Rapid Response for SATURDAY, December 7, 2019

Rapid Response for MONDAY through WEDNESDAY, January 22 through 24, 2018

1. Effect Medical Mal-Practice Reform, thereby saving a third of current medical costs wasted in "Defensive Medicine". In the process: yes: TAKE ON THE TRIAL BAR and their thousands of political representatives. The People are vastly more numerous.
2. Pay physicians and nurses what they are worth, according to education, training and experience - and their COMMITTMENT to this noble and vital profession. For the last three decades we have been the victims of Theft of Services of at least 30% of what we should be earning based upon the value of our work.
3. Restore collegiality and cooperation to the relationship between health care providers and the business people, instead of the current "win - lose" attitude too often found in current relationships, an attitude which is highly corrosive among the physicians and nurses who actually take care of people.

Rapid Response for SATURDAY, January 13, 2018

Rapid Response for SUNDAY, July 16, 2017

Rapid Response for SUNDAY, July 2, 2017

Rapid Response for THURSDAY and FRIDAY, March 9 and 10, 2017

Rapid Response for TUESDAY and WEDNESDAY, December 13 and 14, 2016

Rapid Response for FRIDAY, May 13, 2016

Rapid Response for TUESDAY, February 18, 2014

Rapid Response for SATURDAY through MONDAY, September 28 through 30, 2013

OBAMACARE - AND MY PLAN B

As a practicing physician (not a "provider") for over 56 years, I know what works - and what doesn't work - for my patients and for me.  That is what has kept me eager and effective in my work.  OBAMACARE is just the latest challenge to that work.  OBAMACARE is a monstrosity that will fall of its own stupidities within the next three years: a gaudy Christmas Tree of wants with no attention paid to the true reforms needed in the U.S. delivery of health care. 

But we must survive the next  three miserable years.  Herewith, my personal Plan B for survival in practice. 

• My greatest value to my patients is my TIME. 
• Decades ago I decided to maximize my professional time by integrating my work with that of highly trained Registered Nurses.
• This has allowed me to accept all insurance programs, regardless of the often - insulting levels of payment, except for those programs that require a prior referral from a less qualified physician, impinging on the patient's right of choice of physician.
• This has also allowed me never to have "closed my practice" to new patients.
• The only condition I place on patients in return for my continued interest and efforts on their behalf is that they be equally interested in their own care.  I work with patients, not for patients; and those who are not equally engaged, cooperative and compliant with my instructions find themselves discharged from my care.
• I offer my "best efforts " and personal devotion.  I never guarantee my work or the outcome of that work.  And I never take personal or financial risk for the outcome of that work, a stance that would put me in a conflict of interest with the patient and which thus would be unethical. 

Some of the coming demands of medical practice under OBAMACARE will place the above approach under great strain.  But that approach will not change.  Contrary to the posture of too many of my medical colleagues who, in the last two decades when ordered to "JUMP", have supinely responded "HOW HIGH?", my response will continue to be "SEZ WHO?". 

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Rapid Response for TUESDAY through THURSDAY, June 18 through 20, 2013

MEMORANDUM FOLLOWING LM HOSPITAL STAFF MEETING, JUNE 20, 2013

1.       Large revenue reductions imposed on hospitals. 

2.       Bundled payments and other changes imposing the risk of health care outcomes onto the health care providers.

3.       A significant reduction in patient volume.

4.       Regulatory impediments to maximizing economies of scale in the recent hospital merger.

5.       Alleged “quality” tracking which really turns out to be cost tracking, with payors incentivizing their customers (our patients) to enter a race to the bottom.

6.       Electronic Health Records: A Mess….

7.       A large loss of patient care to tertiary centers (eg. Yale, 40% of whose patients come from here!)

8.       Yale romancing this hospital…a change in attitude.

MY OBSERVATIONS:

1.       No surprise.  ObamaCare has no logical means of paying for its Christmas tree of gifts without making the Health Professions pay the bill…thereby hastening the demise of private medical care and the acceptance of a one payor system: the Government, and resultant lower quality, higher cost and reduced access.

2.       Imposing the risk of patient health care results on the providers is unethical, pitting the physicians’ interests against those of his patients: a conflict of interest totally at variance with the doctor-patient relationship.  It also places hospitals against physicians and physicians against fellow physicians.  This should be prohibited as against Public Policy.

3.       There are several reasons for a reduction in patient volume.  But I believe that this is temporary and that it will reverse to a mis-match between the future demand for patient care and the reduction in availability of that care by qualified personnel.  This should be one bright spot in efforts to secure a future for the Practice of Medicine: the impact of Supply and Demand.  But several points should be remembered: a) the First Rule of Service is Survival; b) if you are losing on every transaction, you cannot make it up in volume; c) “fast nickels are as good as slow dollars”; d) take all comers as patients, but devise a more efficient means of taking care of them…specifically by using more physician extenders in broadened roles (ie. one good physician in an outpatient setting can supervise as many as four good physician extenders).

4.       Appeal all adverse regulatory determinations.  Regulators – the Administrative sector – know little about the requirements of proper Medical Care, this including their academic advisors.  Therefore, the reply to the demand from Washington (“JUMP”) should not be “How High”, but “Sez Who?”  The corrosive current laws and regulations must be challenged and changed, through the Courts and through the Legislative process.  HOW LONG HAVE I BEEN SAYING THIS TO WHAT PASSES FOR OUR MEDICAL “LEADERSHIP” THAT WILL DO ANYTHING TO BE “AT THE TABLE”…AND WHICH FINDS ITSELF UNDER THE TABLE.  Also, regulators and politicians don’t give a damn about what doctors think…only about what the public thinks.  SO, EDUCATE AND MOTIVATE YOUR PATIENTS TO DEMAND FOR THEIR OWN BENEFIT.  (Again, how long have I been saying that?)

5.       And what did you expect?

6.       A pig  in a poke.  Take the penalty and run.  Even the reported benefit in coding and charging, particularly by hospitals, has been detected and is about to be attacked.

7.       A lesson for those, generally business-types, who think that there is such a thing as a “Win-Lose” outcome in negotiations, particularly when there is a disparity in negotiating strength.  The “Loser” will find a way to get justice, even if only rough justice.  So, cultivate and don’t abuse your new physician-employees…especially  now, when they are temporarily vulnerable.

8.       This is not the past.  Are there current opportunities for “Win-Win” situations here?

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Rapid Response for SUNDAY, October 5 and 6, 2012
PERSONAL SUMMARY, THE L&M LEADERSHIP RETREAT, OCT. 2012  

The following are based upon the speaker's presentation, my contemporaneous comments, a review of his slides and my reflections.  My comments are presented in italics.

1. "Transition away from episodic fee-for-service reimbursment and toward accountable forms of risk-based payment, involving case managers or population managers".     Risk-Based is based upon perverse incentives and conflict of interest between "Providers" and patients...inherently Unethical.  Case and population managing can be performed now with patient and provider incentives and dis-incentives.
2. "Value=Based Competition".  I've been doing that for 55 years...and counting.
3. 1% withhold starting now, based upon a) 70% Process Measures...Good, based upon hard research; and 2) 30% based on patient surveys...overweighted, soft and subject to manipulation. 
4. Penalty for re-admission rates: progressively 1-3%, even re-admissions for totally different diagnoses from the original admission...CRAZY. 
5. All about Cost Containment.  For example, L&M estimates that it must reduce its costs by $35 Million over the next 5 years.  At what cost in quality and in availablitry of care?  A cynical and cowardly effort by our national "leaders" to force the Medical Profession into being Rationers of Care - a worthy principle that should be decided broadly by the public and by public policy.  It is done by placing MD incentives opposite to patient needs: Unethical, undermining a learned Profession and thus  against Public Policy.  This must be litigated right up to the USSC.
6. "Hospital and MD Allignment is Critical".  YOU BET!!  Hospitals had better take care of their physicians, especially now when they could "stick it to them" in the short-term.  We are in a 5-8 year Transition period, full of uncertainties, with MD's in a weak bargaining position.  Then will follow a long period of MD ascendency...based entirely on MD shortages and population demographics.  A word to the wise. 
7. How to reduce patient and provider utilization?  We need patient motivation: passive in the form of HSA's and increased self-payment; and in the form of active penalties for continuing to pursue unhealthy life-styles.  And we need to reduce the 20-25% of health care costs that physicians produce because of DEFENSIVE MEDICINE in the current litigious malpractice climate.  Madical Mal-practice reform is crucial, changing perhaps to Health Courts. 
8. "What are the main market movers?  And what do they want?"  Of the payors, Employers should get out of the business, certainly abandoning "Defined Benefit" for "Defined Contribution" plans, with prominent patient-employee contribution.  Insurers will survive and thrive as Wall Street does: by expanding into markets that approximate Las Vegas activities.  And what about physicians? They want to provide quality care with adequate reimbuserment and little hassle.  Patients have long wish lists - as long as someone else pays for them, and as long as they don't have to change their ways.  Enough of That!
9. Currently great uncertainty.  Great expansion of Medicaid, with little concept of who will pay for it,  Changes in Medicare. The Election: a referendum on "Entitlement" spending.  A very difficult pending budget debate right after the Election.  And there will be no clear winner, resulting in the losers being enraged - more grid-lock.  All the more reason for "deciders" in the Heath Care Industry to base their current decisions not only on the transition period of the next few years, but especially on the subsequent decades - a different paradigm. 
10. This is a Penalty program, not a Reward program.  The deck is marked. 
11. Physicians programs, willingly assisted now by venture capitalists, may be better than Hospital / Physician programs.  PHYSICIANS: YOU ARE PLAYERS, NOT VICTIMS,,,if you don't "sell your soul to the company sto" during this Transition period. 
12. In some programs, consumers (patients) are being Paid to pick the lowest cost providers!  "Caveat Emptor"...and don't expect medical malpractice lawyers to get you out of this one.  Your Choice got you in trouble. 
13. Coordination of Health Care is the vital missiong link in this scenario.  This can be done by "any willing provider"...primary care or specialist...with proper financial support.  It should also be provided by Home Care (both transitional and permanent), by para-professionals (physician extenders, very valuable), by sharing resources and expenses through smart alignments, and by providing perceived quality and convenience to patients.  Regarding the last point, every in-patient in a hospital needs an advocate / ombudsman to negotiate the day-to-day uncertainties of the hospital experience and provider communication. 
14. Finally, this "Crisis" is truly one comprising both danger and opportunity,  This hospital should carfefully nurture its rerlationship with its Medical Staff, providing a true "Win-Win" situation...short-term and long-term.  And it should continue to develop itself as "sui generis" in this locale and region...and not try to follow the methods of larger, distant and different areas, which will likely be totally inappropriate to our needs and opportunities. 

I have been speaking and writing on this subject - Health Care Delivery - since the mid- 1970s.   Several of these commentaries are available on this website (www.asthma-drsprecace.com).  And any one of them could be re-published with very little change at this time.  So:

"Now is the time for all good men to come to the aid of their Profession".     

George A. Sprecace, M.D., J.D.

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U.S. HEALTH CARE REFORM: A PRIMER

Introduction:

As a practicing physician for 55 years, and as an attorney practicing and studying Health Care Law for the last 28 years, I have been writing and publishing on this subject for decades.  Much  of this production is available on relevant sections of my web site (www.asthma-drsprecace.com).

In fact, an early publication, dating back to 1978, could be re-published with only minor revision…reflecting how little progress our society has made in addressing the real issues of Health Care Reform. 

The “Accountable Care Act” (aka ACA and ObamaCare) is a Christmas Tree of “wants” that gives short shrift to the real needs awaiting health care reform.  As such, that ode to political expediency needs to be repealed and replaced. 

“With what”, you say.  Alright: ONCE MORE, WITH FEELING.

1. Nearly half of health care expenditures in this country are directly life-style related: obesity, tobacco use, alcohol abuse, illicit drug use, irresponsible motor vehicle practices, the governmental support of unhealthy personal practices like abortion, children out of wed-lock, defending failed schooling, etc.  These practices should be heavily taxed and otherwise discouraged instead of being supported as “personal choices”. 
2. A large percentage of health care costs incurred by individuals and by society occur during the last 6 months of a person’s life.  This, while a strong majority of adults support Advanced Directives…and a small minority of them actually have such “personal choice” instructions to guide their loved ones and their physicians.  Furthermore, physicians should recognize that they have an ethical obligation to refrain from offering “futile care”. 
3. At least 20% of health care costs represent “Defensive Medicine”, defined as actions taken by health care providers predominantly to protect themselves from allegations of “medical mal-practice” adjudicated in a lucrative and unnecessarily adversarial system.  The current practices should be replaced by Health Care Courts similar to Patent Courts and Bankruptcy Courts.  Only in that way can Justice be achieved and defensive medicine minimized. 
4. The great need in the existing system of health care delivery is Coordination of Care among the increasing number of medical specialists and other health care providers involved in much if not most of current patient care.  Such services are time-consuming and require a broad - based knowledge of Medicine to be effective.  They can be provided by any one of a patient’s physicians who is willing and who has the necessary level of insight and expertise.  And they must be paid for adequately!
5. There must be established and enforced – by society as a whole and not by the Medical Profession – a system of Prioritization (Rationing!)  - among the many services and potential recipients of those services.  Coverage of cosmetic surgery and of Viagra does not rise to the level in importance of immunizations.  Right now, cynical efforts are being made to force physicians to make such decisions through unethical mechanisms such as “accountable care organizations” which place a physician’s self-interest in direct opposition to the interests of his or her patients. 
6. Payment for all medical care, subject to clearly defined exceptions for indigence and serious medical necessity, should require at a 20% co-pay by the patient.  The patient must be a serious first decision-maker in his quest for medical care.  For, once a patient enters a physician’s office, the cost is generated and the service is provided.  The physician cannot and will not be the arbiter of the “need” for the care requested – or demanded. 

A comment about the much-discussed “Electronic Medical Records”.  These have been given a very high priority and much pressure by our “leaders”…not because they are so important, but because they are the easiest of the above issues to address.  Easiest, but not in-expensive and definitely disruptive of the vital eye-to-eye physician / patient and physician / physician relationships on which all good medical care rests. 

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GENERAL:

• Good attendance…a teachable moment?
• Good ideas
• Questions were fair, but could have been more probing and less repetitive.
• Too long for a sustained effort at that time of day.  Lost some control at the end.

SPECIFICS:

• Nearly all of the discussion was reactive, not pro-active.  Don’t cope; rather, Drive.  When Washington says “Jump”, don’t say “How High?”  Say “Sez Who?”.  We know better than the academicians regarding what is really needed in Health Reform.
• There was little or no discussion regarding PATIENTS, their needs, their expectations (rational and otherwise)…and their ultimate unique power to effect change (vs. we “health care providers”).
• The government interests and goals are all about COST CONTROL…at all cost, and much less about coverage.  The only ways to get cost control without provoking at least the passive aggression of health care providers are: Rationing / Prioritization, decided upon with broad public input and not imposed by the government through physicians; Medical Malpractice Reform to minimize the now substantial Defensive Medicine costs; end of life issues; motivating people, positively and negatively, regarding life-style changes that drive 50% of health care costs. 
• Coordination of Care, vital and to be performed by – and reimbursed to – any willing physician and not just “primary care” physicians.  “Specialists” now do a great deal of “primary care” and are often in a comparable position to effect coordination of care. 
• Physicians should be enlisted to help, and not demonized.  Ultimately, they are far from powerless. 
• The hospital must commit to a “WIN – WIN” game plan with their medical staff.  The alternative is only “LOSE – LOSE” !
• We cannot allow the marginalization of any of our Staff physicians, either by neglect or intent.  Again, they are far from powerless. 
• The hospital must encourage and not block the effective reorganization of the Organized Medical Staff that is in process with the development of the PAC, the re-alignment of the MEC, and their coordination as the eyes and ears of the Organized Medical Staff as the ultimate governance body. 
• There must be, in fact and in perception, a true Partnership between the Hospital Board – Administration and the Medical Staff.  And it must be realized and accepted as such by the Community we all serve.  That is not the current perception…and that is damaging.   

WE CAN DO ALL THIS !

George A. Sprecace, M.D./, J.D.

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HEALTH CARE REFORM:    ONCE MORE, WITH FEELING.

"ObamaCare", as enacted last year, is a Christmas Tree of wants, without dealing with true needs for health care reform.  And it is supposedly "paid for" through gimmicks and slights of hand.  What follows is a list of true needs for reform, from a practicing physician of 54 years experience...and counting. 
Are you ready for this? 

• Reject "capitation" as an unethical abrogation of a physician's fiduciary responsibility to his patient.  A perverse incentive if there ever was one, this method of payment places a patient's needs in direct conflict with the physician's.  It should be rejected as against Public Policy. 
• Enact effective Tort Reform, including Medical Mal-Practice Reform, in order to markedly reduce the practice of "defensive medicine", which now accounts for 20-30% of health care costs.  Specialized Health Courts, like those used in Bankruptcy, Patent and Construction controversies, would be the best way to go. 
• Encourage - and pay for - Coordination of Medical Care, by one physician for each patient, this function performed by primary care physicians or by properly inclined specialists.  
• Emphasize Health Care Accounts to restore patients' interest in the cost of their desired and needed medical care...and in their personal health and life-style. 
• Consider and approach physicians as part of the solution, and not as part of the problem...as is now the general attitude.  
• Encourage and reimburse physicians in the broad use of paraprofessionals in their practices and under their direct supervision.  
• Require that all members of the public carry a minimum amount of Health Care Insurance.  I expect that that provision of the current law will survive US Supreme Court scrutiny as being in accord with the public policy goal of covering all potential patients.  
• Distinguish between "the deserving underserved", between the honestly indigent and their lazy and greedy counterparts with regard to subsidized health care.
• Regulate drug costs, currently uncontrolled and abusive, while allowing sufficient return on company investments to promote good research...and not mainly shareholder profit.  
• Stop trying and expecting physicians to ration care, through various underhanded mechanisms - like "capitation" and "bundled payments".  A system of rationing and prioritization is needed, to separate health needs from wants, and to exclude "futile care".  But that is the purvue of public policy, arrived at through the political process and not by physician fiat, another example of abrogation of fiduciary responsibility.  
• At the same time, "futile care" as defined by two physicians in a given case, is neither obligatory or even permissive on the part of the treating physician.  Patients must be educated regarding this bedrock concept of the practice of Medicine.  
• Stop enacting and repeal rules and regulations that inevitably promote "gaming the system" in self-defense: Emergency Room practices that may be called "offensive medicine" in order to produce profit centers for hospitals so inclined; declaring as "Never Events" occurrences that are actually not under the reasonable control of the physicians and hospitals, but whose occurrence results in non-payment for the care; promoting through over-emphasis on electronic health records imaginative billing practices while ignoring the communication needs of physicians at the bedside and on the wards; a blizzard of regulations, sometimes internally contradictory, that promote an ever-increasing number of hospital administrators, each of whom has to justify his or her presence on the table of organization. 

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HEALTH CARE REFORM – A PRIMER 

1. Many articles in recent months in NEJM, JAMA, WSJ
2. “The New Value On Provider “Value”, Treatise by Alice Gosfield in Health Law Handbook, 2011 edition.
3. “What Paul Ryan’s Critics Don’t Know About Health Economics”, by Alain Enthoven, WSJ June 3, 2011, pA15.
4. “Reforming Medicare – Toward A Modified Ryan Plan”, by Gail R. Wilensky, Ph.D., NEJM May 19, 2011 p1890.
5. Articles by GS, recently posted and also written and published since the 1970’s (www.asthma-drsprecace.com)

Letter to Tom Blum, GS

It's time for another update on your future health care.  This industry and the related professions are undergoing a revolution whose outcome is very much in doubt: for the ever - increasing number and severity of sick people, for the physicians and other health care workers who provide that care in return for progressively reduced reimbursement over the last twenty years,  and for the economic health of the Nation. 
Obama-Care is a Christmas Tree of "wants" without hardly any consideration of health reform "needs" that are begging to be addressed.  This is tantamount to returning to the "bleeding" treatment of the Middle Ages instead of the judicious use of antibiotics. 
To document some of the problem, I offer several readings:

• "Obama's Running Mate", Editorial of the WSJ Thursday, May 12, 2011, pA14;
• "WellPoint Shakes Up Hospital Payments", by Janet Adamy, WSJ Monday, May 16, 2011, pB1;
• "The Millionaire Retirees Next Door", by John Cogan, WSJ Thursday, May 12, 2011, pA15...an effort to promote generational strife, in my opinion.  What is the value of $500,000. contributed by and for an average worker over 30 or 40 years of gainful labor, and invested as a fiduciary on his promised behalf by the Federal Government over that time?  At least $1 Million. 
• "The Case Against Accountable Care Organizations (ACO)", by myself.  See below.

THE CASE AGAINST ACCOUNTABLE CARE ORGANIZATIONS

(ACO)

BY GEORGE A. SPRECACE, M.D., J.D.

APRIL 21, 2011

Three tiers of ACO’s have been described.   The following refers only to Tier lll, involving partial or full capitation.  A bibliography of supporting articles and data is available. 

A)     A QUESTION OF ETHICS.  Tier lll ACO’s, and any other system involving “capitation”, a form of health care payment wherein the provider agrees to provide all necessary health care for a patient for a period of time for a fixed and pre-determined fee – in effect becoming the insurer of that patient’s health or disease needs – is Unethical: 1) it is a breach of the physician’s fiduciary responsibility to the patient in that it is based upon an inherent conflict of interest that cannot be waived by the patient; 2) it properly undermines the critical trust of a patient in his or her physician; 3) it undermines the integrity of a learned profession and should therefore be considered as against public policy; 4) it is a blatant attempt on the part of the government to make the physician impose a rationing of health care, an action properly in the realm only of the public in a democracy; 5) it is an insane risk for any physician to take upon himself, given the fact that about 50% of all health care needs are life-style related, under no control of the physician.

B)       FINANCES. 

• A Loser.
• A clear invitation and expectation for “bait and switch” tactics by the payor.
• “Price Transparency” can lead to anti-competitive practices and even to increased prices.
• Implementation can easily impact the following laws: Stark Laws; Anti-Trust laws; Civil Fraud Legislation; Fraud and Abuse statutes and their attendant “Qui Tam” actions. 
• Great limitations of data and indices used by the government in setting payment levels and other rules.

C)      ACO DEMONSTRATION PROJECTS AND ANALYSES SO FAR….

D)      THE GOOD NEWS ABOUT U.S. HEALTH CARE

E)       THE REAL NEEDS (vs WANTS) FOR HEALTH CARE REFORM.  Please see my articles and analyses dating back to the 1970’s, to be found on www.asthma-drsprecace.com

F)       ONE OF THE BASIC NEEDS IS COORDINATION OF CARE AMONG A PATIENT’S MULTIPLE PHYSICIANS…SOMETHING TOO OFTEN LACKING IN THE MEDICAL PRACTICE OF TODAY, AND SOMETHING THAT CAN BE UNDERTAKEN BY ANY ONE OF THOSE PHYSICIANS, REGARDLESS OF SPECIALTY. 

GS

February 19, 2009 - And now to the greatest preoccupation of the new Administration after the Economy: "Health Care Reform".  Here, the best we can hope for is efforts at the margins of what really needs to be discussed and resolved; electronic health records, the least important but the most and most easily discussed; too much health care, a veritable buffet requiring priorities and rationing of needs vs wants; forced mediation of malpractice disputes instead of litigation...a lose-lose exercise for everyone except the lawyers; promote heavily Health Savings Accounts, thereby finally including the demanding/needing patient in the decision-making process, instead of systematically undermining that vital option; bring abusive managed care organizations to heel; emphasize patient responsibility, while half of Americans' illnesses are directly life-style related; emphasize and pay for coordination of care, whether by the primary care physician or by a caring specialist; promote and encourage the activities of "physician extenders", under the direct supervision of physicians; and reach out to physicians and other health care providers for a partnership in the process...instead of reaching out with the stick for the favorite pinata.  And wouldn't that be a breath of fresh air.  Meanwhile, don't hold your breath.

Managing Managed Care, GS

What is the Doctor-Patient Relationship?, GS

Two articles in a recent edition of the New England Journal of Medicine discuss "new developments": "Large Employers' New Strategies In Health Care" (NEJM, Vol 347, No 12, Sept. 19, 2002, p939); and "Changing Health Insurance Trends" (ibid, p 956).  The latter article even reports the finding that 'on average, insured persons seek medical attention less often when they have to pay a portion of the cost out of pocket'.  Imagine that!  All such disclosures should be compared with the contents of my article published in the New London Day, May 27, 1978, and entitled "Don't Blame The Doctors For Rising Medical Costs."  Some things never change; and some people never learn.

See, "Lawrence & Memorial Needs New Vision For The Future", by Robert A Linden, M.D., The Day, Tuesday, May 10, 2005, Commentary, pA9

"Managing to Survive...an Internist's Story," Anonymous

"Getting Uncle Sam To Cover Your Massage", the Wall Street Journal, Tues, Nov 5, 2002, JKPersonal Journal, Sec. D1.

"Rationing Health Care: Does it work?" The Pharos,  Summer 2002, pp. 13-19

"You Can Make Them Pay: new ways to appeal make it easier to take on health insurers and win", the Wall street Journal, Personal Journal, Sept. 17, 2002,  D1.