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
... William Penn's Quaker Colonies
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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.
The American Medical Association
has several hundred thousand physician members, all of whom consider
themselves important members of their communities, hence important
members of the AMA. "The Association" maintains a large, experienced,
and frequently successful lobbying staff in Washington. It would be
wildly impractical to permit every individual member of the Association
to walk into the Washington office and give orders to the staff. Even
when individual doctors have a very good idea, and the staff members
thoroughly agree with it, it's never safe to assume the professional as
a whole agrees. And in fact, it is always possible to find some doctor
who violently disagrees, no matter what the topic.
So, a couple of centuries of experience led to a system of funneling physician opinion up to the line to the House of Delegates,
and passing it through that narrow neck of the funnel before it is
released to the Washington office as "policy". Sure, a couple of
knuckle-heads can sometimes block a good idea at the narrow neck of the
funnel, just as an occasional Leonidas can save civilization at this
Thermopylae, against a bad idea. Sometimes an idea slides all the way
through on the first try, and sometimes it is necessary to build up a
head of pressure behind it. The fundamental question before the House
of Delegates is not entirely whether a proposition is a good idea or a
bad one; an equally important question is whether it likely reflects
the prevailing viewpoint of the profession.
My first salvo in the campaign to win AMA approval for Medical
Savings Accounts was a letter to Jim Sammons, the Executive Vice
President. He wrote back promptly that he had read the Medical Savings
Account proposal three times, and still didn't understand it. Although
my opinion of him was never quite the same, he did me the favor of
demanding simplicity, to be more quotable. An IRA for Health. An IRA
plus a catastrophic policy. What's good about that? Cheaper. What makes
it cheaper? Compound interest. How does it help poor people? More
people can afford to buy something that's cheaper. Sammons said, ok, I
can live with that.
The letter to the EVP turned out to be a good idea because it
established my claim to ownership. A few months later I arrived in
Chicago with a crisp, brief zinger of an MSA proposal, only to find
that somebody from Louisiana was attending the same meeting with an
almost identical proposal, called CHIP. Mike Smith was president of the
Louisiana Medical Society, and not only had the same idea but
personally had a lot of Louisiana oil money which he freely spent on
professional packaging of his presentation. Mike and I suspiciously
circled each other like two wildcats for a few hours, but we had so
much in common that very shortly we were the best of friends, remaining
so for years until his unfortunate death. He introduced me to his
Southern friends, I introduced him to my Northern ones, and the idea
itself picked up some allies on its own merits. It had a fairly easy
time of it in the House of Delegates. However, it was referred to a
committee for polishing and deeper consideration. Six months later it
had disappointingly picked up quite a lot of unforeseen opposition,
probably after the hospital and insurance executives heard about it. It
took another six months to fight through a wall of specious argument,
but an endorsement of the Medical Savings Account did become a policy of the
AMA and the eager Washington staff was thus free to run with it.
It has remained AMA policy ever since, and the main technical
problem for its main sponsors became one of keeping the idea alive in a
House of Delegates with constantly shifting turnover. The AMA is like
the court system; it doesn't like to keep revisiting an issue that is
settled policy. Too many other members have proposals requesting
attention, so why should we go on reaffirming old matters? However, the
proposal was stalled in Congress, and for the momentum, we needed to keep
beating the drum with variations which somewhat stretched the patience
of the more senior members of the House of Delegates. To them, I
apologize, with gratitude for their tolerance.
But what was the matter with Congress? What was the matter with the
editorial page of the New York Times? I was always uneasy about a protracted debate because reducing the cost of medical care (from the
patient's point of view) was apt to translate into reduced income for
doctors. I was leading a procession of self-employed entrepreneurs into
a proposal to cut their own income for the benefit of the public; how
long could physician enthusiasm be maintained for that? I'm proud to
say the answer is at least twenty-five years.
Even in retrospect, I am a little surprised that even such
sophisticated students of medical economics could remain focused for so
long. They might have come to regard the sponsors of MSA as being on an
ego trip, or else nutty fanatics obsessed with a lost cause. Or they
might have joined the young newcomers in fearing that such determined
opposition at a national level might signify the opponents were somehow
right to oppose it. The arguments advanced by the opponents really
seemed to have very little merit, but perhaps in private, it might be
possible to sympathize with some embarrassing circumstances that
explained the vigor of the resistance without crediting its excuses.
Political debate after all, even in scientific organizations, quite
characteristically wraps venal motives in a cloak of logic and
altruism. I remained fearful for years that the House of Delegates
would shrug its shoulders and let the opponents have their way. That
they never, ever, did so was probably related to medical care being
physician home turf; where you get used to hearing a lot of dumb
arguments, but you don't have to credit them with any merit until merit
is displayed. You can tell doctors a lot of fairy tales about
architecture or investment banking perhaps, but if you talk medicine
with them, you better have your facts.
Whenever my colleagues would privately draw me aside and ask why in
the world a lot of people were so resistant to the MSA, I had to tell
them I was not entirely certain. However, it was notable that three
groups had important things to lose, and would probably fight to
preserve them. The Medical Savings Account threatened the
eighty-year-old pricing preferences between hospitals and insurance
companies. Secondly, it threatened the sixty-year-old preferential
healthcare pricing for members of organized labor. And finally, the
politicians who were so anguished about the uninsured population might
possibly be more interested in preserving the grievance than achieving
its solution.
I can never remember a private conversation of this sort that didn't
satisfy the doctor who asked the question. And I also never met a
representative of health insurance, hospital administration or
organized labor who would admit any truth to it.
There are plenty of problems with American health financing, but three features are the basis for optimism and the subject of this book. The first is the possibility that research can get us out of the jam we are in. The National Institutes of Health has started to prioritize its research, sensibly focusing on the most expensive diseases first. Opportunities will always dictate the attractiveness of a particular line of research to the investigator, but to the extent, a funder can influence choices, the N.I.H. has started to put a priority on the cost of diseases that cost the most to treat. It is their estimate that eighty percent of healthcare expenditures can be roughly assigned to only six diseases (Cancer, Diabetes, Parkinsonism, Arteriosclerosis, self-inflicted Conditions, and Psychosis.) If somebody gets us an inexpensive cure for only one of them, it would have a big impact on costs. At the moment, the best estimate of lifetime health costs is roughly three-hundred fifty thousand dollars per person, in the year 2000 dollars. By spending the present annual 33 billion dollars on research, it seems reasonable to look for a decline in health costs in the next decade, after which even research costs should decline. Expense is most heavily influenced by the need to institutionalize certain situations. I once wrote a paper on the patients in the Pennsylvania Hospital on July 4, 1776, and the diagnoses were remarkably similar to the present time, concentrating on disorders of the legs and brain, where you have to be put into bed to be cared for.
One thing we can, of course, be very sure of: everyone will eventually die, and thus will have one terminal illness. We can eliminate any or all five-- and you can be sure that something fatal will take their places, although you can't be sure it will be cheaper to treat. Nevertheless, longevity will lengthen, making healthcare cheaper, per unit of longevity. Perhaps the way to put this is to aim for only one fatal condition per lifetime and to re-design our insurance to anticipate this direction of things. As a side consequence, the longer you delay the grim reaper, the more income will be generated within Health Savings Accounts, more patents and copyrights will expire, more drug competition will lower costs. Unfortunately, the longer you live, the more it will also cost to extend that retirement. The resulting certainty is for greater consumption pushed into old age, and the likelihood is, more money will be spent on living expenses and less on sickness expenses. Any way you turn it, Social Security or it's equivalent will need more money, and Medicare or its equivalent will probably need less.
In later sections of this book, we discuss the creation of last-year-of-life insurance, as a re-insurance step to make this transition more automatic and less a debate about fairness. It takes decades to grow this fund to the point where it can accomplish its intended goal, so if we procrastinate, the problem will someday be upon us, leaving too little time to get it started. In the meantime, it's entirely possible to spend the premium money on short-term expenses, leaving it to our children and grandchildren to worry about. Since it's absurd to suppose toddlers and grammar-school children can be persuaded to fund their retirement by agreeing to consume fewer lollipops, it seems likely the first-movers will be well-to-do-parents, seeing an opportunity to escape taxes or refund future expenses of their own, like college tuition. And then, we might play the counter-cyclic game with the economy. Ingenuity might be applied to linking immigration quotas to domestic unemployment, or top-heavy stock markets. The worse our unemployment pool becomes, the less we need immigrants, and the more we need surplus cash for retirement endowment. If we are destined to have a fairness argument about prefunding retirement, let it be based on considerations like this. At least it has the potential to set ground-rules far in advance and can demonstrate what is politically feasible. For many decades it will be impossible to guess what future costs will look like. but meanwhile, actuaries and statisticians will be encouraged to speculate on how well we are doing, and how much individuals will have to supplement from their own resources. Newsmedia will have room to find examples of people who gambled and lost, or gambled and won, or what is likely to happen to everybody who ignores the problem.
The second optimistic direction to take has been known since Aristotle. Compound interest thrives on increased longevity. Ever since the pirate ships of the sixteenth century, our country has resisted the simple teachings of this mathematical assertion. In the past thirty years, we have crossed over the bend in the curve where it really is possible to derive astonishing multiplications of assets, simply by living as long as most people now survive. Never mind the trivial or even negative interest rates imposed by the Federal Reserve. The Fed has the mandate to maintain stable prices, and it will return to it, after a brief interval of praising inflation as a useful tool to manage a recession. The sixteenth-century pirates liked shares better than gold because they never could tell in advance when a sail they were pursuing into harm's way was a rich prize or a molasses barge. If we had to, we could base our currency on common stock index funds just as well as on debt or credit, and after a brief turmoil, things would be much the same.
And finally, we are edging toward a recognition that healthcare ought to enjoy a common tax exemption. We aren't there yet, but the tax exemption of Health Savings Accounts could close most of the gap for all Americans, and it has already made considerable progress. You could close the gap entirely by the passage of a one-line amendment, but you could also essentially close it by extending Health Savings Account deposit accounts to the point where differences were no longer worth fighting over. Once again, we have crossed an invisible line. When the public sector grows to be more than a quarter of the Gross Domestic Product, tax preferences become dominant and are no longer tolerable. We aren't going to shrink the public sector appreciably, we can't grow the GDP even up to a 2% growth target. So increasing the tax exemption is about all that is left.
We might, if you like, add a fourth direction to take. At 18% of the GDP, healthcare is too large to be distorted by a linkage to employment. Everybody naturally is reluctant to threaten a gift of 20% of his income; indeed, it would seem monster ingratitude to do so. Even though we know it is unfair (after all, life is unfair), and it makes the whole structure unsound to balance the health cost of the whole nation on the one-third of the population which is working -- and on less than half of that third -- who mostly aren't particularly sick. This can't last, folks, and you can say you read it here, first.
Ben Franklin expected a hospital to pay for itself by returning sick people to employment. That misconception runs through medical payments even today.
Instead, our good intentions have created a more expensive problem, with its solutions always just out of reach. If you live longer, you get more retirement to pay for, because society also asks for an age limit to employment. Like Franklin, we might miss our target, but at least we see the goal. Right now the inevitable consequence of eliminating the disease is the extension of longevity. Because retirement is continuous while illness comes in episodes, the extra retirement cost (Social Security payments, if you please) might even become more costly than Medicare. Science may eventually cure enough disease to shave costs down to the first and last years of life, starting if possible with the most expensive diseases first. All fine enough, but not right now.
We must devise a better system than that, which like Health Savings Accounts, could expand from cradle to grave (and 21 years beyond death), generating a surplus by age 65, retaining unused medical surpluses for retirement, and taxable only at death. Because of compound interest, such a result is actually achievable but requires a discouraging length of time. We can buy more time with more money, but the public must agree it is worth it.
A lifetime perspective has six new features, because we begin with a deficit and end with a surplus: 1) Passive investing of reserves as a new revenue source 2) Twenty years of post-mortem Trust Funds to pay for transition 3) Redeployment of current Medicare payments to individual Health Savings Accounts without changes to its delivery system 4) Hooking the pieces together on individual Health Savings Accounts like beads on a string, to increase compounding. 5) Funding retirement with unused augmented Medicare funds, as diseases become cured by science. 6) Reaching zero balance at age 18, by grandparents half-funding the first 18 years for each of 2.1 grandchildren out of HSA surplus. These are unfamiliar concepts, consuming the rest of this essay.
Unfortunately, even if Congress devises a system to do all this, a century is a long time to leave your money in the hands of strangers. There would be one invariable consequence. Whether money is diverted to bankers' salaries or to aircraft carriers, rulers always prefer inflation to long term taxes, and sometimes prefer "imperfect agency" to other short term solutions. Even the Roman Empire eventually succumbed to this conflict. No one oversees other peoples' money as carefully as he would spend his own, so we stand warned by Milton Friedman that your own money management is the only peaceful oversight with a chance of widespread success. Even that success depends on running dual systems during the transition, one fading out and the other fading in. In the technical section which follows, ways are suggested to manage this dilemma, but above all, it seems best to prevent false starts by planning for them. Allow duplication, the ability to make mistakes, and a certain amount of waste from repairing bad choices, as the cost of doing business. Most flaws start as proposed solutions, so it will prove best if winners and losers are widely visible.
This Lifetime Health Savings Account is not a competition of ideologies; it is a series of seemingly unrelated mid-course corrections relating to changing age environments. It leans heavily on putting idle money to work at compound interest, preferably by John Bogle's total market indexing. Even Bogle's system works best with some initial lucky timing. But after a few decades, it would scarcely matter when you started, it only matters how much time you have left. Since the beneficiary is dead by the time of settlement, the ones who will really care are those who must pay off the debts. It is up to beneficiaries to fund it and to educate their descendants to begin early. A single system for everyone will probably never prove universally sensible for hundreds of millions of people. A voluntary system with age quotas seems the most painless way to smooth out an admittedly protracted transition. This is a long term plan with short term concessions.
Non-profit systems are not very good at weeding out failures, so for-profit competition is advisable, to speed things up. But anti-trust violation is a common for-profit short-cut, so modern approaches concentrate on preserving competition, not necessarily efficiency. Always remember we probably have plenty of money, never plenty of time. Young people almost never see it that way.
No other large nation has the money or the brashness to attempt so much change all at once, so there are few foreign models. We are pioneers, and costs will be higher for it. Scientists are not fools, they concentrate research on the eight or ten fatal diseases which (they are told) cause 70% of present costs. But several hundred other diseases wait in line, undermining cost prediction for the coming century. Nevertheless, there are only three stages in life with transitions to consider: childhood, working years, and retirement. Two out of these three are dependent on the remaining one at any particular time, but everybody gets a turn. The easiest way to pay for children is for grandparents to donate at death; the best way to pay for retirement is to add compound interest to what we already have saved, and all the rest depends on working people doing more saving, or less spending than they formerly did. There are lots of gimmicks, but that's the basic plan, while we pray for scientists to eliminate the most expensive disease instead of marking time, counting the number of grains of sand on every beach.
A good plan uses demonstration projects and accepts the possibility of occasionally slowing down. Research and development can be costly at first before costs eventually decline. We may be--or may not be-- as lucky as we were with heart attacks, in which the commonest cause of death was greatly diminished by a daily aspirin tablet. Or we may struggle on as we did with pernicious anemia and diabetes. Both diseases are treated with injections discovered almost a century ago. But pernicious anemia is treated at trivial cost while diabetes struggles as the most expensive chronic disease we have, prolonging life but not extinguishing cost. Only Americans would plunge ahead anyway, while a President would be foolish to try to change deep cultural attitudes too rapidly. We are warned not to see ourselves as exceptional, but we do see ourselves as exceptional, no matter what the facts.
The facts are the Medicare age group has most of the costs, younger people generate most of the savings. Third rail or not, the problem is to manage a gigantic funds transfer between generations while avoiding imperfect agents who divert money to their own purposes. In some ways, it is more a financial problem than a medical one. We watch private insurance pay its executives multimillion-dollar salaries, and we watch our government divert medical money for battleships and babysitting. It is time to stop watching and try modified individual ownership, putting our idle money back to work. Saving our own money for our own retirement if given a choice, instead of forcibly moving money among demographic groups of strangers. Choices should be voluntary and for-profit, so people will actually notice which approach works best, and then switch to it when convinced. This being political, some people will put their thumbs on the scale. But this being America, the public will not be fooled for long.
So this summarizes the idea. What follows is a general outline of vital technical details for pulling it off.
There are reliable estimates that about 65 cents per health insurance claim could be saved by receiving the information in electronic form rather than on paper. While the physician community may not yet be ready to submit its claims over the telephone, there are several other sources of claims over the telephone, there are several other sources of claims where there would be no technical obstacles at all to the elimination of paper claims. The first is the transfer of the unpaid balance from a primary coverage to major medical coverage ("piggybacking"). The second is the transfer of unpaid claims balances from the primary coverage to a secondary carrier ("electronic crossover").
There seem to be three reasons this obvious efficiency has not been much implemented. The first is the fact that a number of just claims are not currently submitted because of confusion by patients and their families. The second is that speedier claim payment would reduce the interest income for the insurance carrier on the premium pool, or "float". The third reason is that resulting efficiency would decrease employment in the data processing department, a consequence which is resisted by data processing managers and which top management feels insecure in demanding.
To a degree, this situation is encouraged by employers. Increased payment of benefits to the patient would increase the premium up to what it ought to be; that would benefit employees but not their employer. Elimination of the interest float would benefit physicians, raise premiums for employers. And top management in all business shares a feeling of sympathy with insurance management when it, too, demonstrates it cannot cope with the vestal virgins in the data processing division.
It seems very likely this problem would move quickly toward a spontaneous solution if a little public attention were drawn to it. The problem might profitably be discussed with members of the press, with union officials, with consumer representatives, and with state insurance commissioner, all of whom could be expected to be unsympathetic to further stalling. The introduction of a bill in the legislature would be a way of attracting the attention of the public.
IV. MEDICARE PREVAILING CHARGES (LEVEL II) 1984- PENNSYLVANIA
V. ADJOURNMENT
Influence of HCFA Regulations on Cross-Over Billing
Definition: Cross-over billing is a process by which a provider bills the primary insurance carrier, and the primary carrier then sends an electronic notification to the secondary insurance carrier. This process reduces duplicate billing, prevents errors, reduces key-entry costs, speeds the claims flow, and produces administrative savings to both insurance carriers as well as to the provider. All parties are consequently anxious to promote cross-over billing.
Problem: In the case of cross-over billing between Medicare and Medicaid, a problem is created when the provider number for group providers or assignment accounts is used since these provider number usually differ from those of the individual provider himself. HCFA rules permit Medicare to utilize group and assignment-account provider numbers, but HCFA insists that Medicaid utilize only individual provider numbers.
Proposal: That HCFA reconciles the rules for the two programs so that a uniform system is employed. The Pennsylvania Medical Society has no position as to position as to which system is superior and limits its petition to the creation of uniform rules for provider numbers.
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.
