FUSsa-talk Mailing List: Health-care

[Robert Tapp (tappx001]

[A colleague of Hadler's at UNC Medical School urged me to get this  
book. Many parallels to Becca's concern]

(this is lengthy because of the urgency of the US situation)

Clearly we spend more and get less than any other developed country.  
And the <health> share of the GDP is growing, and is already a major  
cause of bankruptcy and foreclosure. Equally clearly, the monies being  
spent by defenders of this status quo weigh heavily on congressional  
prudence!

I've just finished a rare book by Nortin Hadler. Rare because he is a  
physician, researcher, educator who has voiced his dissatisfactions  
loudly. Below are my recordings from the book (and no substitute for  
full reading!).. If you have little time, skip to the final section,  
beginning at Indemnifying Rational, Not Rationed, Health Care.

Bob
-------------------
Hadler, Nortin M. 2008. Worried sick : a prescription for health in an  
overtreated America. Chapel Hill: University of North Carolina Press.

Acknowledgment xi
Introduction 1
one The Methuselah Complex 9
two The Heart of the Matter 15
three Risky Business:
Cholesterol, Blood Sugar, and
Blood Pressure 33
4 You Are Not What You Eat 57
5 Gut Check 65
6 Breast Cancer Prevention:
Screening the Evidence 77
seven The Beleaguered Prostate 95
8 Disease Mongering 105
9 Creakiness 111
ten It's in Your Mind 135
11 Aging Is Not a Disease 153
12 Working to Death 171
13 "Alternative" Therapies Are Not
"Complementary" 191
14 Assuring Health, Insuring Disease 213



The wealth of health information disseminated by all sorts of health- 
care vendors, including those in the medical  profession, may be  
intended as helpful but often is not. Much of this information does  
violence to our sense of invincibility without doing equivalent good   
for our health or longevity. This book levels the playing field. ...is  
imbued with the teachings of Karl Popper..... Truth, he taught, is  
only the hypothesis that is yet to be disproved. 3
 Medicalization is the process  by which the morbidity is framed by  
the person as a medical illness for which medical treatment could or  
should be sought. 4
 I am not setting out to turn you into biostatisticians and  
epidemiologists. I am setting out to mold your critical skills so that  
you can recognize and contend with the unfounded assertions, tortured  
and massaged data, and egregious marketing that has always been  
present but is now industrialized. There is no other way to avoid  
sacrificing the sense that you are //well to medicalization, or worse  
yet, losing your actual wellness to iatrogenicity, the illnesses that  
are caused by medical treatments. And there is no other way to recruit  
you to my "hidden" agenda: fomenting a debate that demystifies   
"modern" medicine so that we can promulgate a rational health-care  
delivery system and underwrite its cost. 6f
A millennium ago, Europe sacrificed its intellectual roots and   
traditions to . superstition and wallowed in the Dark Ages. Meanwhile,  
science, philosophy and medicine thrived in the Arab world, with  
centers of excellence such a: Alexandria. Japanese and Chinese  
medicine and medical education also advanced in rationality and  
organization. 196
 Ginseng and echinacea are useful only as statements that you have  
disposable income and are unfazed by the clinical trials that fail to  
discern benefit for either, in particular for ginseng for dementia and  
echinacea for the common cold. ...As far as I'm concerned, they are  
all worthless unless they taste good. 204


.
The Retired Worker
I am saddling you, the reader, with quite a burden in terms of your  
health.
Even if my profession approached perfection in the healing art, it  
would not be
enough without your essential contributions. Youmust be aware of much  
more
than your own socioeconomic status. You must be aware of much more than
your own sense of accomplishment at home and at work. The greatest  
burden
I am placing on you is the understanding of the political context that  
shapes
your well-being. If yours is lacking, you will pay a personal price.  
If too many
around you are lacking in this understanding, you will find yourself  
in a world
that is angry, even desperate and possibly violent.
As for the octogenarians, to be well at your age means you have  
managed to
cope with a laundry list of life challenges. To be well, now, means  
you voyaged
through life in a comforting socioeconomic stratum. To be well, now,  
means
you managed to avoid being mired in circumstances that rendered you  
disaffected
or hostile at work or at home. To be well means you were sophisticated
enough, or lucky enough in your choice of providers, to have  
negotiated with
health-care professionals so as to enjoy interactions with favorable  
benefit/risk
ratios, to avoid iatrogenesis, and to avoid medicalization. I have  
written this
book to offer guideposts to the generations behind you who aspire to  
be well
octogenarians. However, if you're a well octogenarian, then what? You  
are of a
ripe old age. Can this be an enjoyable and joyful time of life?
Family and community are the precious underpinnings for a joyful last  
decade.
The other prerequisite relates to the entitlement of senior citizens  
to the
best health care money can buy. Senior citizens are a powerful lobby  
in that
regard. However, they have been duped into marching arm-in-arm with the
pharmaceutical industry, the hospital industry, and components of the  
medical
industry. Is Plan D of Medica re an advance in health care or in Type  
II Medical
Malpractice? Analysis of Medicare data documents that excess spending  
and
excessivecare transfers considerable wealth but does nothing for the  
well-being
or satisfaction of the elderly. All they gain is the hazards of  
iatrogenicity.
Beware of medical schemes that are offered to prolong your life. For  
octogenarians,
the goals of self-effectualness, independence, interaction, and comfort
are primary. Besides, the goal of prolongation of Iife by medical  
interventions
WORKING TO DEATH I 18g
for anything but acute intercurrent events is even more ephemeral at  
eighty
than it was at sixty.
Beware of the use of pharmaceuticals to serve the primary goals of  
selfeffectualness,
independence, interaction, and comfort. The drugs that are available
to serve these goals are limited in number and efficacy. They are  
severely
limited in effectiveness. Their therapeutic indices, the tightness of  
their benefit/
risk ratios, are inversely related to your age. That means that side  
effects
are almost as likely as benefits. Don't take any drug for these goals  
that is not
clearly moving you in the right direction. Negotiate with your doctor  
for trials
of agents where the trial has an a priori end point: either you are  
clearly better
or you will stop the drug. Otherwise, you will join the majority of  
your cohort
that is consuming pills; 40 percent consumes five or more different  
prescription
drugs each week, and one out of every eight pill takers suffers a  
serious side
effect each year.
The same sophistication in health-care utilization that will avail  
those in the
generations that follow is as relevant to you who are attempting to  
enjoy the
ripe old age you have attained. I wish you love. I wish you  
friendship. I wish you
well.
190 I WORKING TO DEATH
als of acupuncture, physical therapy, and massage. There are even  
randomized
controlled trials of "therapeutic touch" and "distant healing" that  
yield little
encouragement, if any.
The one exception relates to spinal manipulation. In 1987 my  
colleagues and
I published a randomized controlled trial we had performed with  
funding from
the Robert Wood Johnson Foundation. We recruited from the community
young people who were suffering from acute regional back pain for less  
than a
month, who had never undergone any form of spinal manipulation in the  
past,
and whose predicament was not confounded by issues of work incapacity.  
All
were examined by me and reassured. All underwent a mobilization: they  
were
gently moved from side to side and administered flexion/extension by  
my colleague
and coinvestigator, a professor of family medicine who had been trained
by James Cyriax in London in "orthopedic medicine." Half underwent a  
longlever
arm, high velocity, lateral thrust "back crack" - the bread-and-butter  
maneuver
of osteopathy. All subjects felt better on leaving the office,  
regardless of
the modality. For those who were hurting for two weeks or less at the  
time of
the intervention, all were better two weeks later, and the pace of  
healing was not
influenced by the modality. For those who were hurting for two to four  
weeks
at the time of the intervention, all were better two weeks later, but  
those who
received the single "back crack" healed more rapidly.
The world of spinal manipulation holds this investigation up as a  
landmark.
It has been reproduced many times. However, it does not reproduce in any
other subset of the universe of people suffering back pain. Only those  
who have
nonconfounded regional backache for two to four weeks are advantaged by
spinal manipulation, and only by a single encounter. Furthermore, the  
benefit
is measured in days of extra relief, not more.
All these studies are an attempt to test the therapeutic modality  
independent
of the treatment act. If the treatment act is allowed to play out,  
benefit is demonstrated
more often than not. The risk of most of these modalities is low. There
are anecdotal reports of neurological consequences of manipulating the  
neck.
Otherwise, untoward physical consequences are rare.
The Ethical Conundrum
I am willing to admit that much that is therapeutic in the practice of  
medicine
as purveyed by my guild relates to the treatment act and not just to  
the modality.
I am further willing to admit that many of our therapeutic modalities  
barely
210 I "ALTERNATIVE" THERAPIES ARE NOT "COMPLEMENTARY"
pass scientific muster. Furthermore, I am willing to admit that  
becoming a
medical patient is entering the medical therapeutic envelope more  
often than
not, and clearly too often. This book stands witness to the fact that  
I am willing
to recognize and decry many a medical modality that masquerades as  
"proven
effective." It takes its place in the scientific tradition that  
Western medicine
holds sacrosanct and that is embodied in the philosophy of Karl  
Popper. The
proud history of Western medicine is the history of recognizing,  
decrying, and
discarding all therapeutic modalities found to be lacking in adequate  
benefit/
risk ratios (though not always with blinding alacrity). The process  
may be inefficient,
is sometimes contentious, and currently is denigrated. But it is  
sacrosanct.
Therein lies progress.
Alternative and complementary modalities are widely perceived to work  
and
indeed have a life of their own. They survive in the face of science  
by relying
on such lame defense as the idiosyncrasies of their application or  
preparation;
practitioners argue that they do something differently or purvey  
something
different than whatever proved ineffective in a randomized controlled  
trial.
Circumlocution masquerades as progress. The treatment act, palliative  
or not,
is grounded in such fallacious reasoning, in beliefs that are buffered  
from refutation.
There is no progress, only the self-perpetuation of the treatment acts.
"So what?" you ask. "Who cares if the modalities are fatuous, as long  
as the
treatment act is not harmful and the clinical effect is palliative?"
I do. I care if fellow citizens are being duped into thinking that  
they are
participating in a therapeutic contract that is more than magical. I  
care that I
am being forced to underwrite such magical therapies. And I care if  
people are
unknowingly being drawn into a therapeutic envelope.
Life has many aspects that are beyond reason. Poets conceptualize "love"
better than neurobiologists dissect it. Religion has a place, for some  
a healing
place. There are even attempts to study the fashion in which religion  
might
create a therapeutic envelope. Ethnic identities, cultural norms, and  
social constructions
all have their place in the fabric of our lives. We need our beliefs as
individuals, and we need their pluralism as a global village. All can  
provide for
beauty, caring, and comfort. All can have excesses and require close  
scrutiny in
this regard. None of these aspects oflife is supported by health  
insurance. Individuals
choose to participate in and support these :valuesin their own fashion.
They are not aspects oflife supported by health insurance. Treatment  
acts based
on modalities whose effectiveness has been scientifically refuted are  
not treatment
acts; they are belief systems. I am aware of no insurance scheme that  
sets
"ALTERNATIVE" THERAPIES ARE NOT "COMPLEMENTARY" I 211
"quality" is not the goal, it is the process. Efficacy first, then  
quality promotes
effectiveness.
There is an "Effectiveness Movement," bloodied and bent but unbowed. It
can muster far more illustrative science than the Quality Movement.  
Worried
Sick is exemplar. But the forces that thwart the demand for  
effectiveness are
powerful, wealthy, and predictable. Most of the high-ticket items  
(procedures
and pharmaceuticals) are minimally effective or ineffective. Many of  
these are
considered standards of care. Many are cash cows, touted by vested  
interests.
They may be resistant to a voice such as mine, but I can teach you how  
to advocate
for yourself.
Let's say I have to treat more than fifty people in the hope of doing  
something
important for one. Do you believe that's an effective treatment?  
Nearly all of us
involved in biostatistics will tell you that such an outcome is barely  
measurable
and not likely to reproduce. Here's a partial list of treatments (most  
the topic of
chapters herein) that would not even qualify at this level of  
effectiveness based
on scientific trials designed to test their efficacy:
• Coronary artery bypass grafts, angioplasties, or stents to save  
lives or
improve symptoms
• Arthroscopy for knee pain
• Any surgery for backache
• Statin therapy to reduce cholesterol and thereby save lives
• Newer antidepressants for situational depression
• Drugs for decreased bone density
• PSA screening and radical prostatectomy to save lives
• Screening mammography to save lives
• Many a cancer treatment to save lives
The list of treatments that have been studied and fail at the one-in-  
fifty levelgoes
on and on, including many of the new drugs touted as "breakthroughs."  
Many
surgical treatments have yet to be studied. From my perspective as a  
clinician
who has cared for patients and taught students for over three decades,  
ifI have
to treat more than twenty patients to do something really meaningful  
for one,
I regard the treatment as marginal; I do not prescribe or advocate it  
and would
have no problem if it was not covered by health insurance.  
Furthermore, designing
trials to test whether new or old treatments meet this one-in-twenty  
level of
effectivenessis not difficult, expensive, or time-consuming. We would  
no longer
be marketed to prescribe and consume minimally effective treatments or  
treatments
that offered no important improvement over the tried and true.
ASSURING HEALTH, INSURING DISEASE I 21g
Ifwe have effectiveness at the base of our health-care insurance  
system, adding
cost-effectiveness and quality would be rational and straightforward. We
could well afford such a rational health-care delivery system, with  
most of the
$2 trillion to spare. We would be more "high performance" than any other
country. And our unsung, well-trained, and caring physicians, nurses,  
and allied
health professionals could get back to serving patients instead of the  
healthcare
delivery system.




Indemnifying Rational, Not Rationed, Health Care
At the outset of Worried Sick, I promised to set forth a "solution"  
that would
promulgate rational health care. I also acknowledged that no such  
solution was
possible until the people, both the well and the ill, were prepared to  
seek and
recognize the sophisms that riddle America's vaunted "health-care  
delivery
system." If I've done my job and you've done your reading, you are  
prepared,
indeed. I will keep my promise. You are also prepared to grasp the  
substance of
the solution I am proposing.
The current approach to health benefits in the United States is  
uneven, unwieldy,
ineffective, and unsustainable. Nearly all attempts at reform target its
costliness with the assumption that improvement will translate into an  
improved
benefit/cost ratio. The shibboleth of the current iteration is  
"quality," a
construct weighted heavily toward efficiency (usually in the  
industrial sense of
"throughput"). It is argued that if care was delivered more  
efficiently, it would
be less costly and therefore more cost -effective. This iteration of  
reform, I predict,
will prove as counterproductive as the precedents of recent decades.
Worried Sick is a primer on the fashion in which science calls into  
question
the basic tenet of the "quality improvement" approach. If  
medicalization and
Type II Medical Malpractice are the scourge, then the solution is to  
first target
effectiveness to improve the benefit/cost ratio. Yes, "evidence-based  
medicine"
(EBM) provides the scientific footing, but no more. But the innovation  
is to harness
evidence to the task of informing effectiveness. If any clinical  
interaction
has been studied and cannot be shown to be meaningfully effective, it  
is worthless
at any cost.
Such a simple precept demands definition of "meaningfully effective"  
in a
fashion that vests all interests in the well-being of the recipient of  
the care and
caring. The definition must preclude any other motivation. There are  
very few
unequivocally salutary events in medicine or in life. Hence, I am  
proposing an
indemnity plan that institutionalizes this creed. It is conceived as a  
benefits plan
220 I ASSURING HEALTH, INSURING DISEASE
to be provided by larger employers, although it is expected that  
mechanisms
will be developed to offer the plan to smaller employers (through  
chamber of
commerce organizations, for example). In fact, this approach could be  
state
based; each state would fund a plan based on income-tax revenues with  
provision
for those who have no substantial gainful employment. But the modeling
we have done, for convenience, is for an employer-based plan.
Financing of the Plan
Employers will contribute a fixed sum - 12 percent of wages. It  
matters little if
these moneys are collected by the state as a form of income tax on all  
employees
(my preference) or contributed by all employers and wage earners  
individually.
The money generated needs to be used to purchase the form of private  
insurance
I will describe. I fear that a federal program will be no match for  
the pressures
of Big Pharma and similar political action committees, a fear that truly
saddens me. However, competing private-sector insurance companies  
constituted
as I will describe should live out the "free-market dream," or all is  
lost.
These moneys will be apportioned as follows:
1. Administrative costs for running the indemnity scheme will be fixed  
at
1percent of wages.
2. Likewise, 1 percent will be the "profit."
3. There will be multiple codicils attached to the contracts of  
employees of
the indemnity scheme regarding conflicts of interest. Furthermore, no
officer will be allowed remuneration greater than five times that of the
average wage of those employed by the plan.
That leaves some 10 percent of annual wages, tithed monthly, available  
for Plans
A and B of the indemnity scheme.
Plan A: The Health Plan
As you are aware (since I emphasize it repeatedly in Worried Sick),  
there are important
lessons that derive from the work of social epidemiologists. Life-course
epidemiology pegs our optimal species longevity near eighty-five. The  
major
confounders to longevity reside in the course of life in a resource- 
advantaged
country such as the United States. When one examines our mortal hazard,
some 75 percent of the risk is subsumed by two questions:
ASSURINC:; HEALTH, INSURINC:; DISEASE I 221
1. Are you comfortable in your socioeconomic status?
2. Are you satisfied in your employment?
Based on these realities, monies in Plan A will be available to the  
worker to
underwrite self-improvement activities of her or his choice, which are  
offered
by professionals licensed in the state of residence. Examples include  
English as
a second language, skills training, child care, and clinical  
activities not covered
in Plan B, such as the services of licensed complementary and  
alternative
health-care providers. The indemnity scheme will offer an advisory  
service,
informing the worker of the likelihood that particular services will  
diminish
their mortal hazard as discussed above.
Plan A is financed with the moneys not expended in Plan B. Plan A is  
not a
shared-risk pool. Co-pay will be a function of years of service and  
cost to the
plan. Indemnified workers will be educated to realize that moneys  
poorly spent
in Plan B compromise their Plan A resources. Likewise, moneys not poorly
spent in Plan B provide more of the advantages inherent in Plan A.  
Moneys in
the employee's Plan A account that are not expended transform into a  
pension
at retirement or are expended to support Plan Bpremiums when the  
employee
is between jobs. These moneys are conservatively invested and secured  
from
any other expenditure.
Plan B: The Disease Plan
Plan B is the more traditional "health-insurance" component of the  
indemnity
scheme. It follows from the theoretical considerations underlying Plan A
that only some 25 percent of our mortal hazard can be ascribed to  
"proximatecause
epidemiology," or the diagnoses on our death certificates. Underwriting
programs designed to improve longevity are limited by this reality. Plan
B underwrites this "disease insurance" by indemnifying those  
interventions
that are designed to manage or cure intercurrent disease so that one  
is afforded
the longevity predicted by life-course epidemiology. "Disease  
insurance" also
indemnifies interventions that palliate illnesses consequent to  
diseases that
cannot be cured.
Plan B will be informed by a vast science, the work product of  
international
collaborations of investigators who are quantifying the evidentiary  
basis of diagnostic
and therapeutic options. Several thousand such documents are in the
public domain, supplemented by FDA analyses and, to a lesser extent,  
by similar
analyses in journals. It is estimated that some 10,000 systematic  
reviews will
222 I ASSURING HEALTH, INSURING DISEASE
be needed for a comprehensive EBM library. Furthermore, it is  
estimated that
reviews must be updated with some frequency, approaching every four  
years.
This effort will not be duplicated in the indemnity scheme. Rather, a  
group of
individuals trained in this effort will cull the practical essence of  
the extant EBM
library.
Realize that the thrust of the EBM movement is whether there is  
reliable evidence
for or against a particular clinical interface. That question is only  
the first
order for" disease insurance." The reviewing group in the indemnity  
scheme
will be charged to review the EBM literature with the goal of  
discerning effectiveness.
If reasoned attempts have failed to discern benefit from a particular
intervention, that intervention will be considered useless and  
therefore not indemnified
under Plan B.
Plan B only indemn ifies fully when there is evidence that the  
clinical interface
leads to a meaningful outcome for the individual patient:
1. For a "hard outcome" (death, stroke, heart attack, renal failure,  
etc.),
interventions are indemnified if they clearly advantage one in every
twenty patients treated (NNT = 20).
2. For a "soft outcome" (feel better, function better, etc.), there  
must be a
clear advantage to one in every five patients treated (NNT = 5).
These cutoffs are set at my level of comfort. They are driven by one's  
philosophy
of life, one's value system. I would argue that a NNT = 50 is  
ephemeral; it is
too small a health effect to measure reliably. I would countenance a  
debate as
to setting the cutoff at greater than NNT = 20 but less than NNT = 50  
for hard
outcomes. However, the debate must be transparent and public, so that  
all who
are indemnified understand that this indemnity plan is not deSigned to  
"save
money." Rather it is deSigned to "saveyour money," since moneys not  
expended
in Plan B revert to Plan A. All of us have to realize that by setting  
the cutoff
at NNT = 20, we are demanding something approaching a 5 percent absolute
likelihood of "hard" benefit. If the plan were to share the cost of  
interventions
with lesser likelihood of benefit, all the indemnified are tithed and  
each of the
indemnified have less Plan A largesse as a consequence.
However, the debate is to NNT cutoff, not co-pay.
To the extent that any clinical interface (diagnostic or therapeutic)  
falls short
of NNT criteria, co-pay will be levied. Furthermore, co-pay is  
categorical- either
100 percent or nothing. The plan will utilize the federal Medicare- 
billing scheme
with the above co-pay provisions. Many chapters in Worried Sick bear  
witness
that nearly all the elective "high-ticket" items (in terms of expense  
per event
ASSURING HEALTH, INSURING DISEASE I 223
or cumulative expense for screening/prevention) will not be covered in  
Plan
B without 100 percent co-pay according to the criteria I am  
advocating. For
example, the co-pay for coronary angioplasty, stenting, and bypass  
grafting
would be 100 percent. If you are convinced you need it, you can use  
your Plan
A moneys, and when they run out, you can payout of pocket. This is not a
"hard-nosed" posture to rationing; Plan B will not pay because the  
data says
these procedures are not worth paying for.
Furthermore, there is data speaking to the effectiveness of all  
pharmaceuticals
licensed by the FDA for thirty years. If an agent does not meet Plan B's
effectiveness criteria when compared to an older agent, there will be  
100 percent
co-pay. Therefore, the co-pay for cholesterol screening as primary  
prevention
would be 100 percent, as would the cost of pharmaceutically altering  
serum
cholesterol levels as primary prevention.
Obviously, this approach will seem counterintuitive in the United  
States, a
country that is medicalized both in terms of personal health and  
social constructions
regarding medical miracles. The introduction of the indemnity
scheme will call for a major public education and public-relations  
effort. The
readership of Worried Sick will be recruited to this effort. It is  
greatly facilitated
by the realization that all moneys not expended in Plan B reverts to  
Plan A.
Therefore, the levying of co-payments is designed to spare the insured  
unnecessary/
ineffective medicine and not to "save" money. The patient has the right
to draw available funds from her/his Plan A reserve to cover co-pay.  
However,
the insured will be asked to sign a form acknowledging an  
understanding that
the plan is levying co-pay because the value of the particular  
intervention has
proved elusive in systematic studies, and not to "save" money.
Coverage in the absence of quantification of effectiveness. Many  
aspects of
health care that are common practice have not been tested; many are  
not testable.
Most of these are not "high ticket items." However, some provision needs
to be made for their indemnification. For example, it is proposed that  
each insured
worker will be afforded a certain number of primary-care hours each year
(one or two) and counseling hours (one or two) without co-pay under  
Plan B.
Hours not expended will accumulate. Additional hours incur 100 percent  
copay,
which can be funded through Plan A.
Administering the Plan
The entire indem nity scheme will be online. Each provider will have a  
PIN to access
a personal web page, and each insured worker will have a PIN. The  
provider
224 I ASSURIN(i HEALTH, INSURIN(i DISEASE
web interface will be interactive. Based on details of the diagnosis,  
available
options will be listed with co-pay. That is true even if a patient is  
a candidate for
hospitalization or arrives at an emergency department. For  
pharmaceuticals,
the worker will be offered a menu of pharmacies convenient to his/her  
residence
when enrolling. Prescriptions will also be accessed online.
Billing will be electronic at the point of service and at the time of  
service.
Moneys will be transferred instantly to the provider's bank account.  
Administrative
overhead will be minimized for providers and the plan.
Every insured worker will receive a summary of the charges. If the  
worker
has ready access to the Internet, an e-mail will instruct the worker  
to visit a
personal website. Otherwise, summaries will be mailed. The worker will  
be
responsible for monitoring the accuracy of charges. Software exists  
for nearly
all the elements of this process, albeit for other purposes in the  
current healthcare
delivery system.
Cost/Effectiveness
Based on the per capita health-care expenditures in other resource- 
advantaged
countries, it is likely that no more than 5 percent of wages is  
required to insure a
worker and family under Plan B. This reflects the value inherent in  
underwriting
only effective interventions and the savings inherent in an online  
processing
scheme. It is hoped that pressure can be brought to bear on the U.S.  
proVider
enterprise to reduce the current 50 percent overhead costs by more  
than 50
percent, bringing them into the range of the national health schemes  
operating
elsewhere. That would lead to a substantial increment in moneys  
funding Plan
A by further reducing the cost of the effective "health benefits"  
under Plan B.
"Quality"
The indemnity scheme is designed to be intrinsically free of moral  
hazard by
institutionalizing the fiduciary responsibility of its administration.  
The design
also facilitates minimizing moral hazard on the part of providers and  
patients.
Effective care is its raison d' etre. Measuring "quality" in terms of  
efficiency and
safety is rational in a scheme that indemnifies effectiveness. It is  
also highly feasible
in a scheme that utilizes the Internet so extensively. Even  
pharmacovigilance
becomes feasible; patients can be monitored for the incidence of adverse
drug effects over time.
ASSURING HEALTH, INSURING DISEASE I 225