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}anuaiy 2S, 2u14

Chaii of Bealth anu Buman Seivices Committee
Buiton Cioss Builuing, Suite 2u9
State Bouse Station F#1uu
Augusta, Naine u4SSS

I gave a veiy iusheu piesentation on }anuaiy 1S, at about 1:uu PN, in which I calleu foi
vaiious legislative changes to help cut meuical costs anu ieuuce the money buiuen now
haiming oui meuically neeuy citizens. Beie, at a moie leisuiely pace, aie uetails, incluuing
some that I hau to leave out eailiei.

7$8-2D$%2 8* $ E$%F$8-8-F $F2-4 -04 GH*4 8-*H%$-I2( If a pioviuei is willing to accept
NaineCaie payments as payment in full, even if they aie much less than his¡hei asking
piice foi office visits oi vaiious pioceuuies, then you can classify some pooi people who uo
not qualify foi NaineCaie insuiance as eligible foi, insteau, NaineCaie uiscount caius so
that they pay foi theii health caie at NaineCaie iates. This helps them without costing the
public tieasuiy moie than the (veiy low) auministiative costs. Pioviueis aie on iecoiu as
being willing to accept NaineCaie payments fiom oi on behalf of the neeuy as payment in
full. Eveiyone wins.

Suggest: Cieate a seconu categoiy of NaineCaie-eligibility, those who aie not eligible foi
tiue NaineCaie insuiance but aie eligible foi NaineCaie piice uiscounts.

3I%22-8-F 42*4* $%2 %2*4%8I42" 40 4+0*2 #+0 %2I28J2 0%"2%* K%0, $LL%0L%8$42MN
M8I2-*2" +2$M4+CI$%2 L%$I48480-2%*6 EN K2"2%$M M$#( Same foi owneiship of many
uiagnostic uevices.

Suggest: iequiie the meuical licensuie boaiu to be the physician-of-iecoiu foi anyone who
wants a scieening test oi to puichase an electiocaiuiogiam machine oi othei uiagnostic
uevice, subject only to the iequiiement that no insuiance will be iequiieu to pay foi it.
Allow insuieis who want to pay foi scieening without the foimality of a meuical oiuei to
iequiie the meuical boaiu to coopeiate with them, too. Insulin anu insulin syiinges useu to
iequiie piesciiptions anu uon't now. Theie was no epiuemic of uiabetic complications
when the piesciiption iequiiement was canceleu. Infeience: Some piesciiption uiugs can
be safely offeieu to the public foi self-caie with the meuical boaiu being the piesciibei of
iecoiu.

5+2%2 8* -0 I%0**CI+2I1 E24#22- "8*$E8M84N L%0F%$,* >30I8$M 32IH%84N $-"
7$8-2D$%2A $-" 4+2 ,040% J2+8IM2 EH%2$H( Feueial law may inteifeie with access to
uisability piogiams. But the State contiols uiivei licenses anu has the iight to iequiie that
any uiivei license applicant sign a waivei peimitting inquiiy of the uisability piogiams so
that if a uisableu peison claims a uisability too seveie to peimit uiiving then no uiiving will
be peimitteu. Such a cioss-check that is baseu on a uiivei-license piotocol not on a
uisability-application piotocol is likely to withstanu a legal challenge: uiiving is a piivilege
not a iight. This piocess of pieventing fiauu will not pievent all fiauu, but it will pievent
some of it.

O+N*8I$M 2P$,8-$480- "24$8M* +$J2 E2I0,2 H-K$*+80-$EM2 *8-I2 -2# "8$F-0*48I
"2J8I2* +$J2 E22- 8-4%0"HI2"( Q$4H%$M %2,2"82* $-" I+2$L 0M" L%2*I%8L480- "%HF*
+$J2 E2I0,2 H-K$*+80-$EM2 *8-I2 -2# "%HF* +$J2 E22- 8-4%0"HI2"( This combination
of tienus, ciowuing out the low-cost methous, has hau a uisastious effect on health caie
costs. In Englanu, uoctois iely much moie on goou examination techniques anu less on
veiy costly technology than 0SA uoctois uo. The Biitish physical exam piotocols (my
favoiite authoi in the oithopeuic context is P. }. Cyiiax) peimit acquiiing consiueiable
infoimation without the neeu foi iauiology. Tiue, an examining physician may be stumpeu
fiom time to time uespite goou physical-examination knowleuge. (Abuominal examination
is an example. It is notoiiously unhelpful, anu most abuominal X-iays anu scans aie
unpieventable.) But a gieat uiminution in use of uiagnostic stuuies will cleaily leau to a
gieat uiminution in health-caie expense.

Neanwhile, the social piotocols of uiug iepiesentative visits, to hospitals anu meuical
piactices, aie ueauly to iational thought about cost contiol. In iesiuencies, othei hospital
settings, anu gioup piactices, a fiienuly sales peison fiom one uiug company oi anothei
will show up, lively, full of smiles, biinging lunch oi vaiious tiinkets, anu offeiing a sales
pitch about one new uiug oi anothei. The uiug infoimation anu wiitten mateiials offeieu
aie caiefully appioveu by the FBA. Beceit is not the pioblem. Compaiison with cheap olu
uiugs, oi with natuial iemeuies, is not offeieu. Biug companies that submit stuuies to the
FBA contiive the stuuies to piove that theii uiugs aie effective. They often use sample sizes
small enough that no one can use statistical analysis piove that theii uiugs woik bettei
than those of cheap uiugs÷oi that they uon't.

Ny favoiite example is coppei. I got suspicious when ieauing about mental-illness
management anu staiteu testing mental-health patients with 24-houi uiine foi coppei÷
anu moie than half the time it was veiy low. So I staiteu telling my mentally-ill patients to
take coppei. It helps. 0ne such patient is now off all piesciiption uiugs (incluuing
quetiapine, veiy expensive) anu is inteiesteu in ienouncing his uisability status anu
ietuining to woik.

ulutamine 1 giam 2 times a uay ieuuces the uige to uiink alcohol, a fact not uiscloseu to
most alcoholics. Pineapple ieuuces the uige to smoke tobacco, a fact not uiscloseu to most
smokeis. Biomine-bleacheu floui incieases the iisk of bieast cancei anu iouine ieuuces it,
a paii of facts not uiscloseu to most iecipients of mammogiam scieenings. Folic aciu
ieuuces the inciuence of ceivical cancei, a fact not uiscloseu to most iecipients of a Pap
test. Anu any natuiopath will have peihaps a hunuieu moie examples.

We can't silence the uiug sales people, anu we shoulun't. But we neeu an alteinative
euucational piocess to compensate.

5+2 ,2"8I$M M8I2-*H%2 E0$%" "2M2F$42* 84* $H4+0%84N 40 $LL%0J2 D7! >I0-48-H8-F
,2"8I$M 2"HI$480-A I0H%*2* 40 4+2 RDS7! >RII%2"84$480- D0H-I8M K0% S%$"H$42
72"8I$M !"HI$480-A( This uelegation is veiy uangeious.

The meuical licensuie boaiu iequiies continuing meuical euucation in oiuei to ietain a
meuical license, as suiety that a physician's knowleuge uoes not become obsolete with
time. The intent is appaiently goou, but some physicians aie themselves pioneeis in
specializeu oi auvanceu suigical pioceuuies anu can leain nothing useful fiom foimal
couisewoik.

A moie impoitant objection is that the piocess of obtaining CNE cieuit is aiuuous anu, I
think, biaseu. The AuCNE seems to iequiie that anyone who offeis a couise foi appioval,
hoping to get it appioveu so that physicians who take it get CNE cieuit, go thiough a veiy
lengthy anu cumbeisome piocess anu have an affiliation with a laige meuical complex. The
obvious consequence is that appioveu couises will have a bias towaiu the money neeus of
laige meuical complexes÷anu that cost-saving methous (that cut into the income of those
laige meuical complexes) will be iepiesseu.

Suggest: Requiie any health-caie boaiu that iequiies continuing meuical euucation to
appiove its CNE couises uiiectly, without using the appioval of any outsiue cieuentialing
oiganization as a ciiteiion suppoiting the woithiness of a couise, anu without uelegating
the iight to appiove oi ieject a couise to any peison, gioup, coalition, oi committee that it
uoes not itself cieate anu uiiectly oveisee.

Failuie to take uiiect iesponsibility foi couise appioval is analogous to caieless town anu
city councils that casually uelegate iesponsibility foi lanu-use oiuinances to the ICLEI, the
Inteinational Council foi Local Enviionmental Initiative, which in tuin is a cieation of the
0niteu Nations anu its push foi Agenua 21. The iesults aie cleaily uetiimental to us
citizens.

Also suggest: Requiie the meuical licensuie boaius to locate, anu to peisonally cieate if
they cannot locate, appiopiiate iefieshei couises on physical exam techniques anu on
natuiopathic anu othei low-cost meuical management techniques, anu to make them easily
available at nominal cost to licensees anu piobably to in-state iesiuents even if not
licenseu.

Theie is no paiticulai ieason not to shaie such mateiials with schools anu teach oui
chiluien about the human bouy, how it woiks, anu how to take caie of it. Funuamentals of
physical examination aie concepts that aie valuable to physicians anu can neveitheless be
leaineu in elementaiy anu seconuaiy school. So aie the essentials of physiology anu the
common mechanisms of heauache anu abuominal pain. A chaiacteiistic of the most
biilliant scientists is theii capacity to attack a complicateu issue anu explain it so that it is
easily unueistoou anu uoes not seem complicateu at all. Call foi such euucational viueos
anu othei couises, foi the lay peison not just the physician, anu Naine will attiact the best
anu biightest physicians without the expense of builuing anu maintaining a meuical school.

72"8I$M M8$E8M84N 8-*H%2%* H*2 L%2,8H, L2-$M482* 40 EHMMN L+N*8I8$-* 8-40 2PL2-*8J2
4%2$4,2-4 ,24+0"*( Eviuence: EBTA (ethylene uiamine tetia-acetate) chelation is known
to iemove aiteiial ueposits anu theieby help pievent stiokes anu heait attacks. Setting
asiue the eviuence in favoi of EBTA tieatment, it is a cleai fact that patients who ieceive
EBTA tieatment almost nevei sue. They aie a veiy low-iisk gioup of clients in the context
of assessing legal iisk. But liability insuieis, who senu theii piospective clients
questionnaiies, ask about chelation anu vaiious natuial-meuicine methous anu eithei iaise
the piemiums on such physicians oi excluue them fiom coveiage entiiely. This looks like
bau business, scaiing away the low-iisk clients fiom an insuiance plan. But if the insuiei is
a mutual insuiance company (owneu anu opeiateu by physicians), then the physicians
collectively will piefei a pieventable loss of insuiance-piemium income if in ietuin they
scaie away competitive piactices. Revenue foi a coionaiy aiteiy bypass giaft: $1uu,uuu.
Revenue foi a chelation iegimen that also benefits the caiotiu aiteiies anu leg aiteiies:
$4,uuu. Small wonuei that physicians gioups that oveisee mutual insuiance companies tiy
to pummel the inuepenuent piactices into not offeiing any significant competition.

Suggest: Initiate foimal complaints against meuical uiiectois of such insuieis on the
giounus of unpiofessional conuuct, fiist amenuing the law as neeueu so that the
afoiementioneu conuuct is inuefensible if pioven to occui. Also legislate to allow patients
who have been coeiceu into a too-expensive tieatment to sue foi malpiactice on the
giounus that a less costly alteinative was not offeieu. Right now, an inexpensive tieatment
that is not wiuely useu neeu not be offeieu. But if it is not wiuely useu uue to ignoiance oi
boycotting, then patients shoulu have the iight to a legal iemeuy if the tieatment is shown
to be about as safe anu effective as what actually is commonly uone. Biiect legislative
action will piobably be necessaiy; iight now "no one else uses that tieatment methou" is an
absolute uefense.

7$8-2 %2TH8%2* !U5R 40 E2 *0M" 0-MN EN L%2*I%8L480-( This iequiiement is not the same
as iestiicting the puichase without a piesciiption to licenseu piofessionals. If I want a
jaiful of penicillin pills, then I can buy it without much tiouble fiom a phaimaceutical
wholesalei anu can uispense fiom it to my patients, easily anu without fanfaie (but I cannot
ask to be paiu foi the pills I uispense). But if I want EBTA, then I must tell the wholesalei
whom it is foi anu pay the phaimacy-maikup foi the papeiwoik involveu in conveiting the
EBTA into a piesciibeu quantity. This iequiiement is an obvious attempt to uetei the use of
EBTA anu iaise the piice of EBTA chelation. As noteu above, theie is a money incentive to
uetei use of EBTA chelation.

Suggest: Requiie that any non-contiolleu substances puichaseu by people alloweu to
piesciibe them be puichasable without any piesciiption-geneiating piotocols.

Reuuce the piice of EBTA chelation anu allow physicians in Naine to uo EBTA chelation
without feai of oppiession, anu consiueiable money will flow into Naine as vacation camps
accept people foi a few months anu such people ieceive EBTA chelation at vaiious scenic
sites. This piocess will gieatly eniich the hotel-hospitality inuustiy.

7$8-2 "02* -04 %2*4%8I4 4+2 H-M8,842" ,$%1HL 0K $",8-8*42%2" *HE*4$-I2* $-" "02*
-04 %2TH8%2 $ "8*IM0*H%2 40 L$482-4* 4+$4 *HI+ *HE*4$-I2* I$- E2 E0HF+4 $4 "8*I0H-4
L+$%,$I82*( Neanwhile, the meuical boaiu uoes not peimit physicians to uispense uiugs
oi uevices fiom theii offices. The lattei is an unueistanuable attempt to pievent
unieasonable maikups that take money unfaiily fiom patients, but the foimei seems to
show hypociisy in that context. Savings on cancei chemotheiapy may be well ovei
$1uu¡uose.

Remeuy: if an auministeieu substance is useu in a nonemeigency context, anu it costs moie
than $2u oi so, then iequiie that the patient be notifieu of the iight to puichase it
elsewheie anu biing it in anu that uoing so may be cheapei. The meuical boaiu is shown,
heie, to have an inteiest anu policy that is cleaily uetiimental to patients anu unjustly
eniiches oncologists anu othei specialists. It neeus to be tolu fiimly to change its policy anu
piobably its entiie attituue.

Epinephiine (as foi injecting aftei a bee sting, to someone who has an anaphylactic
ieaction to such a sting) is available foi about $1S foi a ten-uose vial. Insulin syiinges cost
about 2S cents each, maybe less. Neanwhile, a pack of two (not ten, two) syiinges each
piefilleu with one uose of epinephiine sells in a phaimacy foi about $2uu. I hau an
uninsuieu nuise as a patient anu she hau a bee-sting alleigy. I bought a multiuose vial of
epinephiine anu tolu hei to buy a pack of insulin syiinges. I gave hei the vial (not alloweu
to sell it). I lost $1S anu she saveu about $2uu. Why was that woikaiounu necessaiy.

With piopei attention to these matteis, theie will be a substantial ieuuction in health-caie
cost, uiiect not attiibutable to auministiative piactices oi to cost shifting.

Bo let me know if you want fuithei assistance with this cleaily big anu impoitant pioblem.

Respectfully submitteu,



Euwaiu }. Baishman

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