崇 優 by 陶傑

好像「美國偶像」（American Idol）之類的才藝表演，一個蹩腳人才上台，剛開口唱歌，一分鐘不到，台下的評判已經按「叮叮」，表示「下一位」，Next。


香港的特首上任才一年半，香港中環的政商精英，已經很熱烈地呼叫着Next。


下一位，Next，到底是誰？不管有沒有普選，人性總有點愛自欺，總之下一個快點上來，不管好不好，先取代了眼前台上很叫人吃不消的這位表演人，好像就有點希望。


前政務司司長陳方安生女士認為，現任政務司司長林鄭月娥，會是相當稱職的特首，而她目前的處境和言論，只是「身不由己」。


陳太太說出了許多中產和知識階層的心聲，越來越多人覺得林鄭月娥女士的形象好，如果她當特首，至少香港不會比現在更爛。


林太太最近改穿民國風味的中國旗袍：絨衣、硬企領、深色的套裝，是六十年代邵逸夫爵士領導邵氏明星何琍琍、李菁、歐陽莎菲等出席希爾頓酒店雙十國慶酒會時流行的那種系列，有舊上海的典雅之氣，本來舊上海出身的陳方安生穿這種旗袍，也富有氣質；現在廣東人林太太穿上，也有了，着實令人欣喜。


當然，香港官場女性的高貴氣質，由鄧蓮如開始這個系列，有一個特點，就是沾染過英國淑女的文化，不受激進思想如共產文革街坊女組長或女紅衛兵式的污染，在這方面，前後兩位女政務司司長都及格有餘。


香港人對林太太有好感，林太太民望長期高踞，因為她的老公和公子，都曾經長住英國劍橋──是在劍橋大學授課和讀書，不是在劍橋開賣咕嚕肉和揚州炒飯的中國餐館。這樣的家庭，品質有保障，不會出壞人。


連香港的老人院，有一家以「劍橋」命名，大家都覺得形象好，也生意滔滔啦，不關親英、崇洋，是人性自然人望高處的崇優。不信？你叫它改名做「東莞護老院」試試看？

---

Source: http://hkm.appledaily.com/detail.php?guid=18597510&category_guid=vice&sup_id=12187389&category=daily&issue=20140119

马年炒趋势 不要买大细 by 大细 – 曹仁超投资者日记(简体)

一元复始，万象更新。2014年元旦刚过去不久，蛇年将过，马年将临，后市如何布局？

1980年开始，发达国家与新兴国家经济进入再平衡期；但全世界社会贫富差距却在扩大，主因是列根总统、戴卓尔夫人为首的西方政权采纳佛利民经济政策，令各国境内富有阶层积聚财富能力大增，变成富者愈富，中产阶级却陷入没落期，M形社会出现。

1980年前是富国与贫穷国家差距很大，自1990年起蔓延至其它国家及地区内部，首先是日本、香港自1997年起、美国自2000年起，社会内贫富差距日渐扩大，因为发达国家将工序及服务业出口，令发达国家境内工人阶级收入，其后是中产阶级的收入，与社会上20%富有阶级的收入差距日益扩阔。

今天在贫穷国家境内亦有豪宅、高级消费场所，发达国家境内亦有贫民窟，全球发达国与新兴工业国之间的差距缩窄，同时社会上贫富差距却日益扩大。

社会重返过去经济结构，即20%为富有阶级（其中0.1%是超级富豪），50%为中产（数字仍在下降中），30%为贫穷阶级，结束1967年至1997年的阶级流动时代。那段日子由一个阶级晋身另一个阶级十分容易。

世界贫富走两极

香港自1997年起、美国自2000年起中产变成富裕阶级，或贫穷变成中产阶级极之困难；至2014年，年轻一代港人欲跨越阶级更是难上加难。单单靠读书成绩好已不可行，社会走向两极化，形势对中产阶级极之不利。

2007年5月起，人民币开始升值，令中国日渐失去“三廉优势”，即廉价劳动力，廉价资源、廉价土地成本。告别GDP高增长期，陷入中等收入陷阱。最终能否摆脱中等收入陷阱？成为马年最大考验。香港过渡期只需三年（1981年下半年至1984年上半年），由1984年8月起香港GDP由内需拉动，重新恢复较高增长。中国由2007年第四季开始进入经济转型期，至今已有六年了，能否在第七年（马年）进入10至15年GDP中等增长期？仍不清楚。

理论上冬天来了，春天还会远吗？但春寒往往较冬季更寒冷，近年全球社会主义思潮复苏，过去发达国家透过税制改革令社会财富分配稍为得到平衡，新兴国家当财富分配两极化，通常走向不稳定，例如埃及、西班牙及泰国等。

持强沽弱赢面高

香港这个特区因为不能改变税制（《基本法》不容许），会否因为贫富日渐两极化而一步步走向不稳定？

虽然政府已推出关爱基金、筑福香港等计划去帮助穷人，可惜作用不大。马年展望：香港社会贫富差距问题继续困扰整个香港，令社会走向不稳定。中日之间矛盾升温虽然不会引发战争，但可影响日本企业在中国发展及中国向日本出口。

泰国两党之争令经济进一步滑落，在可见将来仍无法解决，印度尼西亚情况亦不乐观、北韩局势令人担心。2014年中国政府在习李领导下能否走向廉洁及高效率，上述种种因素令外资在可见的将来，仍不会大量回流东南亚及香港，令马年经济展望阴晴不定。

2009年3月，美国联储局实施QE政策，根据PIMCO主席格罗斯（Bill Gross）计算，过去五年美国上市公司每年回购约1万亿美元股票，即在过去五年美国大企业将赚回来的钱主要用作回购股份而非投资（2014年2月起联储局仍未退市，只是减少买债）。2013年黑石集团（Blackstone）发债集资用作购买美国房地产收租，赚取租金与债券利率之间的差距。下月新上任的联储局主席耶伦乃典型鸽派，即低利率环境持续，令不少美国企业或个人仍继续借钱买楼收租，意味2014年美国股市及楼市不会太差。

各位有没有在伯南克QE政策下受惠？下月他退休了，透过QE政策令各项资产升值，金价牛市在2011年9月结束，债券市场亦一样，至于股票及房地产方面牛市是否结束？香港恒指自2010年第四季开始不济，楼价自2013年第三季开始亦死气沉沉。

过去40年，即1973至2013年，标普500 P／E见20倍后结束牛市，2000年那次标普500 P／E升至36倍才结束牛市。目前标普500 P／E升至18倍，后市又点睇？过去一年（2013年）有人呱呱叫牛市结束，至今仍未实现（旺市莫估顶），到底由2009年3月开始的美股牛市何时结束，No body really knows anything，世上无先知，不过扮先知者通街都是。

2014年中国政府致力解决信贷危机，尤其是地方政府债务。相信中国经济不会塌下来，理由是2014年中国情况并没有如1994年“三角债问题”那么严峻，当年在总理朱镕基领导下亦能安然度过（那年全世界仍在制裁中国）。2014年中国政府有3万亿美元外汇储备，足够应付地方债有余……。

已故总理周恩来早说过：困难总会有的，解决问题的方法总较困难多。2014年上半年A股指数仍是横行，出现个别发展，例如天然气取代煤的地位，上述情况大大增加电力公司的生产及炼钢成本，令经济进入调整期。

蛇年香港科网股与赌场股行大运，资源股、公用股、地产股则无运行。最成功的投资者是那些short the worst stocks, and buy the best ! 各位可利用过去本人曾教大家的R/S（Relative Strength）投资法，强势股才买，弱势股则只可抛空！

新岁非晴也非雨

蛇年跌到四脚朝天的股份，马年能否翻身？风水轮流转，问题是何时而已。年年难过年年过，如你认为蛇年投资已十分困难，便不应再做投资者了，做个普通人算啦。欲成功必须多做功课，知识代表力量。蛇年精于选股者可赚取100%利润，反之普通人损失超过50%亦比比皆是。

不要预测，请追随趋势，趋势形成后才加入，趋势结束后才退出。

金融市场 信息太多，多到令人眼花缭乱，不要说普通人，甚至专业投资者亦疲于奔命。如何做一个精明决策者？例如1970年至1997年的香港通胀是wage-pull（工资上升令物价上升），2003年至2013年的香港通胀是currency collapse因美元汇价回落所引发。

马年两大通胀压力（工资上升或货币崩溃）皆不大，既非晴天又非下雨，可以说阴晴不定。既没有太高的通胀，通缩又未出现，进入金发女郎（Goldilock），在如此客观环境下，如何制订马年投资策略？

金价走势同一般人所“信”不同。1975年至1979年金价与利率齐齐上升，1980年利率再升，金价却大跌。1981年至1999年利率无论升降，金价都是反复回落。2000年起利率回落，金价又上升，证明“利率与金价”升降没有直接关系。

通胀亦一样，1980年至1999年美国通胀年升幅下降，同期金价回落，2000年至2007年美国通胀率未见大幅回升，却令金价上升。2009年3月至今联储局推出QE政策，令金价升完又跌，原来增加货币供应，金价一样可升可跌。

马年金价又点睇？值得注意的是，由2002年开始的上升趋势（250天线）在2013年已失守，即金价大方向仍是偏淡，加上目前金价只处于合理水平，仍不算便宜，买十両八両旁身无妨，视作马年投资对象仍太早。

美国的货币宽松政策在耶伦领导下最少维持多12个月。2013年标普500指数上升29.5%，同期MSCI亚洲（不包括日本）指数只上升3%，长期以来MSCI亚洲GDP增长率较美国高。上述情况不会长久维持，或迟或早亚太区股市将恢复大幅上升，是否由马年开始则没有答案。转角市可能在第一季、第二季、第三季甚至第四季才出现，目前需要的是耐性。

大部分投资者都在不合适时间离市及入市。例如2003年4月受沙士疫情影响而不敢投资住宅楼市，2007年9月受港股直通车谣言刺激大量投资港股，2008年9月受金融海啸影响而抛售股票，错过了2009年至2010年恒指大幅反弹。

免费贴士累街坊

大部分投资者最大的缺点是：应该入市时恐惧、应该离市时贪心。当“趋势”形成之时不肯入市，例如2000年金市、2003年楼市及股市；当趋势结束时又不肯离开，例如2011年金市及2013年楼市；加上不肯付钱请专业人士代为管钱，只想攞免费贴士（世界又点会咁便宜）。

香港投资市场一如外国先进金融地区，已进入炒股不炒市时代，散户缺乏这方面知识，买卖股票仍然如买“大细”，又怎会有好成绩？

春节期间大家不妨停一停、唞一唞。一年之计在于春，业精于勤，没有做功课何来好成绩？趁新春佳节大家好好计划马年投资大计。2009年起美股出现V形反弹，港股是W形、A股却是L形，马年又如何？过去经验是上年度美股上升20%或以上，第二年保持上升机会高达64.5%，出现回落的机会是7.4%。换言之，马年美国经济出现衰退（GDP连续两季负增长）的机会不大。

美国10年期国债升至3厘后，未来上升空间已不大，估计最高可见3.5厘，对股市影响力已有限。美国上市公司在2014年纯利仍有机会上升6％以上，在纯利升幅倍于利率3厘的情况下，马年美股表现又怎会差？港股平均P／E更只有11倍，相信亦不会太差，相信一如蛇年，马年港股波幅不少！请继续利用R/S挑选强势股。

春天不是读书天，夏日炎炎正好眠，等到秋来冬又至，收拾书包好过年！你不想读书，永远会找到借口，你不想投资，道理亦一样。请问哪一年没有危机？Think positive，成功人士永远保持乐观精神，不向困难屈服，在危机中找寻商机。蛇年如此，马年亦如此。一个趋势形成后通常维持「数年」，少点做“即日鲜”，买入一只好股，在趋势未完之前，请不要赶着卖掉！

投资愈老愈精明

今天，毕非德的个人财富已超过600亿美元。在60岁那年他的身家亦只不过30亿美元，即余下570亿美元财富是他在60岁之后才赚回来。如果你25岁开始投资，60岁退休，即使有毕非德的天分，你的财富相信仍然有限。此乃为何“富”字后面通常加个“翁”字。十个富翁九个在他60岁之后才大富。只有打工仔才有退休年龄，投资者则愈老愈精明。

天增岁月、人增智慧，在投资市场姜愈老愈辣。摇滚的石头不会生青苔，在股票市场做即日鲜者，本人保证他不会发大达！学习“趋势投资法”，学习R/S投资法（平嘢无好、好嘢无平），摆脱散户心态，做一个精明投资者。

There is always opportunity in the market, if you know where to look. 不要一朝被蛇咬，一世怕草绳。马年一如蛇年，同时存在赚取100%利润及亏损50%的陷阱，精于拣股者，胜利永远与你站在一起，成功不是靠运气，学精于勤疏于懒，投资失败者，80%与不肯做功课、一味信运气有关。

蛇年将过，马年快来临，在此时此地宜好好检讨过去，计划将来。

七 天 天 氣 預 報@香 港 天 文 台 於 2014 年 01 月 19 日 06 時 15 分 發 出 之 天 氣 報 告 by HKO

七 天 天 氣 預 報

天 氣 概 況 ：
乾 燥 的 冬 季 季 候 風 會 在 今 天 繼 續 影 響 華 南 。 由 於 雲 
量 較 少 ， 內 陸 地 區 的 日 夜 溫 差 將 會 較 大 。 預 料 一 股 
季 候 風 的 補 充 會 在 隨 後 一 兩 日 抵 達 華 南 沿 岸 地 區 。 
此 外 ， 熱 帶 氣 旋 玲 玲 會 在 今 明 兩 日 橫 過 菲 律 賓 南 部 
並 逐 漸 減 弱 。 

一 月 十 九 日 ( 星 期 日 )
風 　 ： 東 至 東 北 風 4 至 5 級 。 
天 氣 ： 大 致 天 晴 及 乾 燥 ，   但   初   時   部   分   地   區   有   煙   霞   。 早 上 寒 冷 。 
氣 溫 ： 12 至 17 度 。
相 對 濕 度 ： 百 分 之 50 至 80 。

一 月 二 十 日 ( 星 期 一 )
風 　 ： 東 北 風 3 至 4 級 ， 後 轉 北 風 5 級 。 
天 氣 ： 天 晴 乾 燥 ， 但 部 分 地 區 有 煙 霞 。 早 上 相 當 清 涼 。 
氣 溫 ： 13 至 19 度 。
相 對 濕 度 ： 百 分 之 40 至 65 。

一 月 二 十 一 日 ( 星 期 二 )
風 　 ： 北 至 東 北 風 4 至 5 級 。 
天 氣 ： 天 晴 及 非 常 乾 燥 。 早 上 寒 冷 。 
氣 溫 ： 12 至 17 度 。
相 對 濕 度 ： 百 分 之 35 至 60 。

一 月 二 十 二 日 ( 星 期 三 )
風 　 ： 東 至 東 北 風 4 至 5 級 。 
天 氣 ： 天 晴 及 非 常 乾 燥 。 早 上 寒 冷 。 
氣 溫 ： 11 至 16 度 。
相 對 濕 度 ： 百 分 之 35 至 65 。

一 月 二 十 三 日 ( 星 期 四 )
風 　 ： 東 風 4 級 ， 離 岸 5 級 。 
天 氣 ： 大 致 天 晴 及 乾 燥 。 早 上 相 當 清 涼 。 
氣 溫 ： 13 至 18 度 。
相 對 濕 度 ： 百 分 之 55 至 80 。

一 月 二 十 四 日 ( 星 期 五 )
風 　 ： 東 風 4 級 。 
天 氣 ： 部 分 時 間 有 陽 光 。 早 上 相 當 清 涼 。 
氣 溫 ： 14 至 18 度 。
相 對 濕 度 ： 百 分 之 65 至 80 。

一 月 二 十 五 日 ( 星 期 六 )
風 　 ： 東 風 4 級 。 
天 氣 ： 部 分 時 間 有 陽 光 。 早 晚 有 幾 陣 薄 霧 。 
氣 溫 ： 16 至 20 度 。
相 對 濕 度 ： 百 分 之 75 至 90 。

1 月 18 日 下 午 二 時 北 角  錄 得 之 海 水 溫 度 為 17 度 。
1 月 18 日 上 午 七 時 天 文 台  錄 得 之 土 壤 溫 度 為 ：
0.5 米 18.1 度 ；
1.0 米 20.1 度 。

七 天 天 氣 預 報 插 圖
第 一 天 插 圖 編 號 93 - 冷 
第 二 天 插 圖 編 號 50 - 陽 光 充 沛 
第 三 天 插 圖 編 號 93 - 冷 
第 四 天 插 圖 編 號 93 - 冷 
第 五 天 插 圖 編 號 51 - 間 有 陽 光 
第 六 天 插 圖 編 號 51 - 間 有 陽 光 
第 七 天 插 圖 編 號 51 - 間 有 陽 光 

天氣報告@香 港 天 文 台 於 2014 年 01 月 19 日 7 時 02 分 發 出 之 天 氣 報 告 by HKO

上 午 7 時 天 文 台 錄 得：
氣 溫 ： 13 度
相 對 濕 度 ： 百 分 之 77 
天 氣 插 圖： 編 號 51 - 間 有 陽 光 

請注意：

火 災 危 險 警 告 為 黃 色 ， 表 示 火 災 危 險 性 頗 高 。 
寒 冷 天 氣 警 告 現 正 生 效 ， 天 氣 寒 冷 可 能 影 響 健 康 ， 
市 民 應 小 心 保 暖 。 

  
本 港 其 他 地 區 的 氣 溫 ：

京 士 柏              12 度 ，
黃 竹 坑              13 度 ，
打 鼓 嶺               5 度 ，
流 浮 山              10 度 ，
大 埔                 10 度 ，
沙 田                  9 度 ，
屯 門                 11 度 ，
將 軍 澳              12 度 ，
西 貢                 12 度 ，
長 洲                 13 度 ，
赤 鱲 角              13 度 ，
青 衣                 12 度 ，
石 崗                  8 度 ，
荃 灣 可 觀           10 度 ，
荃 灣 城 門 谷         9 度 ，
香 港 公 園           13 度 ，
筲 箕 灣              13 度 ，
九 龍 城              12 度 ，
跑 馬 地              13 度 ，
黃 大 仙              13 度 ，
赤 柱                 13 度 ，
觀 塘                 12 度 ，
深 水 埗              12 度 。

Patients’ Costs Skyrocket; Specialists’ Incomes Soar - NYTimes.com by Elizabeth Rosenthal

CONWAY, Ark. — Kim Little had not thought much about the tiny white spot on the side of her cheek until a physician’s assistant at her dermatologist’s office warned that it might be cancerous. He took a biopsy, returning 15 minutes later to confirm the diagnosis and schedule her for an outpatient procedure at the Arkansas Skin Cancer Center in Little Rock, 30 miles away.

That was the prelude to a daylong medical odyssey several weeks later, through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an anesthesiologist and an ophthalmologist who practices plastic surgery. It generated bills of more than $25,000.

“I felt like I was a hostage,” said Ms. Little, a professor of history at the University of Central Arkansas, who had been told beforehand that she would need just a couple of stitches. “I didn’t have any clue how much they were going to bill. I had no idea it would be so much.”

Ms. Little’s seemingly minor medical problem — she had the least dangerous form of skin cancer — racked up big bills because it involved three doctors from specialties that are among the highest compensated in medicine, and it was done on the grounds of a hospital. Many specialists have become particularly adept at the business of medicine by becoming more entrepreneurial, protecting their turf through aggressive lobbying by their medical societies, and most of all, increasing revenues by offering new procedures — or doing more of lucrative ones.

It does not matter if the procedure is big or small, learned in a decade of training or a weeklong course. In fact, minor procedures typically offer the best return on investment: A cardiac surgeon can perform only a couple of bypass operations a day, but other specialists can perform a dozen procedures in that time span.

That math explains why the incomes of dermatologists, gastroenterologists and oncologists rose 50 percent or more between 1995 and 2012, even when adjusted for inflation, while those for primary care physicians rose only 10 percent and lag far behind, since insurers pay far less for traditional doctoring tasks like listening for a heart murmur or prescribing the right antibiotic.

By 2012, dermatologists — whose incomes were more or less on par with internists in 1985 — had become the fourth-highest earners in American medicine in some surveys, bringing in an average of $471,555, according to the Medical Group Management Association, which tracks doctors’ income, though their workload is one of the lightest.

In addition, salary figures often understate physician earning power since they often do not include revenue from business activities: fees for blood or pathology tests at a lab that the doctor owns or “facility” charges at an ambulatory surgery center where the physician is an investor, for example.

“The high earning in many fields relates mostly to how well they’ve managed to monetize treatment — if you freeze off 18 lesions and bill separately for surgery for each, it can be very lucrative,” said Dr. Steven Schroeder, a professor at the University of California and the chairman of the National Commission on Physician Payment Reform, an initiative funded in part by the Robert Wood Johnson Foundation.

Doctors’ charges — and the incentives they reflect — are a major factor in thenation’s $2.7 trillion medical bill. Payments to doctors in the United States, who make far more than their counterparts in other developed countries, account for 20 percent of American health care expenses, second only to hospital costs.

Specialists earn an average of two and often four times as much as primary care physicians in the United States, a differential that far surpasses that in all other developed countries, according to Miriam Laugesen, a professor at Columbia University’s Mailman School of Public Health. That earnings gap has deleterious effects: Only an estimated 25 percent of new physicians end up in primary care, at the very time that health policy experts say front-line doctors are badly needed, according to Dr. Christine Sinsky, an Iowa internist who studies physician satisfaction. In fact, many pediatricians and general doctors in private practice say they are struggling to survive.

Studies show that more specialists mean more tests and more expensive care. “It may be better to wait and see, but waiting doesn’t make you money,” said Jean Mitchell, a professor of health economics at Georgetown University. “It’s ‘Let me do a little snip of tissue’ and then they get professional, lab and facility fees. Each patient is like an ATM machine.”

For example, the procedure performed on Ms. Little, called Mohs surgery, involves slicing off a skin cancer in layers under local anesthesia, with microscopic pathology performed between each “stage” until the growth has been removed. While it offers clear advantages in certain cases, it is more expensive than simply cutting or freezing off a lesion. (Hospitals seeking to hire a staff dermatologist for Mohs surgery had to offer an average of $586,083 in 2010, even more than for a cardiac surgeon, according to Becker’s Hospital Review.)

Use of the surgery has skyrocketed in the United States — over 400 percent in a little over a decade — to the point that last summer Medicare put it at the top of its “potentially misvalued” list of overused or overpriced procedures. Even the American Academy of Dermatology agrees that the surgery is sometimes used inappropriately. Dr. Brett Coldiron, president-elect of the academy, defended skin doctors as “very cost-efficient” specialists who deal in thousands of diagnoses and called Mohs “a wonderful tool.” He said that his specialty was being unfairly targeted by insurers because of general frustration with medical prices. “Health care reform is a subsidized buffet and if it’s too expensive, you go to the kitchen and shoot one of the cooks,” he said. “Now they’re shooting dermatologists.”

The specialists point to an epidemic, noting there are two million to four million skin cancers diagnosed in the United States each year, with a huge increase in basal cell carcinomas, the type Ms. Little had, which usually do not metastasize. (A small fraction of the cancers are melanomas, a far more serious condition.) But, said Dr. Cary Gross, a cancer epidemiologist at Yale University Medical School, “The real question is: Is there a true epidemic or is there an epidemic of biopsies and treatments that are not needed? I think the answer is both.”

Patient Given No Choice

A fair-skinned redhead who teaches history at the University of Central Arkansas, Ms. Little had gone to a private dermatology practice in Heber Springs, Ark., to check some moles on her arms when the physician’s assistant on duty noticed a whitish bump — like a “tiny fragment of thread” — on her face, she said. Her family practitioner had told her it was just a clogged pore.

A diligent medical consumer, Ms. Little has read up on the Mohs technique (invented by Dr. Frederic Mohs in 1938) before she and her husband arrived for her surgery in November 2012 in a doctors’ office building at Baptist Health Medical Center here. Pressed for time as the end of the semester approached, she asked Dr. Randall Breau, the dermatologist, why the tiny growth needed the specialized surgery, as she had asked the physician’s assistant earlier. They both answered that it was because it was on her eyelid, a delicate area where Mohs surgery is always required; she repeatedly insisted that it was on her cheekbone below her eye.

After the 30-minute removal, the dermatologist told her that she would have to go across the street to the Arkansas Center for Oculoplastic Surgery, another private doctors’ office on the hospital’s campus, to have the wound closed by a plastic surgeon with “a couple of stitches.”

When Ms. Little protested that she did not want a plastic surgeon and did not care about having a tiny scar, the doctor told her she had no choice, she said. The vast majority of Mohs procedures are sewed up by the dermatologist or just bandaged and left to heal. Yet when Ms. Little arrived at the second practice, nurses took her clothes, put in an IV, and introduced her to an anesthesiologist who would sedate her in an operating room.

Sitting in her cozy office recently, Ms. Little, who has a faint scar under her eye on her right cheek, still fumes at the thought. “It was no bigger than many cuts that heal on their own, and it definitely could have been repaired by one doctor, but at that point what was I going to do?” she recalled. “I have an IV in my arm and a hole in my face that Dr. Breau refused to stitch. And the anesthesiologist is standing there with his mask on.”

Her bills included $1,833 for the Mohs surgery, $14,407 for the plastic surgeon, $1,000 for the anesthesiologist, and $8,774 for the hospital charges.

Mohs surgery is preferable when the removal of a skin cancer is complicated or in a sensitive area, because it typically excises less tissue and leaves less of a scar than other treatments and allows dermatologists to see the borders of a growth and be confident that it is removed entirely. The surgery is generally not used for melanomas, which require more extensive cutting.

In an email, Dr. Breau declined to discuss Ms. Little’s case, but noted, “When I make decisions concerning patient care, I have only the patient’s best interests in mind.” He said that he and one partner own the Arkansas Skin Cancer and Dermatology Center and receive no payments from the hospital or the doctors to whom they refer patients. In most cases, he said, he takes care of the wound left by Mohs surgery himself. The plastic surgeon did not respond to requests for comment.

It is often impossible in any one case to determine whether a course of treatment was necessary or cost-effective. Even among doctors there are differences of opinion about optimal treatments. That is partly because the guidelines for when to perform many procedures are often ill-defined or based on the specialists’ experience rather than carefully controlled research.

“Though Mohs surgery is disseminating rapidly, there are very few comparative studies and the evidence is still evolving about when it’s beneficial,” said Dr. Gross, the Yale epidemiologist. “When people are trained to perform a procedure, and believe in it, and equip their offices to do it, they will do it. That’s just human nature.”

The same specialties tend to appear at the top of physician earners: orthopedics, cardiology, anesthesiology, radiology, dermatology, plastic surgery, urology, gastroenterology and ophthalmology. Physicians in those fields typically earn more than $350,000 annually, according to American Medical Group Association, a trade organization. In many specialties, income has risen more than 10 percent since 2011, according to Medscape, a Web company that follows the industry.

Physicians often complain that government and commercial insurance reimbursements for seeing patients are decreasing while their office expenses are going up to deal with mountains of paperwork and demands from insurers. Congress currently is considering a bill that would freeze doctors’ Medicare fees for the next decade. Still, many doctors have found alternative income streams that do not show up on surveys.

Dr. Mitchell of Georgetown University estimates, for example, that many urologists make 50 percent of their income from dealing with patients and the rest from investing in the machines that deliver radiation for prostate cancer or to treat kidney stones. In 2012, urologists had an average income of $416,322, according to Medical Group Management Association data, which often does not include the investment income.

Oncologists benefit from the ability to mark up (and profit from) each dose of chemotherapy they administer in private offices, a practice increased dramatically in the late 1990s. The median compensation for oncologists nearly doubled from 1995 to 2004, to $350,000, according to the M.G.M.A. One study last year attributed 65 percent of the revenue in a typical oncology practice to such payments.

When policy makers reduce one type of payment, some specialists find another. Though orthopedists’ reimbursement from Medicare for performing joint replacements has gone down in the last two decades, the Medscape survey on physician income showed that orthopedists’ average compensation has risen 27 percent since 2011. They are still paid handsomely by many private payers for many minor procedures, and — more important — often own the surgery centers, scanners and physical therapy offices they use.

In a country where top hospital executives typically make more than a million dollars a year, American physicians may feel entitled to high fees, especially because they face costs that their European counterparts do not: Medical school is expensive and new doctors graduate with an average of about $150,000 in debt. Likewise, some specialists face malpractice premiums of over $100,000 a year.

Though medical societies tend to point to the long haul of medical training and the unpredictable hours to justify generous salaries, health economists point out there is often little correlation between compensation and that investment of time. Obstetricians, for example, arguably have the most rigorous schedules but are relatively modest earners. A number of high-income specialties — radiology, ophthalmology, anesthesiology and dermatology — are often called the “lifestyle specialties,” because training is more compatible with a home life than some other disciplines and there are fewer emergencies in these fields. Eighty percent of dermatologists see patients 40 hours or fewer each week, according to a 2013 Medscape report, less than the average doctor.

Profitable Dermatology

In America’s for-profit, fee-for-service medical system, dermatology has proved especially profitable because it offers doctors diverse revenue streams — from cosmetic treatments that are fully paid by the patient to medical treatments that are covered by insurance.

Cosmetic dermatology is a big moneymaker in high-income markets like New York and Miami. Botox injections take 15 minutes and cost a minimum of $500; doctors pay about $100 for the amount of medicine needed for a typical session, according to dermatologists. Still, cosmetic work makes up less than 10 percent of all skin procedures, studies show, and their volume tends to fluctuate with the economy.

For medical treatment, many dermatologists have been able to compensate for cutbacks in insurance payments by offering new services and by increasing their patient volume through hiring “physician extenders” — nurse practitioners and physicians’ assistants — to do basic tasks like biopsies and chemical peels. Whether the physician or the nurse wields the scalpel, the charge is generally the same.

The dermatology office where Ms. Little’s initial biopsy was performed is one of six satellite offices operated by the Arkansas Skin Cancer and Dermatology Center. They are often staffed by physician assistants, who refer patients to the dermatologists in Little Rock for Mohs surgery. The dermatologists also do their own pathology, meaning that they can sometimes bill extra for that service. (That also means there is no independent confirmation of a cancer diagnosis.)

With such practices, even minor dermatology procedures can lead to big bills. When Ashley Lanning, 28, of Oregon was seen by a nurse practitioner for a mole removal, the tab came to $915.46 — “way more than I’d anticipated,” she said. The growth was scraped off with a scalpel and no stitches were required. In New York last year, Kyle Snow Schwartz, 26, went to a dermatologist at New York University Medical Center to have a wart removed from his foot. The visit took five minutes, including a chat about his plans to teach English in Vietnam and a squirt of liquid nitrogen on the growth. The invoice from the billing office: $500.

Both patients have insurance with high deductibles, so they faced large out-of-pocket payments.

In contrast, in Germany where private doctors’ allowable charges are set by the government, dermatologists are paid $30 for a whole body skin check, $40 for a standard biopsy and $20 for a pathology exam, said Dr. Matthias Augustin, who studies the practice of dermatology at the University Medical Center of Hamburg-Eppendorf. There is far less use of Mohs surgery in Germany than in the United States, he said. Most patients with a possible skin cancer get a biopsy and come back a few days later for full removal if it is positive.

Harris Williams and Company, a consulting firm, estimates the $10.1 billion dermatology market in the United States will grow to over $13 billion by 2017, in part because of an aging population. The Affordable Care Act requires 100 percent coverage for preventive dermatology screening sessions for seniors, which will inevitably lead to more biopsies and treatment. With more doctors being trained in Mohs surgery — generally an extra year of training, though it is not required — it has become a go-to treatment. Dr. Coldiron, who is a past president of the American College of Mohs’ Surgery, said it was “not generally overvalued,” adding that the cure rate after a single treatment was somewhat higher than with other techniques, avoiding the need for a second procedure. He said that Mohs typically cost only 30 percent more than the standard procedure. But Healthcare Blue Book, which tracks pricing in the private market, found that payments by insurers for Mohs surgery were typically twice as high.

Dr. Coldiron acknowledged that Mohs was not appropriate for “every little bitty thing.” Indeed, to stem the use of Mohs surgery where cheaper procedures would suffice, the American Academy of Dermatology in 2012 issued “appropriateness” guidelines about what kinds of cancers should be treated with the technique — such as those on the eyelids or nose, or those that were large or deep.

At the annual meeting of the Pacific Dermatology Association this fall, Dr. Sumaira Aasi, a Stanford dermatologist, told her colleagues that Medicare would come after dermatologists if those guidelines were not heeded, noting: “We might be killing the goose that laid the golden egg ourselves.”

The Medical Lobby

More than 750 lobbyists represent groups of health professionals in Washington, pushing back on any effort to limit their incomes. The biggest spenders on lobbying — $80 million annually by health professionals — closely align with the highest-paid specialties.

Medicare’s valuation of physicians’ services is based on a complex algorithm that is intended to take into account the time and skill required to perform a medical task, with an adjustment made for a specialty’s malpractice rates. Many insurers follow Medicare’s lead, often paying anywhere from 80 percent to 200 percent of the Medicare fee. But “time and skill” are easier to quantify for procedures than continuing patient management. And, experts say, Medicare has not reduced payments for many procedures that now take far less time than when they were invented, because of improvements in efficiency or technology.

But renegotiating payments involves a highly contentious process that plays out behind closed doors at the American Medical Association’s Relative Value Scale Update Committee, which consists of doctors representing 26 medical disciplines who advise Medicare. In dermatology trade journals, Dr. Coldiron, who has served on the committee, describes it like this: “Everybody sits around a table and tries to strip money away from another specialty.” It’s like “26 sharks in a tank with nothing to eat but each other.”

Primary care doctors — who make up only 12 percent of physicians in practice — say they have little clout, with at most five representatives on the panel. “That committee keeps the perverse incentives in place,” said Brian Crownover, a family physician from Boise, Idaho.

Indeed, less than two years ago, Dr. Coldiron predicted that reimbursement for Mohs surgery could drop 20 percent. But that did not happen. When Medicare placed Mohs on its list of potentially misvalued procedures last summer, it was deluged with protests from dermatologists, and the A.M.A. Update Committee declared Mohs surgery worthwhile.

This year, Medicare reimbursement will drop only about 2 percent to about $1,000 for a typical procedure. (In recent years, the American Academy of Dermatology Association — the dermatology academy’s political action committee — has also fought proposed Medicare requirements that dermatologists provide preoperative pictures of lesions they had treated with Mohs surgery, and it has pushed states to classify Botox injections as well as skin procedures using lasers as “the practice of medicine,” to prevent spas from offering such services.)

Critics say the robust revenues from doing procedures has led to overuse — colonoscopies by gastroenterologists, steroid injections by pain specialists and M.R.I. scans by orthopedists, to name a few. Dr. Thomas Balestreri, a recently retired anesthesiologist from Washington State, said in an interview that to increase revenue, some fellow specialists used an ultrasound to guide placement of a nerve block when it was not really needed.

But in some cases dollars from procedures keep practices afloat, because insurers pay so little for time with patients. Dr. Stephen Asher, a neurologist in Boise, Idaho, said his 50 to 60 hours a week seeing patients accounts for only about 10 percent of his income, To cover office expenses he relies on revenue from performing a few procedures — Botox injections for eye movement disorders and muscle conduction studies — as well as from an M.R.I. scanner that he co-owns with a group of orthopedists and neurologists.

Outrage at Charges

Ms. Little left Baptist Health Medical Center with a tiny skin flap and more than two dozen stitches. For five days she said she was “hung over” from the IV sedation that she had not wanted — a problem because she drives 60 miles on rural Arkansas roads to her university each day.

She spent months arguing down her bills, which were finally reduced: About $1,400 for the Mohs surgeon, $765 for the anesthesiologist, $1,375 for the ophthalmological plastic surgeon, plus $1,050 in operating-room charges from the hospital.

For her follow-up, she refused to return to Baptist Health and went instead to the University of Arkansas Medical Center, where a dermatologist told her she likely had not needed such an extensive procedure. But that was hard to judge, since the records forwarded from Baptist did not include the photo that was taken of the initial lesion.

And she was outraged as she wrote checks for the nearly $3,000 she owed to the doctors under the terms of her insurance. “It was like, ‘Take out your purse, we’re robbing you,' ” she said.

---

Source: http://www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html?ref=elisabethrosenthal&pagewanted=print

提高孩子的免疫力（一） by 嚴浩

孩子愛感冒，有鼻敏感，或者有哮喘，應該用甚麼食療？抵抗力低的孩子首先應該清血，讓細胞不容易敏感發炎，含亞麻酸高的冷榨亞麻籽油是治發炎高手；體弱的孩子需要補充容易被身體吸收的優質蛋白質，與亞麻籽油攪混之後的茅屋芝士最容易被身體吸收，這個組合叫布緯食療。以下是一個案例。


心焦的媽媽：「我看了您的專欄，跟着買了您的書， 按照書中介紹的方法，對準家人的問題開始用油拔法，結果我的睡眠好轉了；家中的食用油也全部換了，MCT油和茶油用來煮菜，杏仁油用來拌麵食或意大利粉。大女兒現在6歲多，從6個月始至1歲期間，每個月因為咳嗽引起支氣管炎要打點滴瓶（之前在深圳住），一般要7天，還要做霧化治療幫着祛痰，其中有兩次轉成了肺炎住院了十天。1歲至2歲全年都很好，沒生病，跟着2歲開始又是咳嗽，每月去醫院，3歲在內地讀幼兒園，咳嗽更加頻繁，打針吃藥，中醫西醫全都用上了，又有兩次支氣管肺炎住院治療了一星期。


在生病過程中小便次數頻密，測了小便，有潛血。4歲多來香港讀幼稚園，因衞生比內地好，生病次數少了很多，但平常呼吸聲音很大，晚上睡覺會打鼾，累的時候打得很響，平常打一會兒換一下睡的姿勢就會好些，但經常張着口睡覺……」


孩子聽來有嚴重鼻敏感，不知道醫生怎麼說？

---

Source: http://hkm.appledaily.com/detail.php?guid=18597521&category_guid=vice&sup_id=12187389&category=daily&issue=20140119

名媛明星好賣袋 by 李碧華

奇怪，何以今時今日，仍有報章雜誌刊登「城中名媛」宣傳活動？一些來歷不明形跡可疑的女性，沒幾個知「名」，也不見得很「媛」，這個名詞不是已隨黃金歲月流逝而淪落了嗎？還有人臉上貼金沾沾自喜？


字典中的「媛」：帶着貴氣的美女，從前出身名門望族，有才華有內涵的千金小姐，才得享稱譽。大家閨秀佳人淑女，美名遠播但表現低調內斂，怎會成為不問場合但求見報的風頭躉？當然這也不是她們的錯，只起題者誤會了，或濫用了，綑成一堆，省事。


「明星」亦與「名媛」一樣，徒具虛詞。隨着邵氏六老闆大去，影城星光已冉。中港台已很久沒出過什麼明星了。時見內地大製作，高價請來大腕、影帝、巨星，為一些面目模糊演技平庸，但算青春可人的小三小四紅顏知己配戲，潛規則後的「女主角」，雖成不了你們老闆娘，但一眾男主角是收了人工去捧小花的，心知肚明，無所謂委屈。


該等「媛」與「星」，不管買賣身體或子宮狀況，先囤積一大堆名袋上算，花無百日紅，一旦需要，拎幾個去××站脫手，短期內不餓。

---

Source: http://hkm.appledaily.com/detail.php?guid=18597514&category_guid=vice&sup_id=12187389&category=daily&issue=20140119

崇 優 by 陶傑

好像「美國偶像」（American Idol）之類的才藝表演，一個蹩腳人才上台，剛開口唱歌，一分鐘不到，台下的評判已經按「叮叮」，表示「下一位」，Next。


香港的特首上任才一年半，香港中環的政商精英，已經很熱烈地呼叫着Next。


下一位，Next，到底是誰？不管有沒有普選，人性總有點愛自欺，總之下一個快點上來，不管好不好，先取代了眼前台上很叫人吃不消的這位表演人，好像就有點希望。


前政務司司長陳方安生女士認為，現任政務司司長林鄭月娥，會是相當稱職的特首，而她目前的處境和言論，只是「身不由己」。


陳太太說出了許多中產和知識階層的心聲，越來越多人覺得林鄭月娥女士的形象好，如果她當特首，至少香港不會比現在更爛。


林太太最近改穿民國風味的中國旗袍：絨衣、硬企領、深色的套裝，是六十年代邵逸夫爵士領導邵氏明星何琍琍、李菁、歐陽莎菲等出席希爾頓酒店雙十國慶酒會時流行的那種系列，有舊上海的典雅之氣，本來舊上海出身的陳方安生穿這種旗袍，也富有氣質；現在廣東人林太太穿上，也有了，着實令人欣喜。


當然，香港官場女性的高貴氣質，由鄧蓮如開始這個系列，有一個特點，就是沾染過英國淑女的文化，不受激進思想如共產文革街坊女組長或女紅衛兵式的污染，在這方面，前後兩位女政務司司長都及格有餘。


香港人對林太太有好感，林太太民望長期高踞，因為她的老公和公子，都曾經長住英國劍橋──是在劍橋大學授課和讀書，不是在劍橋開賣咕嚕肉和揚州炒飯的中國餐館。這樣的家庭，品質有保障，不會出壞人。


連香港的老人院，有一家以「劍橋」命名，大家都覺得形象好，也生意滔滔啦，不關親英、崇洋，是人性自然人望高處的崇優。不信？你叫它改名做「東莞護老院」試試看？

---

Source: http://hkm.appledaily.com/detail.php?guid=18597510&category_guid=vice&sup_id=12187389&category=daily&issue=20140119