maker of tomorrow’s scientists and engineers is the NSF. Great basic research is funded by the NSF. If
§ 3.10.2 We must be examining basic physiological processes, pharmacological fundamentals, applications of genetic mapping to the development of vaccines. As tens of thousands of Americans return from
§ 3.10.3 Research programs must be coordinated between NSF, other federal, state, and international agencies.
§ 3.10.4 The
§ 3.10.5.1 - The present system of NSF grants is inefficient for grant recipients. While 16 percent of the government’s budget covers the costs of ADMIN, 20 percent of grant recipients’ budgets are ALSO spent on ADMIN. I recommend that enhanced technologies and policy changes be implemented to reduce this figure to 7.5 percent within 4 years for each grant recipient. This 12.5 percent reduction in recipients’ ADMIN costs will increase the number of grants able to be funded by 14 percent, without budgetary increase. Remember, our goal is to generate more scientific advancements, not make sure investigators dot their i’s and cross their t’s.
§ 3.10.5.2 - I suggest that the current spending of $1.1 billion (16 percent) per year on ADMIN makes the NSF a less efficient organization. I recommend that spending on ADMIN increase over the next 7 years from $1.1 billion to $3.4 billion (while reducing the proportion from 16 percent to 7.5 percent). I suggest that the budget for the NSF be increased from $6.8 billion to $45 billion per year in the next 7 years. Some funds ought to be identified to aid
§ 3.10.5.3 - GOLDEN FLEECE AWARD: Between the costly ADMIN operations and the costs of grant ADMIN, the NSF overspends on ADMIN.
§ 3.11.0 CENTERS FOR DISEASE CONTROL & PREVENTION (CDC)
§ 3.11.1 The leadership role of the CDC is critical today and will grow in future years.
§ 3.11.2 With faster transportation, global warming, new bio-threats, and greater biochemical terrorism, CDC must have a physical presence on all continents. The recent outbreak of the pneumonic plague in northwest China is an example of the need for coordinated and focused resources greater than the WHO alone can provide (particularly in third world nations).
§ 3.11.3 Bioterrorism prevention, monitoring, and intervention programs must be expanded. Where the Anthrax scare of October 2001 was “surgical” in nature, it cost hundreds of millions of dollars to clean up.
§ 3.11.4 Prevention programs might be operated through FHCs with CDC and NIH.
§ 3.11.5 New Information Technologies ought to permit global prevention monitoring and education and intervention by CDC.
§ 3.11.6 The CDC ought to assume an increasing role in Quality Assurance and centralized wellness programs.
§ 3.11.7 Health sciences prevention must use the business model of Return On Investment (ROI). For example, if a plague will likely result in 5 million US deaths, 25 million chronic illnesses, and $12 trillion in costs next year, an escalation in resources would be merited in proportion to that threat. The
§ 3.11.8 Many special drugs and vaccines will be developed through these programs that, I would envision, would be beneficial to the pharmaceutical industry. It ought to go without saying, but, if the CDC increases the average life expectancy by 3 years, the additional 9 million people will be purchasing private health insurance, medicines, perhaps paying taxes, perhaps receiving Social Security payments longer.
§ 3.11.9 I would envision that many drugs and vaccines will be purchased from pharmaceutical manufacturers and distributed to citizens across other nations.
§ 3.11.10 - The CDC must have a mission beyond simply controlling disease and preventing disease in the
mission, while focusing ultimately upon the health of Americans, must include international programs.
§ 3.11.11 - I envision that the CDC budget must increase from $9 to $45 billion per year over the next 7 years. I also
envision that with global expansion in its mission, that the CDC will obtain part of its funding from other nations and corporations and, perhaps, foreign citizens. As the first Iraq War resulted in foreign countries paying the
§ 3.12.0 NATIONAL INSTITUTES OF HEALTH (NIH)
“Knowledge will forever govern ignorance; and a people who mean to be their own governors must arm themselves with the power which knowledge gives.” - James Madison
§ 3.12.1 NIH is the premier health research organization worldwide. It’s suffered insufficient funding in recent years. From 2000 to 2003, its share of research funding decreased from 36 percent to 28 percent.
§ 3.12.2 GOLDEN FLEECE AWARD: I suggest that NIH is inefficient and needs new management approaches. It must be revitalized to include new perspectives. Many “proven” old lines of basic research have been ineffectual, although titillating and scholarly-sounding. Economically desperate times require that most NIH research funds be “applied”, practical, or clinical much more so than basic. NIH spends too great of a portion of its budget on ADMIN.
§ 3.12.3 Basic research ought to be funded by the National Science Foundation.
§ 3.12.4 Most basic researchers cannot effectively administer “applied” divisions.
§ 3.12.5 Grant recipients spend 20 percent of research budgets on ADMIN. If this were automatized and policies updated, ADMIN costs could be reduced to 7.5 percent, saving a projected $19 billion per year ($4 billion per year under the current funding level).
§ 3.12.6 Health science research must be funded from the business ROI model. Given risk, our desired ROI ought to be 8 percent (more if a stock trader but less if a mom who doesn’t want her daughter to die). AD, set to increase 33 percent, could cost $250 billion per year to simply manage. At 8 percent ROI, an investment of $3 trillion over 20 years could be justified ($150 billion per year).
§ 3.12.7 A private – public – international collaborative ought to be formed, coordinating research on prevention and treatment in a cogent, planful manner, rather than the haphazard manner by which science currently progresses. A program will be established providing loans and grants for businesses to conduct research with total funding of $10 billion annually in 7 years.
§ 3.12.8 NIH budgets must increase to $150 billion per year over the next 7 years. Some funds ought to be identified to aid
CHAPTER 4
THINGS THAT WON’T WORK
“It is by acts and not by ideas that people live.” - Anatole France
§ 4.1.0 PRIVATE INSURANCE STIPENDS
§ 4.1.1 Stipends could be given to companies to help them provide insurance to the uninsured.
§ 4.1.2 The problem is that many employers would stop providing health insurance, making employees obtain insurance through this plan.
§ 4.1.3 The shift in insurance coverage could cost the government more than $200 billion unless we could assure private companies provide fair coverage and dumping is prevented.
§ 4.2.0 PAYMENT FOR OUTCOME OVER SERVICE
§ 4.2.1 At first, I liked this. Payments for how good you are! If a heart surgeon only gets paid if he saves 95 percent of
patients, he’ll do two things. He’ll perform “safer” and less invasive procedures that are less risky in the short term but he’ll increase the “denominator” by performing excessive surgeries upon people who might only marginally benefit from such services.
§ 4.2.2 Let’s look at golf. The outcome is directly related to skill. Except, during a hurricane, when children stick gum on the golf club head, when the ball is defective, when the t breaks, or when colleagues sneeze. It is impossible for a professional to control all of the variables one must face when resolving an issue.
§ 4.2.3 If a cardiologist has made great effort and used best practices but the heart attack patient dies, ought he receive no payment? That would be wrong! The woman at McDonalds gets paid whether the French fries she serves are hot or cold.
§ 4.2.4 Local surgeons perform routine surgeries with great results. The brilliant “cutting edge” surgeons at the distant
§ 4.2.5 Outcome is often very idiosyncratic to the individual – “I feel better”, “I go to work four days instead of just one day a week”, “I didn’t commit suicide last week”, or “I still hear voices telling me to kill you but I’m ignoring them more often now.” How do you define success?
§ 4.3.0 COST BUNDLING
“It is no measure of health to be well adjusted to a profoundly sick society.” - Jiddu Krishnamurti
§ 4.3.1 Health care cost bundling is sort of like the bundling of mortgages that caused the current international financial mortgage fiasco that drove the world economy to the crevice’s edge.
§ 4.3.2 When will we learn that bundling groups to sell or pay does not motivate, lower cost, or increase honest profits. Bundling is non-sense and must stop!!!
§ 4.3.3 You’re fortunate if you get the inexpensive groups of patients. If you get high risk bundles, you are paid less,
despite your skill level.
§ 4.3.4 Some medical conditions are related to environment. Higher altitude or descent from more equatorial regions
might result in the expression of some immune disorders. People west of a chemical plant might have increased risk of cancer. People who hold certain sets of values might have increased risk of alcoholism, infidelity, divorce, etc. Individuals in rural communities are more likely to have certain disorders, perhaps in relation to the use of pesticides. Individuals in inner-cities are more likely to have certain disorders. Ought providers be punished or rewarded for these epidemiological variations? If an inner-city trauma surgeon has a success rate of 90% in performing surgery on gun shot victims on a daily basis, whereas the rural practitioner who performs surgery on this year’s gun shot victim because he had experience performing the same surgery three years ago, ought the rural practitioner not be paid if his second patient (50%) dies? If he moves to the inner-city, he’ll get lots of experience, but, the residents of his rural community will be without a provider.
§ 4.3.5 Cost bundling makes doctors raise severity levels so patients with greater need can obtain needed treatment. Doctors personally benefit from the raise in severity level. And, insurance companies pay more, charge more, and profit more.
§ 4.3.6 Cost bundling is not a viable cost-containment strategy but, in theory and on paper, it looks very appealing. It will increase costs, not lower them!
§ 4.3.7 I am gracious in my criticisms of physicians elsewhere, but, what moral imperative urges reformers to conclude that providers ought to share risks, given that the majority of patient outcomes is out of the hands of providers and in the hands of the individual patient?
§ 4.3.8 If we reduce defensive medicine, modify tort law, directly address the issue of medical errors, use evidence-based practices, and institute effective prevention programs, then cost sharing by providers will be unnecessary, .
§ 4.4.0 TAXING HEALTH CARE BENEFITS
§ 4.4.1 Taxing high-end health care plans is an option, but, our ultimate goal is to improve the health of all Americans. A tax on health care benefits would jeopardize this goal. One proposal before Congress recommends that the federal government tax insurance plans valued above $8,000. Since the average health insurance plan provided by employers now costs $13,000, the typical American will have an additional $5,000 more each year eligible for taxation. In times of prosperity, that might be fine, but in times of economic dire straights, that is not appropriate.
§ 4.4.2 If greater taxes on the wealthy are desired, then let’s do it upfront. Simplify the tax code and raise the tax rates on the very wealthiest Americans.
§ 4.4.3 One proposal that I read would not tax policies that cost less than what the members of Congress get. Great. So, we’ll tax any health care plan greater than what employees of the biggest employer can negotiate with big insurance companies, given their enormous size. No! We have two goals – improving health / health care AND reducing cost. My solution to this is simple – every employee receives the same benefit from an employer and that benefit is then used by the individual employee to purchase the best program for him or her – private, not-for-profit, or public. None of these employee benefits are taxed, up to, say, twice the value of the average policy. Individuals could place extra money into a LSA on a tax deductible basis.
§ 4.5.0 HEALTH & CHILD CARE THRIFTS
§ 4.5.1 Thrift or savings programs are extremely costly, burdensome, less beneficial, and unjust.
§ 4.5.2 Kady buys her child cough syrup from the drug store at night, submitting the bill for $3.29 to the benefits management company, and, one month later, it sends her a check from her own savings account for $3.29. Even at a 36% tax bracket, she saved $1.20 in taxes and it “only” cost $20 in total operations to do it! In December, when the end of the year rolls around and beneficiaries lose roll-over, they spend more money to use up the balance. In other cases, the balance is lost, forfeited to the federal government.
§ 4.5.3 Why should Congress discriminate, allowing some employees to use “pre-tax” monies but establish a system that denies the desire of other Americans to have equal access to these tax benefits? Is this contradictory to the due rights clause? Many companies can’t afford to offer these services to employees. Congress should not establish a system in which individuals who are employed by less wealthy employers do not share in the same benefits as others employed by wealthier employers.
§ 4.5.4 These programs are inaccessible to the wealthy, the unemployed can’t access them, the middle classes find them inefficient.
§ 4.5.5 These costly programs ought to be replaced with direct federal support of child care and elder care, and health care programs.
§ 4.5.6 Child and elder care as well as health care must have a tax rebate / deduction, phased out at highest incomes which is available in advance on a monthly basis.
§ 4.5.7 GOLDEN FLEECE AWARD: Thrift programs cost more to operate than they save taxpayers. This inefficiency costs tens of billions of dollars to the
§ 4.6.0 GIVING PRIVATE INSURANCE COMPANIES ANOTHER CHANCE TO REDUCE COSTS AND IMPROVE QUALITY
§ 4.6.1 When I first heard Senator Baucus’ suggestion that we give private insurance companies another chance to reduce expenses, I liked the suggestion. But, as a slept on it a few nights, I thought – we live in a capitalistic society. The market should have brought profits and costs under control at some time in the past 60 years. Capitalistic incentives for companies to compete with one another and provide the best product at the lowest cost have not been working. Why would they work now, suddenly?
“If an ass goes a-traveling, he'll not come home a horse.” - Akan Proverb
§ 4.6.2 No, I think that insurance companies have had plenty of opportunities to improve quality and reduce costs. They have chosen to build up the profits of their oligopolies and offer generous remuneration packages to their executives at the cost of shareholders, taxpayers, businesses, and employees of those other businesses.
§ 4.6.3 The phoenix program that I propose blends the private, not-for-profit, and public spheres. It covers all Americans. It provides opportunities for private insurance companies to compete with one another and the public sector by providing high quality low priced products for a market 300% larger. It includes mandatory coverage for all Americans in all 8 categories of health care.
§ 4.7.0 EXCISE TAX ON MEDICAL DEVICES
§ 4.7.1 The Senate Finance Committee proposed an excise tax on medical devices. While some of these devices
conceal tremendous profits, an excise tax on them will be paid by the insurer, half of the time the government (and thus taxpayers) and half of the time by private insurers who will increase premiums to meet this increased tax. It won’t work. I suggest elsewhere that taxing excessive profits, salaries, and bonuses throughout the health care sector would be a more just method of raising revenue. Further, if the government feels that it is paying too much for scooters or surgically implanted defibrillators, it ought to lower the payment that it authorizes.
§ 4.8.0 2010 MEDICARE CUT OF 21%
§ 4.8.1 Desperate times require desperate measures. Cutting payments to health providers by 21% in 2010 will make
many providers have to stop accepting Medicare patients. Medicare already pays 15% below the actual cost of providing the service. When the government awards contracts to defense contractors 300% above cost, why does it think that it can keep paying medical providers below cost?
Now, let’s examine an option. Imagine in 6 years down the road, many physicians have a NP or PA and a
behavioral health expert working on their staff who can treat patients in a cost effective manner, reducing costs. Imagine that the 15 percent of providers’ time that is spent in ADMIN of insurance paperwork is reduced by 10% so that more patients can be served at a lesser cost. Imagine that medical tort law reform is modified so that doctors don’t feel the need to order $225 billion per year in unnecessary procedures. Imagine that every NH has a geriatric NP or geriatric PA who coordinates care for the elderly, saving billions per year in transportation and physician visits. Imagine instituting a capitalistically-based system in which government negotiates price of medications so that the cost of Medicare can be reduced 5 percent. Imagine a system in which actuarial and best-practice data are fed into a computer system so that predictive models can be utilized in evaluating care - $700 billion of the $2,500 billion we spend on health care is spent keeping people alive the last days to months of life. Early referral to hospice programs would allow dignity and closure and coming to terms with death and, if one-half of costs are eliminated for only one-third of these “near death” patients, $125 billion more would be saved. All together, these efforts alone would more than pay for keeping current payment levels or making costs align with payments.
CHAPTER 5
PROGRAMS FOR CHILDREN AND YOUTH
- Paula Poundstone
§ 5.1.0 BAD NEWS 
§ 5.1.1.1 THE MOST COMMON CAUSES OF INFANT DEATHS IN THE
Congenital Malformations Short Gestation / Low Birth Weight
Sudden Infant Death Syndrome Maternal Complications
Accidents Cord & Placenta Complications
Respiratory Distress Bacterial Sepsis
Neonatal Hemorrhage Circulatory System Diseases
§ 5.1.1.2 - The US ranks very poorly for infant mortality, low birth weight, and death in the first year of life. US infant mortality rates are worse than in
§ 5.1.2 Most variance in childhood death rates is related to two factors – underfunding of maternity and children’s health and wellness as well as parental lifestyle (e.g., illicit drugs and alcohol misuse). One confound is that the US, Netherlands, and Japan, all register children of “unsustainably low” birth weights as live births whereas the rest of OECD nations don’t. This is relatively minor.
§ 5.1.3 The
§ 5.2.0 YOUTH MEDICAL EQUIPMENT AND SPECIALIZED TRAINING
§ 5.2.1 Non-profit hospitals, free clinics, physicians practicing in underserved regions who primarily serve the publicly insured, school health providers, laboratories, and health science education and training programs require specialized medical equipment (smaller or more sensitive) for use with infants, children, and youth. I estimate that the provision of this equipment will cost about $1.5 billion per year for each of the next five years. I estimate that savings will result through improved health care and reduced child mortality will total about $500 million per year for each of the next five years, thus creating a net cost of $1.0 billion per year.
§ 5.2.2 More generalist medical personnel require better training in OB-GYN and pediatric issues, especially providers in rural communities and inner-cities. I estimate that this will cost about $100 million per year for each of the next five years. I estimate that savings will result through improved health care and reduced child mortality and save about $100 million per year for each of the next ten years.
§ 5.2.3 More OB-GYNs, pediatricians, pediatric NPs, pediatric PAs, and specially trained nurses must locate in underserved regions [this will be discussed elsewhere]. I estimate that this will cost about $400 million per year for each of the next five to ten years. I estimate that savings will result through improved health care and child mortality and save about $600 million per year for each of the next 10 to 15 years.
§ 5.3.0 PUBLIC SCHOOL PROGRAMS
“In general, my children refused to eat anything that hadn't danced on TV.” - Erma Bombeck
§ 5.3.1 The US childhood obesity rate is higher than other OECD nations; one in six children is overweight, triple the 1980 rate; obese children have a 70 percent chance of becoming obese adults, posing health problems similar to people twenty years older and posing greater health costs than heart disease.
§ 5.3.2 We must: (1) … encourage children to be healthier in their selection of foods and beverages and
exercise. The DOE / PHS / FHC might provide learning tools, videos, games, prizes, handouts, posters and teacher “manuals” to encourage children to be healthier in their selection of foods and beverages and exercise. As this is a value and not a simple fact to recite, information ought to be presented in short 3 minute bursts each week while children and youth attend school. I would envision this program may cost $300 million per year. Savings would be realized over the long term through reduced obesity rates and related disease and would save [at least] $300 million per year, for a net cost / savings of $0 per year.
(2) … provide healthier foods in schools. This would require eliminating access to vending machines and unhealthy snacks and replacing “marginally” nutritious foods with foods that might be more costly but fully nutritious. Buy local produce programs might be instituted. Each public school district ought to have (a) pediatric RD nutritionist to plan meals. Special meals ought to be available for children with special dietary needs. I would envision this program to cost $3.6 billion per year and would save [at least] $900 million per year, for a net cost of $2.7 billion per year.
§ 5.3.3 I suggest that school districts operate their own health department that can employ licensed professionals and submit bills to third party payers. I recommend increasing staff in the fields of pediatric nursing; health information services, education, and prevention; pediatric dentists and hygienists; pediatric optometrists; and pediatric behavioral health counselors and school psychologists. I estimate that this will cost $33 billion per year, but school districts would only be spending an additional $16.5 billion per year. The full costs would be billed to third party providers. The assessment of children for the purpose of determining need for special services due to medical conditions has previously been excluded from coverage by third party payers but it is essential that these services be covered routinely for all children, nation-wide. This unfunded mandate has cost school districts at least $10 billion per year, has been especially difficult for poor school districts, and must be met. I propose that public school health infrastructure investments would include additional office space, dental chairs, counseling rooms, video-teleconferencing equipment, and medical equipment. It would cost about $2.5 billion per year and would save $833 million per year for each of the next five years.
§ 5.3.4 Provide sex, STD, AIDS, pregnancy prevention, and safety education (for each $1.00 invested in the Safer Choice Program, $2.65 ROI is realized). Of course, some parents would prefer to discuss matters of sexuality themselves or, perhaps, not even allow their children to ever hear of these issues. Societal costs versus respect for parental wishes must be weighed. I propose that new health education programs would cost $3 billion per year and would save $4.5 billion per year.
§ 5.3.5 The federal government ought to fully fund science education, faculty, equipment and supplies, and related materials in order to promote the fields of science and engineering. Local school districts do not have sufficient resources, given the nation’s economic crisis. We ought to offer summer science programs, develop kid-friendly web-sites, encourage youth to explore careers in the sciences, and develop science magnet schools. I propose that health and science education programs would cost about $15 billion per year and would save about $5 billion per year. I propose that health and science programs would require infrastructure investments of $1 billion per year and would save $333 million per year.
§ 5.3.6 We must expand science, engineering, and health-related library purchases, subscriptions, and computers. I propose that this program will cost $5 billion per year. This program will result in savings of $1.666 billion per year.
§ 5.3.7 Only one in four high school students attends Physical Education (PE) each week. I propose a revitalized national program of physical fitness. Federal contributions to PE programs must increase and PE ought to be required of every student, K through 12, for at least two hrs weekly. I propose that hiring of additional staff and increased equipment purchases would cost $10.5 billion per year. This program will result in savings of $5.3 billion per year. I propose that PE programs would require infrastructure investments of $5 billion per year for each of the next 15 years and would save $1.666 billion per year.
§ 5.4.0 CHILDREN’S PROGRAMS
“When I see the Ten Most Wanted Lists ... I always have this thought: If we'd made them feel wanted earlier, they wouldn't be wanted now.” - Edie Cantor
“Diet cures more than the lancet.” - Hindustani Proverb
§ 5.4.1 Most habits (nutrition, exercise, social skills) practiced by adults were learned as children and, without a second thought, carried forward.
§ 5.4.2 Pre-school, after-school, and summer program fees are often prohibitive. Fees of $5,200 a year are standard and $10,000 a student a year is common. For minimum wage employees, the cost of care for two children is often greater than their wage. The cost of child care for average income couples is itself prohibitive. Many couples now must factor the cost of child care into equations of whether or not it is viable for one to work.
§ 5.4.3 Thrift programs are pointless to the poor and unavailable to the wealthy. Thrift programs are costly, operationally, and must be stopped, as they often cost more to operate than they, in fact, save.
§ 5.4.4 Having quality child care allows more people to work, adding to the GDP, increases health care provider availability, and provides care for children while parents receive medical services.
§ 5.4.5 Monthly stipends ought to be directly paid to authorized child care providers, based on community costs, parental eligibility (1 child or 21 children), and income. I suggest that employers ought to be required to provide at least $10 a week for employees who require child care or elder care. Employers with sufficiently large operations ought to operate a day care at their facility, allowing flexibility for parental involvement in child care. Employees would pay the balance of operating costs.
§ 5.4.6 In the
§ 5.4.7 Salaries of child care workers are less than $25,000 a year, often near the minimum wage. Wouldn’t all parents agree that they care much more about their child getting quality and safe care than about getting crispy French fries! Salaries of child care workers ought to increase by at least 25 percent. I would argue that programs ought to have a pediatric nutritionist on retainer who plans meals; a child development specialist who consults with teachers on curriculum planning; and a pediatric behavioral specialist who consults with teachers and parents on specific social skills developmental programs. When children acquire these skills early, they are more apt to retain and utilize them well into adulthood.
§ 5.4.8 Prevention programs will be regularly conducted by FHC employees on fire safety, exercise and nutrition, disease and prevention, and safety.
§ 5.4.9 Child care must be offered for ill children, through FHCs. Modest fees will be assessed to parents and perhaps school districts. Federal funding for programs for sick children would cost $1 billion per year and would save $2 billion per year. I propose that infrastructure investments might also cost federal contributions of $600 million per year, with $200 million per year in savings over each of the next five years.
§ 5.5.0 LABELING
“So often time it happens, we all live our life in chains, and we never even know we have the key.” - The Eagles
§ 5.5.1 Once labeled “disabled”, that name often sticks to our psyche – “something must be wrong with me.” This internal questioning becomes internalized “fact” – that old self-fulfilling prophesy - contributing to lower grades, higher drop-out rates, under-employment, adult disability, drug use, and crime. The assimilation of the label “disabled” results in lost wages and taxes and increased service utilization. Over a lifetime, this can cost several million dollars for each child. If only two percent had the effects of labeling prevented or reversed, those 400,000 people would add to productivity and reduce costs approaching $30 billion per year. Such labeling programs would provide structure, incentive, stimulation, educational and vocational opportunities for the 33% of people most likely to benefit. I propose that the cost of this program would be $1 billion per year and would save, over 20 years, a net average of $29 billion per year.
§ 5.6.0 SCHOOL ORGANIZATION
§ 5.6.1 Thomas Alva Edison is a great American hero. He was born in 1847. His mom realized that Thomas was “special”. His teachers found him bothersome. Mom removed him from school and home-schooled him. If
§ 5.6.2 Genius that he was, he did not conform to the imposed structure of school. It’s hard for children to sit in a classroom for seven hours with minimal recesses and PE. They are not built that way. We must provide recess for all younger children and PE for all children. With additions built in for recess, physical education, and sciences, the school day might be extended 45 to 90 minutes per day. This would result in increased salaries for teachers and would decrease the after school day care programs. The federal contribution toward extending the school day, providing children with more physical education and recess, more competitive education with other economically developed nations, and higher salaries for teachers who must work longer hours would be approximately $16 billion per year and would save $12 billion per year (teachers’ taxes and reduced need for after school programs).
§ 5.6.3 I think that education ought to be revised to specifically address the needs and strengths of each individual student. That, I suppose, is fodder for another document.
§ 5.7.0 CHILDHOOD SPORTS & ATHLETICS
§ 5.7.1 Wellness is essential from the beginning.
§ 5.7.2 Community childhood sports and athletics programs should be marketed and normalized. Funding ought to be provided by the federal government for 5 years until communities fully invest in the programs. I propose that sports and athletics programs be divided into school and civic. School related programs may cost $3 billion per year and save $3 billion per year. Civic programs may cost $1.5 billion per year and save $1.5 billion per year. Education of medical and psychology personnel in sports medicine will cost $150 million per year and save $50 million per year. Infrastructure investments in civic sports fields and equipment will be approximately $300 million per year and save $100 million per year for five years.
§ 5.7.3 These programs result in improved self-esteem, reduced mental health issues, improved physical health, reduced obesity, and reduced educational and behavioral problems.
§ 5.8.0 SCHOOL NUTRITION
§ 5.8.1 I argue that school lunch programs ought to contain a healthful balance of nutritional foods and beverages. Unhealthy foods and beverages must not be available to children in schools. Cooking classes ought to examine nutrition and every child should appreciate and be able to calculate nutritional daily recommended allowances. I propose that federal contributions for school meals programs increase an additional $8 billion per year. Much of this increase will address added costs of snacks after school and summer programs. Much will be used to purchase more costly but healthier foods. Much will be used to purchase locally grown foods. Savings from food programs will be $5.333 billion per year. I advocate re-introduction of nutrition / cooking classes that emphasize healthful lifestyles. The federal contribution for these home economics programs will cost $3 billion per year and will save $2 billion per year.
§ 5.9.0 COLLEGE SCIENCE PROGRAMS
§ 5.9.1
§ 5.9.2 Government must fund more scholarships, facilities, equipment, and hiring of additional university faculty in sciences, mathematics, nutrition, health sciences, biology, chemistry, physics, PE, and behavioral sciences. I propose that funding toward scholarships, equipment, and staffing will cost $18 billion per year and will save $6 billion per year, plus an additional $2 billion per year for each of the next 30 years. I propose that infrastructure investments will cost $4 billion per year and will save $1.333 billion per year for each of the next 5 years. Some of the new science programs ought to include “universal” instruction, in which the finest instructors provide lessons on specific topics, freeing many local faculty for student interaction and tutorials and research.
§ 5.9.3 Higher education provides a model for the current health care crisis. Higher education costs have risen faster than inflation in the last 40 years, as demand outstrips supply. Colleges have become increasingly competitive. Colleges charge much higher tuition, but, most colleges are offering greater financial aid.
§ 5.9.4 Colleges and universities are, in part, keeping their costs slightly lower by higher adjunct faculty. An adjunct teacher might cost $4,000 per course whereas a professor might cost $20,000 per course.
§ 5.9.5 This program would result in improved self-esteem, reduced MI, improved health, reduced obesity rates, reduced societal costs, increased knowledge base on diseases, and increased production of future health care providers and medical researchers.
§ 5.10.0 COORDINATED PROGRAMS WITH OTHER FEDERAL AGENCIES
§ 5.10.1 - Some of the diseases found in infancy, childhood, and youth are due to environmental conditions (e.g.,
pollution, dangerous emissions, etc.). Medical clinics ought to work with the EPA in identifying health threats and needed services across agencies.
§ 5.10.2 - Again, if, indeed, global warming proves valid, then the National Oceanic and Atmospheric Administration
(NOAA) and the CDC will assume an increasingly active role in monitoring changes and investigating the effects upon the population. I would envision that the federal funding for NOAA, under global climate change, ought to increase from $4.1 billion per year to $16 billion per year. I argue that the development of sound prevention and intervention strategies today might reduce global conflict, war, pestilence, famine, disease, and mass emigration in areas near sea level. This will “save” $5.333 billion immediately and may reduce future costs related to the above.
§ 5.10.3.1 - The FDA has its hands full, being responsible for many more services than it can presently attend to
in a conscientious manner. That said, it would seem that changes in the production, preservation, and distribution of foods and beverages over the last 50 years might have a relationship with increasing violence, especially among females, changes in hormone levels, earlier onset of puberty, as well as onset of certain illnesses and death. Further study on the effects of pesticides, preservatives, genetic alteration, and growth hormones ought to be conducted longitudinally.
§ 5.10.3.2 - The FDA ought to work collaboratively with its counterparts across the world in the development and
regulation of new drugs and medical procedures and medical equipment. New streamlined procedures might be introduced to quicken the speed in which new regulated materials are brought to market. Items that have obtained approval from select other counterparts might be eligible for streamlined review by the FDA. The FDA ought to require more longitudinal studies on the efficacy and dangers of new materials: This ought to be achievable by regular monitoring of EMRs. In order to reduce the difficulties that are imposed by drug developers conducting later stage trials and the ethical conflicts that result, I suggest that the FDA impose a “development – later stage research fee” upon drug developers. That “fee” is then used, probably through the NIH grant process, to obtain independent, university researchers who can conduct “double-blind” ethical and more trustworthy results.
§ 5.10.3.3 - The current administration recommended an increase in funding of the FDA from $2.7 billion to $3.1 billion.
Given the increased needs for FDA to inspect foods, protect against bio-terrorism, quickly but safely investigate and authorize use of medical materials, I urge that the budget of the FDA be increased to $9 billion over the next three years.
§ 5.10.4 – Elsewhere, I propose increased funding for the NSF, NIH, IHS, VA, DoD, and CDC.
§ 5.10.5 – The Health Resources and Services Administration is being tasked with Herculean tasks and, as such, it
requires greater funding in order to accomplish the tasks of implementing specific targeted healthcare programs. I propose that the budget of HRSA be increased from 2008 of $6.9 billion (with dip of $5.9 billion in 2009) to $18 billion over the next 3 years.
§ 5.10.6 –The Agency for Healthcare Research and Quality is being tasked with Herculean tasks, and, as such, it
requires greater funding in order to accomplish the tasks of cultivating and disseminating information that is necessary to formulate health care policy. I propose that the budget of the AHRQ be increased from 2009 of $267 million (with dip from $276 million in 2009) to $1 billion per year within the next 3 years. Much of this increase will be associated with the task of reforming the present healthcare system and finding systems to affect cost savings while improving quality and access to care. It is disappointing to see how this agency has been given billions of dollars in the last decade, yet healthcare costs continue to soar while health declines. Programs designed to disseminate and implement new knowledge is vital for containing costs.
§ 5.10.7 – The Immigration and Naturalization Service / Customs must be provided with proper funding to monitor the
millions of registered IAs, deport the hundreds of thousands of violent IA offenders to their homelands, and serve almost a probation officer’s role during the five year “probationary” period. It, and other law enforcement agencies, must know in advance of every take off from a foreign airport, every passenger aboard every plane, biological identification (hand print or eye scan), history (e.g., legal, scholastic, medical), and full papers (passport, visa, etc.). They must be able to monitor all non-US citizens and activate swiftly to assure that threats to the national security are not realized. I propose that such monitoring and deportation will cost an additional $4 billion per year for the next five years and then be reduced to $2 billion per year thereafter.
§ 5.10.8.1 – The Border Patrol must build a wall, not a fence, as tunnels are frequently found under fencing and, thus,
fences are, thus, already deemed to be useless. The construction of a wall similar to those that the Israeli’s
have constructed, 40’ in height, 20’ in depth, reinforced, for the 1,962 miles of US – Mexican border would cost
$7.5 billion per year for each of four years.
§ 5.10.8.2 –More Border Patrol agents must be hired. Ultimately, they will be responsible for assuring border safety and
the National Guard would be de-activated. I recommend hiring an additional 20,000 Border Patrol agents that will cost $2 billion per year.
§ 5.10.9.1 –The National Guard ought to be activated in states that are most in danger of illegal immigration threats. I
would anticipate that federal funding of 20,000 troops at a cost of $3 billion per year.
§ 5.10.9.2 –The Coast Guard also ought to increase patrols in the Pacific off the coast of
off the coast of
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