Are Obesity Policies Too Thin?

Russell Jackson reports in Southern California Physician: Obesity is an increasingly urgent medical issue. A Journal of the American Medical Association report says that obesity-related deaths - those caused by lousy eating and exercise habits - rose by one-third from 1990 to 2000, to about 400,000 a year. By comparison, smoking-related deaths totaled about 435,000 in 2000.

Indeed, the Rand Corporation, a think tank in Santa Monica, says that in the next 20 years, obesity-related diseases will cancel out advances in technology and treatment. It predicts that by 2020, about 20 percent of health care expenses for people between 50 and 60 will be tied to obesity-related disabilities.

Further, the National Institutes of Health in Bethesda, MD, reports that about two-thirds of American adults are clinically overweight-meaning their body mass index is between 25 and 30. Of them, about one third - or about one in five adults - is actually obese.

All that extra flab has an enormous price tag. "Among the obese, lifetime medical costs related to diabetes, heart disease, high cholesterol, hypertension and stroke are $10,000 higher than among the non-obese," says Fay Bhattacharya, MD, PhD, Assistant Professor of Medicine at Stanford University. "In year-2000-equivalent dollars, $31 billion was spent in 1996 for adult overweight- and obesity-related cardiovascular disease treatments alone. Among the overweight, lifetime medical costs can be reduced by $2,200 to $5,300 following a 10 percent reduction in body weight."

So why haven't insurance companies stepped up to he plate to make obesity "prevention" a priority? Some have. (Seewww.socalphys.com.)

Our Voice: They shouldn't. Preventive medicine is not an insurance issue. I once ran a cigarette-withdrawal clinic. As in most cases, our success rate was less than sterling. One patient epitomized the attitudes about prevention: If I join your group, I really have to stop smoking. So I'm joining Smoke-Enders because they said I can join them and not have to quit smoking.

Patients will utilize their insurance benefits as well as their preventive medicine benefits and see no connection with the latter changing their behavior in the former unless they are partially responsible for their insurance benefits. We have found that a copayment proportional to the total cost of care is the only way patients learn the connection between habits and health. If all insurance had a copayment for every hospital stay or office visit proportional to the cost,utilization would decrease, health-care effectiveness would increase, quality would improve, and cost of health care would be brought under control without any government or HMO intervention. The army of reviewers could return to the practice of nursing, relieving the nursing shortage.


Despite the Hype, Bottled Water is Neither CLEANER nor GREENER than Tap Water.

Brian Howard, Managing Editor of E Magazine, reports in CSA Bulletin: Message in a Bottle. "You drink tap water? Are you crazy?" asks a 21-year-old radio producer from the Chicago area. "I only drink bottled water." In a trendy nightclub in New York City, the bartender tells guests they can only be served bottled water, which costs $5 for each tiny half-pint container. One outraged clubber is stopped by the restroom attendant as she tries to refill the bottle from the tap. "You can’t do that," says the attendant. "New York’s tap water isn’t safe."

Whether a consumer is shopping in a supermarket or a health food store, working out in a fitness center, eating in a restaurant or grabbing some quick refreshment on the go, he or she will likely be tempted to buy bottled water. The product comes in an ever-growing variety of sizes and shapes, including one bottle that looks like a drop of water with a golden cap. Some fine hotels now offer the services of "water sommeliers" to advise diners on which water to drink with different courses.

A widening spectrum of bottled water types are crowding the market, including spring, mineral, purified, distilled, carbonated, oxygenated, caffeinated, and vitamin-enriched. There are flavors, such as lemon or strawberry, and specific brands aimed at children. Bottled water bars have sprung up in the hipper districts, from Paris to Los Angeles.

The message is clear: Bottled water is "good" water, as opposed to that nasty, unsafe stuff that comes out of the tap. But in most cases, tap water adheres to stricter purity standards than bottled water, whose source–far from a mountain spring–can be wells underneath industrial facilities. Indeed, 40 percent of bottled water began life as, well, tap water.

To read the entire report, go the California Society of Anesthesiologists site atwww.csahq.org/pdf/bulletin/issue_6/water043.pdf.

Our Voice: The United States has safe tap water. There is no need to spend three times as much for bottled water as for gasoline, or pay as much for one Evian bottle of water as for 1000 gallons of tap water.


The Tale of a Battle That May Be Lost Before You Even Know of its Existence.

Barry B Sheppard, MD, President of the San Mateo County Medical Society, writes in "Of Gypsies and Gaffs": "When I was a much younger man, the term Gypsy brought to mind romanticized visions of a nomadic people able to tell fortunes and work small magics. And Gaffs were very large and wicked-looking hooks mounted on the ends of poles used to land the sharks my father and I sportfished off the coast of South Carolina. For the past few weeks, however, I have become embroiled in a struggle involving GPCIs and GAFs of a very different nature. To emphasize the point that this is my own, and therefore biased, account of the situation as well as to allow for some blurring of the identities of the players, I have set this tale to paper in the form of a Grimm’s fairy tale—the grim part being apropos as well.

"Once upon a time, about seven years ago, a wicked Queen, later to be known as the Centers for Medicare and Medicaid Services, sent out a decree across the fair land of California. The land was to be divided into regions on the basis of similar expenses incurred in providing health care to the people in an effort to adjust for, to some extent, widely varying office rents, employee reimbursement levels, etc. in the various regions of the state. Each resulting Locality would then be assigned a GPCI (Geographic Practice Cost Index), which had the power to transform itself into a GAF (Geographic Adjustment Factor); and each GAF had the power to alter the Medicare gold that funneled through the office en route to physicians. The piles of gold, when touched by the GAFs, would be adjusted heavier or lighter depending on the cost of practicing medicine in each region. Each GAF, however, only had a single spell and thus each pile of gold entering a particular locality was adjusted to the same amount for all the GAFs in that locality. Even though the system was designed to correct inequities of cost incurred by physicians, the amounts of gold were so miserly that no one in the kingdom was happy.

"In setting up the localities, however, the wicked Queen was not diligent in her duty. She began by carefully measuring and sifting through regional differences in cost of practice and established six counties as rightfully having their own locality. She then lumped two similar counties into a seventh locality. Beginning to tire of the tedium of the process, she lumped three counties into one locality, Locality 3, despite a significant cost difference in one county from the other two. Looking at the daunting number of counties still to be apportioned, she threw up her hands in disgust and lumped all 47 of the remaining counties into one locality, Locality 99.

"Soon afterward, four of the 47 in Locality 99 realized that their costs were significantly more than the costs of their fellow counties in that locality. However, try as they might over the ensuing years, they could not escape the locality. One well-conceived plan was stymied by Parliament largely because of opposition from the other 43 counties that benefited from GAF-averaging with the "high-cost" counties..."

If you're still with Dr Sheppard's government fairy tale, feel free to read the entire Grimm story atwww.smcma.org/Bulletin/BulletinIssues/Oct04issue/President.html.

The Voice of H R Greene of SMCMA's Board of Directors: "We all know that the RBRVS hasn't done what it's supposed to do, accurately build our overhead costs into Medicare reimbursements. If we don't get everything we're entitle to, we pay doubly because the commercial payers peg their reimbursements on Medicare... . We have joined with ACCMA and SCCMA to reject the CMA plan."

Our Voice: Actually, there is no need to read the entire Grimm Fairytale. All government programs are variations of a Grimm tale. As physicians, we deal with the medical needs of each individual patient. Any attempt to lump one patient's needs with another's, even our own, interferes with helping one or both. When the government groups millions in one pot, no individual’s medical needs can be fully met. The quality of care plummets and a large segment of society is no longer helped. This then begs the validity of the initial government "help" program.


The Battle to Defeat Cancer: Intro to 'OMICS

This current issue of the UC Davis Cancer Center SYNTHESIS discusses the battle to defeat cancer, which progresses on multiple fronts. The two most important aspects of the battle are patient education and biomedical research.

For generations, scientists have worked to understand the cell down to its smallest components. Today researchers in genomics, proteomics, transcriptomics and metabolomics seek to understand the cell as a whole, in all its complexity.

Elbert Branscomb, associate director of the Biology and Biotechnology Research Program at Lawrence Livermore National Laboratory, likens cells to small cities. "Think of a cell as the whole city of Chicago, at rush hour, busily making another Chicago," says Branscomb, who is also a member of the UC Davis Integrated Cancer Research Program.

The mind spins at the immensity of the challenge: Each human cell has at its disposal about 30,000 genes, the sum of the human genome. Together these genes are capable of producing, via a manufacturing process known as transcription, perhaps 100,000 different proteins. It's the proteins that carry out the cell's work, or metabolism. How many byproducts of metabolism there are - the metabolites - is unknown; a common estimate is 3,000.

For cancer research, the implications are tremendous. "We are moving towards an understanding of cancer that will enable us to tailor-make the optimal treatment for each person," says Hsing-Jien Kung, deputy director of the UC Davis Cancer Center and director of its basic science program. "This university has made a tremendous, multidisciplinary commitment to this revolution, and we are leading the way into the future."

Read the entire article on the exciting research at our own UCD Medical Center at www.ucdmc.ucdavis.edu/synthesis/.


The Secretary of the Navy wants YOU on ACTIVE DUTY In Washington, D.C.

Richard Deaner, MD, in a Guest Editorial in the Kern County Medical Bulletin, reports recently that in February 2004, he received an official looking letter from the Navy Department. He opened it with foreboding as if opening a letter from the IRS. But these were official orders 25 years after his Navy retirement in 1979. He pulled his Navy dress blues out of mothballs and found they didn't come close to fitting. He then reread the entire set of orders, more calmly this time. "Don't wear a uniform," they said. "I would be on active duty for only 10 to 14 days, unless they decided they needed me in Iraq."

Dr Deaner was being asked to serve on the Secretary of the Navy's Retiree Affairs Committee–the only MD among the 24 retired Navy and Marine Corp members comprising the committee. In the subsequent email exchange, "Why Me?" was answered "We want to pick your brain about Medicare, VA benefits, medical benefits, retiree pharmacy benefits–cool stuff like that."

Dr Deaner states he really enjoyed this ego trip at age 72, flashing a military ID, snappy salutes of the Marine guards, a stay at the Marriott with a view of the Pentagon while his wife enjoyed shopping, visiting old friends, touring the monuments and memorials. Dr Deaner said working from 7-5 daily sure beat being retired.

When asked what else did the committee discuss? He replied classified stuff sometimes. As in Mission Impossible, "I could tell you–but then I'd have to kill you." You gotta love it, he concludes. This editorial is not posted at their site:www.kms.org.


Thoughts on Rights, Privileges, and Medicare

Merwyn G Scholten, Executive Director, in his Mert's Musing column, thinks health care is a privilege and not a constitutionally guaranteed "right," as some seem to believe. As a fiscal conservative, I worry about the ultimate cost of things. Unfortunately, there are too many who tend to take health care expenditures for granted. We've been isolated from actual costs of medical care since the post WWII days when health insurance became a fringe benefit of employment for literally millions of Americans. Individual responsibility was lost in favor of letting someone else pay the cost.

And when Medicare and Medicaid became law in 1965, millions more Americans took the coverage offered and were mostly immune to the costs of providing the care beyond small copays for Medicare and a few dollars withheld. from Social Security checks.

Now, we are reaping the end result mode where everyone is questioning every cost and trying to find solutions. We're seeing employee unrest at increasing co-pays and premium cost-sharing which is cutting into their take-home pay. Unfortunately for medicine, the solutions are too often found in simply paying the provider of the service less for each service rendered in an effort to save dollars to provide care for more eligible citizens.

Meanwhile, government continues to add benefits. Currently it is the prescription drug benefit which is being added (at some ultimate cost yet to be determined). I continue to question the arguments for adopting the program. It was always made to sound like every Medicare recipient is a poor, downtrodden street person or a lonely widow who can barely afford to buy food or find shelter yet alone buy expensive needed drugs. The reality is that a relatively small percentage of Medicare recipients really need (or desire) drug coverage. Many of our elderly live very happy, healthy lives taking nothing more an occasional aspirin while others do require maintenance drugs for their diabetes, heart conditions, etc.

Let's not forget that our current Medicare population is also worth a collective trillion dollars plus according to estate planners and others who talk frequently about what the current generation is going to have passed on to them over the next 10 to 20 years. They are not all street people; they have dignity and fiscal ability to be responsible for themselves.

I, for one, am not looking forward to having to enroll in Medicare in the next couple of months; I'm not excited about a "one size fits all" program that begins to limit my choices and options and whose aim is to make me dependent on the federal government to make my health care decisions.

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Vital Signs, the official organ of the Fresno-Madera Medical Society, is a 12-page non-glossy magazine published monthly. It is primarily written by physicians and thus a true "Voice of Medicine." Hats off to a medical society whose members still communicate with each other on a monthly basis. We've selected two "Voices" from the last two issues.


Solution for Malpractice Actions

David Hadden, MD, a Fresno pathologist, was sworn in as President of the Fresno-Madera Medical Society in January 2005. He recently attended a NORCAP meeting where the speaker sported both law and medical degrees. Hadden found it hard to conceive of someone being able to keep up with all the changes required to be both a good physician and a competent attorney.

When the speaker gave forth with the trial attorneys' talking points that the problem with malpractice was poor investments on the part of insurance companies and not outrageous awards, it was easy to see that he had eschewed science for money. He made the unsupported claim that MICRA had nothing to do with California's lower rates. At that point, Hadden turned him off and resorted to his own musings.

What kind of system is it where an attorney can sue beleaguered physicians and make more money in a year or two than the doc will make in a lifetime?

What kind of system is it where a lot of money is considered to be the salve for pain and suffering?

What kind of system is it where we cure illness and get Medi-Cal while the attorneys cure nothing and get contingency fees? Ah, there's the answer. Let's give the attorneys "Law-Cal."

It would start, of course, with the promise of usual and customary fees. These would be scaled back as the system runs out of money. Each attorney would be entitled to a thick book of billing codes. Each person he deposed would be assigned a code based on age, sex, height, prior experience, education and more. Of course, these codes would be regularly denied, forcing appeals--all of them handled by disgruntled, failed paralegals. Need I mention delayed payments? Certainly, any claimant who felt a settlement was unfair could sue the attorney.

This system would work because of a surplus of lawyers. This state supports, with our taxes, a number of law schools. But we have a shortage of nurses. Why not close the law schools and open nursing schools? Would health care improve with more nurses or with more lawsuits?

As the conference went into a break, Hadden just wanted to say, "Give me a Break."


Will Computers Rule Our Lives

Merwyn G Scholten, Executive Director of the Fresno-Madera Medical Society, writes his Mert's Musing column about a penetrating and thoughtful email missive he received in December from retired cardiologist Lauren Grayson, MD. The information that can be gleaned in unrelated activity is phenomenal.

The audio-visual email allows the viewer to witness a conversation between an employee and a gentleman ordering two pizzas via his cell phone. Before he identifies himself, the young lady taking his order knows his name, national identification number, address, place of business, etc. When he tries to order two double-meat pizzas, he's told he should be ordering the healthy "sprout submarine combo" with tofu sticks because of his high blood pressure and cholesterol count. She accessed his health record via his health insurer.

She further notes (from her computer) that considering his recent 42-waist trouser purchase, he should be eating the healthy special. When he insists on the double-meat pizzas, he is told the cost includes a $15 delivery surcharge because he lives in an "orange zone" of criminal activity-- a house on his street was recently burgled.

He will have to sign a wavier to absolve the pizza shop of any health liability. She allows how he can afford the now-$67 order given a recent purchase of airline tickets to Hawaii, but then reconsiders when she sees he bought a book on how to do Hawaii on the cheap. Finally, she tells him he'll have to pay cash because his credit cards are maxed, but he can save $3 with an on-line coupon available through a magazine to which his wife subscribes. By now he’s relented and ordered the sprout submarine combo, so his total after using the coupon will be only $19.99.

Although Mert makes an excellent point that we must be on guard to prevent our lives from being taken over by automation, he veers sharply to the left in saying that's why HIPAA regulations make sense. But HIPAA safeguarding our privacy exposes us and our patients to the greatest invasion of our privacy, without consent or even disclosure. It is a fox at the chicken house door.


Personal Health Information is Freely Available Because of HIPAA

Before I could purchase my prescriptions recently, I had to sign a HIPAA agreement. It was impossible to read all the fine print standing in line. But there were six Health Information Rights (HIR) concerning my Personal Health Information (PHI). These included: (1) request a restriction, (2) request an amendment, (3) receive an accounting of disclosures that have been made, (4) inspect and receive a copy of my PHI on file, (5) request communication at a specific phone number or place, (6) an assurance that they will accommodate if they think it is reasonable. Implement any of these HIRs would cause great consternation for the people in line and so my signature was given. But it is a signature given under duress, as most government signatures are given.

What is not always apparent is how the pharmacy (or other health providers) can use the PHI without any further notice. My PHI can be used to contact any health care provider deemed necessary; emonitor my performance; inform contract providers, business associates, or anyone involved in my care or that pays for my care; contact me for refill reminders, treatment alternatives or other health-related benefits and services they think may be of interest to me; fulfill any requirements of my insurance or workers' comp carrier. My PIH be discloses to my insurer or benefits manager; the FDA; public health or legal authorities charged with preventing or controlling disease, injury, or disability; to oversight activities including audits, investigations, and inspections, as necessary for their licensure. It can be used for law enforcement purposes, or as required by any law; for the government to monitor the health care system, government programs, and compliance with civil rights laws. My PHI can be used in response to any lawful process by someone else involved in the dispute.

The pharmacy is also permitted to use or disclose my PHI under any of the following circumstances: research; coroners, medical examiners, and funeral directors; organ or tissue procurement organizations; notifying a family member, personal representative, or another person for my care; correctional institution; military commanders if in the military; federal officials for intelligence, counterintelligence, and other national security activities authorized by law; protective services to the President, or foreign heads of state or special investigations; to government authorities or social service or protective service organizations if they suspect that I'm a victim of abuse, neglect, or domestic violence.

The pharmacy will obtain my written authorization before using or disclosing my PHI for any other purpose other than those listed above.

I wonder WHO does not have access to my Personal Health Information under HIPAA? HIPAA really opened Pandora’s box for wide dissemination of PHI without notice or disclosure.

Who was sleeping at the brig when this law was being introduced? Either advocacy does not work, or our organizations were on the wrong side of the debate and failed to protect ours and our patients’ interests.


Does America Need Socialized Medicine?

Jane Orient, MD, in the current issue of The Freeman, responds to New York Times’ Columnist Paul Krugman, who attributes "America's Failing Health" to the lack of Canadian-style socialized medicine and thus to the persistence of a free-enterprise sector in American Medicine. Because these "interest groups are too powerful, and the anti-government propaganda of the right has become too well established," his prescription is a "modest step in the right direction," rather than a one-step enactment of a Canadian system.

Dr Orient, who is the Executive Director of the American Association of Physicians and Surgeons, enumerates how we have been taking such "modest steps" toward socialized medicine since the 1940s. There was Hill-Burton, or federal aid to build hospitals, in 1946 (costly hospital care taking decades to dismantle); Kerr-Mills, to provide federal aid to elderly who couldn't afford needed medical care, in 1960; then Medicare in 1965, and Medicaid. During the Clinton years, there were additional modest steps, notably the State Children's Health Insurance Program (SCHIP). Then George W Bush brought us another try at a Medicare prescription-drug benefit, to be implement in 2006 - unless there's a replay of seniors' reactions to the last attempt to introduce a prescription-drug benefit in 1989, when they assaulted Rep Dan Rostenkowski's car.

Orient asks, "What has been the result of these incremental intrusions into American medicine? An ever-increasing number of uninsured!"

Krugman disagrees. He feels the real explanation is that there hasn't been enough federal intervention. The remnant of a private sector competing with the government for those scarce resources is, paradoxically, the cause of the problems.

To read Dr Orient's analysis of what Krugman's recommendation for a Canadian Medicare system would mean for our country, please to go www.fee.org/~web/0105iolpdf/IJAS.pdf.

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Doing the Right Thing - Return to Solo Practice

Eric Holmberg, MD, a Petaluma family physician , writes the featured article in Sonoma Medicine. He left a salaried position at the Petaluma Health Center and embarked on a solo medical practice. "This move seemed to fly in the face of common sense because the number of private-practice physicians in Petaluma has steadily dwindled over the past decade, with the principal efflux going to Kaiser and most of the remainder to practice opportunities outside of Sonoma County."

Holmberg states "... in 1992, most young physicians I knew would have been happy to open their own offices or join existing practices to replace their happily retiring older colleagues. Today, however, the ravages of managed care, and the advent of a health system controlled by the insurance industry and neglected by government, have left a barren landscape for new physicians."

He had for some time thought about returning to a smaller model of care, "... and the shift finally seemed right last year," he states. "I didn’t intend to practice completely alone; but when partners did not readily materialize, I realized that solo practice was quite doable and perhaps in some ways for the best." After being on his own for almost a year and enjoying work once again, he's been able to fix nearly everything he was unhappy about previously.

"With the exception of a few out-of-town trips, I have taken all my own call during this time. Call is much less burdensome than I thought it would be, other than the need to be always available. Patients have both my home and cell phone, and they don’t abuse them. I know the patients who are calling, and I can access their charts and our appointment schedule over the Internet. I never have to quibble with the on-call doctor’s decisions. My patients seem quite happy, and the practice continues to grow steadily without the need for advertising."

He concludes that to be of real value to patients, the private-practice community needs to offer something unique. "We need to differentiate ourselves from the HMO model by being more accessible, flexible, and caring, and by knowing our patients as well as we possibly can. We have lost the early battles for information retrieval, system organization, and pharmacy management; but as we strive to improve these aspects of our practices, we should also offer the one alternative that patients are most enamored of: the chance to know and be known by your doctor." To read the featured article, go to www.scma.org/magazine/scp/sp05/holmberg.html. 


A Gynecologic Perspective of The Young Female Athlete

Susan J. Spencer, M.D., who practices obstetrics, gynecology and reproductive endocrinology in San Mateo, writes in the San Mateo County Medical Association Bulletin, that exercise is good, but from the gynecologic perspective, there are potential reproductive health concerns for the adolescent engaged in strenuous sports. "Back in 1970, Rose Frisch published in Science the seminal paper on the link between body fat and the initiation of menstruation (menarche). Her key observation was that late-maturing girls gain fat more slowly. Her research established the hypothesis that menarche, as well as maintenance of menstrual function, is related to the percentage and absolute amount of body fat. We now recognize that there is a link between extremely vigorous physical activity in female athletes and menstrual dysfunction. The term 'exercise-induced amenorrhea' has been used to describe the suppression of central nervous system pulsatile hormone secretion by the stress of vigorous exercise and concomitant negative energy balance.

"In 1992 The American College of Sports Medicine coined the term 'Female Athlete Triad.' This syndrome is defined as disordered eating, osteoporosis, and amenorrhea that occurs in women engaged in regular strenuous exercise or sports activities. For those of you accustomed to acronyms, I do not believe the authors wish to refer to the syndrome as "FAT."

"In the young female athlete, weight can become a preoccupation. Abnormal eating behaviors may arise in young women, but most vulnerable are those involved in athletic activities that are weight-bearing and favor leanness for performance, such as ballet and gymnastics.

"By the age of 10 years there is a demonstrable difference in concern about eating and weight between girls and boys. One study showed that by fifth grade 31 percent of girls are dieting, and by sixth grade, 62 percent are dieting to lose weight. Thus it appears that attempts to diet in an effort to control weight are common in prepubertal and pubertal girls. All it takes is a glance at Teen Vogue or Britney Spears’ latest video to realize that young girls are bombarded with images that reinforce abnormal eating patterns. Other factors thought to increase a young athlete’s risk for the disordered eating component of this triad include frequent weigh-ins, an overcontrolling parent or coach, and the social isolation of individual sports compared with team sports."

In summary, Spencer states there are potential health risks for young women in strenuous sports and exercise programs. "Physicians and parents need to be cognizant of the Female Athlete Triad. Supportive care for the adolescent, with collaboration between pediatrician, gynecologist, orthopaedist, and parents, greatly enhances recovery." To read the entire article, go to www.smcma.org/Bulletin/BulletinIssues/March05issue/A%20GynecologicPerspective.html.


The Trouble With Day Care

David Feddes, in his Mother's Day message on the importance of motherhood, points out that a Canadian kennel will not place a new puppy in a home with both parents working. He states that equally damaging as a dog being at home with no master, evidence is increasing that a child without either parent at home has a significant chance of behavior problems.

Heide Lang, in the current issue of Psychology Today, discusses the trouble with day care and questions whether scientists are telling parents the whole truth? Stanley Greenspan, a George Washington University child psychiatrist, says the current state of day care could be the greatest social experiment of our time, in which millions of parents are unwitting participants. "In just 25 years, American families have been radically restructured as the number of women in the workforce has nearly doubled. Instead of parents providing early child care, it is outsourced to virtual strangers. An estimated 12 million American infants, toddlers and preschoolers-more than half of the children in this age group-attend day care. The majority of these kids spend close to 40 hours per week in day care; many start when they are only weeks old.

The raging debates around maternal guilt, work/family balance, money and childrearing often drown out scientific insights into the developmental pact of day care. But the latest findings from a huge, long-term government study, are worrisome. They show that kids who spend long hours in day care have behavior problems that persist well into elementary school. About 26 percent of children who spend more than 45 hours per week in day care go on to have serious behavior problems at kindergarten age. In contrast, only 10 percent of kids who spend less than 10 hours per week have equivalent problems."

"Developmental psychologists are sweeping this information under the rug, hoping studies will churn out better data soon," argues Jay Belsky, a child development researcher at London's Birbeck College and a longtime critic of his fellow scientists. He contends that the field of developmental psychology is monopolized by women with a "liberal progressive feminist" bias. "Their concern is to not make mothers feel bad," he says. To read the entire article, go tohttp://cms.psychologytoday.com/pto/home.php. 


Saving MICRA

Sonoma County Medical Association President Heather Furnas, MD, notes that "In the CIA thriller Spygame, Robert Redford’s secretary bemusedly questions his flurry of seemingly paranoid activity. He pauses a moment before asking her, "When did Noah build the ark? Before the rain …… before the rain."

"Dark clouds are presently gathering over MICRA (the Medical Injury Compensation Reform Act that California enacted in 1975), and CMA is making plans to build an ark. In the current legislative session, Sen. Tim Torlakson (D-Antioch) plans to introduce a bill to raise MICRA’s $250,000 cap for 'pain and suffering' to more than $900,000." (This has since been withdrawn.)

"How lucky are physicians in Sonoma County? Compared to non-MICRA physicians in similar locations around the United States, our malpractice premium costs are almost 80% lower. The average non-MICRA annual premium for all specialties is $90,602; for MICRA, it’s just $19,445.

"What are we up against? A whole lot of money. The No. 1 priority of California trial lawyers is to defeat MICRA. For every dollar California physicians contribute to protect MICRA, trial lawyers contribute $200 to defeat it. Worse yet, while only 20% of California physicians contribute to CMA’s political action committee (CALPAC), 100% of the trial attorneys contribute to their PAC."

Furnas concludes: "All of us need to pitch in to defend MICRA. If you specify MICRA on your CALPAC donation, 100% of your contribution will go directly to the cause, with none spent on administration. It’s going to take a lot of timber to build this ark, and I think I hear some thunder in the distance." To read the entire article, go towww.scma.org/magazine/scp/sp05/furnas.html.

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Federal Government Finally Issues Compliance Rules: HIPAA's Little Instruction Book

Curtis Franklin, Jr, reports in Network Computing, www.nwc.com, that the federal government has finally issued, after nine years, guidelines for complying with the Health Insurance Portability and Accountability Act. He concludes: "The publication would have been worth its weight in gold nine years ago. But if your organization could use some guidance today on HIPAA compliance... you've got some new required reading." To read the entire report, go towww.nwc.com/shared/article/printArticlePage.jhtml?articleID=160911499&pgno=1. Also listed are Franklin's three must reads: An Introductory Resource Guide for Implementing the HIPAA, Security Rule (Special publication 800-66) at http://csrc.nist.gov/publications/nistpubs/index.html#sp800_66, An Introduction to Computer Security: The NIST Handbook (NIST SP 800-12) at http://csrc.nist.gov/publications/nistpubs/800_12/800_12_html/index.html, HIPAA Helpful Hints at www.hipaa.org/hints/.


Overworked or Underpaid - How You Can Solve One of Those Two Problems

John Toton, MD, a Healdsburg orthopaedic surgeon reports in Sonoma Medicine,www.scma.org/magazine/scp/sp05/toton.html, about his experience when he worked at Kaiser Permanente.

"As an orthopaedic intern at Oakland’s Highland Hospital in the 1960s, I met Dr. Jim Johnston, who had established himself at Kaiser Oakland as an orthopaedic pathologist with national credentials. He taught UC San Francisco residents pathology, and his teaching slides were exceptional; I brought his collection with me to residency in Philadelphia. After residency, I spent two years fulfilling my military duties in Okinawa, Japan. The setting was so remote that I lost most of my contacts with California orthopaedic groups, and going it alone seemed impossible. But then I remembered Jim, who became the local contact for my post-military job search. I figured if Kaiser employed doctors of such caliber, I should check it out.

"An interview followed at Kaiser San Francisco, where there was an "opening." It wasn’t exactly an interview; the physician-in-chief talked at me about Kaiser’s history and practice opportunities for more than an hour. I left with an application form and the experience of saying no more than 10 words. I doubt he even knew who I was.

"The next contact, four months later, was a phone call letting me know I had a full load of patients scheduled for next Monday! I didn’t even know I had been hired; that was how Kaiser took you on board 30 years ago."

Dr Toton outlines these exciting years and how his life changed at Kaiser Permanente.

"And then, quite unexpectedly, probably because the stock market was hot and medical dues were flat, Kaiser offered me an early-retirement package that was too good to turn down. I suspect they wanted the top salaries to move on and to hire younger and cheaper doctors. I was not insulted: although I always felt I was a valued member of the group, I recognized early on that Kaiser is a business and I was an employee.

"I was not compelled to take advantage of the retirement package, but I wanted to see what was on the "other side," so I went into private practice. It has been and continues to be a learning experience!"

To read the comparison of his private practice experience to his Kaiser Permanente experience, seewww.scma.org/magazine/scp/sp05/toton.html.


Pain Management and End-of-Life Care - Is Untreated Pain a Disease?

The California Society of Anesthesiologists have a series of 12 modules beginning in 2004 and published quarterly thereafter. Completing this series of CME Modules published in their bulletin will satisfy the California law that requires 12 credit hours in pain management and end-of-life care by end of 2006. The first five modules are now available on the CSA website, the rest to be completed by December 2006. All physicians can register and take the course atwww.csahq.org/xtpl.php?tpl=internal.xtpl&section=cme&name=cme_list_online . (Sounds like a relatively pain-free way of obtaining the pain credits demanded by a naive and uninformed Assemblywoman trying to control the legislative Medical Curriculum Committee, as well as practice medicine from the Dome.)

Module 1:Repeal of Triplicate Prescribing and the New Security Paper Prescription Requirement in California

Module 2: Is Untreated Pain a Disease?

Module 3: Concepts in Opioid Tolerance

Module 4: Pain Physiology

Module5: Complex regional pain syndromes.


Will the Great State of Tennessee Please Withdraw Senator Frist's Medical License?

Barry Sheppard, MD, President of the San Mateo County Medical Association, asks the question in his President's message and makes the argument.

"On occasion, in the history of the world, there have been those individuals who, after having been appropriately credentialed with medical degrees, have exhibited behaviors that fly in the face of the most basic tenets of physician behavior; individuals like Dr. Frankenstein, Dr. Jekyll, and Dr. Mengele, for example. In such circumstances it becomes appropriate for the medical profession to protect the public from those individuals by withdrawing their licenses to practice and, in the most egregious circumstances, to distance the ethical medical community from such a physician by withdrawing that physician’s medical credentials altogether, as was done posthumously in the case of Dr. Josef Mengele.

"I would like to make a case for withdrawing the medical license of Bill Frist, MD, our current Senate majority leader. Senator Frist’s statements during the debate preceding last month’s congressional ‘Schiavo’ bill was to my mind the final example of a physician gone far astray, but before considering that situation in detail, allow me to provide some pertinent background information that has bearing on my case.

"The basis of the Frist family fortune, which among other things has allowed the purchase of a Tennessee senatorial seat for one of its own, is the Hospital Corporation of America (HCA), the largest for-profit hospital chain in the country, which was founded by Bill Frist’s father and brother. Senator Frist’s personal investment in the family business is estimated at approximately $26 million for him and his wife. The senator skirts the issue of "conflict of interest" by declaring that this is held in a ‘blind trust,’ the holdings of which are determined by an independent trust manager. The approximate amount of HCA stock is fairly easily assessed by Dr. Frist, however, since he knows how much HCA stock it contained in 2000, when it was converted from a ‘less blind’ trust, and since he must divulge the amount of income the blind trust generates every year when he files his annual financial disclosure statement to the secretary of the Senate. Knowing these figures he can easily calculate a ballpark figure of his holdings. I am absolutely confounded how anyone can consider this flimsy excuse of a blind trust as removing the senator’s conflict of interest. If Senator Frist truly wished to minimize conflicts of interest with his congressional deliberations, I submit that he sell all of his HCA stock. Even then the influence exerted by the financial well-being of his first-degree relatives would not be inconsequential...

"Bill Frist was instrumental in passing the ‘Trojan Horse’ amendment to Medicare in the guise of the November 2003 drug benefit bill. This bill does little to alleviate the financial burden of pharmaceuticals on patients but codifies a moratorium on negotiating bulk discounts with drug manufacturers, forbids the importation of less expensive Canadian drugs, and opens wide the coffers of federal funds to HMOs, pharmaceutical companies, and corporations that agree to extend prescription drug coverage for their retired employees."

Sheppard concludes: "Bill Frist’s actions do not, unfortunately, preclude his ongoing designation of senator. They do, however, speak strongly against his claim of being a physician. His transgressions warrant the withdrawal of a practicing medical license. We could then only hope that he not publicize his prior inclusion in our ranks."

To read the entire message, including his arguments in the Schiavo case, go towww.smcma.org/Bulletin/BulletinIssues/April05issue/President.html.


Mert's Musings

Vital Signs, the official organ of the Fresno-Madera Medical Society (FMMS), wasn't the same this month without Mert's Musings. We frequently pay tribute to his medical insight. The FMMS course offered in Yosemite in April was successful. Executive Director Merwyn Scholten, who has been around the medical profession most of his life, was present despite his angina which was easily relieved with nitroglycerine. He has since had emergency five-vessel coronary bypass graft and is doing well. We look forward to his column next month, when he will announce his future plans. We suspect we will no longer be quoting this insightful Voice of Medicine. You can enjoy an aerial view of Yosemite and some Ansel Adams photos at www.fmms.org/%5Cpdf%5CYosemite2005.pdf.


New Physician ID Number (National Provider Identification): NPI to replace the UPIN

In their Bulletin, The Humboldt-Del Norte County Medical Society (HDNCMS) reminds physicians to begin submitting applications for their unique National Provider Number (NPI) which, over the next two years, will replace the existing Unique Provider Identification Number (UPIN). Health plans are required to use them by May 23, 2007. The NPI will be a ten-digit number unique to every provider and is expected to stay with the physician regardless of practice location. The Centers for Medicare and Medicaid Services (CMS) is tying this closely to the HIPAA confidentiality requirements for electronic transfer of health care information. CMS is expecting to have a system in place which will allow a physician to apply on-line.

The cost of switching to the new system will not be cheap for CMS or for any of the health plans. Small plans which can't make the two-year transition will be given an extra year before they must begin using the new NPI number. Seewww.humboldt1.com/~medsoc/the_bulletin.html.

This should make it easier for the government to police and control us ever more tightly.


Lawsuits Threaten Our Health Care

Don Wolfe, President, Citizens Against Lawsuit Abuse (CALA), writes in The Bulletin of the Santa Clara County Medical Association about the drain on health care caused by personal injury lawyers.

"To get a flavor for how personal injury lawyers are fishing for future clients, we just have to follow the advertisements. One headline reads: $18,000,000,000 Expected in Vioxx Damages. . . Another web site claims, "Most Vioxx patients and their families do not want to go through the pressure associated with going to court and having a full trial. While we can't guarantee there will be no trial, lawyers work hard to settle the cases without going to trial. However, it is important to realize that the threat of trial is what brings the maximum amount of compensation, so it is essential to prepare a case with this in mind."

Wolfe states, "Let me be clear: not one of us want people to be hurt by unsafe products, and anyone that is truly injured deserves justice. But when lawsuits are filed out of greed instead of justice, and personal injury lawyers and unharmed plaintiffs threaten justice for the truly injured, our legal system is being abused. And lawsuit abuse has certainly impacted health care in our nation." 

To read the entire article on how patients are hurt by law suit abuse, go towww.sccma.org/public/components/societytools/admin/viewNewnews.asp.


More Physicians Without Health Care

Eugene Blum, MD, as he steps down from serving 10 years on the editorial board, writes in an OpEd article in The Bulletin of the Humboldt-Del Norte County Medical Society (HDNCMS), about a family that was in financial trouble due to their medical bills. The family had a health insurance policy with a large deductible and share of cost. Ironically, the father is a surgical resident and the mother is a family practitioner. Their little girl is a three-year-old diabetic whose blood glucose must be monitored 6-8 times a day. Because the mother is only able to work a limited number of hours, her salary has been reduced to $36,000. The father earns a modest income as a resident. However, the family owes $140,000, in addition to a medical school debt of $360,000.

"A recent Harvard University study of medical bankruptcy found that financial hardship caused by medical bills is not a problem that affects the uninsured. Most people who file for personal bankruptcy because of health care expenses actually have health insurance, the study found. The study concluded that the problem seems to be largely a middle class phenomenon." www.humboldt1.com/~medsoc/the_bulletin.html

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Why health insurance costs so much

The Bulletin Humboldt-Del Norte County Medical Society, summarizes the California Medical Association’s report on health plans that spend the least of the premium dollar on health care. Those spending less than 10 percent on administration included Scripps Clinic, Sharp, Kaiser, Cal Optima and others.

Those spending 15 to 25 percent on administration included SmartCare, BC, BS, Aetna, Great-West, Molina, PacificCare, HealthNet, Cigna and UHP Health care. Leonard Schaeffer, the CEO of WellPoint, the parent company of Blue Cross of California, received over $11 million in total stock, salary and other compensation. Next highest was Aetna CEO John Rowe, MD, at more than $3.4 million.

CMA states: “We have included three new additions to our report this year. First is the reintroduction of health plans that have become insolvent, filed bankruptcy or who were absorbed by other health plans over the last five years. Second, is the Executive Compensation table that provides a glimpse of salary and bonuses for 2002. Finally, we’ve included an appendix of websites to access consumer related report cards.” To read CMA’s entire Knox-Keene Report, go to www.calphys.org/html/bb545.asp

Trying to Stop Medicare Rate Cuts

Southern California Physician reports, “The California Medical Association and the American Medical Association launched a grassroots campaign to ask Congress to permanently rewrite the Sustainable Growth Rate (SGR) formula. The SGR formula reimburses physicians based on the gross domestic product, instead of the practice cost index. If the formula isn’t fixed soon, physicians will face a 5 percent cut to their Medicare reimbursement starting Jan. 1, 2006, and will see cuts totaling approximately 30 percent over the next six years.

“‘We want to get rid of Medicare’s SGR formula altogether,’” says Elizabeth McNeil, director of federal issues in the CMA Policy Department. “’The formula is based on the gross domestic product. Although that is a general economic indicator, it does not tie to the cost of practicing medicine. We want Congress to at least avert the cuts for the next year.’

“But the CMA and AMA not only want to reverse the cuts, they are seeking a rate increase, too. The Medicare Payment Advisory Commission, an independent federal commission established in 1997 to advise Congress on issues affecting Medicare, recently recommended a 2.7 percent physician rate increase in 2006.

“‘The AMA is going to introduce a bill that will replace the SGR formula and implement a 2.7 percent increase in 2006,’” McNeil says.“’Any rate reform will be attached to a pay-for-performance initiative, which is based on quality measures.’”

The entire report by Dina L. Burwell is at http: //www.socalphys.com/jun05/policy_news.pdf.

Note: My discussions with patients on physicians' need for higher fees falls on deaf ears. I've had patients tell me physicians could survive a 100 percent cut in income. That may not be entirely the result of our schools' inability to teach math. Hence, the current 31 percent cut in Medicare reimbursement generates no public sympathy for a profession perceived as "well-to-do." When patients realize we are asking for more tax dollars in payment for their health care services, they get very annoyed.

An alternative and probably more appropriate strategy would be for Medicare to try to survive in the medical marketplace. As physicians leave Medicare (and the CMS web site suggests that many in our own area are doing so) patients will resort to the political process. Physicians will then have taken the high road instead of merely lining up at the public trough, and patients who can't find a Medicare physician will take the low road to their politicians. Members of Congress will be more sympathetic to 37 million patients who can't find a doctor than to a half million doctors who don't have enough patients. Thus, market-based medicine can even be a corrective influence on socialistic schemes such as Medicare.

As for the pay-for-performance (P4P) initiative, this is strictly a payment to those physicians most skillful in denial of care that patients need or want. Eventually patients will rise up against this subterfuge, just as they did when HMOs were paying for low-cost performance under the guise of P4P and Quality of Care (QOC) issues. This resulted in such a lower quality of care that improvement became a clarion call against physicians and hospitals when it was really the result of Medicare and HMO reimbursement performance.


Redux: Resistant, Resurgent STDs

Jeffrey D. Klausner, MD, MPH reports in San Francisco Medicine: “In 2004 the San Francisco Department of Public Health (SFDPH) published or collaborated in new research demonstrating the introduction and spread of azithromycin-resistant syphilis in San Francisco; the continued increase in ciprofloxacin-resistant gonorrhea; and the presence of lymphogranuloma venereum (LGV). These three reports resulted in changes in sexually transmitted disease (STD) treatment recommendations of which medical providers who take care of patients with STDs should be aware…

“Data from a molecular monitoring project of syphilis conducted by the San Francisco Department of Public Health in collaboration with researchers from the University of Washington-Seattle demonstrated that a mutation in Treponema pallidum caused azithromycin-treatment failure in patients with syphilis…. Those findings make the use of azithromycin as a preventive or therapeutic treatment for syphilis in San Francisco no longer an option. The current recommended medication for the prevention and treatment of syphilis remains penicillin benzathine G long-acting (LA). In penicillin allergic or intolerant patients, doxycycline 100 mg by mouth twice daily for 14 to 28 days is recommended.

“Gonorrhea, while decreasing in heterosexual men and women, young adults and African-Americans in San Francisco, remains a relatively common infection in men who have sex with men. In 2002, treatment recommendations changed in California such that fluoroquinolones were no longer recommended as first-line therapy. In 2004, those recommendations were expanded to include all men who have sex with men throughout the United States. Continued vigilance is required in all populations throughout the United States. In lieu of treatment with fluoroquinolones, the current recommended treatment for gonorrhea is a third-generation cephalosporin…. All patients treated for gonorrhea should be cotreated for chlamydia (doxycyline 100 mg by mouth twice daily for 7 days) unless chlamydia has been ruled out. We also recommend that all patients treated for gonorrhea are retested at three months to rule out reinfection.

“Chlamydia trachomatis has two distinct classes or biovars: A-K and L types. Types A-K cause typical urogenital infections like asymptomatic infections, cervicitis or urethritis while the L types cause the disease lymphogranuloma venereum (LGV).

The entire report and summary of new issues and treatment changes in STDs is at http://www.sfms.org/sfm/sfm605e.htm

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San Mateo County’s Century

In the San Mateo County Medical Association Bulletin, Michelle B. Caughey, M.D., President of the San Mateo County Medical Association, reflects on the society’s 100th anniversary.

“On September 21, the SMCMA will host an event celebrating 100 years of (somewhat) organized medicine on the Peninsula. A full-length book will debut in September as well, A Century of Medicine in San Mateo County. The book will chronicle the history of the practice of medicine in the county in the last century. We have had our share of scandals and our share of famous people, who after all, are human.

“The Medical Association has functioned in various ways over time. It seems natural that physicians would come together to discuss the coordination of medical care, the building of hospitals, and the care of the poor. Later, physicians worked together to protect their practices from intrusion and even competition. Medical societies became places where private physicians could buy malpractice insurance and staff benefits or telephone answering services as a group, to keep costs affordable. With the advent of Medicare, funding determinations, ’what’s covered,’ are made by the Congress of the United States. Now physicians have an intense interest in politics.

“Interest in state policy has grown out of the state’s increasing regulation of all aspects of the practice of medicine. Historically the state has regulated the licensing, and therefore the scope, of practice of various practitioners. Although sometimes seen as self-serving, much of the physicians’ concerns about licensing really arise from worry about the patients’ best interests. The state also regulates the insurance industry, including HMOs. Doctors turned to their medical societies to advocate for fair payment, as for-profit HMOs swooped in to limit reimbursements in the 1990s.”

This brief recitation of the history raises the themes that should carry us into the next year and beyond. To read more, go to www.smcma.org/Bulletin/BulletinIssues/July-August05issue/President.html.

A Domestic Violence Guide

The Alameda-Contra-Costa Medical Association Bulletin has an entire issue devoted to domestic violence. This guide has been modeled after the Domestic Violence Program developed by the Kaiser Permanente of Northern California. Duplication of these published resources is encouraged.

The president, Sharon B. Drager, MD, introduces this issue as the maiden voyage of the Alameda-Contra Costa Public Health Coalition as she presents it to the Alameda-Contra-Costa Medical Association.

“The goal of this issue of the ACCMA Bulletin which contains the “Domestic Violence Resource Guide" and other resources is to make it easier for ACCMA members to address the issue of domestic violence more effectively and efficiently with their patients. What follows is a "nuts and bolts" approach to improving routine screening for domestic violence in a medical practice.

“Brigid McCaw, MD discusses the ’Nuts and Bolts’ in Detecting, Documenting and Reporting Domestic Violence. At least one in five women will be affected during their lifetime by domestic violence. Data from a study in northern California Kaiser members indicates that at least 5% of women aged 20–44 were assaulted by an intimate partner during the previous 12 months. It is more common than many other conditions that we routinely screen for in our patients. The health effects of domestic violence go beyond physical injury. Its association with depression, suicide attempts, chronic abdominal/pelvic pain, STD's and delayed prenatal care is well documented in the medical literature. Domestic violence is present across ethnicities, socio-economic groups and is present in both heterosexual and homosexual relationships. It is an issue of power and control. Some physicians tell me, ’Domestic violence is not an issue for my patients.’ I suggest to them that if they do not routinely screen for it, they really don't know. In a busy practice things get avoided unless they are obvious, and domestic violence is seldom obvious.”

To read more on how to screen for domestic violence without upsetting patients, where to find support services, what are the resource organizations, a summary of legal reporting requirements, and how to report injuries by a deadly weapon, go to www.accma.org/Content/
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A Snippet on SNPs

In Sonoma Medicine, the magazine of the Sonoma County Medical Association, Stacey Kerr, MD writes about Personalized Medicine.

“No, it’s not health care that takes your whims, your schedule, your favorite color, your sexual preference, and your personal desires into consideration. It’s not monogrammed chart labels. This is much more high-tech than that. This is family history taken to the extreme. This is your genes hung out to dry so all can see and judge them. This is potential loss of privacy, potential loss of insurance. This is medication tailored to your snips. This is the future.

“Each of us is unique. We know this in countless ways, but rarely more significantly than when we need health care. Why does that new headache medicine work for your best friend but not do a thing for you except cause odd sensations? Why did one of your patients have to stop chemotherapy because of intolerable side effects while another breezes through the same course without a problem? Which people are certain to develop chronic disease in spite of checking and treating all known risk factors?

“The genetic basis for individuality is the mere 1% of our gene sequence that contains variations in the DNA. Here reside the polymorphisms that make each individual genome unique. Most of these polymorphisms are single nucleotide polymorphisms, or SNPs (snips). Any two people can have as many as 10 million SNP differences between them.

“New advances in the study of SNPs have created the exciting and hopeful expectation that we will soon understand the genetic components of common diseases. We also hope to identify the SNPs that predict the best and most tolerable drugs for any individual patient’s needs.

“Here is how personalized medicine would work: You go to your primary care physician and give a tissue sample. You return in a few weeks to get your personalized genetic report — a map of your SNPs. The report indicates your genetic risk for developing common cancers, Alzheimer’s disease, and other chronic diseases. You may be told that you need only half-strength doses of certain medications because of a genetic variant that slows down your metabolism of certain chemicals. The next time you get sick, you will be prescribed medication based on your genetic ability to incorporate and metabolize specific drugs. Your complete health care plan will be shaped by your genomics.

“Sounds smart. Sounds safe. Sounds expensive. Sounds controversial. Personalized medicine is all of that. Finding the specific relationship between combinations of SNPs and disease susceptibility is a daunting task.”

Read more at www.scma.org/magazine/scp/wn05/kerr.html

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