The musings of a physician who served the community for over six decades
367 Topics
Downtown A discussion about downtown area in Philadelphia and connections from today with its historical past.
West of Broad A collection of articles about the area west of Broad Street, Philadelphia, Pennsylvania.
Delaware (State of) Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Religious Philadelphia William Penn wanted a colony with religious freedom. A considerable number, if not the majority, of American religious denominations were founded in this city. The main misconception about religious Philadelphia is that it is Quaker-dominated. But the broader misconception is that it is not Quaker-dominated.
Particular Sights to See:Center City Taxi drivers tell tourists that Center City is a "shining city on a hill". During the Industrial Era, the city almost urbanized out to the county line, and then retreated. Right now, the urban center is surrounded by a semi-deserted ring of former factories.
Philadelphia's Middle Urban Ring Philadelphia grew rapidly for seventy years after the Civil War, then gradually lost population. Skyscrapers drain population upwards, suburbs beckon outwards. The result: a ring around center city, mixed prosperous and dilapidated. Future in doubt.
Historical Motor Excursion North of Philadelphia The narrow waist of New Jersey was the upper border of William Penn's vast land holdings, and the outer edge of Quaker influence. In 1776-77, Lord Howe made this strip the main highway of his attempt to subjugate the Colonies.
Land Tour Around Delaware Bay Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Tourist Trips Around Philadelphia and the Quaker Colonies The states of Pennsylvania, Delaware, and southern New Jersey all belonged to William Penn the Quaker. He was the largest private landholder in American history. Using explicit directions, comprehensive touring of the Quaker Colonies takes seven full days. Local residents would need a couple dozen one-day trips to get up to speed.
Touring Philadelphia's Western Regions Philadelpia County had two hundred farms in 1950, but is now thickly settled in all directions. Western regions along the Schuylkill are still spread out somewhat; with many historic estates.
Up the King's High Way New Jersey has a narrow waistline, with New York harbor at one end, and Delaware Bay on the other. Traffic and history travelled the Kings Highway along this path between New York and Philadelphia.
Arch Street: from Sixth to Second When the large meeting house at Fourth and Arch was built, many Quakers moved their houses to the area. At that time, "North of Market" implied the Quaker region of town.
Up Market Street to Sixth and Walnut Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
Sixth and Walnut over to Broad and Sansom In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Montgomery and Bucks Counties The Philadelphia metropolitan region has five Pennsylvania counties, four New Jersey counties, one northern county in the state of Delaware. Here are the four Pennsylvania suburban ones.
Northern Overland Escape Path of the Philadelphia Tories 1 of 1 (16) Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
City Hall to Chestnut Hill There are lots of ways to go from City Hall to Chestnut Hill, including the train from Suburban Station, or from 11th and Market. This tour imagines your driving your car out the Ben Franklin Parkway to Kelly Drive, and then up the Wissahickon.
Philadelphia Reflections is a history of the area around Philadelphia, PA
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Philadelphia Revelations
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George R. Fisher, III, M.D.
Obituary
George R. Fisher, III, M.D.
Age: 97 of Philadelphia, formerly of Haddonfield
Dr. George Ross Fisher of Philadelphia died on March 9, 2023, surrounded by his loving family.
Born in 1925 in Erie, Pennsylvania, to two teachers, George and Margaret Fisher, he grew up in Pittsburgh, later attending The Lawrenceville School and Yale University (graduating early because of the war). He was very proud of the fact that he was the only person who ever graduated from Yale with a Bachelor of Science in English Literature. He attended Columbia University’s College of Physicians and Surgeons where he met the love of his life, fellow medical student, and future renowned Philadelphia radiologist Mary Stuart Blakely. While dating, they entertained themselves by dressing up in evening attire and crashing fancy Manhattan weddings. They married in 1950 and were each other’s true loves, mutual admirers, and life partners until Mary Stuart passed away in 2006. A Columbia faculty member wrote of him, “This young man’s personality is way off the beaten track, and cannot be evaluated by the customary methods.”
After training at the Pennsylvania Hospital in Philadelphia where he was Chief Resident in Medicine, and spending a year at the NIH, he opened a practice in Endocrinology on Spruce Street where he practiced for sixty years. He also consulted regularly for the employees of Strawbridge and Clothier as well as the Hospital for the Mentally Retarded at Stockley, Delaware. He was beloved by his patients, his guiding philosophy being the adage, “Listen to your patient – he’s telling you his diagnosis.” His patients also told him their stories which gave him an education in all things Philadelphia, the city he passionately loved and which he went on to chronicle in this online blog. Many of these blogs were adapted into a history-oriented tour book, Philadelphia Revelations: Twenty Tours of the Delaware Valley.
He was a true Renaissance Man, interested in everything and everyone, remembering everything he read or heard in complete detail, and endowed with a penetrating intellect which cut to the heart of whatever was being discussed, whether it be medicine, history, literature, economics, investments, politics, science or even lawn care for his home in Haddonfield, NJ where he and his wife raised their four children. He was an “early adopter.” Memories of his children from the 1960s include being taken to visit his colleagues working on the UNIVAC computer at Penn; the air-mail version of the London Economist on the dining room table; and his work on developing a proprietary medical office software using Fortran. His dedication to patients and to his profession extended to his many years representing Pennsylvania to the American Medical Association.
After retiring from his practice in 2003, he started his pioneering “just-in-time” Ross & Perry publishing company, which printed more than 300 new and reprint titles, ranging from Flight Manual for the SR-71 Blackbird Spy Plane (his best seller!) to Terse Verse, a collection of a hundred mostly humorous haikus. He authored four books. In 2013 at age 88, he ran as a Republican for New Jersey Assemblyman for the 6th district (he lost).
A gregarious extrovert, he loved meeting his fellow Philadelphians well into his nineties at the Shakespeare Society, the Global Interdependence Center, the College of Physicians, the Right Angle Club, the Union League, the Haddonfield 65 Club, and the Franklin Inn. He faithfully attended Quaker Meeting in Haddonfield NJ for over 60 years. Later in life he was fortunate to be joined in his life, travels, and adventures by his dear friend Dr. Janice Gordon.
He passed away peacefully, held in the Light and surrounded by his family as they sang to him and read aloud the love letters that he and his wife penned throughout their courtship. In addition to his children – George, Miriam, Margaret, and Stuart – he leaves his three children-in-law, eight grandchildren, three great-grandchildren, and his younger brother, John.
A memorial service, followed by a reception, will be held at the Friends Meeting in Haddonfield New Jersey on April 1 at one in the afternoon. Memorial contributions may be sent to Haddonfield Friends Meeting, 47 Friends Avenue, Haddonfield, NJ 08033.
Physicians are in a mood to dislike the insurance industry indiscriminately. Health insurance was once provider-dominated but now is employer-dominated. Since that didn't happen voluntarily, it's a grievance. With health insurance the main source of relentlessly squeezed physician income, insurance middle-men are an unfocused target of antagonism. Unfortunately, irritation unfairly spills over to malpractice insurance, which however is an entirely different thing, run by an essentially different industry with its own principles and belief systems. There is one common historical feature, however. In both cases, health insurance and professional liability insurance, a health-related industry abandoned its field when it became unprofitable, and physicians then had to start their own insurance companies to cope with the resulting vacuum. When the insurance became profitable again, the commercial insurers wanted it back, and this annoying experience dramatized an essential conflict of attitudes. Physicians are in the medical business for life, in good times or bad; the sick are always with us. Businessmen, however, think it's normal economic behavior to drop unprofitable products. Since both sides stumbled into this situation without fully understanding its implications, it is not yet clear how to compromise two legitimate positions without disrupting an essential public service. If insurance will not play by our rules, perhaps we must reluctantly play by theirs.
Blue Cross and Blue Shield
We should examine the origins of provider-dominated health insurance, eighty years ago, some other time. In essence, however, physicians and hospitals started Blue Cross and Blue Shield because commercial insurers avoided the task. The commercial medical liability insurance industry, our present central topic, abandoned its field in 1974. By that time the cat was out of the bag, with physicians feeling endangered, or even prohibited by law, from practicing medicine without liability insurance. So physicians put up the money and started their own insurance companies, nick-named bedpan mutuals. That accidental foray into high finance put physicians on the inside of the industry's secrets, and very quickly put an end to their idea insurance companies were getting rich without taking big risks. We learned about premium cycles, and reserving philosophy, and dual systems (GAP and SAP) of insurance accounting. We learned appalling things about re-insurance, especially finite reinsurance. We learned about the politics of legislative insurance committees, and the politics of insurance commissioners. We learned, in short, that it's a cruel world out there, and that it's very easy to get lost in complicated details. Insurance companies create lots of problems, but we came to feel it was unfair to say malpractice insurance was unfordable because insurers were getting easy rich, that it was unacceptable to drive them out of business, and (quite unlike their cousin, health insurance) the solution to physicians' malpractice problem probably did not lie in reforming the insurance companies, however useful that might otherwise be. In fact, when the highly cyclic malpractice insurance industry just happened to be unusually profitable, the word "contraries" came up, and the day soon followed when I raised my hand and said, Let's just sell this company.
The Internet has made computing power ubiquitous. No longer need individuals to be at the mercy of institutions with whom they do business. However, new habits are hard to learn, so individuals still hesitate to challenge institutions. Sophisticated but inexpensive software from companies like Intuit nevertheless makes it nearly effortless for humble customers to have every bill and transaction cross-checked for them, and actually, in the resulting arguments. Its high time balance was restored because computers do send out lots of errors which have the effect of creating or destroying wealth. Indeed, much of the current credit muddle grows out of abbreviated records systems, organized for the convenience of only one party in a transaction. The transaction system would be streamlined, not hampered, by more adversary challenge and cross-verification at the level of individual items rather than merely cross-footing the totals. Indeed, add the filtering of information by third-party intermediaries, plus monitoring by regulators, and a need for some defined fault-tolerance emerges from the hopeless complexity. We must restructure relationships to ensure that small errors are trapped and isolated, not allowed to aggregate to a point where a mysterious failure of the books to balance can bring enormous systems to a halt. In this article, we mention the vulnerability of banks, financial derivatives, the Federal Reserve system, and the health insurance system. If everything worrisome went wrong at once, it could be quite a mess.
For the opening example, this article was written two days after the author discovered a sizable error in his stock brokerage reporting. It was in my favor, else I might sound less relaxed. Even so, the condescending stone-walling encountered was a powerful warning, since at the end of the day it proved to be entirely the fault of a software vendor for several brokerage houses. A few decades ago, a housewife would have been in a stronger position with her department store billing department because it was effective to refuse to pay the bill. Just try that today: the current practice of employing vendors to handle merchant billing soon separates the dispute from the circumstances of it. That's an underlying difficulty with all third-party arrangements; expedients selected to avoid a problem often make matters even more frustrating for the defenseless counterparty, who eventually longs for government intervention.
To a certain extent, customers have been forced to agree to this situation voluntarily, because of the mind-boggling complexity or greater cost of not agreeing. Until about fifteen years ago, it was conventional to place engraved stock certificates in a safe deposit box. Dividends were received as paper checks, endorsed and deposited in a bank. The bank microfilmed the checks, the customer could photocopy them.
Form 1099
Power was then reasonably symmetrical, arms-length and simple in concept even if overall it was an expensive, inefficient transaction. A mountain of receipts, a quarterly blizzard of mail. At tax time, an error-prone chore to manage the papers. So, in response to the gentle suggestions of tax accountants, it seemed heaven-sent to take certificates out of bank vaults and place them in "street name" with a broker. Tax time condensed to attaching a single piece of paper, the Form 1099, to the tax form. Instead of calling a broker and asking, "How's the market?" people now go to his website and review how a whole portfolio is performing, hour by hour. The efficiency gain is enormous; the transaction cost reduces at least 90%. But then -- you discover seven-figure errors can be created by an invisible computer programmer, initially denied as impossible and then defended with a blizzard of words. Worse still, the error did not come from an employee of the broker, it came from an employee of his software vendor in another city. The error did not surface in the brokerage house records, but in what was transmitted to a second software company a continent away, whose phone is answered in India. Two questions arise: what would have been the predicament if the error had been against me instead of in my favor? And secondly, what might have happened next if the misinformation about my imaginary windfall had been sent, not to a software house, but to the Internal Revenue Service as a Form 1099?
Now think of another order of magnitude. Instead of a housewife coping with the department store bill, replace her with a million brokers, a million investment bankers, a million electronic exchanges, and regulators, and tax collectors. Just one quantitative trader is known to handle ten thousand transactions an hour. Since transactions are global, a zillion foreign counterparties get orders for a zillion transactions. Underneath all this, a magnified error can emerge from one software vendor placing unwarranted faith in one programmer trainee, in a hurry to get home for dinner.
The mouth of the Delaware River once teemed with white swans, but black swans were unknown until the French explorer Nicolas Baudin brought home a few from Australia, where they are now celebrated as the state animal of Western Australia. Empress Josephine Bonaparte was delighted with them, made them known as her birds, and thus made the term "Black Swan" more or less synonymous with rare chance occurrences. The implied inference that every white swan contains a remote potential for breeding a black one is doubtful biology, however. More likely, black swans are a distinct species -- Cygnus atratus-- confined to Australia and New Zealand, and just about extinct in New Zealand. In that view of things, the rarity of black swans is equivalent to the prevalence of black ones, mixed within the population of generally white ones. Nevertheless, for this article, it is convenient to continue the unlikely conjecture that most, or perhaps every, white swan contain a small potential to hatch a black one.
Credit Default Swaps
Many theories exist for the discovery that financial crises are commoner than chance alone would seem to predict; if they follow a Gaussian normal distribution curve, it must be somehow different from the distribution curve of smaller fluctuations. Observing this discordance is more or less how the phenomenon was discovered. The normal volatility of economic activity is calculated from the fluctuations observed in, say, twenty years. When that derived curve is extrapolated to include cataclysmic events which by a theory of the unmeasured "long tail" occur every hundred years, speculators have later discovered by actual measurement that, alas, such disasters actually occur much more frequently. Calculated risks derived from such extrapolations have upended many insurance companies and insurance-like vehicles like Credit Default Swaps, who set their premium charges to match the mathematics. Since CDS approached a hundred trillion dollars in the last crisis, it is important to understand the mechanics of this kind of Black Swan if we possibly can.
Black Swan
One way to do that is to question the conventional equivalence of risk and volatility ; that is, that the more markets bounce around, the riskier they become. Why should that be true, we might ask. And if it is somewhat true, why does that make it is converse true, those calm seas are safe ones? Those of us who sit and watch the ocean shore soon adopt the habit of speech that high waves at the shore mean a storm is approaching, not that it will ever arrive. After all, the center of the storm may be traveling parallel to the coastline, not directly toward it. And calm seas are particularly undependable predictors; no matter how calm it may be, the next storm might arrive in a few hours, or it may not come for months. Many other analogies spring up, once one puts aside the basic assumption that world economies can be depicted as a linear electrocardiogram. At the very least, they are two-dimensional, possibly three. Possibly four, if you regard time as a dimension.
Dow Jones
It must be noticed that market volatility is universally viewed as linked to bad things, and many efforts have been made by central banks to reduce risk by constraining volatility. Alan Greenspan is famous for having controlled the economy for seventeen years without major depression. Is that necessarily a good thing? Is it equally possible that kinetic energy was constrained within the inflating balloon until the bursting of it was a far more damaging explosion than small planned deflations would have been?
Experimental testing of these ideas has itself been constrained by an inability to predict the explosion point of expanding financial balloons. Planned deflations have been particularly feared, because of lack of assured ways to get them to stop deflating. But practical warnings such as these are not the same as claiming that lack of volatility is always the ideal state.
We knew this election was coming; we didn't know who was going to win it. Whether Hillary Clinton would replace the Affordable Care Act with her own plan, or whether Donald Trump would replace the ACA with a different plan, was far less certain. In either case, the many flaws in the Affordable Care Act would be addressed. One thing seems certain: the Affordable Care Act will start off 2017 with a bigger deficit than was expected. My previous four books on the subject were forced to assume the ACA was cost-neutral, offering proposals for lifetime health finance for every age group except age 26 to 65, the working years of life. This book mostly concentrates on that gap.
Cheaper. The core of this lifetime proposal is the Health Savings Account. It was devised by me and John McClaughry of Vermont in 1981, when John was Senior Policy Advisor in Ronald Reagan's White House and I was a Delegate to the American Medical Association's House of Delegates. It flourished after John Goodman of Texas wrote a book about it, Bill Archer of Texas pushed it through Congress, the American Academy of Actuaries found it saved 20-30% of the cost of more usual Health Insurance, the AMA endorsed it, and thirty million accounts were established by June 2015. It consisted of two ideas welded together: a high-deductible catastrophic health insurance policy, and a double tax-exempt Savings Account, acting as a sort of Christmas Savings Account for the deductible. It wasn't free, but it helped a poor man get coverage as cheaply as we could devise it. The individual patient or client owned his own account, so it had no "job lock" to hinder changing jobs. In that sense, it was patterned after Senator Bill Roth's IRA or Individual Retirement Account. A significant improvement followed the question of what to do with an unspent surplus which remained
in the HSA (Health Savings Account) if you turned 65 after being healthy and then got Medicare. The Law was changed to turn such surplus into an IRA.
Retirement Funding. In correcting this oversight, the right thing was done for the wrong reason. Before anyone really understood Medicare was 50% underfunded, a retirement fund had been created. Since increased longevity was an inevitable consequence of better healthcare, it seemed natural for this "Medicare money" to pay for the extended retirement. It soon became apparent that retirement came at the same time as Medicare, and Medicare was thus underfunded. Even though the $3400 annual limit to Health Savings Account deposits was not enough to pay for soaring Medicare costs, it was not needed for that purpose for up to forty years. So augmented funds became available for healthcare at age 26 but had to be invested for fifty years or more until sickness made its appearance later in life. Emergencies might come up before then, but the Catastrophic health insurance took care of them. After many state laws mandating small-cost expenditures were amended, the high-deductible product took off, particularly in California and New York. Millions of policies were issued before anyone took the trouble to count them. When the Affordable Care Act made high-deductible insurance widely mandatory, Health Savings Plans took off like pursuit planes.
So, when competitive plans -- like HMOs, Preferred Provider Plans, First-dollar Coverage, Employer-sponsored plans, and a host of others -- started to encounter criticism, Health Savings Accounts became much more popular. Their flaws, instead of provoking consumer resistance, provoked demand for legislative relief. It was a mistake to limit ownership to people who were employed, or who were age 26 to 65; what good purpose did those age and employment restrictions serve? The advent of DRG payment limits to hospitalization and debit-card payment for outpatient services raised a question of the usefulness of insurance claims processing, which was certainly expensive. Prohibiting the HSA from purchasing the required catastrophic health insurance seemed to hamper unnecessarily a tax deduction which its competitors widely enjoyed. One or two amendments were all that would be needed to enhance sales considerably. People change jobs a lot; why would anyone want to prohibit dual coverage if someone wanted to pay for it, for his own personal reasons? The changes needed to enhance Health Savings Accounts were short and simple and could be enacted over a weekend. Why wait?
Improved Investment. Changes in the HSA Law to permit higher returns on invested deposits, are certain to provoke resistance but should be addressed very soon. If you are serious about replacing the old with the new, there are some zero-sum tradeoffs, especially within the finance industry. Go to the library or the internet, and look up the graphs of Professor Ibbotson of Yale about the performance of stocks and bonds for the past century. You will surely find the total stock market has risen at 9-11% for the past century, and what people describe as crashes and disasters seem like small wiggles in the line -- in retrospect. Some opportunities are better than others, but the main determinate of investing is the year you happen to have been born. In spite of these retrospective results, you will find very few investors who received half of that, but John Bogle and Burton Malkiel have demonstrated that random selection of stocks in a total market index fund beats expert active investors more than half the time, at a hundredth the cost. Bogle has something like 3 trillion dollars invested in his funds, and they have grown so fast he has trouble satisfying the demand. The average investor should be getting 5% on his money over the long run, and regulatory changes ought to aim for 7%. Money invested at 7% tax-free will double every ten years. With an average life expectancy approaching 90 years, that's ten doublings, or 512 times the initial investment in 90 years. And it still leaves 9-12% minus 7% (2-5%) for the finance industry.
But that's only half the problem. If you invest massive amounts of money for 90 years, there are plenty of cheerful brigands out there. Inflation is the main one -- it averages 3% a year -- because governments issue bonds, and enjoy low-interest rates. Federal Reserve and other central bankers are the nicest people in the whole world, mandated to preserve independence from the rest of the government. But they read newspapers and know who appoints whom. Bankers and brokers are also nice people, overvaluing rigidity because counterparties cheat when vigilance gets relaxed. One way or another, spreads should be narrowed.
The present system, plus stronger management, plus a few simple legislative amendments, would suffice to get us started with something workable, while we immediately roll up our sleeves and plan for a revolutionary future, better, system.
OBSERVATIONS AT THE FOUNDING OF THE AMERICAN MEDICAL PEER REVIEW RESEARCH CENTER
George Ross Fisher, M.D.
Congress and the Business Community want someone to define high-quality medical care, presumably, so someone can report it is provided by the health insurance programs which Congress and Business claim to pay for. Since a snappy definition has not yet been recited, we are beginning to hear growls that quality medical care may be a myth; Uwe Reinhardt just said it was a mystical concept. Lest Congress and the Business Community be tempted to act on the assumption no one can prove their policies are harmful to the nation's health, let me give a try at defining medical quality.
My theme is non-Platonic. Plato, as you recall, was the ancient Greek who had us all searching for the Good, the Beautiful and the True. Absolutes. Plato was a far more skillful proponent of absolutism that I am an attacker of it, and Platonism resurfaces in ideas like high-quality care. Take the illustration which occurs to me every time the matter is raised. Albert Schweitzer was a surgeon who won a Nobel Prize for his work in Africa, where he devoted his life. Now, a Nobel Prize should certainly satisfy Uwe's idea of the elevated social plane of European medical care. But I have been told by surgeons who visited his shop that Schweitzer was a perfectly terrible surgeon. As one put it, he would not have been permitted on the staff of even a Veterans Administration hospital. Whether that assessment is accurate and fair is less important than recognizing that it might well have been true that a perfectly terrible surgeon could go to the heart of darkness and greatly improve the quality of medical care. Quality of medical care consists of making the most of the resources available.
Dr. Pierson, the president of AMRRC, can undoubtedly tell similar stories about China, just as most doctors my age can tell stories about making do with little under wartime conditions. I doubt if anyone seriously denies that you c\ut your suit to fit the cloth, so I wish now to extend the idea by describing peer review in three historical contexts of available community resources. In other words: Yesterday, Today, and Tomorrow.
All through the fifteen years I worked in utilization and PSRO peer review, the context was cost-based reimbursement. Hospitals were given a blank check and urged to give unlimited access to the very best medical care. There were no financial excuses for an institution failing to have the latest equipment, hiring adequate numbers of the best-trained personnel, and organizing effective management. If in spite of having a blank check, a hospital nevertheless had substandard buildings, equipment or personnel, or if in spite of having everyone still made a bad job of it, we peer reviewers felt justified in assuming that hospital must be lazy, ignorant or hopelessly incompetent. Some such idea crept into the malpractice courtroom, too.
With the advent of prospective pricing at the beginning of 1985, the environment has suddenly seemed to change. Hospitals are now paid a fixed price per case, and reimbursement is no longer unlimited. Some of us imagined that peer review would be forced to make some allowance for limited resources under the new system; you can't criticize people for not using a machine they don't have and can't get. Since the waste under the old system was fairly obvious even to those who didn't want to see it, it was welcome that cost/ effectiveness should replace money-no-object as the environment within which to assess reasonableness. The money tree had attracted a number of carpetbaggers which it might be beneficial to be rid of. Merit is less important in a system which rewards everyone regardless of merit. So peer review is greatly changed by the new DRG payment system, right? Sadly, no.
For one thing, we still have mostly the same people with the same mindset doing the reviewing. Nowhere is paralysis of imagination more evident than in the bureaucrats controlling the money for peer review. Furthermore, no one has as yet completed the sacrament of carrying a snappy definition of medical quality to the staffers of relevant congressional subcommittee chairmen, to be duly transmitted to The Department for regulations, which will then be duly held in abeyance by OMB, until somebody who has dinner with the President finds a chance to whisper in his ear. Mundane obstacles are indeed present, but the main problem with changing the posture of peer review lies in the fact that the resource environment hasn't changed much, DRGs and prospective pricing, notwithstanding.
Hospitals as a group enjoyed a 6% margin of profit on their costs during 1985, instead of the hardship and losses originally predicted for a prospective pricing system. Therefore, the context within which peer review took place is essentially unchanged from the days of cost reimbursement. "Shame on you for shabby work when you are making a pile of money" is not greatly different from "shame on you for a shabby job when your resources are unlimited". From the physician's point of view, breakeven would be no tragedy for a nonprofit hospital, particularly when physicians so far have felt so little fiscal constraint.
Physician organizations have a glint in their eye, just waiting for some unlucky administrator to propose reductions of medically needed resources, without prior elimination of medically unneeded resources. Competition between physician and administrator for limited resources is likely to come some day, possibly some day quite soon. But at the moment, most of the economies have been derived from reducing the stimulated expenses which took place during 1984. When it became known that prospective pricing was coming and that it would be based on costs during 1984, to magnify that base year, it became very sensible to incur every imaginable cost during 1984, to magnify that base year. Hospitals put on fat for the coming winter, and most of the surplus employees fired so far can be regarded in an accounting sense as temporaries hired in 1983-84 for the purpose.
Well, what of tomorrow? There is little doubt that the idea is in some minds to handle the prospective pricing system by the business-school prescription, as follows: Cut the budget until something bad happens; if nothing bad happens, cut it again. Eventually, something bad will happen, so then pull back a little; optimum expenditure for the line item has been bracketed. Under this classic formula for managing something you don't understand, one problem is to avoid a total wreck. Therefore, the main job of peer review organizations is to maintain credibility, carefully identifying how much or little shabbiness existed when resources were unlimited, and remorselessly showing how with limited resources there is probably more shabbiness. But we must also remember that we will be carrying unwelcome news, which Government and Business will wish to suppress. It is not useful, Uwe, to announce in advance what you would consider being shabbiness because it alone might be spared, while budget cuts remorselessly destroy services more difficult to quantify. With bureaucrats, you have to hit hard and unexpectedly with evidence that they have palpably done wrong; you need a scandal. The higher they rise in the bureaucracy, the less they fear failure and the more they hate criticism. Let's hope we can be shrewd and alert peer reviewer guerrillas, so the scalps we then display scornfully to the public will be early sentinel effects, comparatively non-damaging to the public while still devastating as trophies. on the other hand, if we prove to be indolent and docile peer reviewers, constriction of medical resources will only be halted by shoddiness which is past denying.
If it seems almost inevitable that we will have to play out this guerrilla warfare, there is still a chance that loss of will by Congress and the Business Community may make the worst features of it unnecessary. Perhaps they will see their efforts were misguided in two main ways. First, like Platonists, they misapprehend that medical quality is independent of the cost when in fact it is largely defined by it. Secondly, they have come to believe their own rhetoric that the cost of medical care is their problem; they may come to recognize that it really isn't their money, anyway. Congress is merely dispensing the public's tax dollars, and Business is merely administering a tax dodge in fringe benefits. When it isn't your own money, and you don't really know what you are talking about anyway, a few lurid scandals can sometimes convince you that some other dabblings would be more useful.
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.