Sunday, October 2, 2016

Medical Malpractice Defense Points Not Usually Considered

I am not a lawyer, but I know where they live. Matters are 100 times worse than any one realizes with the lawyer profession.I would want to make the following defense points.  I would appreciate knowing any lawyer rebuttal.

1) Four Elements that must be proven in a tort case.

Injury Caused by Breach

2) Even lawyers forget the fifth. Unforeseen intervening cause. Any plaintiff conduct remotely related to the injury should be brought up, and a motion to dismiss should be made at every procedural step. Examples, smoking, non-adherence, family effects, outside stress.

3) In terms of breach due to a deviation from professional standards of due care, the courts will allow minority views in a subject that is not completely settled, and no medical subject is completely settled.

4) The tort is based on a theory of chain of causation. Great in the 13th Century, total lawyer quackery today. Lawyer quackery violates the Fifth Amendment procedural due process right to a fair trial of the defendant, even in a tort case.

A doctor sued BMW for a bad paint job and was awarded $4 million. The Supreme Court affirmed the Fifth Amendment  due process rights of defendants in torts.

The current view of catastrophes is that multiple factors cluster in a space and time, for example 12 of them in an airplane or car crash. The prevention of any one may prevent the entire catastrophe, often. The chain of causation is a myth. If followed enough, it ends at the Big Bang, and the court should try to collect from the entity that caused the Big Bang. The lawyer is ridiculous and stupid. They start with high IQ's and end up doing stuff from 1275 AD. I call that stupid, except they take in $trillion and damage the economy far more than that.

5) I urge defendants to personally attack the other side, and to share their own misery with the other side. The most powerful attacks are in the trial and in motions to the trial judge. Find a factual mistake anywhere, in the resume of the expert, in the out of court social media postings of all parties, in depositions. Adjectives and opinions are legally immune. I think this person is evil, stupid, greedy, etc. All are adjectives and immunized by the First Amendment. False facts are criminal and criminality should result in dismissal, and in sanctions, such as prison, all legal costs to the assets of the perjurer, exclusion of the testimony, disqualification. Disqualify the plaintiff lawyer, disqualify the experts, then even disqualify the judge.

No defense lawyer will ever do that. You may have to hire a personal lawyer to terrorize the defense lawyer. The latter makes no money until reaching trial. They are paid less than HMO doctors, and may actually lose money on overhead by insurance companies. Your personal lawyer should also threaten the insurance company for paying the defense lawyer too little, as form of insurance fraud, or insurance bad faith. Defendant thought he would  getting the Dream Team, from the slick brochure, got the dead time of losers.

6) If court tactics fail, try regulatory tactics. File complaints with all licensing boards, all Disciplinary Counsel. Even if dismissed, the other side will be spending time and worry in continual investigations. Make it so no amount of money is worth the plaintiff case. They may have to hire lawyers to deal with these investigations. File discrimination complaints, for example, the lawsuit is because the defendant is white, and male.

I find defense lawyers far more detestable than plaintiff lawyers. That is because they pretend to be on your side, but are working only for themselves, even if that means hurting your interests. They are the ones with duties to you. They are the ones with professionalism. They are the ones who betray both. Legal malpractice claims have totally insurmountable obstacles, and are a waste of time. So any understandings can only come before hiring or approval of a defense lawyer. Bring your personal lawyer with you, in your meeting with your defense lawyer, as if you were meeting the FBI. It is that bad.

The above apply to the innocent or controversial defendant. If the defendant is clearly at fault for a serious injury, a quick settlement is in the interest of the doctor, of the  patient and of the profession. A guilty defendant using the above tactics is abusing the system, and should be punished for doing so.The overwhelming fraction of medical malpractice defendants are found, not guilty. So most medical malpractice claims are invalid. This is true even in defendant judicial hellholes. In Philadelphia, a true judicial hellhole, 70% of the medical defendants are found, not guilty. The problem is that the cost of litigation has had an impact on health care. Almost all obstetrical wards have closed in Philadelphia, despite the statistic. As a result of lawyer perfidy, a woman is lucky to get a space in the hallway of the remaining services to deliver a baby.

Sunday, September 25, 2016

Statement on Nurse Practitioners with Independent Prescribing



If any member of the legislature were having crushing chest pain, and had shortness of breath, with a family history of premature  deaths by heart attacks,  would they want to be seen by a cardiologist or by a nurse practitioner filling out a form on the electronic record? Why are the lives of black people on Medicaid worth any less than that of the legislator?

The movement to allow nurse practitioners to prescribe unsupervised, will result in a two tiered health system, one for whites, one for blacks. It stems from racial animus. The aim is to raise the mortality of black people even higher than it is already.

Nurse practitioner programs are so competitive that only people with nearly perfect grades get in. Most qualify to get into medical school. They have chosen to bypass that harder road to clinical competence, to begin making money earlier, and with less student debt. That corner cutting should not be rewarded with independent prescribing privileges.

As a result, they know one quarter that specialists know, and half as much as primary care physicians. They are fit only to prescribe for patients doing well, needing routine refills without any change. They are fit to diagnose routine, common and mild disorders. They are fit to administer first aid and nursing care.

New patients with serious or life threatening conditions should not be evaluated by them. They can read off checklists, but have none of the skills that come from the experience of doctors.

Even after 5 years of experience, because they have not been challenged by difficult experiences of physicians, they will require supervision.

A patient commented on the internet. A nurse practitioner insistently called the growing lesion on his arm  an "age spot" for a year. The patient demanded to see the dermatologist. The doctor arrived at the door, and from that distance, stated, “That is a squamous cell carcinoma. It has to come out.” Squamous cell carcinoma is a common skin lesion in the elderly.

Email sent to You need to address this allegation of fraud


Friday, September 23, 2016

Name Mispronunciation as a Micro-Aggression and a  Evidence of Bias

I suggest an alternative scheme.

Eventually, this idea will be enforced in judge made law and precedent setting. Schools may face ruinous litigation for the mispronunciation of a name. Today, employers face the same for an off color joke at work. Both employers and school systems are mere pipelines from the tax payer and consumer to the pockets of lawyers, mostly, with some crumbs going to injured plaintiffs.

I propose that the naming of a child with an unusual or difficult to pronounce name be deemed evidence of child neglect. The same should go for misspelled names. Hospitals delivering children should assist parents to spell names correctly. The name is Antoine, not Antwan. The French province is called Brittany, not Britney.  It is established that people with such names are less likely to be hired or to be admitted into schools. They are a signal for bad attitudes, low performance ability, and dangerousness, wrongly or correctly. This problem is a problem of the American South, not of blacks alone. The Spears family is white, but from the South. It says, raised by parents who do not know how to spell.

Based of the great economic performance of African immigrants in the 2010 Census, a really impossible to pronounce name, with tongue clicks and other impossible sounds is associated with a great employment prospect, and a curve busting student. So that is likely to result in a form of reverse bias, and superior performance.

Sunday, September 18, 2016

Reply to Government Propaganda Article.

The_Economic_Burden_of_Prescription_Opioid Overdose, Abuse, and Dependence in the United States, 2013The

You forgot some things to deduct from your cost analysis. 

1) The productivity and tax payments of people able to get to work because of opiate pain relief;

2) The value of the 200 crimes a year not committed by the deceased drug addicts;

3) the value of the deaths of criminals to families that will not be exploited, injured, and abused by the deceased.

Thursday, September 15, 2016

Productive and Non-Infringing Restrictions of Second Amendment Right to Have a Gun

Half the murderers, half the murder victims, half the suicides are legally drunk. The most prevention of gun violence would come from restricting access to guns to people with evidence of alcoholism. Such evidence would include convictions for drunk driving, public intoxication, and alcohol induced liver disease.

Paranoid people kill 10% of murder victims around the world, or around 2000 people a year in the US. That number includes almost all rampage killings. It is in the nature of paranoia to not believe there is anything wrong with oneself. So even people doing well in treatment will try to stop treatment, and will relapse.

In the absence of drug induced paranoia, marijuana is associated with lower rates of violent crime. So, its use should not exclude people from their gun rights.

None of these policies are in place. They have the potential to cut the overall murder and suicide rates by two thirds, without infringing on the Second Amendment. They would withstand the strictest of scrutiny. There are no racial differences in the risks of mental illness.

Tuesday, September 13, 2016

Venezuela, Here We Come

As government grows, so does poverty and shortage.

Past a Low Amount of Money, Increasing Wealth Yields Asymptotic Value, Mostly in Esthetics

The Versailles Palace remains a very beautiful place. At the time of its construction, it would be deemed unfit for human habitation today. Only technology adds the value of utility beyond esthetics. The poorest person in our nation has electricity, and goes to the bathroom indoors in the winter.

As wealthy people, we should therefore invest even more in technological development, to exponentially increase our wealth.

One easy place to get money is from the $trillion wasted on a legal system in failure, in every law subject. The nation should have the research and development budget of a technology company, around 20% of revenues. We have to, or we will be overtaken by Chinese and Indian wealth.

The most opulent hotel in the world, today.

Saturday, September 10, 2016

Obama Succeeds in Denying Access to Care. Doctors Now Spending Twice as Long on the Electronic Record as on Patient Interaction

The Obama Administration achieved what they wanted. To cut clinical care. They imposed electronic record mandates. Now doctors spend twice as long on the record than on patient interaction. Organized medicine is collaborating. The article is in plain English.

This a review of the problems of the electronic record and their one solution. It would save $70 billion a year, and potentially end co-pays. Here.

Thursday, September 1, 2016

Personal Patient Experiences with Alpha Stim



On Label:

Off Label:
1) An older woman had the compulsion to climb the stairs precisely 60 times a day. She had severe back pain. She had a heart attack, with heart damage. She could potentially suffer heart failure. She got Alpha Stim 20 minutes day, set at 1 for one week, then at 2 for one week. Her compulsion was gone. I stopped the treatment for 2 weeks, and there was no return of her obsessive-compulsive disorder. There was no substitute compulsion, as sometimes occurs. The compulsion has not returned for 4 months. She requested to continue regular treatments for anxiety and for insomnia. I restarted treatment at her request.

2) An adolescent had a form of autism, once called Asperger Syndrome. He had a very high level of rage, despite high doses of a major tranquilizer, with high blood levels. If he did not get what he wanted, he jumped from a high balcony. I asked him what was the date today. He replied, that is a stupid question, and walked out. He had two treatments at a level of 1. He said, he would go to the pool, for the first time of the summer. The bus was 45 minutes late, but he just paced and waited. He went to the pool. He had two more treatments, and a home visit. Instead of being destructive and assaultive, his mother reported he started talking to her about his interests, such as computers and games. After a year, but only a month on Alpha Stim AID, he went home. He was asking for the treatment, and for an extension of the time to 30 minutes. It is unclear if he liked the treatment or access to the internet offered to him while on it.

3) A woman is received Alpha Stim M treatment for neck pain. After several treatments, she reported no improvement in her neck pain. However, her tinnitus (ringing in the ear) of many years was completely gone.



On label reports here.

Off label reports here

Sunday, August 21, 2016

The Serious and Insurmountable Problems of Evidence Based Medicine

1) Something works in medicine. It spreads around the world in months. When patients are doing well, medicine is a highly paid, piece of cake. It is almost like stealing. When patients are not doing well, it is a living hell of time, effort, and extremely low pay for doctors. So the incentives are in the right direction. Doctors may be trusted to want patients to do great. And the loss of work by patients' cures is not a problem due to the shortage of overly busy doctors.

2) A couple of years later, an academic doctor sees this response, designs a study, writes a research proposal, gets funding, carries out the study, writes up the results, waits for its publication. So, 7 years has passed. A number of studies accumulate. A committee reviews them. They enter a textbook, as accepted practice. It has now been longer than 7 years, by the time a guideline is written based on published studies. Meanwhile, the docs are doing almost nothing the way they were 7 years ago. The standard of care has moved on, except in the minds of guideline writers, government officials using guidelines like laws. These officials only want to slow clinical care to save money by piling bureaucratic procedures, and by denying dark skinned people that white people are getting.

3) On the first day of high school statistics class, coin tossing is discussed. That event is described by the binomial distribution statistic.

4) Studies comparing the fractions of responders to a treatment and to a placebo are supposed to represent the larger population. The parametric statistic is used to compare the fractions. The parametric statistic is the one whose formula describes a bell shaped curve, a common distributions of populations. Before carrying out such a test, one must show that 4 assumptions have been fulfilled. The most important is random selection. So any selection bias, such as an exclusion criterion, makes it so that the test is not even allowed to be done, let alone have any validity. All studies have exclusion criteria and violate the central assumption of parametric statistical testing. The populations in these studies do not represent those in the clinical setting. Doctors do not have exclusion criteria in their practices. Imagine excluding suicidal patients from a depression treatment study. That is routinely done in the FDA approval of new anti-depressants. Worthless.

5) Clinical care differs from the comparisons of the fractions in groups. It is closer to coin tossing. Have or not have a diagnosis. Give or not give a treatment. Have a good result or a bad result. The binomial statistic is more appropriate to clinical care than the parametric. Nevertheless one is not allowed to apply parametric statistics to a population best described by a binomial distribution.

6) Dose response curve is ignored. Low doses of radiation are good for the health, for example, as in radiation hormesis. One must delineate the dose response curve of all remedies. Then one must do so in the individual patient, and this is where experience based medicine beats evidence based medicine in outcomes.

7) Most evidenced based guidelines are not only written by under-achieving, atavistic, and know nothing academics, they are written by associations with undisclosed conflicts of interest. For example, cardiologists proposed doing EKG's on all children receiving stimulants for Attention Deficit Disorder (ADHD). They would be doing the EKG's, and reading them. Cardiologists want to make more money, since the management of cholesterol lowered the number of cardiac problems.  Child cardiac function has not been harmed by stimulants. Once a year, a child, out of hundreds of others, reports a newly rapid heartbeat,  at rest. That child is taken off the stimulant and placed on something else. No EKG is necessary. Requiring EKG's would deter the use of stimulants, and increase the rate of accidental injuries by impulsive acts of untreated children with ADHD.

So evidence based medicine has problems, 1) delineation by academic professors with half the clinical experience and therefore half the insider knowledge of clinicians; 2) obsolescence; 3) based on wrong statistical application; 4) violation of the rules of statistical testing by exclusion criteria in all studies; 5) misapplication to individual patients (a treatment killed 99% of patients who had it, this patient has done well on it, follow guidelines and stop this effective treatment?); 6) ignorance of the individualized dose-response curve.

In a legal context of any kind, the suborning of quackery is a violation of the Fifth Amendment procedural due process rights of the defendant to a fair hearing. Evidence based medicine is  itself is a constitutional tort. I would urge all defendants to sue the plaintiff lawyer, the plaintiff, the plaintiff experts, guideline writers, as individuals, their universities, their chairman that failed to supervise them, their association. The association should be charged with civil RICO. That is subject to punitive damages (triple) because it is an intentional act, not just negligence. If it can be shown to have been financially self serving, it can be converted to criminal RICO, and the guideline writers should be arrested, tried, and sentenced to prison. To deter.

Stuff on civil RICO, only 600 pages.

Put this forward to the defense lawyer. He will never agree, because it would fully deter the other side, and end his business.

Saturday, August 13, 2016

Nixon to China, or the Immutable Law of Political Opposites

This Nixon to China phrase is a political science term. It means, that you vote for the person opposing your interests to get those interests fulfilled.This effect complicates voting choice.
Only the opponent of your interest has the credibility to get it achieved, if it is advantageous.

Who can sign a peace treaty between Egypt and Israel? A rabid former Jewish terrorist with open hatred of Arabs, of course.

Only a rabid anti-Communist could open relationships with China. George Bush II said in a debate, there will be no nation building under my administration. There was an orgy of nation building. Had Gore been elected, he would have been stymied, because he could not be trusted.

Welfare reform was achieved by President Bill Clinton in 1996.

If you want to get the US out of the Middle East and attack it on 9/11, what do you get? The US attacking many countries in the Middle East.

If you hate black people, want them impoverished, unemployed and murdered, whom do you vote for, Obama or Romney? If you want massive income inequality, and massive enrichment of billionaires, who will get that done? If you want to kill health insurance so that nothing can be covered nor paid for anymore, and now no one has any real health insurance, whom do you vote for? Obama, of course.

If you want Bin Ladin killed, instead of being allowed to escape from Afghanistan, whom do you vote for?

Say, you hate homosexuals. You wish they would suffer unspeakable and unending torment at the hands of lawyer predators. Do you support or oppose gay marriage?

That brings up this year's election. I supported Sanders to enrich the rich. I may vote for Clinton to do the following opposites of what she advocates, 1)......................; 2) .....................; 3) ................
I am going to let people fill in the blanks with the opposites of what she is advocating.

Saturday, July 9, 2016

Tales of Conduct Disorder

Conduct disorder is childhood antisocial personality disorder. Its features are selfishness, fearlessness, lack of remorse unless the person is suffering personal punishment, impulsivity, lack of empathy, inability to learn from consequences. Other than that, they may be very intelligent. They have social skills in the form of manipulating people to get what they want. They are precocious in their social development. They party like people 10 years older. The crime meter starts to spin fast around age 3. Everyone, including fellow preschoolers knows who they are by then.

You have to wait for or go to the end of the recording to learn of the motivation for the car chase of this 12 year old girl.

Monday, July 4, 2016

The Future of US Health Care as Government Controls More of the Industry

Rio de Janeiro’s hospitals are running out of syringes and basic medications, and their staffs are running on little-to-no pay, with one month to go before the city hosts the 2016 Summer Olympics.

From here:

Sunday, July 3, 2016

TSA Thugs Beat On a Brain Tumor Teenager

I hope she sues everyone involved, including the Federal government. They negligently hired thugs. They negligently failed to train them. They negligently failed to inform them they work for the public, and not the other way around. Meanwhile, these thugs are failing test contraband by inspectors. Naturally, these thugs are agents of the prosecutor and the lawyer profession.

Sunday, June 19, 2016

Letters to the Medical Directors of the Medicaid Pharmacy Benefits Insurance Companies About Their Refusing to Pay for Alpha Stim Treatment

I had a trouble finding their mailing addresses, not readily available on any of their websites.

I am therefore listing them here, along with the letter their Medical Directors were sent.

RE: Paying for Alpha Stim without Pre-Authorization

Dear Doctor,
Alpha Stim is an FDA approved Class II medical device, as a condom is classified.  It has FDA approved indications for depression, anxiety, insomnia or pain. It requires a prescription in the United States.

The device is reviewed here:

It has the pain management potential to solve the opioid overdose problem. To continue to refuse to pay for it is cruel to extremely distressed patients and unconscionable. It is also stupid. Spend $hundreds on it, save $thousands on medications that can be weaned off and discontinued.

If you pay for other medically indicated FDA approved, medical device of any kind, you must pay for Alpha Stim without a pre-authorization requirement. The Affordable Care Act (ACA) prohibits discrimination against mental health treatment.  I am attaching printed guidance from CMS on the Mental Health Parity provision of the ACA.

If you continue to refuse to fund Alpha Stim treatment, including all necessary accessories, I will be asking the federal prosecutor and the Office of Civil rights to enforce the federal law in federal court. As is my legal duty in Pennsylvania, I will also be initiating regulatory complaints against you personally. Your brazen violation of federal laws is unprofessional conduct.

UPMC Health Plan; U.S. Steel Tower; 600 Grant Street; Pittsburgh, PA 15219

Keystone First; 200 Stevens Dr. ; Philadelphia, PA 19113; Phone:(215) 937-8000

Health Partners; 901 Market St #500; Philadelphia, PA 19107

John B. Bulger, DO, MBA, Medical Director; Geisinger Health Plan Insurance Agency;
108 Woodbine Ln; Danville, PA 17821; Phone:(570) 271-8771

Gateway HealthSM; Four Gateway Center; 444 Liberty Avenue, Suite 2100; Pittsburgh, PA 15222-1222

AmeriHealth Caritas Pennsylvania; 8040 Carlson Drive; Suite 500; Harrisburg, PA 17112

Aetna Better Health Administrative Office; Aetna Better Health; 2000 Market Street, Suite 850
Philadelphia, PA 19103;  1-866-638-1232;  (HealthChoices)

Sunday, April 24, 2016

A Family Theory of History

The Families Theory of History. This is a variation of the Great Man Theory of history. 

Twenty families put Hitler in power, and did great during the war. They each gave him $5000 (like $500K today) for his campaigns, and made $millions off government contracts. The Allies hanged the Nazis by the hundreds. Those families stayed untouchable, and were actively recruited by our government, despite having been the real cause of WWII.

Bush represented West Texas oil families. They did well, when he killed their Takrit competitors and their puppet, Saddam. They did well when gas prices went from 99 cents under Clinton, to $4 a gallon. 

Reagan represented California real estate families. They did well. Inflation made their investments soar in value.

Bill Clinton? Bill is Tyson Chicken. Clinton enacted a law banning the dumping of blood into a river by packing plants. At the next biennial election, he got his chain yanked, and lost the governorship. He gets back into office, and amends the law. Beef packing plants may not dump blood into a river. Chicken processing plants may.

Soros and the homosexual billionaires pulling Obama strings have done well under his carpet bombing of the economy, driving all money into the stock marker due to 0% interest rates. Obama also wiped out the small bank competition of his sponsors. They could not survive the regulatory requirements of Dodd-Frank Act. 

Unless I am missing something, Sanders and Trump are not puppets for any set of families. Both are extreme and frightening. However, they have no nasty "families" behind them.

Friday, April 15, 2016

A Potential Solution to the Problem of the Unemployability of People with a Felony Conviction, or Even Those with a Misdemeanor Conviction

In Pennsylvania, one may deny a job if the felony conviction is relevant to the job. A pedophile may may be denied a job in a daycare center, but may work as a cashier. A thief may be denied a job as a cashier, but may work in a day care.

It never works out that way. And no felon has challenged the denial of a job not related to the conviction. Thank the lawyer profession for the unemployability of former felons. Employers are not willing to risk litigation for negligent hiring, should the worker commit a tort. The lawyer profession must be crushed if this problem is to be solved. Naturally, this burden falls heaviest on black people.

Here is a list of the collateral civil consequences of a criminal conviction. There are 50,000 of them. Thank the lawyer profession.

I have several patients with some petty infraction, committed years ago, who cannot find a job, and are living in poverty despite skills, and even licensed craft skills, such as electrician.

I have advised them to read this article, and to consider going into this business on their own. Guy made $250,000 a year. And, this activity is a win-win-win-win for everyone.

Wednesday, April 13, 2016

The Solution to the Problems of the Electronic Medical Record is Simple, Saves $Billions, and Helps Patients, not Insurance Companies: Video Recording, Period, and Nothing Else

Authors: David Behar, MD, is an adult and child psychiatrist in the Philadelphia area. Brian P. Moquin, Esq., is the president of Digital Abacus Corporation in Silicon Valley and has a law practice, doing civil litigation.

The electronic medical record (EMR) has been touted as a panacea for health care, by reducing costs and errors, increasing efficiency, improving access to care, leading to better diagnoses through data mining. EMR has been a dismal failure, difficult to use, with no interoperability, and focusing practitioner attention away from the patient.

Consider the EMR in psychiatry. An EMR template must be filled out for each patient visit. Patient sobs that her boyfriend was killed in a motorcycle accident. Facing a screen, I reply, “How is your appetite?” the next item on the template. Our relationship has become that with the staff at the Department of Motor Vehicles. Because of the data-gathering demands imposed by EMR, ordinary human sympathy has been replaced by impersonal form filling. These demands also turn a ten-minute medication visit into a fifteen-minute visit: in contrast to its promise, the adoption of EMR has added millions of hours in waiting room delays. While this is a nuisance in psychiatry, increased waiting times for the emergency room is unforgivable.

The problem is that EMR is not an innovation: EMR has replaced the piece of paper with a screen that shows a picture of that piece of paper. The input is still by the keyboard of a 1945 Underwood typewriter. The major difference is that the EMR forces the doctor to do his own transcribing, and doctors have poor transcription skills. Burnout, delays in access to care, frustration result.

One of the stated goals of EMR is to be the “single source of truth” regarding a patient. The set of fixed, predetermined fields (including check boxes) miss most information from each encounter. Problems in mapping a patient’s statements onto the predefined fields of an EMR, as well as the lack of free-form text areas in many EMR templates, virtually guarantee that an EMR will be incomplete, inaccurate, sometimes dangerously misleading. The EMR paradigm forces the health care practitioner to conform the information provided by the patient to a structured data format that offers little or no ability to capture subtleties, ambiguities, and qualities that are not easily quantified. To wit: I had to stare at a beautiful teenage girl because her pediatric record, three times, indicated her penis was anatomically correct, and her testicles had both descended. I just accepted her “No” when I asked if there was something really unusual about her. In short, the EMR paradigm ignores the realities of the practice of medicine as not an exact science.

We can do better.

A Solution: The Real Electronic Record (RER)

We propose a simple fix: the video recording of each medical encounter is stored, with no typing or dictation. We call this a “Real Electronic Record,” since it is an actual recording of the medical encounter. At the end of each patient encounter, the doctor also records a one-minute summary of “What We Found Today” and “The Current Plan of Action,” providing a brief recap of the visit for quick review.

There are currently 1.2 billion outpatient medical encounters per year with an annual cost of more than $700 billion. The estimated cost of storing HD video recordings of all of these encounters is approximately $400 million per year. If records must be preserved for seven years, the total cost would come to $2.8 billion per year. That seems like a lot until one realizes that the HITECH Act of 2009 included $20 billion in incentives for hospitals, physicians, and for infrastructure.

We do not advocate video recording against the will of the patient. Those refusing might have to pay a higher fee for record keeping.

Using Real Electronic Records, the doctor would spend no time transcribing data into an electronic format, instead devoting that time to patient treatment. We estimate a savings of 10%— $70 billion per year—which could be used to lower health care costs or to increase doctor productivity, allowing doctors to see more patients. The arrival of the uninsured could lead to a collapse of the system; consequently, freeing up doctor time is crucial.

With a RER, the patient could review her encounter on demand through a secure Internet portal, and videos will soon become searchable, allowing for direct data mining.

The RER will reduce malpractice claims and defensive medicine, saving another 5-10% spent on worthless care.

The $70 billion in savings should be returned directly to patients in the form of no co-pay. That offer is wildly popular with every patient whom I have ever asked.

Most importantly, when a patient sobs that her boyfriend has just been killed, the doctor will be able to hold her hand, look her in the eye, and express ordinary human sympathy, rather than having to transcribe information into an EMR. That means both patient and doctor can stay human.
Kennebeck, SS, Timm, N, Farrell, MK, Spooner, SA. Impact of electronic health record implementation on patient flow metrics in a pediatric emergency department. J Am Med Inform Assoc 2012 19:443-447. (Longer ER waiting times due to EMR.)

U.S. Census Bureau, Statistical Abstract of the United States: 2012. Table 168: Ambulatory Care Visits to Physicians’ Offices and Hospital Outpatient and Emergency Departments: 2008. Available at (1.2 billion visits per year.)

Health Care Cost and Utilization Report: 2011. Health Care Cost Institute, Inc., Sept. 2012, p. 3. Available at ($709.2 billion in 2011.)

This assumes that the average medical encounter is 15 minutes in length, yielding 300 million hours of video per year. The estimated cost was calculated based upon current storage, equipment, connectivity, electricity, and data center facility costs. (Storage cost estimate.)

Tuesday, April 12, 2016

Letter Submitted to the Federal Trade Commission on the Inexplicably  High Price of Generic Modafinil Produced by Four Companies

        RE: Anomalous Higher Price of Generic Modafinil than Patented Metabolite, Nuvigil (Armodafinil)

Dear Madam or Sir:
Modafinil is a medication that effectively promotes wakefulness. It has found many uses on and off label. Its patent expired. Regulatory action took place after generic companies were paid to delay producing it, in the FTC’s Pay to Delay matter.  (

A metabolite (break down product), armodafinil, was patented, as Nuvigil. Its maker priced modafinil higher to promote the sales of Nuvigil. I understand the logic and their right to do so. Modafinil has longer action, and less of a crashing sleepiness effect than armodafinil. Thus, the longer half life of the original molecule, modafinil, may be more desirable to doctors and patients.

What I do not understand is why other companies making generic modafinil would also price it higher than Nuvigil, a product they do not make. Nuvigil (armodafinil) 150 mg has the same strength as Provigil (modafinil) 200 mg.

Prices for 30 pills (according to Giant Pharmacy, 9/21/15).

Modafinil 200 mg, by Par, Teva, Watson (Actavis), and Qualitest: all $1000.

Nuvigil 150 mg, (armodafinil): $670.

There appears to be a concerted effort to control the pricing of modafinil that violates the anti-trust laws.  Why would a competitor not price the perfectly equivalent, or even superior, modafinil a $1 less than Nuvigil and capture the large market for this medication?

Generic modafinil is also made in India. Its retail cost in a pharmacy in India  is 80 cents a pill. People who have taken it report it to be as good as the US medication. No doubt, maker and pharmacist are making a profit at that price.

I request an investigation into this anomalous pricing situation. The argument that these are different medications is specious. Modafinil is converted into armodafinil by the liver. 

I have standing to take the place of my patients in legal disputes (granted by the Third Circuit, in Behar v DOT)

Sincerely Yours,

David Behar, MD

Maker of Provigil and Nuvigil

Teva Pharmaceuticals
41 Moores Road
Frazer, PA 19355

Makers of Modafinil (generic Provigil)


300 Tice Boulevard
Woodcliff Lake, NJ 07677
 (201) 802 4000


Teva North America
1090 Horsham Road
North Wales, PA 19454 USA
888-TEVA-USA (888-838-2872)

Watson (now Actavis)

 Morris Corporate Center III
 400 Interpace Parkway
 Parsippany, NJ 07054 USA

 Fax: +1-862-261-7914


3241 Woodpark Blvd
Charlotte, NC 28206