More!

Basic Needs
Advocacy Funding
Menu of Services
Habilitation Centers
More Forensic Space
Direct Care Pay
Hancock Amendment
Term Limits
Entitlements
Persons First
Olmstead
Excerpts From: “Children’s Hospitals: On A Precipice”
Children's Hospitals: On a Precipice
Benefactors
Uneven Care "As Parents Age, Agencies Struggle
To Help Disabled"

Basic Needs

Due to the shortage, of money the Department of Mental Health should be focusing on: A. A secure and safe place to live B. A secure and safe place to work C. A secure and safe place for recreation and socialization

State funds from general revenue for Purchase Of Service have shrunk $220,000,000.00 in the past five years! Funding new, innovative (questionable) programs far removed from “basic needs” must stop. There are too many persons on waiting lists and too few services for persons on the current roles to be squandering funds on unproven theories or the latest “fads”. DMH must get back to basics!

Response: From Jack RE: Missouri Association for Retarded Persons Newsletter. Basic Needs

My research shows that your observations on that issue are correct.

My daughter is 37 years old has Down Syndrome (A) lives at home because, in my opinion there is not secure and safe place to live (B) there is not place for her to work, let alone a safe and secure place to work (C) there is little recreation or socialization in our area.

I don’t believe I am very popular over here. I believe DMH advocacy groups are an attempt at a control mechanism. It seems I’ve been called everything; the nicest thing being a demanding strong advocate, to the worst being; a liar and troublemaker. I’ve been saying many of the same things you are saying in this newsletter. From the literature I’ve seen, they don’t much agree with you either. I guess what I’m saying is that if they don’t like you, you can’t be all bad! I am not aware of a chapter of Mentally Retarded Citizens of Missouri anywhere close. Just wanted to tell you that in case you are interested in expanding. Keep me informed please. How refreshing it would be to have an organization like yours truly run by parents of persons with mental retardation in our area.

Advocacy Funding

DMH spends millions of dollars on their “hand picked” advocacy groups. This money would be better spent by funding “basic need” services and eliminating waiting lists. (DMH uses the number of 1700 on waiting lists. Mentally Retarded Citizens of Missouri feels this figure is substantially understated.)

Menu of Services

The time has come to force credibility upon DMH with a “menu” of services, i.e. same money for same service statewide. It is time to stop the “special deals”. Service providers have a right to know “up front” what DMH will pay. They also have a right not to be discriminated against. Everyone should be treated the same.

Habilitation Center Crisis

DMH’s current practice of combining Hab Center and Community Placement budgets must stop!! The drain on Hab Center Staff in deference to community placement is placing Hab Center residents “in harm’s way”. . . this is short of criminal!

More Forensic Space

Mixing law breakers with mental illness and persons with mental retardation (and senior citizens) is a powder keg. Judges have no where to place them. If this is to continue, more specialized places must be provided. Persons with mental retardation are at risk.

Direct Care Pay

While we have helped raise direct care staff pay by 3% each of the past two years, it is still inadequate. The state must address this critical problem. Our most vulnerable citizens deserve better.

Hancock Amendment

Hancock is a roadblock to services. In the current environment of a good economy and record state receipts, mental health spending (state) is down in actual hard dollars. The additional funds and placements are from the federal Medicaid program. While helpful, the downside is: if you don’t qualify for Medicaid or the services they provide, there is no new money for services. ($220,000,000.00 less in the past 5 years.)

Note: Do public officials understand that currently the largest institutions for mental health are jails?

Solution: Groups like Mentally Retarded Citizens of Missouri have to be more diligent in educating public officials to the needs of persons with mental retardation.

Term Limits

Term limits are robbing us of knowledgeable legislators. Almost half of the General Assembly will be gone in two more years; in four years most of the current membership will be replaced. Groups like Mentally Retarded Citizens of Missouri will have to be more diligent in educating public officials to the needs of persons with mental retardation.

Entitlements

The time has come when services for persons with mental retardation need to become an entitlement!!!

“Persons First”

Fancy Names Don’t Necessarily Give Disabled Dignity

Persons-first language stipulates that a mentally slow child is no longer retarded but a child with developmental disabilities, a cripple is a person with a physical disability, a mongoloid is a person with Down’s syndrome and a blind person is one with impaired sight. These cumbersome, tongue-tripping phrases have done little to change our preconceptions and have failed to tackle the real issue of acceptance and assimilation...

“Developmentally disabled” is a clumsy phrase and is quickly shortened to “DD” in discussions and written reports. It also wraps awkwardly around the tongue of any person with a speech impediment. I asked my 38 – year old son who has Down’s syndrome to say the words. He couldn’t. Andrew, who lives at Lambs Farm in Libertyville (IL), said simply and proudly, “I’m Down’s oblivious of the statement made by Down’s Syndrome Congress, “a person with Down’s syndrome should not be referred to as “Down’s.” …

We have become lulled into a sense of righteousness by a jumble of new names that we believe give dignity to the disabled. Less fear is conjured up by the term physically handicapped that cripple, by developmentally disabled than mentally retarded, by Down’s syndrome than Mongolian idiot. But there is a danger in glossing over reality with elaborate nomenclature. Do we really expect persons with impaired sight and hearing to refer to anything else but blind and deaf?

Moreover, tiptoeing around any sensitive issue won’t make it go away. Has the new terminology helped the disabled become assimilated into everyday life? A fancy name doesn’t alter a person’s handicap but has changed our perception of that handicap? Are we less likely to avoid eye contact with a twisted body in a wheelchair because we now call him or her disabled rather than crippled? Are we less likely to cross the street to avoid a group of awkward-looking adults because we call them developmentally disabled rather than retards? Is an employer more willing to accept an applicant whose disability has a new name?

Our overemphasis on doing away with terms such as retarded is mirrored by our insistence on including all children with disabilities into regular classes. Although the letterhead of Lambs Farm describes the organization as “A national center dedicated to the well-being of persons with disabilities,” its mission statement retains the word “retarded.” According to Tim Unsworth in his book “The Lambs of Libertyville,” co-founder Bob Terese says, “Once our special persons accept this fact, progress can be made.”

We should not be misled into believing that polite epithets have wiped out our prejudices. Whether we call the mentally and physically handicapped persons with developmental disabilities, or simply retarded, disabled, blind or deaf, we need to learn to retreat all persons with differences as equal human beings.

Persons like to be referred to as individuals. Each person appreciates recognition of his or her talents and accomplishments. “Persons first” language recognizes each person as a special being in and of thyself. As laudatory as this premise is, it can occasionally be an obstacle to appropriate treatment and care in the handicapped community.

“Persons first” language tends to consolidate all disabilities into one group. This “one group” concept doesn’t accurately reflect the realities of the various disabilities. A physical handicap is different from a head injury. A sight impairment is different from retardation.

Each of the many disabilities have succinct differences and therefore require substantially different approaches, treatment and care.

Persons with physical disabilities are verbal. They can and do speak for themselves; their treatment, their programs. Persons with retardation cannot speak for themselves. Persons with physical disabilities do not adequately, nor can they represent the needs, wishes, desires and wants of the retarded anymore than they can represent so called “normal” persons.

To the extent that persons with physical disabilities want “persons first” terminologies to dominate their environments, Mentally Retarded Citizens of Missouri says “fine”. However, when Mentally Retarded Citizens of Missouri sees this concept as an homogenization of the handicapped community at large, we respectfully disagree.

Missouri Association for Retarded Person's name is the Association of Retarded Citizens, not the Association of Citizens with Retardation. Retardation is not a dirty word! It is a separate and distinct condition. Treatment, programs and services are unique and must not be lumped into the general handicapped community.

We remember when persons “hid” retarded family members in closets and attics. We remember when treatment and care consisted of “warehousing”. If all we have left to debate in certain environments is semantics, then we have truly made great strides.

Part of the problem is that sometimes persons want other persons to be and act like them. Sanitizing the human condition gives them that “feel good” feeling.

That “feel good” attitude does great harm to the retarded. A frank admission and recognition is what’ needed in order to ensure proper and appropriate treatment and care of the retarded.

So, while we have no philosophical argument with “persons first” language and while there will always be those who swear by the “latest” theory, Mentally Retarded Citizens of Missouri will continue to fight for pragmatic programs and services that are tempered by time and experience for all the handicapped community as we have for over 40 years. We are the “founders” of state schools, SB52 sheltered workshops, group homes and SB40 boards.

We will continue to delineate the unique characteristics of retardation. We will continue to refer to our sons and daughters as retarded citizens in spite of new fads, trends and terminologies.

AND MOST IMPORTANTLY, WE WILL CONTINUE TO NEVER APOLOGIZE FOR, NOR FAIL TO ARTICULATE THEIR CONDITION AS WE CONTINUE TO WORK WITH THEM TO IMPROVE THEIR QUALITY OF LIFE EVERY DAY, EVERY WEEK, EVERY MONTH AND EVERY YEAR.

Editors Note: This was a reprint from the Chicago Tribune, May 1997 written by Romy Wyllie.

Olmstead

The Olmstead court decision is about choice. Two women wanted to leave an institution and the court upheld their choice to leave and encouraged states to develop “plans” to insure the choice of a community placement.

Many persons believe the court gave the green light to close institutions. It did not! The court also recognized institutional placements as a choice. The court further stated that all placements must be appropriate.

As most of you know by now, the Olmstead Commission has begun it’s work. While a philosophical “stacked deck,” there is no reason to believe these persons won’t do good work.

However, a word of caution to them is appropriate. In discussions at our annual meeting we found consensus within our membership.

Here is a list: · Choice must be maintained. · Guardianships must be honored. · Placements must be appropriate. · Leave Sheltered Workshops alone.

Remember:

A. Persons with profound mental retardation cannot speak for themselves. We will not let the Commission speak for our sons and daughters.

B. If the Commission discriminates against our sons and daughters by denying a Hab Center placement, we will take appropriate legal action!

Excerpts From: "Children's Hospitals: On a Precipice"

By Pasquale Accardo, M.D.

Pediatric medicine is fundamentally different from adult medicine; children are not simply small adults. The pediatric age group is covered by fewer alternative care structure, and the prediction is that in the next several years approximately 2/3 of all children in Missouri will be covered by a monolithic Medicaid system. 

When persons think about health care and then attempt to make informed decisions about its funding, the unique aspects of health care for children are considered last, if at all. Approximately 1/3 of the population are in the pediatric age group, yet they account for probably something approximating only 15% of health care expenses

Pediatricians have vigorously supported health care reform and cost containment. But we thought that the expenditures that needed curtailing were the huge profits in the pharmaceutical industry. The salaries of CEOs of for profit hospitals and of managed care corporations as well as the dividends that they pay to their investors, the profits to the companies that produce high tech hospital equipment and sterile supplies, the malpractice litigation industry, not to mention the unbelievable fees for many surgeons.

In this contest whose only ethic is naked greed, children’s hospitals are luxuries that no one can afford.

Pediatrics departments that are supposed to train the next generation of pediatricians and provide the cutting edge for research into improving the care of children are constrained to earn more and more of their income from practice options. With the tightening of such reimbursement, there will simply be fewer pediatricians trained; these are the very primary service care providers that are supposed to be the mainstay of managed care and preventive medicine.

What about insurance? The first rule of thumb when considering health insurance policies is that they are never, in no way, ever, ever, friendly to children. What they offer is next to nothing or simply fluff for advertising purposes. For children with developmental disabilities double that in spades.

What about health care for children with disabilities? Well, the proportionately same distance that separates pediatric services from adult services separates pediatric services from services for children with disabilities. When children compete with adults for a slice of the limited health care dollar, they lose.

When children with disabilities compete with non-disabled children for a slice of the health care pie, it’s more like a match between McCauley Caulking and Mike Tyson. Again, a no-brainer.

Solutions 1. All medical services to persons with neuro-developmental disabilities should be categorized as “medical” and not as “mental health”. 2. All contracts should be simplified so as to limit obscure exclusions and allow parents to know up front what is and is not covered. 3. All health insurance contracts should positively specify exactly how their coverage guidelines do not in any way discriminate against children and adults with developmental disabilities and their special needs with regard to the type of specific services reimbursed and the reimbursement rates for those services. 4. A pediatric-based relative value scale to allow sufficient cognitive time to appropriately manage developmentally complex children needs to be devised. 5. Pre-existing condition exclusions should be eliminated with regard to dependent children. 6. Insurance reform should be targeted to specific conditions identified a neuro-developmental disabilities. 7. The Department of Insurance should give top priority to investigating and acting on claims of unfair practices that involve children and adults with developmental disabilities. 8. A fixed percentage of every health care dollar (whether private or public) should be set aside in an Education and Research fund to maintain the stability and progress of medical education and research.

Children's Hospitals: On a Precipice

By Pasquale Accardo, M.D.

If we are going to talk about medical services for persons with disabilities, we first need to understand a few things about the structure of medical care in general. Pediatric medicine is fundamentally different from adult medicine; children are not simply small adults. The adult health care system is multifaceted with multiple fail safes, that is, with much unnecessary duplications:

Medicare (the recent approval by the American Medical Association (AMA) of the Republican plan to save Medicare suggests that program remains over funded) 

Military medicine/CHAMPUS 

VA System (a “shadow” empire, the doppelganger of medicine) 

Insurance/Fee for service/Managed care/Medicaid 

Employer/out of pocket expenses 

The pediatric age group is covered by fewer alternative care structure, and the prediction is that in the next several years approximately 2/3 of all children in Missouri will be covered by a monolithic Medicaid system. To say that this system might be abusive to children would be an extreme oversimplification (perhaps medically negligent would fit better), but the extent to which it deviates from meeting what most persons would consider to be reasonable expectations can best be illustrated by the reluctance of state officials as well as all persons in decision making positions in managed care systems to entrust the health care of their own children to the identical restrictions of similar policies. What I am hinting at here is the suggestion that any managed care system that is presumably good enough for two thirds of the children in the state should be mandatory for the children of all state employees, starting with those in Jefferson City. That way when there are problems wit the system, there will not be any communication problems between the voters and their elected representatives; the politicians will already be aware of them first hand. 

When persons think about health care and then attempt to make informed decisions about its funding, the unique aspects of health care for children are considered last, if at all. Approximately 1/3 of the population are in the pediatric age group, yet they account for probably something approximating only 15% of health care expenses (disproportionately less than their population density). 

The annual health care cost for an average adult is 2.5 times that for the average child. Pediatric services are routinely billed at 1/3 the rate per hour of that charged for adult services; it is therefore no surprise that in every survey of physician salaries, pediatricians have always had a firm lock on last place. In this respect their relatively low pay scale is similar to that of teachers, the professionals to whom we entrust our children but whom we refuse to pay at anywhere near a professional salary level. In terms of fiscal reimbursement, all those professionals who in any way care for children are not ranked highly in our society. 

There are no, none, dada, objective measures of pediatric health service delivery that even approach being on a par with similar services for adults. Pediatrics departments that are supposed to train the next generation of pediatricians and provide the cutting edge for research into improving the care of children are constrained to earn more and more of their income from practice options. With the tightening of such reimbursement, there will simply be fewer pediatricians trained; these are the very primary service care providers that are supposed to be the mainstay of managed care and preventive medicine. Such a reduction occurred when Medicaid managed care went into effect in Tennessee (TENNCARE) and can be expected to happen elsewhere - HERE. 

In addition, research into the diseases of children has been eroding for more than a decade. In his Howland Award address in 1991, Dr. Robert Cooke noted that research on issues relating to children was funded at a level of less than one seventh of similar research for adults. Productive pediatric research in the United States has declined by approximately 15 to 25% over the past decade; those pediatric medical journals that have maintained their page length have only stayed the same size by including papers from Japan, Germany, Italy and other countries. Since we are content to purchase most of our advanced electronics from Japan, perhaps we won’t mind obtaining our pediatric medical advances from them also. When one reads in the newspapers that parts of the United States have neonatal mortality rates approaching those of third world countries, plan on the situation getting worse rather than better. 

Pediatricians have vigorously supported health care reform and cost containment. But we thought that the expenditures that needed curtailing were the huge profits in the pharmaceutical industry. The salaries of CEOs of for profit hospitals and of managed care corporations as well as the dividends that they pay to their investors, the profits to the companies that produce high tech hospital equipment and sterile supplies, the malpractice litigation industry, not to mention the unbelievable fees for many surgeons. But most of these reflect the business side of medicine, and when it comes to cutting expenses, the business or profit side of the equation seems to be left untouched. Recently we have actually seen significant relief with regard to the issue of malpractice. Significantly the impetus behind this reform is not to protect the practicing physician but rather to protect the managed care companies and their investors from liability when their second guessing (their Monday morning non-surgerizing?) causes serious harm to patients whose money they have appropriated. Again, how much of the very impetus for cost cutting actually comes from corporations and companies whose major concern is shrinking profit margins due to the increasing cost of employee benefits? 

In this contest whose only ethic is naked greed, children’s hospitals are luxuries that no one can afford. In the past one of the signs of an area’s level of development was the presence of a children’s hospital. Pediatricians had long ago learned that when inpatient pediatric services were mixed with adult inpatient services, that the quality of the children’s services always lost by comparison. There is not place for that qualitative difference in any of the parameters utilized by managed care systems. Treatment X is allowed a certain number of days inpatient reimbursement whether at a small rural general hospital or at a more expensive tertiary children’s center. It’s all the same. Or is it? Just who is kidding whom? 

Political pundits talk about the Republicans planning a tax cut for the wealthy that will be financed by cutting benefits to the poor and middle classes. On the other side of the aisle, it is claimed that the Democrats may want to tax the wealthy disproportionately but still do not want to give the middle class any tax relief simply because the amount you gain by high taxes on the very rich is piddling compared to the huge amounts you acquire by raising taxes on the average citizen by even a fraction of a percent; there are simply so many more of them. 

I think that the second scenario better reflects the situation in the managed care of medicine. Restrictions on reimbursement for such high ticket items as elective cosmetic surgery and transplantations make sense but don’t save enough money. Across the board reductions in reimbursement rates for the most common doctor patient interactions is the ideal way to increase investor profit margins. The idea that this reflects an efficiency that has no impact on quality of care is patently ludicrous. Most mistakes are made in and through haste. In a much advertised switch from inpatient care to outpatient care, only the responsibility is being transferred, not the cash. What this means for medical services across the board is belt tightening. For those areas that were extremely obese to begin with, this may be a healthy step. For areas such as pediatrics that started out close to the edge, these changes suggest possible scenarios that include the closing of most children’s hospitals and the potential eradication of this primary care specialty altogether. 

The American Academy of Pediatrics is no friend to increasing sub-specialization in pediatrics, but even they have recently voiced concern that the decreasing number of pediatricians entering certain subspecialties has placed those subspecialties at risk to disappear. In educational training programs a certain minimum number is needed to maintain the viability of the field. (These subspecialty programs are also the source of much new research in the field.) The alternative will be to have selected rare conditions treated by pediatric generalists or by adult oriented physicians, an option much favored by managed care.) When you come to the almost anorectic area of health care for children with disabilities, any suggestion of reduction can only be considered as euthanasia. 

What about health care for children with disabilities? Well, the proportionately same distance that separates pediatric services from adult services separates pediatric services from services for children with disabilities. When children compete with adults for a slice of the limited health care dollar, they lose. Just like the Tyson-McNealy fight, it’s a no-brainer. When children with disabilities compete with non-disabled children for a slice of the health care pie, it’s more like a match between McCauley Caulking and Mike Tyson. Again, a no-brainer. 

Contracts are sacred, and insurance policies are contracts. The first rule of thumb when considering health insurance policies is that they are never, in no way, ever, ever, friendly to children. What they offer is next to nothing or simply fluff for advertising purposes. For children with developmental disabilities double that in spades. What are the techniques that the insurance industry uses to abuse children with disabilities? Let me itemize some specifics: A. Reams of paperwork and a complex stepwise process to obtain preauthorization for services head the list. Physicians may need to spend un-reimbursed hours on the telephone attempting to obtain authorizations for diagnostic tests and consultations. The process is set up so that the burden falls on the health care provider and so contributes to the illusion that the patient and the physician are at odds when it is in fact the managed care provider who has created this stumbling block. B. the excluding from coverage of pre-existing conditions makes some sense when applied to adults but represents an irrational loophole when extended to children and adults with developmental disabilities. With only a few exceptions, developmental disabilities are of prenatal onset. Since children are not covered until they are born, almost all developmental disabilities are technically pre-existing conditions and excluded from coverage. Not all insurance companies consistently apply this loophole. C. Failure to cover developmental treatments because they are not curative within a specific time period can be discriminatory and is not necessarily supported by limited outcome efficacy data. D. Listing a physician or clinic as an approved provider and a test or procedure as similarly approved but then denying coverage on the basis of a non-covered diagnosis can only be considered a shell game. Payment at different rates for different diagnoses based on the same diagnostic procedures when the diagnosis could not be known before the assessment was performed is similarly dishonest. E. Classifying neuro-developmental disabilities as mental health conditions is in violation of the best medical thinking; it is obviously a ploy to save money (again, not for the insured but for the investors) by reimbursing services at a lower rate or by denying coverage altogether. In general most insurance companies and managed care systems do not have on their roster of claims adjusters persons who are at all familiar with the unique problems of children, and they are even more ignorant (as if that were humanly possible) of the specific needs of children with disabilities. The one rule they seem to have mastered is when in doubt (what they consider a reasonable doubt would embarrass the O.J. Jury) simply deny coverage. Only those parents and physicians who are willing to spend hours on letter writing and telephoning will ever succeed in an appeal, and since we are dealing here mostly with small outpatient charges, the loss will always be on their side. 

Having covered some of the problem areas, let me over several suggestions for reform: A. All medical services to persons with neuro-developmental disabilities should be categorized as “medical” and not as “mental health” because they are medical (neurological) and not mental health (psychiatric/emotional/crazy), and as soon as you understand the elements of the difference, it becomes crystal clear that this is the appropriate categorization, and insures would expect such services to have been covered (we discussed this very same issue at last year’s conference and saw how problematic a confusion between these tow could be for both the judiciary and the constabulary). B. All contracts should be simplified so as to limit obscure exclusions and allow parents to know up front what is and is not covered; this would also restrict the latitude of insurance carriers to arbitrarily deny benefits by case managers with little knowledge or expertise in the area of childhood disabilities and thus precipitate a long, drawn out appeal process on the part of the families. Fortunately for the insurance company’s investors, this does not occur in many cases, and this may indeed reflect their rationale for doing it in the first place. C. All health insurance contracts should positively specify exactly how their coverage guidelines do not in any way discriminate against children and adults with developmental disabilities and their special needs with regard to the type of specific services reimbursed and the reimbursement rates for those services; this should be in line with the provisions of the Americans with Disabilities (ADA). Any specific exclusion of Developmental Pediatrics should be considered in violation of ADA. The guidelines for the coverage of such services as Physical Therapy, occupational Therapy, Speech Therapy and others need to clarify habilitation for children with developmental disabilities as distinct from rehabilitation for persons without developmental disabilities. D. A pediatric-based relative value scale to allow sufficient cognitive time to appropriately manage developmentally complex children needs to be devised. There will never be sufficient specialists and subspecialtists to assume the comprehensive medical management of all children and adults with developmental disabilities. The largest percentage of such care will need to come from primary care pediatricians. In order for them to be able to provide such care in an appropriate manner, they will need to be reimbursed adequately for the increased time demands that such patients require. An “ear check” can be performed in less than five minutes but not the medical follow up of a child with a serious developmental disability. Managed care is reluctant to assume this burden and allow this distinction. In the past year several primary care pediatricians in the state of Missouri, physicians who had the local reputation of being willing to take on the care of chronically disabled children, went bankrupt and closed their practices. E. Pre-existing condition exclusions should be eliminated with regard to dependent children. F. Insurance reform should be targeted to specific conditions identified as neuro- developmental disabilities; the almost ridiculous extension of the term disability so as to cover over half the population (e.g., with such disabilities as extreme shyness) is counterproductive and renders the term meaningless. G. The Department of Insurance should give top priority to investigating and acting on claims of unfair practices that involve children and adults with developmental disabilities. H. A fixed percentage of every health care dollar (whether private or public) should be set aside in an Education and Research fund to maintain the stability and progress of medical education and research. I. If we are not going to significantly reduce the duplicative systems noted above, then we may need to give serious consideration to setting up an additional division for the delivery of health care to children and especially for children with disabilities. If this route is taken, it is imperative that developmental disability services be kept distinct from (1) mental health services, and (2) services for non-developmental handicaps. Although some of the issues among these diverse groups may overlap, their fundamental interest in effecting a union is political and would ultimately not be to the benefit of persons with developmental disabilities. Such a conglomeration would again reduce the population with true developmental disabilities to a minority and essentially invisible status. 

I regard medicine as a profession rather than a business. Several decades ago the strange idea that medicine was a consumer product or service rather than a sacred trust between the physician and the patient became popular. Medicine was to follow the laws of the marketplace rather than respond to some higher calling. Well, persons got what they asked for. Instead of answering to a high standard of professional responsibility, medicine began to follow rather than lead in a society devoted to greed. 

Things that were unthinkable a quarter of a century ago are now medical commonplaces albeit objected to by a significant minority of the profession: abortion on demand, termination of life support for handicapped infants and the aged, voluntary and involuntary euthanasia, the withholding of food and water as if they were extreme medical treatments, teaching masturbation to children who are so limited as to not have discovered it by themselves, sexual intercourse with patients - all of these were forbidden or at least strongly discouraged by the Hippocratic oath. (Individuals may or may not agree with the problematic nature of each of the specific items in my list, but only a fool would not be troubled by the frighteningly consistent trend that they reflect. Simply consider that this tendency will be continued in decisions mad not by physicians but by MBAs). 

In rewriting their oath, physicians have attempted to better fit into a society that wants to save dollars and spare itself even the slightest inconvenience. But you save money only to spend it on something else. What you finally do spend it on says a lot about you. I suggest that the place of children in a society is the best indicator of the state of health or disease of that society, and the level of service provision for children and adults with disabilities is the best argument that such a society should continue to exist with or without any special life support measures. We have recently seen the Communist system rotted from within because of a financial one; it is an exclusively moral one. The question is not what can we afford to do financially but what can we afford not to do morally. The only ultimate answer to managed care is that the patients themselves, not physicians sub-specialists and certainly not MBA bean counters, must assume greater responsibility to manage their own health care.

The front page of last Sunday’s St. Louis Post Dispatch reported the case of little Allison Marie Bassett of Fayette, Missouri, who was allowed to starve to death by her mother, who was of borderline intellectual abilities. The write-up suggested possible culpability on the part of the welfare agency, the sheriff’s office and just about everyone else involved in the case. It was a complicated case, not a case for floundering social agencies with limited expertise with children and with parents of limited intelligence, but exactly the kind of case that a skilled pediatrician might have successfully managed. But the only pediatrician who was involved in the case was the expert witness called in to testify at the coroner’s inquest. Managed care will likewise move those professionals who best know how to treat patients up to similar supervisory levels where they may comment in court on the deadly failures of the system. God help us all, but we will get the exact health care system that we deserve.

Benefactors

Mentally Retarded Citizens of Missouri seeks benefactors: benefactors who believe that families & the individual should be at the center of discussions about life choices; benefactors who understand that continuity thru historical perspective is essential to appropriate living & working environments; benefactors who oppose Idealogues; benefactors who want common-sensed, practical, time tested solutions to life style decisions..... WILL YOU HELP?

“NEVER DOUBT THAT A SMALL GROUP OF COMMITTED CITIZENS CAN CHANGE THE WORLD. INDEED, IT’S THE ONLY THING THAT HAS”- - - - Margaret Meade

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