Improving Public Education - More is better

This discussion of education is based on the following assumptions.

1.     Democracy should afford its citizens equality of opportunity.

2.     Education, both historically and actually, is a vehicle – probably the principle vehicle for democracy to afford equality of opportunity.

3.     Financial status affords middle class and wealthy students material and cultural advantages that tend to tilt the playing field in their favor.

4.     Changes in the way we educate our children can provide better outcomes for everyone[1] and at the same time help to level playing field for the socially and economically disadvantaged. That said, I am going to principally focus on leveling the playing field. At the end I will make some comments on how this specifically may help the more materially advantaged classes.

As noted in A Framework for Understanding Poverty people are poor in more ways than a lack of money. These include deficiencies in emotional resources, knowledge resources, spiritual resources, support systems, and role models. In addition, people living in poverty learn hidden rules that help them survive in poverty but are different than the hidden rules of the middle class and keep them from moving up the socioeconomic ladder.

I would contend that school can provide these non-financial resources and provide an environment to learn the hidden rules of the class they aspire to but only if children start younger and go to school for more hours/day and more days/year. That would mean children would start school at age three, have a 9-5 school day, and go at least 200 days per year with no school break longer than 3 to 4 weeks.

The model for this can be found in KIPP schools. These are publicly funded K-12 charter schools. Their typical school day is 7:30 to 4:00. Because they are publicly funded they operate on the public school calendar although they offer summer school. Nearly 90% of their students are poor [2] but perform academically at or above grade level when compared with conventional public schools[3]. I would suggest starting this model for preschool, starting the school day later for health and academic reasons[4], and extending the school year to avoid summer learning loss[5].

The principle object of these extended hours days and years is provide an immersion experience in literally an alternative culture from the culture of poverty so that poor children can successfully move out of poverty and into the middle class and possibly beyond.

Of course, if the academic quality of those extended hours, days, and years of schooling is subpar then expanding this time will be a waste of it. That quality will depend on the quality of the methods, the teachers, and the curriculum. I know nothing of teaching methods and close to nothing about teacher standards or curriculum. However, with respect to the latter two I would like to suggest some parameters and I will do that in my next entry. 

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[1] The United States is below average in math and about average in reading and science compared to 34 OECD countries https://www.oecd.org/unitedstates/PISA-2012-results-US.

[2] http://www.kipp.org/results/national/#question-1:-who-are-our-students

[3] http://www.kipp.org/results/national/#question-3:-are-our-students-progressing-and-achieving-academically

[4] https://www.cdc.gov/features/school-start-times/index.html

[5] Summer learning loss is the phenomenon that students regress and lose up to a month of learning after the 10-week summer vacation. This is especially true of socioeconomically disadvantaged students. https://www.brookings.edu/research/summer-learning-loss-what-is-it-and-what-can-we-do-about-it/

A Framework for Understanding Poverty – no really

In 2016 J. D. Vance’s book, Hillbilly Elegy: A Memoir of a Family and Culture in Crisis was published to critical acclaim. Of the book, the Economist said, "You will not read a more important book about America this year." It the story of one family of the Appalachian diaspora that moved out eastern Kentucky and poverty after WW II, fell back into it in the 70’s and 80’s and how the author escaped but left behind the poverty that still haunts the Midwest.

This entry is not about Hillbilly Elegy. It is about a book that, in an organized and systematic way, explains every facet of the origins of poverty that J.D. Vance experienced, the patterns of culture and family structure that he experienced in poverty, and offers instruction in how to break those patterns and where Vance’s escape from poverty is a prime example.

The book is A Framework for Understanding Poverty by Ruby K. Payne.[1] Ms. Payne is a educator and she wrote this book as a workbook for teachers and guidance counselors to help them not merely deal with poor students but help them develop skill sets to get them out of poverty. More than 20% of children in this country live in poverty.[2] This is not only a disproportionate part of our population but we are 34^th out of 35 developed countries[3] with respect to the percent of children in poverty.

A patient of mine who is a retired police officer and runs a shelter for homeless women and children told me about the book and for me I did “not read a more important book about America” in 2016 and I read it on the heels of reading Hillbilly Elegy.

In the introduction she has “Key points about Poverty” and some statistics, about poverty.  Most important in this are the factor that get people out of poverty. These are that it is too painful to stay, a vision or a goal, a special talent or skill, a key relationship.

In chapter one she enumerates the factors that define poverty. Poverty is more than a lack of money. People who are poor also lack:

1.     Emotional resources, the ability to withstand hardship and persevere. She considers this the most important resource

2.     Mental resources, ability to process information

3.     Spiritual resources when present help the individual to not feel hopeless or useless.

4.     Physical resources, People with disabilities lack the ability to be self-sufficient

5.     Support systems, people or groups who provide physical, financial, or emotional support for the person in poverty

6.     Role model/mentor to model the hidden rules of the class (the middle class) to which you should be aspiring if you want to get out of poverty.

7.     Knowledge of the hidden rules of class

 

 

In chapter 3 she enumerates the hidden rules of poverty, middle class and the wealthy. People in these different classes have different relationships to very fundamental aspects of our life. The following are some examples:

	POVERTY	MIDDLE CLASS	WEALTHY
Money	To be used and spent	To be managed	To be conserved and invested
Education	Valued and revered as abstract but not as reality	Crucial for climbing success ladder and making money	Necessary tradition for making and maintaining connections
Time	Present most important. Decision made for moment on feelings and survival	Future most important. Decisions made for future ramifications	Traditions and history most important. Decisions made partially on basis of tradition and decorum

The point she makes here is that first people in poverty aren’t making “bad” choices because they are stupid; they are making the choices they make because that is what allows them to survive in poverty. Second, in poverty crises arise in the moment so time is compressed and everything is about the current moment so middle class skills like perseverance and delayed gratification are hard to master in this environment. Third the object of education (and perhaps by extension any anti-poverty program) is to educate the poor to the hidden rules of the middle class so that when they enter the middle class world (at work or school) and can find success there and hopefully find their way out of poverty.

In chapter four she delineates generational poverty, defined as two generations living in poverty.  Unlike situational poverty in which one has fallen out of the middle class into poverty, in generational poverty the hidden rules of the middle class are unknown and the hidden rules of poverty are more deeply ingrained. In addition, the family structure, discipline, and language (as presented in chapter 2) are such that they only reinforce the hidden rules of poverty.

The last half of the book consists of strategies for educators to use to address these issues. Furthermore, this book is a publication of an organization Aha Process that offers education of these strategies.

Virtually every aspect that Vance described about poverty from the multiple aspects of poverty, to the hidden rules, to the family trees. For me what was so important about this book was that while Vance's personal saga is about Appalachian poor, she make crystal clear, that poverty regardless of race color or creed regresses to the same mean and the path out is identical for all who are born or fall into poverty.

Vance suggestion that the government throwing money at poverty has largely been a waste may be because we are not focusing in on the other co-conspirators in the cause of poverty.

J. D. Vance credits his grandmother’s mentoring as his salvation from poverty and doesn’t think government can reproduce that. Of the factors that get people out of poverty (see above) the only one outside the individual is a mentor to lead them. Ms. Kane suggests that this is a piece of the puzzle that education might provide if the teaching community embraced it.

In my next blog I am going to give my thoughts on education and how to change it. Since this is something about which I know nothing there will probably be a lot of dogma. (Although I will try to reference my dogma as much as possible.) However, I would very much like to hear your thoughts (and corrections).

 

 

 

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[1] The version I read is the 2003 edition. This can be purchased used on Amazon for under $10. The version I bought is pictured above.

[2] http://www.nccp.org/topics/childpoverty.html

[3] https://www.unicef-irc.org/publications/pdf/rc10_eng.pdf

Fixing Healthcare Part 3C: Odds and Ends

Here are some other issues that would come up in a transition from our current health care system to a Guaranteed Healthcare Entitlement (GHE).

Where does the money come from? Well to begin with the money is already coming from somewhere so we could start by identifying the current sources and creating a system around that.  For instance, there could be corporate tax at approximately the rate they pay currently for health care which, from talking to at least one business owner, they would embrace in a heart beat knowing that that rate would be fixed for at least a decade.  However, it should be structured in a way that it is not based on the number of employees so as not to discourage hiring.  Medicare contributions from salaries could still be collected. A small 1 – 3 % tax on non-wage income again fixed for at least a decade could be created to cover any shortfall. 

Where does the money go? Of the $3.3 trillion we spend on health care 80 – 90% would go directly to ACO’s for patient care.   However, there would be additional cost outside of direct patient care. These would include . . .

There would be administrative cost. These would include computing the actuarial tables on which premium payments would be based.  The distribution of these payments to ACO’s would be an expense but much less than current Medicare costs because it would be a monthly lump sum payment for lives covered not a payment for each individual procedure.  Establishing what is covered and standards of care would be required and periodically updated. These would be covered.

The current bill for health care includes government agencies such as the National Institute of Health, the Food and Drug Administration, and the Center for Disease Control.  These would continue to be fully funded.

           

What to do about malpractice: If medical groups are to be open and transparent the malpractice system should be scrapped.

Malpractice is the system we have to identify medical errors and compensate people who are hurt by those errors.  The problem is that malpractice is not a system and it does a very poor job of identifying those errors and providing compensation for the errors. 

Malpractice grew organically out of the fact that there are doctors who make mistakes and there are lawyers to sue them so on a case-by-case basis we have a huge industry that awards payments to around 150,000 plaintiffs annually.[1] It is demonstrably true that there are many more medical errors than this.[2] It has been suggested that this is a reason for even more litigation[3] but the problem is that malpractice itself inhibits the investigative process that would identify individual and systemic problems, formulate corrections, and provide reasonable compensations to the injured.

Malpractice is litigation and to paraphrase Clausewitz litigation is dueling by other means. In addition, when one gets sued, their lawyer immediately advises them that they are only allowed to talk to their counsel, their spouse, or their clergy. In this secretive and adversarial atmosphere in which virtually every physician feels threatened[4] it is virtually impossible for an open and transparent dialogue to take place.

Furthermore, because especially those who, in the current system, are labeled plaintiff and defendant can’t have a dialogue a large part of the healing process is lost.

Finally every discipline has its own system for establishing truth. The legal and medical epistemologies are very different.  Medicine is disinterested, rational, and cooperative; litigation is partial[5], emotional, and adversarial.  In my limited experience legal judgments are hit or miss when they come to accurately reflecting the medical facts. 

This is not to say that medical errors don’t occur. They, of course, do but these errors would be far more likely to come to light in a system if malpractice were replaced with a no fault compensation system for medical errors.  Such a system could be run by the states by strengthening their board of medical licensure and discipline.

In summary the current malpractice system does not allow for the open investigation of medical errors, does not allow for reconciliation between the provider and the patient and family, and in general does not give justice a good name. Health professionals and patients need a better system.

There are of course a lot of other issues that I have not thought of which would effect the implementation and effectiveness of such a radical change in health care delivery.  I would certainly welcome any thoughts from readers on the matter.  If you don’t like this system you don’t have to worry because . . .

1.     I am not emperor.

2.     Most people don’t recognize the long-term deleterious effect the medical industrial complex has on the economy.

3.     Those who are concerned put the blame for health care problems on the insurers or government and not on providers.

4.     Currently, the federal government spends $1.2 trillion dollars on healthcare.[6] With the GHE that number would be 3 times that. Again We the People are already spending that on healthcare but there would still be a significant (I would say knee jerk) reaction to this “socialization” of medicine and corresponding increase in the federal budget.

5.     Since such a system threatens doctors, insurers, lawyers, and drug manufacturers it may be a good thing but the powers (read money) that would oppose it would be all but insurmountable. 

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[1] https://www.npdb.hrsa.gov/resources/npdbstats/npdbStatistics.jsp

[2]https://www.hcp.med.harvard.edu/sites/default/files/methodsmakarydaniel_2016_bmj%20%281%29.pdf

[3] https://centerjd.org/content/briefing-book-medical-malpractice-numbers

[4] 

 

http://www.nejm.org/doi/full/10.1056/NEJMsa1012370

[5] The fact that medical testimony for both litigants comes experts who are paid by those parties is the antithesis of disinterested and counter to the principles of best medical inquiry practices. 

[6] http://www.taxpolicycenter.org/briefing-book/how-much-does-federal-government-spend-health-care

Fixing Healthcare Part 3B: Changes in the delivery of care

The changes I proposed in the organization of health care would bring down the cost significantly. However, I think changes in the delivery of health care beyond what is done anywhere else could have further benefits in reducing the medical industrial complex starting with . . .

Health maintenance: When you first walk in to your doctor’s office the first thing that happens is  - data entry.  You give your demographics and your insurance information and now in a new wrinkle they ask if you are anxious or depressed, if you smoke or if you drink. This happened to me at my orthopedist’s office. None of this data collection requires the skill of a doctor.  Furthermore, the most effective solutions involve specific programs or providers that address those specific problems – the mental health counselor for those who are anxious or depressed and substance cessation programs for patients who drink or smoke.  Adding some simple vital signs and basic blood work would identify problems and direct patients to resources that would actually help them.  All of this could be done with an app without the input, and cost, of a high priced health care provider with an advanced degree.

Computer medicine: Doctors do two things; diagnose, which is pattern recognition, and treat, which always involves risk/benefit analysis.  Both of these processes are precisely what computers are good at and very probably could supplant the clinician.  For a variety of real technical as well as emotional issues that could be a stretch. However, at the very least computers could render a second opinion. As an example, radiology is all about pattern recognition. In England mammograms are read by two radiologists.  In a study they had a computer do the second reading and got results comparable to two radiologists. [1]

Technical care: Sometimes diagnoses or treatment require procedures or surgery.  Sometimes these procedures require operator discretion such as a lot of general surgery and neurosurgery. For example, a surgeon doing exploration and excision in the abdomen for cancer must identify the cancer and its extent and decide what and how he must remove what he has found. However, a lot of procedures and surgeries are routine repetitive. I would submit that technicians trained for the specific task could do a lot of these.

For example, back in the 90’s when sigmoidoscopy was the standard screening procedure for colon cancer Canada had trained nurses do the procedure with results, as would be expected comparable to doctors.[2]

I would submit that there are a large number of surgical procedures that are chronically repetitive could be done at least as well by trained technicians as it is by doctors with nearly a decade of training past medical school.

Surgical outcomes are most highly correlated with operator experience[3], and manual dexterity.[4] [5] Neither of these qualities are screened when candidates are judged by standardized testing. 

I would suggest that procedures such as colonoscopies and arthroscopies and surgeries such as cataract operations and joint replacement could be done by technicians based on their manual dexterity and their demonstrated expertise over time. Training and even a healthy low six figure salary would be a fraction of the cost of the current arrangement.

To the best of my knowledge no developed country does any of this but that isn’t to say that it can’t be done and in a fixed cost health care system there would hopefully be the motivation to experiment in this direction.

In my next installment I will talk about some odds and ends but mostly about malpractice.

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[1] http://www.nejm.org/doi/full/10.1056/NEJMoa0803545

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4071908/

[3] https://www.ncbi.nlm.nih.gov/pubmed/23932603

[4] http://www.nejm.org/doi/full/10.1056/NEJMsa1300625

[5] https://well.blogs.nytimes.com/2013/10/31/a-vital-measure-your-surgeons-skill/

Fixing Healthcare Part 3A: The organization of care

In order to implement the GHE accountable care organizations (ACO’s) would have to be created.  ACO’s are large group of physicians who would be responsible for the complete care of the several 100,000 lives who have enrolled with them. The Mayo clinic and Kaiser Permanente are groups that have already functioned in this way for decades. 

However, medical groups have been moving in this direction for a number of years so new groups could form to function in this coordinated fashion.  As an example in Rhode Island one could conceive of a metro group that would include Rhode Island and Miriam hospitals (med/surg/peds) along with Women and Infant’s (Ob/Gyn) and Butler/Bradley (psych) and all the physicians who admit to those institutions.  Another group might be northern Rhode Island and include Roger Williams, Fatima, and Landmark.

Patients choose the group they wish to belong to and groups are paid on a monthly basis.  If someone moves from Boston to Chicago they can start up with a new group at the first of the month.   If they don’t like the group they are in they can move to the group across town.

Compensation: Groups could design whatever compensation system they deemed appropriate.  However, the fee for service model would be a non-starter so all groups would have some sort of salary model. 

The following is a model I would propose that would quickly mitigate health care expenditures for the group.  Physicians would be compensated with a base salary plus incentives for care outcomes, and patient satisfaction.  There could be additional incentives for providers who create programs or procedures that improve outcomes or efficiency.  Different specialties would have additional incentives.  For instance, the specialty of primary care would have incentives for lifestyle improvements and screening compliance.  Surgeons would be would have incentives for weighted* surgical outcomes and low morbidity.  Furthermore all of these metrics would be public information so patients can make informed judgment about what group they choose to belong to. 

           

Another adjustment that, introduced over time, would create significant savings would be to make the base salary the same for all doctors regardless of specialty.  Specialists are not any more talented or intelligent than primary care physicians.  The only rational reason to compensate them at a higher level is that they have deferred salary by extending their training.  This could be addressed by either paying all doctors in training the base salary or having groups that hire specialist pay them the difference between their training salary and the base for the number of years beyond the minimum (3) they spent in additional training.  The object would not be to increase the pay of primary care but to have specialists regress to that base and thus create savings.

Such a system then shifts the incentive from adding care to optimizing care thus correcting the fundamental underlying problem with the cost of healthcare. All this can be done by restructuring medicine in a direction it is already heading and changing compensation from fee for service to salary plus incentives.

Fixing Healthcare Part 2: The Cure The Guaranteed Healthcare Entitlement.

Virtually every other developed country has a single payer system. Everyone is covered, medical outcomes are at least as good as ours, and it costs per capita half of what we spend. Those who wish to tweak the current system or introduce things like medical savings accounts are traveling in uncharted waters with four decades of mostly failure as a legacy to build on.

That said, if we are to have a single payer system what should it look like? The following is my proposal for such a system, which restructures what we have and would, by design, bring our health care cost into line with other developed countries within a decade.

In 1992 the then commissioner of education for Rhode Island Peter McWalter proposed what he called the Guaranteed Student Entitlement.  In the program the cost of a solid education for each student would be determined.  This would cover basic subjects, electives, arts, and physical education.  The state would guarantee that each student would have this amount spent on him or her throughout the state.  Recognizing that there are students with special need, these students would get an additional stipend above the initial base stipend.  At the time the base stipend was approximately $7000 and additional funding of $1500 went to students who were either low income or had English as a second language.  They would get $3000 if they were identified with a learning disability. 

            Using this program as a model I would propose a Guaranteed Healthcare Entitlement as a comprehensive plan for the complete overhaul of the American health care system.

Coverage:  The government will pay a provider group the insurance premium for everyone living in America.  The coverage will be for a level of service, which most everyone would recognize as complete coverage.  This would include office visits, tests and procedures, hospitalization, prescription drug plan, and mental health.  There may be nominal co-pays as out of pocket expense. 

The premium:  This would be determined based on the actuarial risk of the patient.  The government might pay $1000/year for a healthy 20-year-old male and $25,000 for a blind diabetic on dialysis.

However, the average premium payment would be about $10,200/year. In addition and most importantly this average reimbursement would not increase until we moved to some fixed percentage of the industrialized per capita mean (mean plus 5-10% for instance). The cost of health care would be fixed for at least a decade. Up front then the government would know their annual healthcare costs would be $3.3 trillion which is what we currently spend on health care. Thus, like the GSE, the GHE would vary the payment for the enrollee based on their projected needs. However, despite the fact that the payments would be much more variable because the projected needs would be much more variable, the national annual cost would be known and fixed.

Cost containment:  Such a system would cost essentially the same as it is now which is still twice what other countries pay.  However, we would come into line with other countries over time simply by not increasing the premium.  Initially there would be a health care bonanza for providers.  This would give provider groups time to adapt to the new healthcare order. However, for all the reasons that the cost of health care goes up, provider groups would have to find more and more efficient ways to provide for their patients.  Once we reached our target health care costs (some percent of the OECD mean) the cost of health care could go up at the rate of that target rate.

            An additional source of savings would be to allow the federal government to negotiate drug prices.  We are paying the bill.  If we realized the saving that other developed countries do with this kind of policy we could expect an immediate saving of $130 billion annually[1]. As an offset to the drug makers, the government can help streamline bringing new drugs to market and help fund research as ways of helping such companies to continue to produce new products. 

Such a plan would, in a finite and relatively predictable period of time, bring our health care cost in line with other developed countries. In doing so, it would go a long way toward allaying the anxieties that individuals, businesses, and government all feel about the cost of our medical industrial complex.

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[1] http://www.ncsl.org/research/health/pharmaceuticals/costs-and-pricing.aspx

Fixing Healthcare in 3 parts: Part 1 the Diagnosis The Medical Industrial Complex

“We don’t have a deficit problem; we have a health care expenditure problem.”

Aaron Carroll*

What’s wrong with American health care?  To paraphrase James Carville, the problem is “the cost stupid”. ** In 2016 we spent $3.3 Trillion on health care. This is twice as much per capita as any other developed country on health care.  In those countries access is not an issue because no one is uninsured.  In those countries medical bills are not the cause of bankruptcy as they are more than half the time in the United States because no one is under insured.  If our health care system were as efficient as any other developed country we would cover everyone and currently be saving $1.6 trillion per year.

If we a spending $1.6 trillion more than we should, where is that money going?  Well, Consumer Reports looked at the growth of health care spending in the United States from 1970 to the 2008.*** (This report is dated but I think the statistics hold up for another decade.) They found that the biggest growth went first to hospitals and then to doctors.  This was followed by pharmaceutical sales.  The lowest increase was in insurance administrative costs.  Therefore, most of the inordinate increase in the cost of health care goes to care.  Since we are not twice as sick or live twice as long as people in other countries why do we spend so much more on care?

The answer is multifactorial but it starts with the perverse fee for service payment system.  The problem with fee for service is not that doctors are rewarded for providing service; it is that they are rewarded for creating service.  From the extra office visit, to the extra test, to the extra procedure or surgery, doctors have an almost limitless capacity to create service and in doing so drive up costs.  The fee for service system rewards providers for the quantity of the service without regard to its utility.  If America is to cure its ailing health care system it must abandon the fee for service system once and for all. 

A second problem coming from providers, that is doctors and hospitals, is that there are no financial consequences for inefficiency.  The following is a trivial example. It had been pro forma to order 2 liver tests when following a patient who had been placed on a statin for high cholesterol.  These tests are usually done semi-annually. About ten years ago the American College of Cardiology determined that these tests were unnecessary after the tests done at the initiation of therapy.  I stopped ordering the test as soon as I read this but virtually every cardiologist with whom I share patients still orders these tests at an average of $64 for the two tests.  If this is the norm throughout the country then tens of thousands of these tests are being performed by professionals whose organization says they are of no value.  I am not sure if this is just force of habit or an “It can’t hurt” mentality but it is unnecessarily wasteful.

While the lion’s share of wasteful spending comes from providers, others share in the problem including . . .

Insurers get a lot of heat for the mess that healthcare is but their contribution to high healthcare costs is indirect. Competition in our “free market” health care system is among insurers. Since they don’t directly control the delivery of care the only things they can do to hold down costs are to limit care and to select for the healthiest panel of patients. This is inefficient and adds to higher administrative costs to providers – the estimate being an additional 10% (remember of a very big number) to the cost of health care.

Pharmaceuticals cost about twice what they do in other developed countries.[i] They spend more on marketing than they do on research which is a complete waste of money (but we all pay for it). More importantly Medicare is blocked by law from negotiating prices as part of the Medicare prescription Drug Law of 2005[ii] (sometimes referred to as the Big Pharma Relief Act of 2005).

There is controversy about how much malpractice laws drive up the cost of medicine. I think malpractice laws significantly impede best medical practices and I will discuss this in a later entry. However, if it is driving up the use of unnecessary medical services as part of defensive medical practice that is still money being spent on providers and is going into their pocket.

As I move in to my later years of practice as a physician, my biggest embarrassment is that I have been a participant in and benefactor of this wildly inefficient system that is a chronically debilitating disease impeding the health and well being of the rest of society and the responsibility for that falls largely on the people (like me), organizations, and institutions providing the care.

That said, there are no bad actors here in the sense that the players in this game are not cheating.  Providers, insurers, pharmaceutical companies, and personal injury lawyers are all doing what the system pays them to do. If you want better outcomes from your system you have to change the system and that is not going to be easy to do. Every one of these players has a huge stake in this very big pie so they have fought and will continue to fight changes that affect their share of this market.

Since the 50’s when President Eisenhower coined the phrase we have talked about the military industrial complex but no one talks about the medical industrial complex even though it is 5 ½ times bigger than the military budget. When I talk to people about this they seem to have a hard time getting their head around this probably because spending on medicine is seen as helping people and that must be a good thing. All I can say in response is, “Trust me. I'm s doctor.”

Next blog I will propose the cure.

* More dogma – not sure if this is his original quote or he is quoting someone else

** https://www.nytimes.com/2018/01/02/upshot/us-health-care-expensive-country-comparison.html?_r=0 This article antedates my comments and corroborates them. However, the article cited in the 4^th paragraph predates my thoughts on this. However, I did not plagiarize the title of the article cited.  I am not that well read to have been aware of it.

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[i]https://www.aarp.org/health/drugs-supplements/info-2017/rx-prescription-drug-pricing.html

[ii] https://www.aarp.org/health/drugs-supplements/info-2017/lower-rx-prices-drug-costs.html