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.
It's a convenience for the insurance company perhaps since it reduces the insurance cost by 20% and is easily figured on the back of a salesman's envelope. Therefore it helps in the three-way negotiation between the employer, the insurance company, and the union. The union calculates how much income tax the employees save by how much income is split between the "fringe benefits" (non-taxable) and the "pay packet" (taxable), and the negotiations shift around these offsets, usually at the end of grueling collective bargaining.
It was once explained to me that Co-pay was very popular with negotiators for unions and management because it was easy to calculate the total cost of it for an entire self-insured corporation. If a proposed budget for the employees was known, and the budget for health benefits was agreed, the arithmetic was easy. If the company has a 20% co-pay, it can reduce the company's total insurance cost by 20%, and if it doesn't come out right, you can negotiate 18% or 22% or whatever. Late at night when these negotiations characteristically get serious, the cost of the offer and counter-offer can be quickly calculated. By contrast, if a deductible is proposed, you have to know how many people use the program, how often they would get sick per year, and even so the calculation is difficult, requiring actuaries or at least accountants. So, the explanation ran, everybody, likes co-pay, and everybody hates deductibles. The insurance people present especially like co-pay, because there will soon be a demand to add it to the package as second insurance, and the premiums for that are also easily quoted, up or down as the negotiations proceed. When it got to involve Medicare and Medicaid, the Congressmen were in essentially the same position of only wanting to know what bulk costs of the whole program would be. In short, co-pay is easy to "score". But the best that can be said for it is, it's just another short-term benefit for which long-term costs are increased because there are diminished incentives for the third-party to hold them back. Just kick the can down the road.
It has never seemed completely credible that anyone would base expensive decisions on considerations so trivial, but you never know. Having invented Medical Savings Accounts with John McClaughry in 1980, for me the mysterious resistance to high deductibles has never seemed adequately explained. Negotiators must easily see that two (or three) insurance policies will be more expensive to administer than just one. They must immediately acknowledge that being 100% insured will increase costs by making the beneficiary ignore the cost, and they are probably willing to accept (off the record) the American Actuary Association's estimate that costs are thereby increased 30%. That much alone would free up about 5% of the Gross Domestic Product since we are currently spending 18% of GDP on Health care. There has almost seemed no point to go on that wages could be increased by diverting this wasted money to the pay packet, to say nothing of the frustration many doctors feel at having no idea of the true cost of what they order, and hence little interest in making the number smaller. Obviously, if true costs are concealed, they go up. This blinding of the doctor to true costs is what makes cost-shifting easy to do without criticism. The absence of a pool of deductibles makes it impossible to generate compound interest, and that in turn makes it less practical to consider "portability" of health insurance from one employer to the next. It is at the very root of fictitious costs for medical care of all sorts, which somehow seem to the advantage of many participants in the health field. Eliminating co-pay would result in a small saving, and it probably would result in a big saving in healthcare costs. The aggregate national savings would be astonishing. Health Savings Accounts are slow to be adopted, not because they fail to save money, but because state laws have imposed mandatory insurance benefits for small-cost items, apparently passed for the main purpose of undermining deductibles.
Most people initially resist the idea of a high deductible on the ground that poor people can't afford it. When it is explained that what is intended is basically to give the poor the money to pay for it, most resistance disappears. A more correct description is that some method is constructed to give them the money, but in a way that allows them to spend money left over from healthcare, for something else they want to buy. The ability to buy something else is not the same as wasting it, and safeguards are only prudent. Retirement is the use most commonly considered. Because interest rates are being suppressed by the Federal Reserve, this proposal may be somewhat retarded for a year or two, until interest rates return to normal levels. Addition of an inflation-protection feature (like TIPS) might well enhance its attractiveness. Ultimately, the first step would be to eliminate Co-pays. Completely and permanently.
There are exceptions, but in the interest of preserving their own flexibility, the three branches of Constitutional government generally try to stay out of each other's way. The Constitution specifies no penalty short of impeachment for getting on another branch's turf, presumably because the threat of retaliation would make each branch hold back from it. To fall back on impeachment requires a decision that a particular turf battle qualifies as "high crimes and misdemeanors". That term is so vague it probably implies a threat of exile or execution, which in the past were only considered in hereditary monarchies with a succession issue. While King James I was beheaded for falling afoul of parliament, many other Anglo-American governments have been changed peacefully since that time. In any event, the events attendant on the passage of the Affordable Care Act were exciting enough that few realized it might soon appear before the United States Supreme Court. Immediately after enactment, twenty-some state Attorney Generals sued that the Affordable Care Law exceeded the limited powers granted by the Constitution to the federal government. Following a puzzling resolution of that issue (that its penalties were really a tax), the Speaker of the House soon announced he was also planning to sue because the President's actions did not "faithfully" match the intent of Congress. Representing only one half of the Legislative branch probably does not give the Speaker sufficient "standing" but if the coming elections provide him with the concurrence of the Senate, it seems unlikely the Court would permit a President to veto his own impeachment.
Responding to this unexpectedly legal turn of events, this book about healthcare and its insurance could, unfortunately, be forced into a series of national debates about Constitutional Law. In spite of strong misgivings that lawyers knowing little about medical care were digressing from insurance into Constitutional Law, there seems little choice but to hang on, waiting for an opportunity to get back to medical care. We can consider it lucky that James Madison was anxious for the Constitution to be simple enough for the public to understand. And that Gouverneur Morris, the "Penman of the Constitution", was talented enough to make it so.
All legislative Powers herein granted shall be vested in a Congress of the United States, which shall consist of a Senate and House of Representatives.
Article 1, Section 1.
The power to legislate is exclusively vested in the Legislative Branch by Article 1. of the Constitution, but the Executive Branch is permitted to issue "necessary" regulations to enforce the law. Because party control of Congress changes, sometimes the new party in control may think what the other party felt was "necessary", is in fact contrary to a new definition. There are two choices: either let the new Congress repeal and rewrite it, or let the Supreme Court issue a mandamus order to enforce that "intelligible principle" which every law must contain if it is to be Constitutional. In the case of the Affordable Care Act, the persistence of Democratic control of the Senate leaves the Speaker of the House only with the choice of a writ of mandamus ("We command") or a declaration of unconstitutionality. The narrow margin by which the Democrats hold the Senate majority does open an additional possibility of defeating them in the November 2014 elections, thereby strengthening The Speaker's case that he represents the whole Legislative Branch.
So long as Congress 'shall lay down by legislative act an intelligible principle to which the person or body authorized to [exercise the delegated authority] is directed to conform, such legislative action is not a forbidden delegation of legislative power.'"[2]
J,W.Hampton v US, 1928
The President does have room for maneuver before any such lawsuit reaches the Court. There are 450 sections to the Affordable Care Act, and the White House staff seems to be busy devising regulations which implement them. However, most of the regulations are emerging in the form of Temporary Regulations, followed by a comment period. Therefore, there is the potential to hold back until the very last moment on making some or all of them into Permanent Regulations. This could create an opportunity to display politically attractive features for the purpose of the November elections, while at the same time reducing the number of persons actually affected. And thus reducing the number with "standing" to join the lawsuits. (The Court has traditionally refused to hear the complaint of anyone who cannot claim personal damage.) This explains how the unusually early timing of the suit of the State Attorney Generals was possible, maintaining the states were being coerced to accept Obamacare duties and costs. There was no need to sell any insurance in order to examine that complaint. Even then, dating from John Marshall's declaration that "The power to tax is the power to destroy", the penalties for noncompliance can only be described as a tax if they remain small (otherwise, they would be coercive).
Turning in a somewhat different judicial direction, many snarls in Medical Care trace to Legislative action; reforms almost always begin in that Branch. But the same logic applies to Courts. If a problem begins with Constitutional design or Judicial action, its reform might best begin within Courts, because the other Branches may feel inhibited. Such initiation is not necessarily "judicial activism". Sometimes Court action alone is needed if Court interpretations have changed an issue; anti-trust is an example. But the most important need for Court initiative is in Tort Reform, where Chief Justices have administrative jurisdiction. Other branches may feel it is not their place to meddle; some Chief Justices may feel administrative intervention is not to their taste. If other problems grow out of Constitutional design or Judicial action, it can also be awkward for other Branches to deal with them. Still, other problems straddle the Branches; Judicial action might at least be considered. For example, hardly anyone would have predicted a collision between the President and Congress while his party dominated both branches; that was true during the brief period after the Affordable Care Act was enacted. The way it was enacted so enraged a segment of the population that political control soon shifted to the opposition in the House of Representatives, and threatens to shift still further in the November 2014 Senate elections. As Mr. Dooley famously observed, "The Supreme Court follows the election returns."
The Affordable Care Act has 450 sections, so it may be some time before it is legitimate to criticize a failure to write and implement all the sections, even though the law passed the House of Representatives in a single day, nearly three years ago. It is therefore much more likely a charge of failing to enforce the intent of Congress faithfully would take the form of asserting that regulations were promulgated based on no underlying intent expressed in the law. On the other hand, just what a clever lawyer can do with a President who promises on television not to do something which has already been done after the direction not to do it is written in (Section 1251) the law, may prove to be a greater challenge.
The Legislative cannot transfer the Power of Making Laws to any other hands.
John Locke, 1690
For lawyers, however, the possibility of modifying Franklin Roosevelt's Court-packing effort is probably the greatest legal challenge in a century. In the 1933 case of Schechter Poultry, the National Recovery Act was declared unconstitutional because of its unconstitutional delegation of regulation to an executive agency. Violation of the nondelegation doctrine may well be present in the Speaker's suit. President Roosevelt responded by threatening to keep appointing Supreme Court Justices until he achieved a majority. Public uproar was deafening, and both sides backed down. That is, Roosevelt did not pack the Court, and the Court upheld , which declared that an Iowa farmer was engaged in interstate commerce, even when he grew vegetables for his own personal use. By some sort of Judicial logic, this ruling has been taken to mean that "commerce among the several states" is just commerce, and the Interstate Commerce Clause of the Constitution has become merely the "Commerce Clause". Such judicial magic was a long step toward eroding the meaning of the Tenth Amendment, and subsequent decisions have considerably retreated from it as the country continues to outgrow the ability of a central Federal government to manage so much over so large an area. It is a matter of considerable importance therefore, whether Obamacare litigation might signal a continuation of, or a retreat from, the direction it took in the Court Packing dispute. It is very hard to predict whether some event, like the appointment of a new Justice, might change the direction of things, but the most immediately predictable event will be the November 2014 Senate elections and anything which might strongly affect their outcome. An additional prediction would be that every nuance of every decision will be scrutinized for some indication of how each Justice might likely vote on an Obamacare case. By that time, unfortunately, the outcome of the Obamacare case may have no more to do with the practice of Medicine, than the Schechter Brothers case had to do with the price of chickens.
Meanwhile, in the increasingly uncertain climate of an Obamacare decision affecting medical care, we offer a few suggested areas where the Supreme Court might take actions as the initiator, rather than the passive referee, of relevant rules.
The U.S.Supreme Court might be urged to:
1) Mandate income tax equity for health insurance, disregarding who pays the premium and how, 2)Reconsider the 1982 Maricopa Case; at least, remand it for trial, 3) Assert Judicial leadership in Tort Reform. 4) Define ground rules for coordination between Regulations and Statutes, 5)Review the inconsistencies between Obamacare and ERISA, particularly the question of who has standing in the two instances. 6) Review the rules of the House and Senate, particularly as they apply to House-Senate reconciliation of two versions of a bill. If possible, the Legislative Branch should request this kind of intrusion, first.
2624 State and Federal Powers: Historical Review
2250 Obamacare's Constitutionality
2289 Roberts the Second
2625 What Can Supreme Court(s) Do About Tort Reform?
2592 More Work for the U.S. Supreme Court: Revisit Maricopa
When a full transition to a new system of personal finance takes ninety years, you might as well say the system is the transition. However, it explains better if you know where you are going, original intent, as it were. Therefore we first present Lifecycle Health Savings Accounts as if everyone is born on the same day, and then explain we understand perfectly well that a lot of people were born on every single other day for the past ninety years. There's going to be a lot of transition, and therefore a lot of calculation. Somebody will have to prepare a big book of tables for computer terminals. In the meantime, the effort seems better spent on describing the theory, which is fairly simple. If you are going to have your ninety-ninth birthday tomorrow, Lifecycle HSAs aren't going to do you much good. We, therefore, pick someone half-way through the transition, which might appear to result in a saving of $175,000 dollars per person per lifetime remaining, if we aren't careful about it. Moreover, we propose phasing in one section of the program at a time, so if the person in the example is financially unable to afford the whole deal, he will "only" save $85,000. The explanation for this "disappointment" lies in the quirks of how Medicare has been financed in the past, but if someone has already lived half his life, he will naturally only cost roughly half as much for the remainder.
Medicare Financing for Dummies.Aside from deductibles and co-insurance, Medicare is financed by three sources. Roughly a quarter comes from payroll deductions for working people in anticipation of later Medicare costs. No interest is currently paid, so one of the sources of financing for this proposal is to earn interest, crediting it to a (voluntary) buy-out escrow fund for the program, within each HSA. By itself, this generates much of the savings we anticipate.
Another quarter of Medicare cost is contributed by premiums paid by the elderly subscribers to the program, generally starting when they reach 66. We propose eliminating such payments, as a way of rewarding those who voluntarily join the transition. Some people will inevitably reach age 66 without generating the necessary buy-out funds, so they alone will have to pay the premium until it replaces their deficiency. They should still save some money by recognition of whatever they did pay in, but it will be less. The design anticipates this particular feature of the program to be a no-lose offer.
And the final 50% of Medicare is currently a subsidy out of general tax receipts. Since we already run a deficit, we borrow the money from foreigners, mostly the Chinese. And if we start paying the full cost, it won't generate actual revenue, it will only stop making the deficit worse. It will also stop paying extra interest to borrow it, which we presume is about 5%, the interest on 10-year Treasury bonds. We presume the government would be willing to pay this interest to the Medicare fund, in return for not borrowing the principal from foreigners. The consequence of such an agreement would be to generate an extra 5% for the transition fund, in addition to the payroll deductions.
This part of the proposal will stop further borrowing on behalf of those who agree to it, but it will not pay off existing debt. Congress will have to decide how rapidly it wishes to rid itself of the principal of this debt. If the two revenue sources already mentioned are deemed insufficient, it can reduce the benefits to those who accept the buy-out, although it will probably slow the transition to do so.
If Congress should feel the incentives need further adjusting, my own suggestion is that it should be effected by adjusting the payroll withholding, either up or down. With an average lifetime calculated healthcare cost of $350,000 per person, there is ample room to do it. To do so would have only minor overhead cost, and it would maintain the system of having working people pay for non-working ones. Or rather, of all persons paying for healthcare while they are earning, including the beginning and end of life, when they cannot work. To do so would preserve the natural way families pay for non-working family members without insurance except catastrophic insurance. We have worked ourselves into the corner of the health insurance industry itself consuming nearly 2% of gross domestic product, mainly because of expanding abusive benefits in response to an unwarranted tax deduction. It is not necessary to criticize the health insurance industry for responding to this incentive.
As a side comment, those people who are given a subsidy are asked to take no risk. Everybody would naturally prefer to avoid risks, so we must create incentives to avoid the implicit adverse incentive. That will usually take the form of avoiding unearned benefits for those who are given risk-free subsidies. The rest of the system is already a balance between risk and cost, offered in the form of less risk, more cost. Stocks are riskier than bonds, long-term bonds are riskier than short-term ones, but the income rewards are reversed. Unfortunately, bonds, money market funds, and Treasury bills pay so little interest, there is little point in exploring HSAs which purely consist of them. In fact, equity financing has only become feasible in the last few decades, as longevity increases. Since the serious risks are infrequently encountered, a young person can afford to take the risks of the stock market, banking on later gains to rescue early mistakes.
So, the time to buy stocks is early, adding bonds later when there might not be time left to recover from a stock crash. Since the full potential of high-quality American stocks is 12%, most young people would start with that, adding a growing proportion of bonds as they approach the end of their longevity. Health risks rise appreciably after age 50, so the balance of stocks and bonds should approach 60/40 at that age, lowering the lifetime income return from 12% toward 6%. Some people will get lucky and be making substantially more than that, and therefore can take the risk of making still more if they delay the dilution of the portfolio with bonds. There will be some who fall short of the benchmark, and who will then have to gamble on the stock market even longer to make the goal of $80,000 lump-sum payment at age 66 to Medicare. That's what it takes to cover half of $175,000 average expenses from age 66 to the end of life -- a half which the government currently subsidizes. By the way, there's another risk, that Congress will not approve of buy-outs, and your Medicare costs will be double, which summarizes the incentive to do it if you are permitted. It's even worse: to spend $175,000 you will have to pay income tax on what you earn before you can spend it on Medicare premiums after age 66, and on Medicare withholdings before that age. That's a pretty strong incentive.
This directory contains Fee Screen Year 1984 Medicare reimbursement data based on physician charges submitted to
Medicare during the calendar year 1982 in each of the reasonable charge localities within each Part B carrier's service area.
Maps are provided for each State which outlines the separate charge districts (localities) the Carriers use
in reimbursing claims under the Medicare program. The counties within each locality are listed to aid in
identifying the exact geographic breakdowns. More detailed locality information can be obtained on selected
carriers by referring to AppendixA in the back of the directory.
The directory was compiled from magnetic tapes submitted by each of the carriers. Every effort has been made
to minimize errors in the data displayed for each of the carriers however because of differences in coding
systems it may sometimes be necessary to consult directly with the carrier for clarification.
EXPLANATION OF MEDICARE CHARGE DATA
The dollar amounts shown in the directory are the prevailing charges in the indicated locality for each of the
services listed. Except where there are unusual circumstances or medical complications so that more than the
normal service is provided, these figures represent the highest dollar amounts that Medicare can use in determining
the medical insurance benefits which can be paid on Medicare claims for services in the locality. Others factors,
explained below, are also used in determining the medical insurance benefit that is payable.
How The Medicare Allowed Amount Is Determined
Under the law, the allowed amount for a given service shown on a medical insurance claim is generally the lowest of (1) the actual charge made by the physician for the service; (2) the customary charge generally made for that service by the physician; (3) the prevailing charge, which is the charge most physicians in the locality would find acceptable for that service; or (4) the charge that would be recognized by the carrier for its own (non-Medicare)
subscribers or policyholders for the service.
The rules that are applicable in calculating the amounts allowed for physicians' services also apply to other
services covered under the medical insurance program.
How The Medicare Prevailing Charge Is Determined
Under the law, just before the beginning of each fiscal year Medicare must review the actual charges billed by
physicians in the preceding calendar year. The mid-point of these actual charges by a physician for a service is established
as his customary charge for that service. The prevailing charge is then established at the 75th
percentile of all the individual physician's customary charge for each service. In effect, the prevailing charge
for any given service is the amount which is high enough to cover I full the customary charges of those physicians
whose billings accounted for at least 75 percent of all claims for that service in the locality in the preceding
calendar year.
The amount of prevailing charge recognized under Medicare is also affected by an additional program restraint.
In accordance with Medicare law, prevailing charge levels for physicians services for any fiscal year after fiscal
year 1973 may not exceed the fiscal year 1973 level except to the extent justified by an economic index that
reflects changes in the costs of physician practice and in general earnings levels.
The prevailing charge data represents the Maximum amounts upon which reimbursement is based with the Medicare
Part B program. It also reflects the influence of the Economic Index Provisions. For each locality, prevailing
charges are listed for 29 medical services performed by General Practitioners (GP) and for 100 physicians services
performed by medical Specialists. Where the carrier makes no specialty differentiation in its screens, the top of
the page states "combined locality designation". Blank spaces in the prevailing charge columns indicate that
(a) prevailing charge data was not collected for GP specialty category, (b) the procedure is not performed in the
locality, or (c) the carrier does not use the same definition of the procedure as listed. When an asterisk (
*) appears beside a charge, it means that the charge is adjusted by the application of economic index. When
a letter "P" appears next to a charge, the amount represents the Professional component only. The letter "L"
stands for the lowest charge levels applying to selected laboratory and durable medical equipment screens.
The physician procedure (excluding lab and DME) lists represent the amounts established at the "freeze" level and
will continue to be in effect until October 1, 1985.
When reviewing the specialist charge screen data, it should be noted that the amounts represent the prevailing
charge screen for the specialist who most frequently performs these procedures. Therefore, the procedure list
in Table A contains the category of medical specialists for which charge screen data was collected for the 103
procedures. Seven additional procedures are listed for durable medical equipment.
If you have any questions about the data or locality information displayed in this directory, please direct your
questions to James Barnett (301) 594- 6743), Health Care Financing Administration, Bureau of Program Operations,
Room 367 Meadows East Building, 6325 Security Boulevard, Baltimore, Maryland 21207. For technical questions
involving computer programming of the data, contact our Bureau of Support Services (301) 594-0810).
It was sixty years before Philadelphia had a second hospital, so the way things were done at the Pennsylvania Hospital tended to set patterns. The central pattern was: charity for poor folks, during a period when prosperous people were treated in their homes. Since Franklin was the secretary of the Board of Managers, it is in his own handwriting that we see "Founded for the sick poor and, if there is room, for those who can pay." In 1900, two-thirds of all hospital beds in Philadelphia were still ward beds for the poor. In 1948 when I was a two-year unpaid intern there, a posted sign said the accident room charge was fifty cents, but in fact, it was only collected if the patient happened to have insurance. The student nurses ran the place unpaid, and the main exceptions were the two paid administrators, the Steward, and his secretary. Philadelphia was settled for religious freedom, enjoyed many new religions, and consequently had a long era of Methodist, Episcopal, Presbyterian, two Jewish hospitals and the hospitals belonging to three Catholic Orders.
With the advent of the Civil War, PGH (Philadelphia General) grew to seven thousand beds, all of them free, when it was discovered more soldiers were dying from diseases than from wounds. Surgeons and obstetricians built specialty hospitals for their patients, mostly small ones, like Babies Hospital, Preston Retreat, Contagious Disease (mostly polio), Casualty, and a host of tuberculosis and psychiatry hospitals, Eye Hospitals, HEENT Hospitals, Children's Hosptial, and a number of small paying hospitals. The Civil War and the invention of anesthesia created a need for small hospitals for people who could pay, like Skin and Cancer.often in the shadow of larger charity hospitals for those who couldn't' pay. The first question any audience asks with bewilderment is about the cause of so many current hospital mergers. Part of the answer is we once had too many hospitals, and the rest of the answer was that the Flexner Report created a surplus of government money, intended to support research, and similarly stimulated by the creation of Blue Cross in the 1920s. Flexner favored research money, and the Universities grabbed it. The insurance mechanism was the best available means to save money when you were well, in order to spend it later when you were sick, but insurance muffed the chance. They chose one-year term insurance, mostly because short-term business was paying the bill. When money was no object, money was wasted.
The quickest example of honey attracting flies was observed shortly after 1965, when Philadelphia teaching hospitals (there were 104 of them at the time) went to Mayor Rizzo, suggesting PGH should be closed, ostensibly in order to facilitate the flow of federal funds to private hospitals. Thus they would help teaching hospitals absorb the abundant flow of government charity while eliminating the $11 annual cost of PGH to the City. That transformation from mostly charitable to largely private hospital care took from 1977 to 2010, to the private amusement of those who had been present at the meeting. At the end of this transformation, their positions had reversed; the teaching hospitals now bemoaned the shocking disappearance of the city's medical charity through PGH, casting such people back onto the teaching hospitals. Vannevar Bush probably had a hand in this, as the pretext was that only teaching hospitals did research. Meanwhile, they lobbied strenuously to retain monopoly control of federal research money, at the expense of charity beds within the teaching hospitals. In other words, we had a reasonably satisfactory system of charity care until charity patients demanded equal facilities from public money. Lyndon Johnson gloried in his achievements, but the fact is they opened the door to the unsupportable expense. The nursing profession was utterly flummoxed to be given degrees in return for the disappearance of their profession. If the combatants had stopped long enough to ask, there simply was not enough money to do what politics was demanding. The nursing school was always the heart of the hospital; the doctors were too busy tending to patients. And charts which they mostly falsified to save wasted time. Adding to the confusion was the effect of shifting nurse training costs, from the hospitals (diploma) to university responsibility (bachelorette degrees) and the adverse effect on nurse quality was noticeable. Doctors no longer married nurses, for example, they married lawyers and similar pre-professionals. The greatest effect, aside from higher cost, was to remove the loudest objectors from the scene, at just about the wrong time. The universities were clamoring to transform the nursing profession into administrators, in order to satisfy a seemingly insatiable demand stirred up by muddling the medical record-keeping system with the task of creating huge records which no one has time to read. The public regards medical matters as too obscure to understand and so does not appreciate how much cost has been created by switching everything non-essential around. It seemed obvious to them that non-essentials were poorly done. But not being medically trained, they weren't able to tell what was non-essential. Improving legibility and interphysician communication was nice, but it wasn't the main business of a hospital. Physicians learned to practice good medicine in tents and scarcely saw any difference.
Lawyers have learned something, too. They learned that antitrust violation is not signaled by per se violations or even vertical integration. It is signaled by mergers. Senator Specter may have kept Robert Bork from the Supreme Court. But the Law is slowly catching up with mergers, and Bork's books are still in print.
The future of hospitals does not lie in buildings. Doctors' practices are easily moved to retirement villages where the old folks are. Patients are there a long time, and equipment is easily moved there to be with them. It would save a lot of money because diseases are disappearing. Something like five diseases now represents something like 80% of the cost, but all that money spent on hospital buildings has already been spent, so it will take too long to get there peacefully. For all I know, five new diseases will replace five old ones, but the trend is downward. Costs keep going up. Doesn't that tell you something? What's going to happen to all that real estate after we cure cancer?
109 Volumes
Philadephia: America's Capital, 1774-1800 The Continental Congress met in Philadelphia from 1774 to 1788. Next, the new republic had its capital here from 1790 to 1800. Thoroughly Quaker Philadelphia was in the center of the founding twenty-five years when, and where, the enduring political institutions of America emerged.
Philadelphia: Decline and Fall (1900-2060) The world's richest industrial city in 1900, was defeated and dejected by 1950. Why? Digby Baltzell blamed it on the Quakers. Others blame the Erie Canal, and Andrew Jackson, or maybe Martin van Buren. Some say the city-county consolidation of 1858. Others blame the unions. We rather favor the decline of family business and the rise of the modern corporation in its place.
Originally the "lower counties" of Pennsylvania, and thus one of three Quaker colonies founded by William Penn, Delaware has developed its own set of traditions and history.
Start in Philadelphia, take two days to tour around Delaware Bay. Down the New Jersey side to Cape May, ferry over to Lewes, tour up to Dover and New Castle, visit Winterthur, Longwood Gardens, Brandywine Battlefield and art museum, then back to Philadelphia. Try it!
Millions of eye patients have been asked to read the passage from Franklin's autobiography, "I walked up Market Street, etc." which is commonly printed on eye-test cards. Here's your chance to do it.
In 1751, the Pennsylvania Hospital at 8th and Spruce was 'way out in the country. Now it is in the center of a city, but the area still remains dominated by medical institutions.
Grievances provoking the American Revolutionary War left many Philadelphians unprovoked. Loyalists often fled to Canada, especially Kingston, Ontario. Decades later the flow of dissidents reversed, Canadian anti-royalists taking refuge south of the border.
