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29 February, 2008

e-Second Opinions: 100 Search Engines and Tools for Medical Self-Diagnosis

Post below lifted from Nursing Online. See the original for links

Although seeing a doctor is best, it's not always easy to get to a doctor right away. Fortunately, there are loads of tools online designed to help you diagnose and treat symptoms right at home. Here we've listed 100 of the best.

Search Engines: Simply type your symptoms or ailment into these search engines, and you'll find helpful information.

eCureMe: To self diagnose with this search engine, you'll just have to search for your most troublesome symptom.
MedlinePlus: MedlinePlus is designed to make finding information on drugs, diseases, and more easy.
Google Health Co-op: Find hand-picked sites for your condition with this search tool from Google.
Amniota: Find all of the information you need with this health search engine.
iSeekHealth: With this handpicked directory, you'll find loads of information.
Healia: This search engine offers high quality information and personalization.
InteliHealth: Powered by Aetna, this site will help you learn about symptoms, conditions, drugs, and more.
NOAH: On this site, you can research health topics by body area or disease.
e-Lynks Health: You'll find lots of information with this portal to health websites.
CureResearch Symptom Center: In this symptom checker, you can search for diseases that match up with what you're feeling.
Healthline Symptom Search: Find possible cures based on your symptoms with this search engine. You can even get a search plug-in for Firefox.
gopubmed: Search for medical publications with this tool.
Yahoo! Health: Use Yahoo! Health to find information about drugs, diseases, and more.
AnswerMed: Simply type in a query to learn about a medical condition or surgery.
OrganizedWisdom: Use this human-powered health search to find the diagnosis information you're looking for.
Afraid to Ask: Use this search tool to find answers to the questions you're afraid to ask your real doctor.
Mayo Clinic: Look up a disease, symptom, and more with the Mayo Clinic's search tools.

Databases: Check out these databases to get answers to some of the most common medical questions.

Conditions and Concerns: This reference provides easy access to information about common ailments and symptoms.
Go Ask Alice!: Check out Go Ask Alice! to find answers to medical questions.
Medical-Articles: Find published medical news with this resource.
Healthwise Self-Care Checklist: On AOL Body, you'll find this checklist that walks you through diagnosis, education, and treatment.
Dr. Koop's Symptoms Reference Index: Go through this extensive list of symptoms to find out what's wrong.
Healthcyclopedia: This site offers an alphabetic index of health conditions.
WrongDiagnosis Symptom Center: Here you can research popular symptoms for more than 10,000 diseases.
Medifocus: Get researched information with Medifocus' guides.
Netwellness: This resource has more than 55,000 pages of information from the faculty of three leading universities.
Home Healthcare Guide: This service from Surgery Door offers lots of information on conditions, emergencies, operations, and more.
Health Library: Check out this library for information that's hand-picked from government agencies, nonprofits, and universities.
Ohio State University Medical Center Patient Education: Find information on conditions, tests, and much more with this resource.
Medinfo: Here you'll find lots of patient-centric information on specific conditions.
eMedTV Health Information: This library of medical information offers data on diseases, procedures, drugs, and more.
Netdoctor Library of Diseases: Find an extensive library of expertly reviewed medical articles here.
All Health: Here you'll find a great medical reference library and symptom finder.
Stop Getting Sick: Use this database to find general information news, and research on diseases and conditions.
SHARing Point Server: This health information system shares data across the world.
Family Doctor: This database has more than 600 articles and guides on medical topics, all reviewed and edited by medical experts.
Diseases Database: Here you can look for information on diseases, symptoms, drugs, and more.

Online Professionals: These sites feature professionals that offer their services online.

Just Answer: With this service, you'll be able to talk to doctors and nurses that are online and ready to answer questions.
eDocAmerica: Whether you're looking for a physician, psychologist, or advice from a nurse, check out this site for help.
BumperBrain: Use this site to locate and get health experts in just about any field.
Netwellness Ask an Expert: Get information from more than 500 world-class experts in this resource.
aarogya: On this wellness site, you can talk to doctors in specific specialties, like cardiology, homeopathy, and oncology.
InteliHealth Ask the Doc: In this resource, you can search for questions and answers related to your ailment, or ask a question of your own.
The ICU Answer Page: Learn all about the ICU in this guide from a critical care nurse.
WrongDiagnosis Ask a Doctor: Choose from 5 fully reviewed doctors for medical advice on this site.
HealthySelf: Ask this expert to do medical research for you.
Allexperts Medical Q&A: Here you'll find past answers to medical questions, plus be able to ask your own.
Kasamba Health & Medicine Experts: Choose from over a hundred health experts online with this site.
Afraid to Ask: Talk to Afraid to Ask's doctors to get answers to the questions you don't want to ask your regular doctor.
Ask the Doctor Online: Contact these doctors for a standard or urgent consultation.
Dr. Sinatra: Check out Dr. Sinatra for information on solutions to health problems.
Consult Doctors: With this service, you can choose to get a standard or stat consultation, and even a full report on a medical question within just a few days.

Tools: Simply plug your medical issues into these tools, and you'll get all sorts of information.

The Analyst: Answer 900 optional multiple-choice questions to get a look at your entire health spectrum with this tool.
Health A to Z: Get a look at what's ailing you with this symptom checker.
PreOp Patient Education: Use this tool to research surgery procedures.
Symptom Checker: Select symptoms, find factors, and get results with this tool.
Descipher: With this tool, you can self-interpret lab test results from your doctor.
MSN Health & Fitness Symptom Checker: Use this visual symptom checker to cure what ails you.
HealthCentral: Use HealthCentral's illustrated guide to find out where it hurts.
EasyDiagnosis: Designed by a team of doctors, EasyDiagnosis takes a look at your main symptoms to determine your illness.
MedicineNet: Use this illustrated guide to pinpoint where it hurts.

Communities: Get support and advocacy from these medical communities.

ThirdAid: Find out how others with your condition are doing, and get independent knowledge from this community.
MSN Health & Fitness Support Groups: Find others with your condition with these support groups.
iMedix: Join this healthcare community to get information on symptoms, diseases, treatments, and more.
WrongDiagnosis Conditions Forum: Check out these forums for information on specific conditions from other sufferers.
Afraid to Ask Forums: Discuss sexuality, body functions, and much more in this community.
Healthcyclopedia Support Groups: Here you'll find support groups for all sorts of conditions and diseases.
MDJunction: Find a support group and learn more about your condition on this site.
Netdoctor Forums: Get information on general health and beyond in these forums.
MedHelp: On MedHelp's Ask a Doctor forums, you can find answers and ask questions of certified doctors.
Case Health: Hear about the medical success stories of others on this site.
MSN Health & Fitness Message Boards: Learn about and discuss conditions like pregnancy, depression, and more on these message boards.
PatientsLikeMe: Share your experience and learn from others on this support site.
DailyStrength: Here you'll find more than 500 support groups for just about every health issue out there.
HelpShare: Here you can ask a medical question and set the value of a good answer.
WrongDiagnosis Symptoms Forum: Learn and share information about symptoms for fertility, allergies, and more here.
HealthWorldWeb: On this site, you'll find loads of communities in which to learn more about your symptoms and conditions.

Assessment: Stay on top of your health and possible risks using these resources.

Heart Attack Risk Calculator: Learn how susceptible you are to a heart attack with this quiz.
Postpartum Depression Assessment: Find out if your intense feelings after pregnancy are normal or discover the sign of a condition that needs to be treated.
Alcohol: Are You Addicted?: Follow this questionnaire to find out if you have a problem with drinking.
How to Review Your Blood Test Results: This guide offers advice on normal ranges for test results.
New Hope Health Clinic: Get this holistic clinic's home testing kit, and you'll learn about your body and what you can do to take care of it.
Online Checkups: Get quick assessments for a variety of conditions with HealthFinder's online checkups.
Stress Trigger Assessment: Assess and identify the stressors in your life with this tool.
Nicotine: Are You Addicted?: Use this questionnaire to assess your addiction to cigarettes.
Fitness Assessment: Find out just how fit you are using this quiz.
Do I Have an Eating Disorder: Answer these questions to find out if you have a problem with food.
Breast Cancer Risk Assessment: Find out if you're at risk for this commonly diagnosed cancer.
Risk Factor Center: Find out your risk factors for diseases and more based on your lifestyle, exposure, and other factors.
The Menopause Assessment Scale: Assess your menopause symptons here.
Type 2 Diabetes Risk Assessment: This quiz will help you determine your risk for Type 2 diabetes.
Lab Tests Online: Get information on lab tests, conditions, and more from this resource.
Urinary Incontinence Test: Follow this questionnaire to determine whether or not you suffer from urinary incontinence.
Interactive Weight Tool: Determine your risk level for weight-related diseases using this tool.
Coronary Artery Disease Assessment: Use this quiz to find out how high your risk is for this common heart disease.
KnowYourRisk Assessment: Revolution health's tool will tell you your risk for diabetes, stroke, and heart disease, and offers information on how you can better prevent these conditions.
WrongDiagnosis Home Diagnostic Testing Center: Get tested right at home for ailments like diabetes, fertility, and more.
Depression Risk Assessment: Follow this questionnaire to see how likely you are to have depression.
Cold or Flu?: Find out if you're sick with the cold, or worse, the flu.
Pitfalls of Online Diagnosis: This article warns against some of the problems that can arise from online diagnosis.




Australia: Over ten years of dodgy doctoring and only now is immigrant doctor stopped

"Your government will look after you", once again

An investigation into a Czech-trained obstetrician and gynaecologist, whose Queensland registration was suspended last night, has found two suspect cases in his work in the state. Dr Roman Hasil worked as a locum at Rockhampton Hospital, in central Queensland, from December 18, 2006, to January 12, 2007. After working for one day at the Redcliffe Hospital, on Brisbane's northern bayside, on March 7, 2007, he disappeared following an inquiry into his performance in New Zealand.

The Medical Board of Queensland last night suspended Dr Hasil's registration after receiving a damning report into his professional conduct from New Zealand authorities. An investigation into Dr Hasil's practices was launched in New Zealand last March after women who underwent sterilisation at Wanganui Hospital later fell pregnant. A NZ Health and Disability Commission report found Dr Hasil had not placed clips correctly on patients' fallopian tubes.

NZ authorities also noted Dr Hasil had a chequered work history in Australia from 1996 to 2005. He had lied about a criminal conviction for domestic violence in Singapore and left Lismore Base Hospital in NSW in 2005 after an allegation against him for "fiddling" timesheets, an accusation he denied. He had been dismissed from a Victorian hospital in 2005 for recording a blood alcohol reading of 0.2 while on call, the New Zealand report said.

Queensland Health acting director-general Andrew Wilson said today a specialist had reviewed Dr Hasil's work in the state and found two cases "indicating an unexpected outcome or deviation from standard practice". The findings of the two cases had been passed on to the medical board, he said. Dr Wilson said Dr Hasil had been involved in 17 obstetric and gynaecological related procedures in Queensland.

Beryl Crosby, who has advocated on behalf of patients of rogue surgeon Dr Jayant Patel, said health authorities needed to improve checks on overseas-trained doctors. Indian-trained Dr Patel, dubbed "Dr Death", is being sought for extradition from the United States on manslaughter charges relating to his work at Bundaberg Base Hospital in southeast Queensland. "They (medical authorities) need to be bloody thorough in their checks and not hire anyone with a record that harmed people," Ms Crosby said. "We don't want this here in Queensland - we've had a gutful. I know we are desperate for doctors, but we are not that desperate that we want to put people in harm's way again. It's just not on."

Dr Hasil remains registered to practice in NSW. The chief executive of the NSW Medical Board, Andrew Dix, said the board was aware of concerns about Dr Hasil, but no complaints had been received in NSW. "We will be taking urgent action to see whether there are grounds for referring him to the medical tribunal," he said on Fairfax radio today. Without a decision from the tribunal, the board did not have the power to deregister, he said.

NZ authorities declined to refer Dr Hasil to prosecutors, but the inquiry report concluded: "Many women of Wanganui have been deeply affected by the substandard care provided by Dr Hasil, and some women have been harmed".

Source





28 February, 2008

SCOTUS ruling favors medical device firms

A defeat for the legal piranhas

Patients who are injured by federally approved medical devices can't collect damages if the manufacturers complied with government standards, the Supreme Court ruled Wednesday. The 8-1 decision in a New York case applies to the riskiest devices, like heart valves and pacemakers, which need Food and Drug Administration approval before they can be sold. The court said the 1976 federal law that required FDA clearance for those products would be disrupted by negligence suits under state law, just as it would be impaired by varying state regulations.

Congress' concern for those injured by FDA-approved devices was outweighed by its "solicitude for those who would suffer without new medical devices if juries were allowed to apply the (injury) law of 50 states to all innovations," said Justice Antonin Scalia in the majority opinion.

The court allowed damage claims for injuries caused by products that violate FDA manufacturing specifications or labeling rules, and left intact an earlier decision permitting a broader range of suits over defects in medical devices that don't require FDA review before marketing. But the ruling - on a day in which the justices also limited states' authority to prevent cigarette shipment to minors - was a substantial victory for businesses and a possible foreshadowing of another case, to be argued this fall, about suits by patients claiming harm from FDA-approved drugs.

The medical ruling is "a victory for a national system designed to maximize the benefits to patients" from exhaustive review by government experts, said Theodore Olson, lawyer for Medtronic, manufacturer of the heart catheter involved in the case. While FDA scrutiny is imperfect, he said, it's preferable to product assessment by a jury that "isn't evaluating the needs of patients all over the country and doesn't have expertise."

The plaintiffs' lawyer, Allison Zieve of the Public Citizen Litigation Group, said the decision was "potentially dangerous for patients," because the prospect of damages against manufacturers is an incentive for safety. The suit was filed by Charles Riegel, whose Evergreen Balloon Catheter burst during a 1996 angioplasty. Riegel survived, after emergency bypass surgery, and accused Medtronic of negligence in the design, manufacture and labeling of the device. He died in 2004 of unrelated causes, and his wife, Donna, took over the suit.

In upholding lower-court rulings dismissing the case, the Supreme Court said the catheter, like other devices requiring pre-marketing approval, receives rigorous scrutiny from the FDA, which spends an average of 1,200 hours reviewing each application and grants approval only to those that provide reasonable assurances that the product will be both safe and effective. Scalia cited a provision of the 1976 federal law prohibiting states from enforcing any requirements for medical devices that differed from FDA standards. A jury's finding that the catheter was improperly manufactured or labeled, despite FDA approval, would amount to an additional requirement, he said. "A jury ... sees only the cost of a more dangerous design and is not concerned with its benefits," Scalia said.

Justice Ruth Bader Ginsburg dissented, saying the 1976 law was not intended to thwart negligence suits. She said Congress passed the law to provide uniform regulation after states - led by California - began their own approval process for medical devices in response to lawsuits over infections attributed to the Dalkon Shield intrauterine device. Wednesday's ruling is "at odds with the (law's) central purpose: to protect consumer safety," Ginsburg said.

Source




Australia: Government sorry over 'mutilation doctor'

"Your government will look after you", once again

The NSW Government says it is sorry, but it can't yet explain why a doctor banned from obstetrics was able to continue performing operations which allegedy left many women mutilated. Dr Graeme Steven Reeves is alleged to have mutilated or sexually abused as many as 800 patients. The NSW Medical Board ruled in 1997 that Graeme Stephen Reeves "suffers from personality and relations problems and depression that detrimentally affects his mental capacity to practise medicine". The board ordered him to stop practising obstetrics, but he defied the ban and took up a position in 2001 as a specialist obstetrician and gynaecologist for the Southern Area Health Service, working at Bega and Pambula hospitals. He was struck off the medical register in 2004.

NSW Health Minister Reba Meagher was today asked by reporters how Dr Reeves had continued to practise when hospital and nursing staff must have known about the type of surgery he was performing. "I don't know what was known then by others around Dr Reeves, but I do know this Government radically overhauled the Health Care Complaints Commission to ensure a greater level of protection for patients that have complaints," Ms Meagher said. Since 2005, hospitals had taken greater care in confirming a doctor's references with the NSW medical board, which has increased its transparency in relation to deregistered doctors.

The NSW Government and police have begun investigations following new allegations about Dr Reeves but it will be some time before authorities determine how he was able to continue to practice as an obstetrician and gynaecologist. "I can't explain that," Ms Meagher said. "But what I can assure the women who are coming forward now is that we will support them in every way we possibly can. "I am sorry that they have had such an awful, awful experience at the hands of somebody who was not fit to deliver a medical service."

Source





27 February, 2008

Massachusetts Hospital Association's New Recipe for Fudge

Delusions About Cost & Benefits of Health "Reform" Persist

An amazing story in the usually reliable Boston Globe by Steve LeBlanc made me gulp: might I have to recant my position on the ineffective and expensive Massachusetts health reform? Luckily, no: a report by the Massachusetts Hospital Association on the reform's "success" manages to fudge the numbers just enough to convince the casual reader that the "reform" is achieving its primary objective: reducing hospitals' so-called "uncompensated" care (actually quite well compensated by taxpayers), by enrolling uninsured residents into mandatory health insurance.

Through some kind of magic understandable to politicians, this insurance would transform these folks into responsible patients who would consult with doctors as soon as they felt poorly, instead of waiting until their illnesses turned critical and they crashed the emergency room, only to check out without paying the bill. Sadly,the MHA's exquisite recipe for fudge did rope in Mr. LeBlanc:

It was a key premise of the state's landmark health care law -- the more uninsured people who were enrolled in subsidized health care plans, the fewer uninsured people would show up at hospital emergency rooms for routine care. Now a new study says that's exactly what's happening. The report by the Massachusetts Hospital Association finds that the number of so-called "free care" visits to hospitals have declined by 28 percent over the past three years. That mirrors a 28 percent increase in enrollment in subsidized health care programs, MassHealth and the new Commonwealth Care program, which was created by the law.

It's hard to know where to begin dissecting this outrageous claim. Obviously, the exact mirror-image of savings versus cost increase, 28%, should make any reader suspect that the numbers are being cooked. Here's a list of the ingredients for the fudge recipe:

The 28% decrease in hospital free care visits is from October 2004 to September 2007, versus the same combined increase in MassHealth and Commonwealth Connector enrolment. But MassHealth is just the state's Medicaid program. The "reform" is the Commonwealth Connector, which did not start enrolling people until January 2007. So, the time period, while conveniently resulting in a balanced ledger, is quite irrelevent to the effect of the "reform".

Neither of the 28% figures are dollar costs: they are both head-counts: enrolment in MassHealth and Commonwealth Connector plans, and uncompensated care patient accounts in hospitals. Obviously, comparing the two is meaningless.

A graph on page 3 of the report shows the dollar decline in hospital uncompensated care costs: from just under $700 million (FY2004) to $613.5 million (FY 2007): about 12%, in current dollars. (In order to stretch this figure, the report also notes constant dollars, for which it claims a reduction of 23%, but what difference does this make, as it does not report dollars spent on MassHealth and Commonwealth Care, only heads counted?)

So, what really happened to hospitals' uncompensated care costs during the relevent period? We can't quite tell, but the report does state actual savings from July 1, 2006 to June 30, 2007 of a (sarcasm alert) whopping $10.1 million! Because the Commonwealth Connector launched in January 2007, only the last six months of the fiscal year are relevent. So, let's be generous and guesstimate that savings will have increased to $15 million for the first operating year of the Commonwealth Connector.

Ho, hum.....Is this all that Bay Staters get for a reform for which Governor Patrick is requesting $400 million this year? Uncompensated care savings that barely stretch into the double digits? We have already busted the Commonwealth Connector's boss for cooking up a rotten story about the program's originally budgeted costs. Now, the main beneficiary of the plan's handouts contributes its sugary recipe for fudge to the menu.

Well, if you can't stand the heat, get out of the kitchen - or the state, I suppose. At least that's what many small businesses will do if this "reform" keeps boiling over with new taxes to fund ineffective change - or no real change at all.

Source




Australia: Ambulances wait three hours to hand over patients

No reserve capacity at hospital for surges in demand



This scene outside Cairns Base Hospital's emergency department yesterday is another stark reminder why the region needs a new hospital, now. Ten ambulances were queued outside the choked department by early afternoon, forcing frustrated paramedics to wait for up to three hours before unloading patients.

Officers said they had been putting up with the "bad old days" of no emergency beds for at least a week but yesterday's jam-up had gone from bad to worse as the day went on. "It's beyond a joke," one told The Cairns Post. "Something's got to change." Queensland Ambulance Service area director Warren Martin, who oversees a fleet of 12 vehicles across Cairns, Smithfield and Edmonton, said up to 10 ambulances were effectively out of action for hours. The situation peaked about 2pm when several patients arrived around the same time, causing 10 or 11 ambulances to back up, Mr Martin said.

But he stressed that while the ambulance gridlock outside the emergency department, also known as "ramping", was still happening, new systems to fast-track patients were helping. "It means that when we do ramp, it's not lasting as long," Mr Martin said. "Today was just one of those days." All the patients forced to wait in ambulances yesterday were being closely monitored by emergency doctors, and were in the mid-urgency rather than high-urgency categories, he said. "It's a bit of a cross-section, everything from gastro upset tummies to someone with abdominal pain . I think the hot weather back with a vengeance today has been knocking older people around a bit," Mr Martin said.

Mr Martin said he was "really looking forward" to next year's expected completion of a major expansion to the emergency department, which would double its size and add 12 more beds. A Queensland Health spokesman attributed the delays to a rush of patients at once, with 30 arriving during the most intense period of 12.30pm to 3pm, or about 12 an hour. On a normal day, the department averages five patients per hour. The spokesman said his information was that the maximum number of ambulances waiting at one time had been eight.

Source




Australia: Butcher doctor. Your regulators will protect you (NOT)



THEY call him the Butcher of Bega - a NSW doctor who has committed such monstrous acts that hundreds of terrified victims have remained silent for more than five years. Dr Graeme Stephen Reeves is alleged to have routinely mutilated or sexually abused as many as 500 female patients while he was working as a gynaecologist and obstetrician at various hospitals across Sydney and the NSW south coast.

Despite the NSW Medical Board ruling he had psychiatric problems which "detrimentally affect his mental capacity to practice medicine" more than a decade ago, he managed to continue treating women without detection in a devastating trail of botched operations and negligence.

Hundreds of former patients have come forward with harrowing and graphic evidence about Dr Reeves, who was struck off in 2004 for breaching practice restrictions. As many as 500 emails from women were received by the private watchdog, Medical Error Action Group, last week telling of their humiliation and pain after parts of their genitals were removed or sewn up without their consent.

The outpouring came after a former patient of Dr Reeves, Carolyn Dewaegeneire, broke her five-year silence with two other women to give a public account of her ordeal on Channel 9's Sunday program last weekend.

Despite the shocking revelations on the program, Dr Reeves is still not being investigated by the police, the NSW Medical Board or the Health Care Complaints Commission, over the latest allegations. He is also free to re-apply to return to medical work at any time after serving a three-year ban. Dr Reeves has refused to comment on the allegations. The hospitals where Dr Reeves has practised include Hornsby Ku-ring-gai, Sydney Adventist at Wahroonga, The Hills Private at Baulkham Hills, Royal Hospital for Women and the Bega and Pambula hospitals.

Source. More here and here





26 February, 2008

Authoritarian medicine in Britain -- Health "insurance" with a difference

If they cannot afford to give you a drug or service that you need, you are forbidden to pay for it yourself!

Created 60 years ago as a cornerstone of the British welfare state, the National Health Service is devoted to the principle of free medical care for everyone. But recently it has been wrestling with a problem its founders never anticipated: how to handle patients with complex illnesses who want to pay for parts of their treatment while receiving the rest free from the health service. Although the government is reluctant to discuss the issue, hopscotching back and forth between private and public care has long been standard here for those who can afford it. But a few recent cases have exposed fundamental contradictions between policy and practice in the system, and tested its founding philosophy to its very limits.

One such case was Debbie Hirst's. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologist's support, she decided last year to try to pay the $120,000 cost herself, while continuing with the rest of her publicly financed treatment. By December, she had raised $20,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down.

Mrs. Hirst heard the news from her doctor. "He looked at me and said: `I'm so sorry, Debbie. I've had my wrists slapped from the people upstairs, and I can no longer offer you that service,' " Mrs. Hirst said in an interview. "I said, `Where does that leave me?' He said, `If you pay for Avastin, you'll have to pay for everything' " - in other words, for all her cancer treatment, far more than she could afford.

Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones. Patients "cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs," the health secretary, Alan Johnson, told Parliament. "That way lies the end of the founding principles of the N.H.S.," Mr. Johnson said.

But Mrs. Hirst, 57, whose cancer was diagnosed in 1999, went to the news media, and so did other patients in similar situations. And it became clear that theirs were not isolated cases. In fact, patients, doctors and officials across the health care system widely acknowledge that patients suffering from every imaginable complaint regularly pay for some parts of their treatment while receiving the rest free.

"Of course it's going on in the N.H.S. all the time, but a lot of it is hidden - it's not explicit," said Dr. Paul Charlson, a general practitioner in Yorkshire and a member of Doctors for Reform, a group that is highly critical of the health service. Last year, he was the co-author of a paper laying out examples of how patients with the initiative and the money dip in and out of the system, in effect buying upgrades to their basic free medical care. "People swap from public to private sector all the time, and they're topping up for virtually everything," Dr. Charlson said in an interview. For instance, he said, a patient put on a five-month waiting list to see an orthopedic surgeon may pay $250 for a private consultation, and then switch back to the health service for the actual operation from the same doctor. "Or they'll buy an M.R.I. scan because the wait is so long, and then take the results back to the N.H.S.," Dr. Charlson said.

In his paper, he also wrote about a 46-year-old woman with breast cancer who paid 250 pounds for a second opinion when the health service refused to provide her with one; an elderly man who spent thousands of dollars on a new hearing aid instead of enduring a yearlong wait on the health service; and a 29-year-old woman who, with her doctor's blessing, bought a three-month supply of Tarceva, a drug to treat pancreatic cancer, for more than $6,000 on the Internet because she could not get it through the N.H.S. Asked why these were different from cases like Mrs. Hirst's, a spokeswoman for the health service said no officials were available to comment.

In any case, the rules about private co-payments, as they are called, in cancer care are contradictory and hard to understand, said Nigel Edwards, the director of policy for the N.H.S. Confederation, which represents hospitals and other health-care providers. "I've had conflicting advice from different lawyers," he said, "but it does seem like a violation of natural justice to say that either you don't get the drug you want, or you have to pay for all your treatment."

Karol Sikora, a professor of cancer medicine at the Imperial College School of Medicine and one of Dr. Charlson's co-authors, said that co-payments are particularly prevalent in cancer care. Armed with information from the Internet and patients' networks, cancer patients are increasingly likely to demand, and pay for, cutting-edge drugs that the health service considers too expensive to be cost-effective. "You have a population that is informed and consumerist about how it behaves about health care information, and an N.H.S. that can no longer afford to pay for everything for everybody," he said.

Professor Sikora said that oncologists are adept at circumventing the system by, for example, referring patients to other doctors who can provide the private medication separately. As wrenching as it can be to administer more sophisticated drugs to some patients than to others, he said, "if you're a doctor working in the system, you should let your patients have the treatment they want, if they can afford to pay for it." In any case, he said, the health service is riddled with inequities. Some drugs are available in some parts of the country and not in others. Waiting lists for treatment vary wildly from place to place. Some regions spend $280 per capita on cancer care, Professor Sikora said, while others spend just $90.

In Mrs. Hirst's case, the confusion was compounded by the fact that three other patients at her hospital were already doing what she had been forbidden to do - buying extra drugs to supplement their cancer care. The arrangements had "evolved without anyone questioning whether it was right or wrong," said Laura Mason, a hospital spokeswoman. Because their treatment began before the Health Department explicitly condemned the practice, they have been allowed to continue.

The rules are confusing. "It's quite a fine line," Ms. Mason said. "You can't have a course of N.H.S. and private treatment at the same time on the same appointment - for instance, if a particular drug has to be administered alongside another drug which is N.H.S.-funded." But, she said, the health service rules seem to allow patients to receive the drugs during separate hospital visits - the N.H.S. drugs during an N.H.S. appointment, the extra drugs during a private appointment.

One of Mrs. Hirst's troubles came, it seems, because the Avastin she proposed to pay for would have had to be administered at the same time as the drug Taxol, which she was receiving free on the health service. Because of that, she could not schedule separate appointments. But in a final irony, Mrs. Hirst was told early this month that her cancer had spread and her condition had deteriorated so much she could have the Avastin after all - paid for by the health service. In other words, a system that forbade her to buy the medicine earlier was now saying that she was so sick she could have it at public expense. Mrs. Hirst is pleased, but only up to a point. Avastin is not a cure, but a way to extend her life, perhaps only by several months, and she has missed valuable time. "It may be too bloody late," she said. "I'm a person who left school at 15 and I've worked all my life and I've paid into the system, and I'm not going to live long enough to get my old-age pension from this government," she added.

She also knows that the drug can have grave side effects. "I have campaigned for this drug, and if it goes wrong and kills me, c'est la vie," she said. But, she said, speaking of the government: "If the drug doesn't have a fair chance because the cancer has advanced so much, then they should be raked over the coals for it."

Source




Australia: Public hospital kitchens fail hygiene, safety tests

GRUBBY benchtops, sloppy pest control and off deli meats were found during independent audits of NSW public hospital kitchens that found 94 per cent did not comply with new hygiene and safety laws. The Daily Telegraph can reveal 166 of 171 hospitals checked during voluntary audits "required one or more corrective actions" for them to meet new guidelines set down by the NSW Food Authority. Four public hospitals were deemed so bad they failed completely, scoring an "unacceptable" rating for their operations.

But the hospitals won't be named and shamed as the Food Authority claims it would be a breach of their business affairs - considered more important than patients' right to know of threats to their health. It was also claimed identifying the hospitals would make them unco-operative in complying in future audits.

Overall, documents obtained under Freedom of Information laws show there were 719 areas of corrective action required for the 166 hospitals. Censored audit reports for the failed public hospitals show the detail of how poor some hospitals are on hygiene and safety. One of the reports shows a coolroom was running at an unhealthy warm temperature, a precondition for food poisoning. The same kitchen had frozen meats and milk powder stored beyond use-by dates, with sliced deli meats with a 24-hour life found stored for four days. Another report of a public hospital found unclean can openers, no records on pest control and food handling concerns.

Staff involved in food preparation wearing gloves were observed picking up food off the floor. One staff member was "observed coughing into her glove and not removing it".

The unhealthy kitchens are the latest blow to the NSW health system, already reeling over scandals including mismanagement of Royal North Shore Hospital and the bungled construction of the new Bathurst Hospital. A NSW Health spokeswoman said none of the issues incurred penalty notices and there was no threat to public health. [Really??] "In all cases where there was an issue found at audit, remedial action was undertaken immediately."

Brian Holloway, 56, had nothing but praise for the medical staff at Mona Vale Hospital during his long stay last year - but he had no love for the hospital's menu. He was appalled at being served what he said was quiches served flat like pancakes, rice tough enough to put through a slug gun and mashed potato like "quick-set cement".

Source





25 February, 2008

The other health care issue: Getting costs down

A few weeks ago a friend of mine received a bill from a hospital in New York where he had had a routine colonoscopy, one of those preventive procedures that people over a certain age are supposed to have every five years or so. The bill, my friend was surprised to see, was for $8,513.36, not including the doctor's fee, which was a few hundred dollars more - this for a procedure involving no anesthesia and taking less than half an hour from start to finish.

What was most surprising about the bill was not even the total, rather high, amount; it was an indication that Medicare - the government insurance program for people 65 and over - had paid the lion's share of the bill, or precisely $8,200.61. Over $8,000 of the taxpayers' money for a routine colonoscopy - a procedure that would normally cost a few hundred dollars, maybe a bit more than a thousand for a high-cost doctor in a high-cost area. What was going on here?

The truth is: I don't know. When I called Medicare to ask about this, a spokesman said Medicare would normally reimburse a hospital about $500 for a colonoscopy performed in New York City - where costs are higher than they would be in, say, Fargo, North Dakota. Why Medicare would have paid 20 times what it is supposed to pay, or if in fact it did pay that amount (maybe the hospital's invoice was incorrect) are questions buried somewhere in the vast federal bureaucracy.

In the meantime, the matter of a friend's medical costs served as a reminder of a large and lively issue in American life, which is why medical costs are so much higher here than in most other advanced industrial countries, and what, if anything, can be done about it. We pay per capita about twice what European countries pay for medical care - roughly $6,000 per person per year - and costs are increasing at three times the rate of inflation.

And beyond that, another question: health care plans to remedy the gaping holes in the American system, most notably the hole represented by the 40 or so million people who have no health insurance, seem to come out almost every day. Both Hillary Clinton and Barack Obama have produced elaborate plans, while one of the claims to fame of the ex-candidate Mitt Romney was that he put the country's first statewide medical plan into effect when he was governor of Massachusetts.

Analysts have pored over both the Clinton plan and the Obama plan and given both of them pretty high marks. The Clinton plan would get more people on the rolls than the Obama plan, but it would have more enforcement in it and would be more expensive. Either plan would probably mark a major step forward from where we are today, and the country does seem in a mood now to make some kind of step.

But while there is a great deal of discussion on how to get more people insured at rates they and the nation can afford, there seems a good deal less talk about ways to get costs down, which is where my friend's colonoscopy and other rather sizable medical bills come in.

Among the other sizable bills was one for hip replacement surgery I underwent at the end of last year, surgery that, as I said in this space at the time, I'm fortunate to have had - and happy, too, that the entire cost was borne by Cigna International, my health insurance company.

Despite the overall worrying picture, there are some things right about American medicine, especially when you are among the lucky ones covered by a good insurance plan, or for that matter among the millions of people 65 and older whose costs are mostly covered by Medicare.

Still, there's that cloying question of cost. My hip replacement was expertly done by my surgeon, Allan Inglis Jr., and his team at New York's St. Luke's/Roosevelt Hospital. But the total cost will end up being around $40,000, or perhaps a few thousand more, once the bills for anesthesia, for four days in the hospital, for medications, pre- and post-operative exams, physical therapy and the prosthesis itself are added in.

Cigna paid $32,000 to Dr. Inglis for the surgery alone, a sum that seemed stratospheric to me and that even the good doctor allowed, in a telephone interview, was "a lot." When I asked him why, if he thought it was a lot, he charged that much, Inglis described a system of billing and payments so complicated and inconsistent that it defies easy understanding. "It's a number out of a hat," he said of the actual amount paid. "We don't have any idea of what we're supposed to be billing because we don't know what the different insurers are going to pay, which is kind of a funny way to do business."

When he submits a bill to an insurer, he said, he doesn't specify an actual amount. He puts in a code for the procedure he's done, and the insurance company pays what it calls its reasonable customary rate. Some insurance companies, like mine, pay a lot, he said, and others, like Medicare, pay less, with the higher payers subsidizing the lower ones.

In the end, the result is higher costs than just about anywhere else. In Germany, for example, the cost of a total hip replacement would be 7,000 to 13,000 euros, or $10,200 to $19,000, depending on the patient's condition and whether there are complications, according to a spokesman at the national health insurer AOK. A private clinic would charge about 20,000 euros.

And if you're willing to go to Thailand or India, you can have the surgery performed for $10,000 to $12,000 all inclusive, in a state-of-the-art hospital with state of the art prosthetics and surgeons. Maybe the answer to the American problem is a bit of medical globalization. If insurance companies would cover the airfares to send willing patients to Thailand, they could save upwards of $30,000 for each hip replacement they cover. They don't reimburse airfares, but maybe they should.

Source




Australia: A farcical public hospital

Even under great public pressure, the bumbling NSW government still manages to do zilch

THE state of the disastrous new $100 million Bathurst Base Hospital has descended into farce after a head doctor bought an air horn from a sports store so he could be summoned in an emergency because he did not trust the alarm system. It was hoped that non-urgent surgery - suspended indefinitely more than a week ago because of safety concerns - would resume yesterday but doctors instead voted to postpone all operations booked for the next week, calling the situation a "crisis".

A representative on the Medical Staff Council, Dr Stavros Prineas, said the alarm system had serious communication problems, putting patients at risk. The emergency alarm could not be heard across the theatre complex - despite sounding in other areas of the hospital - so nurses had resorted to running through corridors looking for doctors during an emergency, he said. He said Telstra was working yesterday to give the hospital mobile phone coverage. Surgery lists would be reviewed weekly but operations would probably be suspended for at least a further three weeks, Dr Prineas said.

The Health Minister, Reba Meagher, has agreed to a potentially multimillion-dollar redesign because the hospital does not meet national health standards. The co-director of the intensive care unit, Brendan Smith, said nothing had improved after Ms Meagher's visit on Thursday. "We still do not have an effective alarm system in the theatres and recovery. Yesterday we did a couple of cases in the theatre and the only way we were able to do it was because I went to the shop and bought an air horn," Dr Smith said.

"We actually gave it to the director-general [of NSW Health], Professor Debora Picone, and said this was what we've been reduced to and she looked shocked and there were a few comments from her minions in the hospital that said, 'I don't know if that's legal', and we said, 'It might not be legal but it's effective', and they got the message loud and clear."

He said doctors were also considering closing maternity because anaesthetists felt they could not provide a safe service. "Everything but the most dire urgent surgery is being cancelled and it's probably that the obstetrics unit will be closed down because we can't give anaesthetic cover," Dr Smith said.

The doctors have issued a list of demands to Ms Meagher including that a purpose-built annex be urgently constructed for services they say were promised but not delivered such as the ambulatory care unit and outpatient clinics.

The State Government yesterday tabled its response to the Nile inquiry into Royal North Shore Hospital and said it would implement all but two of the 45 recommendations. Doctors say the recommendations do not address the basic problems of bed and staff shortages.

Source





24 February, 2008

The fantasy pharma of the Left

The left, of course, has its own fantasy solution set: drugs should be both innovative and cheap. But clinical trials for a single successful drug cost $500 million, and not because the labs have outrageous administrative overhead. Even if the government were in charge of running them, they would still be on the hook for that $500 million, which would have to come out of taxes. We can get existing drugs on the cheap by essentially stealing the property of shareholders in drug firms, who risked a lot of money on drugs that they reasonably expected to be profitable under existing laws. But that's a one-trick pony. We cannot get new drugs at bargain basement prices.

Many people are holding out the hope that the government can somehow substitute for the pharmas, bolstered by the ludicrous claim that the government really discovers all the drugs. This is arrant nonsense; government-funded research discovers targets that might someday turn into drugs, if the Big Pharma chemists can: find a molecule synthesis can be economically mass produced; keep the molecule from killing rats, mice, dogs, or humans; get the molecule into a form that does not have to be directly injected into the bloodstream; tweak the molecule so that the liver doesn't immediately chew it into pieces that no longer affect your target; and shepherd the entire thing through years of clinical trials. That's just off the top of my head; research chemists will undoubtedly have more.

There is no evidence of a nationalized industry that consistently does cost effective innovation. Yes, you have a list of things invented by the government--but that number is a small fraction of a fraction of one percent of the number of things in the private sector. If the universe of products were your house, the government would have invented one washer inside the tap of your bathroom sink; the private sector would have developed every other thing you use. Even where the government is given credit for "inventing" something, such as DARPANet's invention of the internet; it turns out that 99% of the process of actually turning it into a product that was useful to end-consumers was handled by private actors, most of them corporations like Netscape, Microsoft, and AOL.

This is why when you start to make a list of all the state-run economies that have produced large numbers of innovative products with a high level of consumer satisfaction, you have to throw your privately manufactured gel pen aside in disgust. For whatever reason, the government is just not good at producing innovation.

Before you say it, I know that you are leaning forward in your chair, your eyes alight, preparing to demand "What about the military?!" and lean back triumphantly in your chair. My friend, have you ever taken a close look at the military procurement process? It costs a fantastic amount of money to generate products that often aren't even wanted by the end users--how many times have you read about some military service being forced to buy some gargantuan piece of equipment they don't want because the thing is being manufactured in a key congressman's district? This is how we spend four percent of our national income on something that most of the American public never sees. Forgive me if I'm not excited about applying the same process to health care.

Source




Australia: Public hospital negligence kills again

A DEVASTATED family has been left angry and searching for answers since their beloved grandmother died after tripping on unfinished roadworks outside the Royal Hobart Hospital. Margaret Wakefield, 77, died in hospital last week after falling near the entrance to the new emergency department. The fit and active grandmother had been going to the hospital to visit a sick relative, and now her family is struggling to comprehend how a simple day out turned to tragedy.

Katie Wakefield, 20, was with her grandmother going to visit a relative in the hospital last Thursday. Miss Wakefield, 20, from Rokeby, was carrying her 18-month-old daughter, Shaelah, while her four-year-old son Justin was holding his great grandma's hand. Then Mrs Wakefield tripped on a section of raised footpath, believed to be the base of an old emergency department sign that had been removed. Miss Wakefield and her children were horrified to see their nan on the ground with blood streaming from her face. "She hit her face on the ground. I thought she'd broken her nose. There was blood everywhere and her glasses were stuck to her face," Miss Wakefield said.

She managed to get her conscious grandmother to the emergency department and waited about two hours for attention. They then spent several hours waiting for scans before being sent home. But soon after leaving the elderly woman's condition worsened. "On the way home she started vomiting so we called an ambulance," Miss Wakefield said. "She just got really confused and couldn't walk, she started deteriorating and they did a scan and found she had a blood clot forming in her brain. "She went into a coma and was on life support, and after that she died."

Miss Wakefield reported the problem pavement to hospital staff and a safety barricade was erected. The pavement has since been repaired. But they can't ignore the irony of having their grandmother die from an accident outside a hospital. "You come to hospital to get better, not to die," Miss Wakefield said. "It's simple: if things hadn't been sticking out of the footpath, she wouldn't have died. "And because of her age they should never have sent her home from hospital in the first place, she should have been kept in for observation."

Hospital community relations director Pene Snashall said condolences had been extended to the family in what was obviously a very sad time for them. She said the RHH was unable to comment further until a coronial inquiry was held.

Source





23 February, 2008

Nationalized medicine and the incentives they face

The role of incentives are too easily ignored by individuals who have the idea that the State is somehow, magically, the solution to whatever problem we face. And government-run health care is supposed to be the solution to the scarcity problem in health care. Economists argue that incentives matter and that political-provision of services creates distorted and perverse incentives. And here is a perfect example.

The British National Health Service is notoriously slow in treating patients. Some people deny this is the case and point to various numbers released by the NHS itself to show how efficient it is. And one number the NHS takes seriously is that they require patients admitted to the emergency ward to be seen within 4 hours of admission. Doesn't that sound peachy?

Don't get too excited. Let me point out how well-intentioned interventions can create unintended incentives. A town in a poor country is faced with too many rats. They offer a bounty for each rat that is killed. Proof of a kill required the bounty hunters to hand in a rat's tail. Alas, a bevy of tailess rats were soon seen running about town. To solve that problem the city required the entire carcass of the rat be handed in. And they were inundated with dead rats. But it seemed to have no impact on the number of rats running about. Apparently individuals took to breeding rats.

There was a time when the South African government decided that they would offer an award for every AK-47 that was turned into the police. These weapons were frequently used in major crimes and it was a bit embarrassing to the ANC government that they had been the importers of the weapons in question when they were trying to overthrow the previous government. So they offered a nice hefty bounty on each AK-47 that was turned in. The only problem was that AK-47s could be purchased in neighboring countries for a lower price. One could buy it in Zimbabwe and legally sell it to the South African government at a premium. AK-47s were duly imported in record numbers in order to collect the awards the government was handing out. To say the least they merely increased the number of such weapons in the country.

Governments are very good at establishing perverse incentives without realizing it. And so it was with the NHS. The 4-hour rule is simple. A patient must be seen within 4 fours of admission. If too many patients are not seen in that time the health service could lose funding. Of course the ability to see patients that quickly is not increased by the rule. Instead the local hospitals have incentives to act in very strange ways.

If you know you can't see a patient in emergency care for at least six hours, but you are required to see them within four hours of admission, then the easiest way to solve the problem is to delay admission for an additional two hours. And that is what is happening according to the Left-of-center Guardian. The paper reports, "thousands of seriously ill patients in ambulance `holding patterns'" were being kept outside in the ambulances "to meet a government pledge that all patients are treated within four hours of admission."



The story was originally broken by The Observer. The Guardian notes:

Those affected by 'patient stacking' include people with broken limbs or those suffering fits or breathing problems. An Observer investigation has also found that some wait for up to five hours in ambulances because A&E units have refused to admit them until they can guarantee to treat them within the time limit. Apart from the danger posed to patients, the detaining of ambulances means vehicles and trained crew are not available to answer new 999 calls because they are being kept on hospital sites.

Notice the knock-on effect of this incentive. The hospital can't see the patients within the required 4 hour period. So it refuses to admit the patient until it can see them and meet government edicts. That means the patients is left in the ambulance. That means the ambulance can't treat other patients.

Under normal conditions the government says that it ought to take 15 minutes from the time an ambulance arrives with a patient until they prepared to depart. Ambulance crews say it is usually 5 to 10 minutes. But reports now show that on 14,700 occasions at 35 hospitals in London alone, in the last year, an ambulance mysteriously took over one hour before they could turn around. And on 332 occasions they took more than two hours. The total for the entire country is probably three times that.

For a moment I want you to think about a fast food restaurant -- say McDonalds. Let us say that the manager notices that they aren't serving customers as quickly as they should. So he sets a 4 minutes rule. From the time a customer enters the line, he should not wait more than four minutes to be served his meal. Do you really think that the way they would meet this target is to lock the doors so customers can't get in?

Why is it that clerks at the local grocery store can process your purchase within a few minutes while government departments around the world can keep you waiting for hours at a time? Are clerks at the local Safeway just that much more efficient than those at the DMV? Or do they face entirely different incentives?

Does the DMV fear losing customers? Does Safeway? Does the salary of the checkout clerk at Safeway depend on keeping customers happy? How about the DMV clerks? I don't think the people differ that much. The problem isn't the personnel -- as some Republicans tends to think -- the problem is systemic. Government just hasn't found a way to create the right set of incentives. And people who work for government are responding to the incentives they do face.

Source. See also here on British "patient stacking"




Dying To Save 'The System'

For defenders of Canada's government-monopoly health care system, there is only one goal that truly matters. And, no, despite their earnest insistences to the contrary, that goal is not the health of patients. It is the preservation of the public monopoly at all costs, even patients' lives. This week, the Kawacatoose First Nation, which has an urban reserve on Regina's eastern outskirts, announced it wanted to build a health centre there with its own money. Among other things, the band wants to buy a state-of-the-art MRI machine and perform diagnostic tests on Saskatchewanians -- aboriginal and non-aboriginal-- who currently face some of the longest waits for scans in the country.

This should be a win-win: Aboriginals show entrepreneurial initiative, without any financial obligation on the part of the federal or provincial government, and create well-paying high-tech jobs for natives who desperately need them, while at the same time easing the wait for MRI tests in Saskatchewan that can now run to six or even 12 months. Each year, hundreds or even thousands of Saskatchewan residents -- mostly middle-class -- drive across the border into North Dakota and pay their own money for scans rather than wait for one at home. The Kawacatoose proposal would give them a much closer alternative.

So what was the reaction of the opposition NDP in Saskatchewan? Restrained contempt and veiled fear-mongering. The restraint was a result only of the fact that this proposal was coming from aboriginals. Had a private, non-native company suggested the same thing, Saskatchewan's opposition socialists would have been screaming from the rooftops that greedy insurance companies and health profiteers are lurking under every hospital bed ready to prey on unsuspecting patients the moment they get the green light.

Still, despite their untypical decorum, it was easy to see the NDP's disdain. Health critic Judy Junor said such private facilities threaten the public system, even if they do not offer fee-for-service scans, because they poach staff from public hospitals. "You can buy the machine," she sniffed, "that's the easy part. It's who's going to work it on a day-to-day basis."

The Kawacatoose have said they will not permit queue-jumping by fee-paying patients at their clinic. Instead, they have the money to buy an MRI, and they estimate their band could make some much-needed money by performing scans paid for by the province, so they are seeking permission to go ahead. Still, that is not good enough for Ms. Junor and her colleagues. The NDP sees any service provision not controlled directly by the government as a menace That means health cannot be as high a priority for them as preserving the public monopoly.

During their 16 years in power -- a string that ended just over three months ago -- the Saskatchewan NDP refused to issue licenses for any MRI clinics not owned by government. In 2004, the Muskeg Lake Cree Nation proposed building one on its satellite reserve in Saskatoon. After three frustratingly long years seeking approval, the band gave up and went ahead with plans for an MRI-less clinic. Their members and the public will have to settle for second-best care because of the devotion of medicare's defenders to "the system," first and foremost. By placing "the system" (and the well-paying jobs of NDP-voting union health workers) ahead of providing care for patients, the NDP have shown where their true loyalties lie.

It's the same across the country, and not just among New Democrats. We are short 12,000 to 15,000 doctors in Canada because in the early 1990s, provincial health ministers -- Tory, Liberal and NDP -- desirous of preserving "the system," capped enrolments at medical schools. Doctors, they reasoned, are a major driver of costs with all the tests they order and treatments they perform. The ministers knew that limiting the number of doctors would limit the amount of medical service available to patients. But they were prepared to accept that. They felt they had to limit costs to preserve "the system," so providing care Canadians needed came in second to the system's survival.

The nursing shortage, the sad state of high-tech diagnostic equipment outside our largest cities and the rationing of services via waiting lists are all examples of how medicare's advocates are prepared to sacrifice Canadians' health and comfort -- even their lives -- just so the public monopoly can be maintained.

Source





22 February, 2008

The laser again

A personal memoir for a change

It is a couple of years since my last visit to the laser but last Monday I had to go again. When my skin cancers get too big for excision or freezing, the laser is the last option before a graft.

So about three weeks ago I rang the best dermatological surgeon in Brisbane -- Russell Hills -- and made an appointment to see him a few days later. He agreed that it was laser time and booked me in for the procedure a couple of weeks later. If I had gone through the public hospital system, I would still be waiting for a consultation and the procedure itself would be a year or more off.

As I have had so much dermatological surgery over the years I am a connoisseur of it so when I say that Russell is the best, I am in a position to know. His excisions and joinups are so fine that they heal with maximum rapidity -- which is the main thing from my viewpoint. That skill does however make him much in demand by ladies for their facelifts etc. You can't see the scars where Russell has been.

Anyway I arrived at Northwest Private Hospital at the appointed time in the late afternoon and went through all the introductory bureaucratic procedures that are mandatory these days. I was however at the end of the day's listings so I was the victim of all the prior medical misadventures of the day. Russell's anaesthetist had been much held up by unforeseen circumstances on his morning list (surgery that was more complicated than foreseen and which therefore went on much longer than planned) so I was two hours late going into theatre. Russell came out personally to apologize and explain to me shortly after I arrived, however, so I kept my cool about that. Being treated with courtesy makes a big difference to my responses.

And in theatre I was given only locals at my request so I was awake and alert there. And I had the odd chat and joke with Russell and the nurses while my lesions were being attended to. It was very civilized.

So Brisbane private medicine is a dream as far as treatment of patients is concerned. I guess not all patients are on first-name terms with their surgeon but it can happen for repeat customers like me.

But there is a but. It costs a lot. Not nearly as much as in America but a lot by Australian standards. Russell charges $140 for a consultation versus $40 for a GP consultation and he charged a $850 co-payment for the laser work. The hospital charges were all covered by my insurance.

So if you get an education, work hard and save your money instead of spending it all on beer and cigarettes, you can get the first-class medical service in your declining years that everyone aspires to. I did and I do.

As I sat down to write this little memoir, I was listening to "Goodbye" (from "The White Horse Inn"). Most pleasant. You can see a small picture of the white horse referred to here




Australia: NSW public hospital agonies continuing

Yet another general manager of the Royal North Shore Hospital has left, increasing pressure on the beleaguered Health Minister, Reba Meagher, who tomorrow travels to Bathurst to face the latest debacle in the state's public hospitals. Mary Bonner, who was appointed two years ago, is the eighth general manager in 11 years to walk out of Royal North Shore, the hospital that has become the symbol of all that is wrong with the state's public health system. It is not clear why Ms Bonner has left but her departure follows the recent resignations of two other health chiefs in the Northern Sydney Central Coast Area Health Service: the project manager for Royal North Shore redevelopment, Andrew Bott, and the general manager of Central Coast Health, Ken Cahill.

Ms Bonner had vowed to do all she could to help turn the hospital around but the Herald understands budget constraints and pressure to meet performance targets despite several years of under-resourcing made her task insurmountable. It is also understood that she felt recommendations from the recent parliamentary inquiry into Royal North Shore were so vague they would not rectify problems, and more funding was needed for real change. Several clinicians told the inquiry of their criticisms of the hospital's redevelopment, including a lack of beds and poor cancer and pathology services.

The latest resignation came as Ms Meagher yesterday dodged questions on how the Department of Health or the builders or project managers of the new $98 million Bathurst Base Hospital got the redevelopment so wrong that it failed to meet national patient safety guidelines. The Department of Health also remained silent on how the Bathurst plans were approved when some areas in such acute services as intensive care and emergency were too small to function adequately. The building company, the John Holland Group, and the project manager, Capital Insight, also refused to comment.

"It's a bloody scandal," a Bathurst doctor, who did not want to be named, said yesterday. "Somebody somewhere has to put their hand up and say they caused this mess ... heads are going to roll." The Herald visited Bathurst Hospital yesterday, where all but the most urgent surgery has been suspended indefinitely due to problems with communications.

One doctor, who did not want to be named, said he was concerned for a patient due to undergo breast cancer surgery tomorrow, and was searching for another hospital. He said patients had been sent to Nepean, Mudgee, Lithgow and Orange hospitals for surgery. "There was no surgery here over the weekend apart from two emergency obstetrics patients - one was an emergency caesar and the other was a miscarriage," he said.

The doctor said he had been told that it could take months before the problems were fixed. The paging system had broken down several times a day, the alarm system and backup were inadequate and the situation was so desperate that inquiries were made about whether the fire alarm system could be connected to the switchboard as a public address system. There is also no mobile phone coverage. Telstra maintained yesterday it had always told the Department of Health that it could not complete the required infrastructure until at least the end of March.

The department has denied rumours that the John Holland Group was given $2.8 million in bonuses for finishing the job early. The department said the project was incomplete because the old hospital had to be demolished and the finishing touches put on the new one. It said no bonuses were paid.

One department, ambulatory care, has been left out altogether from the new hospital, and the Bathurst Medical Staff Council is asking for it to move into the mental health unit. Staff are refusing to occupy that section because they say it is unsafe for patients because there are sheer drops and potential hanging points.

Ms Meagher was due to turn the first sod for the Orange hospital redevelopment tomorrow. Yesterday the Greater Western Area Health Service said it would delay construction after doctors there complained that plans are also flawed. "I won't be turning the sod and I have required the Infrastructure Board to undertake a complete audit of the Orange plans to ensure we are not going to have a repeat of the Bathurst incident," Ms Meagher said.

The Opposition Leader, Barry O'Farrell, said the Health Infrastructure Board, set up last year to oversee big projects, "was just another short-term fix designed to distract from the Iemma Government's ongoing incompetence in delivering health facilities". "Reba Meagher can't even tell the public who is responsible for this latest infrastructure disaster," Mr O'Farrell said. "The public can have no confidence Reba Meagher will not repeat the mistakes at Bathurst at similar hospital upgrades at Orange or Royal North Shore."

Brendan Smith, the co-director of intensive care at Bathurst, said doctors had told the John Holland Group that there was no mobile reception as early as September last year. "In this day and age every doctor and his dog has a mobile phone and that's the standard way we communicate ... none of the areas where we have to run to fairly regularly have mobile reception. We pointed that out at the time."

Dr Smith said there had been "very, very limited consultation". "We were never allowed to see the plans; we were never allowed to have copies of the plans," he said. "With the operating theatres, two of the four were meant to be 50 square metres and that's a national standard ... there's 39 square metres. How the hell did they lose 11 square metres?" A spokeswoman for the Greater Western Area Health Service said it was discussing problems with Telstra. The Bathurst Medical Staff Council said the area health service appeared committed to fixing the problems.

Source





21 February, 2008

Over Regulating Health Insurance & The Law of Unintended Consequences

California's Regulators Abolished Legal Underwriting, So Insurers Outsource it to Doctors

I have written quite a few times about California's regulatory adventurism that has made it impossible for health insurers to assess and price health risks in the market for individual health insurance, despite the fact that it is legal to do so. (Although, the recently defeated California Health Care Deforminator, Model ABX1 1 would have outlawed risk-rating, thereby driving premiums up for everybody.)

California regulators recently forbad health plans from rescinding policies wherein applicants have misrepresented their health status or history, unless the plan can prove that an applicant willfully misrepresented himself. Say, for example, you suffered a head injury two months before applying, but did not disclose that on the application, and fooled the health insurer into selling you a policy with premiums set for a person in better health. When the truth comes out, you can just say that you did not realize it was important, or that you forgot about it, and the health plan is stuck with the policy in force. Obviously, this increases everybody's premiums, because health insurers become "gun shy" when they cannot carry out their legal right to underwrite individual health policies.

Because California is a pretty competitive market, one insurer that presumably did not want to jack up premiums has undertaken a different approach, according to an article in the Los Angeles Times. Blue Cross of California has sent a letter to doctors asking them to report any suspected pre-existing conditions to Blue Cross of California when they see a patient covered by an individual policy.

Doctors are appalled that the 3rd party-payer is asking them to "spy" on applicants. I don't blame them. But I find it hard to blame Blue Cross of California, either. After all, California's regulators have eliminated any other way for them to faithfully estimate and price the health risks of individually-written health insurance, despite the law's permitting it.

Many politicians would (mistakenly) abolish risk-writing in individual health insurance, but they have not achieved that yet. Until they do, regulators must allow California's health insurers to underwrite under the protection of current law, not force them to do it through the back door, and jeopardizing the doctor-patient relationship.

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New Zealand public hospital mistakes kill 40

For perspective, there's around 4 million people in New Zealand

Mistakes in New Zealand hospitals led to the deaths of 40 patients and left another 142 people seriously ill or injured in the 12 months through June 2007, according to an official report released today. The mistakes included significant overdoses of medicine, surgeons operating on the wrong part of the body or leaving instruments inside after surgery, patients falling and dangerous reactions to blood transfusions, the Health Ministry report said.

It was the first time such figures had been released, and Health Minister David Cunliffe said transparency was the best way for the health sector to improve. The report said that an average of 2.2 of every 10,000 patients treated in New Zealand hospitals were involved in a serious or fatal medical mishap. Cunliffe said that New Zealand hospitals, which admit 834,000 patients a year, were among the safest in the world and compared favourably to those in Australia and the United States, but could do a lot better.

New Zealand Health and Disability Commissioner Ron Paterson told Parliament this month that complaints to him had increased by 20 per cent in the last two years, and he dubbed New Zealand hospitals unsafe. He said that the main problem was an "unduly complicated" health system for a nation of 4.2 million people and lack of collaboration between the 21 district health boards, which had different standards and operations.

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20 February, 2008

Massachusetts Health Reform: Rewriting History

On January 31, Shikha Dahlia of the Reason Foundation wrote an op-ed in the Wall Street Journal, "Saying No to Coercive Care". It was great to see someone from Reason Foundation have a swing at the pinata: after all, it was back in November 2004 that Ronald Bailey wrote a feature in Reason Magazine demanding "Mandatory Health Insurance Now!" Anyway, Ms. Dahlia points out that, with costs now anticipated at $400 million, the "reform" is costing 85% more than originally budgeted.

That did not sit well with Jon Kingsdale, the reform's czar (officially, Executive Director of the Commonwealth Health Insurance Connector Authority), who responded in today's WSJ that "the original estimate by the conference committee that wrote the legislation in 2006 pegged it at $725 million" (letter to the editor: "Bay State Insurance is Doing Fine, Thanks"). To be blunt: What is he talking about?

Everyone who has followed the travails of the Massachusetts reform knows that the originally budgeted cost was $125 million from the general fund. Indeed, it's on p. 17 of the health care reform conference committee's report to the House joint caucus, of April 3, 2006, which is at the state's website here - or at least it will be until someone in the Connector bureaucracy reads this blog and makes the report disappear!

The wheels are coming off the Massachusetts health reform - and rewriting its history will not change that.

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Australia: Health watchdogs only interested in paperwork

OFFICIALS did not hear the cries of a dying man during a federal investigation into a fatal disease outbreak at a Melbourne nursing home last year because they never left the facility's office, preferring to check paperwork rather than patients.

Minister for Ageing Justine Elliot yesterday accused the former government of sitting on a report by the Aged Care Commissioner into the Broughton Hall nursing home outbreak for nine months. A summary of the report by Aged Care Commissioner Rhonda Parker, filed in May last year and tabled in parliament yesterday, revealed that departmental staff sent to investigate a gastroenteritis outbreak, which eventually killed five people, checked only the nursing home's paperwork and not its residents.

One nursing home resident, Merson Dunstan, who later died, had cried out for help during a departmental visit to Broughton Hall in April last year. But Ms Parker found his calls were not heard because the staff never left the nursing home's office. The departmental staff cited the need to respect infection control protocols for the failure to check on the physical state of residents.

Ms Elliot promised a strengthening of departmental guidelines in order to prevent a repeat of the mistake. "While it does not bring the matter to a close, I hope it is a step forward for the Dunstan family," she said. "It must have been a frustrating and indeed sad nine months for the Dunstan family, and our thoughts are with them as they face the coroner's investigation."

An Aged Care Standards and Accreditation Agency audit on Broughton Hall following the deaths said staff had not known what to do in the event of an outbreak, which delayed reporting and identification of the disease. It found other problems with staff training and in clinical-care management and evacuation procedures at the home.

Then ageing minister Christopher Pyne released the audit results last year, a month before he received the Aged Care Commissioner's report. He said at the time that the audit showed direct links between the breaches and the five deaths at Broughton Hall. Yesterday, Mr Pyne told parliament he had been grievously misrepresented by the new minister's claim that he had done nothing with Ms Parker's report, saying it had fed into later investigations. "Those parts of the report that were germane to the Department of Health and Ageing, which I was a part of, I asked to be implemented," he said.

Ms Elliot hand-delivered a copy of the Aged Care Commissioner's summary report to the Dunstan family earlier this month, but she said the full report could not be released publicly because of Privacy Act considerations. The Dunstan family said through Ms Elliot's office that they were declining comment on the matter. Ms Elliot said guidelines for nurses investigating clinical care in nursing homes were being revised with the help of state, territory and local health authorities. They would provide more specific pointers on how to identify potential problems, she said.

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19 February, 2008

1 in 10 patients gets drug errors in Mass. community hospitals

(Community hospitals are usually charitable institutions)

One in every 10 patients admitted to six Massachusetts community hospitals suffered serious and avoidable medication mistakes, according to a report being released today by two nonprofit groups that are urging all hospitals in the state to install a computerized prescription ordering system. The report is the first large-scale study of preventable prescription errors in community hospitals, and its author, Dr. David Bates of Brigham and Women's Hospital in Boston, said he was surprised that these mistakes were so frequent in these community hospitals. Previous studies in large academic hospitals that also lacked computerized systems found such medication errors occurred less than half as often, he said.

Researchers declined to release the names of the six Massachusetts hospitals, which participated in the $5 million study voluntarily on condition that they would remain unnamed. Of 73 hospitals in the state, only 10, almost all of them large teaching hospitals in Boston, have adopted the computerized physician order entry system, which requires doctors to type into a central database every medical order, including prescriptions, diagnostic tests, and blood work. The doctors' orders are matched against the patient's medical history, triggering red flags to prevent problems related to drug allergies, overdoses, and dangerous interactions with other drugs. Bates said that after this system was put in place at Brigham and Women's Hospital in 1995, preventable medication errors declined by 55 percent over the next two years.

The researchers could not explain the higher rate of preventable errors in the community hospitals but cautioned against patients assuming that these hospitals overall are less safe than academic teaching hospitals. They said this is one of only a small number of studies nationwide that have analyzed prescription error rates at hospitals, and comparisons are difficult because each study varied slightly in its scope and definitions.

Donald Thieme, head of the Massachusetts Council of Community Hospitals, said studies show that many community hospitals offer the same, if not better, care for patients with some serious illnesses. He said community hospitals struggle to adopt the computerized prescription systems because of cost, but they are committed to improvements because they want "errors down to zero." Thieme said he could not comment on the specifics of today's study because he had not seen it.

Community hospitals in Massachusetts may not have a choice but to implement such computerized systems, based on increasing pressure from insurers who see the systems enhancing patient safety and saving money. Gerald Greeley, director of information services at Winchester Hospital, said Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care, over the last year, have demanded the gradual introduction of the computerized physician order entry system as a condition of reimbursement contracts with Winchester Hospital.....

The researchers reviewed a total of 4,200 randomly selected patient medical charts at the six community hospitals, covering stays from January 2005 to August 2006. An average of 10.4 percent of patients suffered a preventable "adverse drug event" - defined as a case in which the patient was given a drug even though the medical records noted that the medication could trigger a drug allergy or that the dose given would exacerbate a medical condition. Medication errors were counted only when patients suffered serious reactions, including going into shock or suffering kidney failure. In nearly every instance, the patients remained in the hospital longer to recover from the mistake. Nobody died from any of the mistakes, researchers said.

Everett said the study's findings can be "generalized to all hospitals" without such computerized systems, and indicate that prescription errors are often made in the rushed hospital atmosphere. She recommended that patients inquire about a hospital's patient-safety systems, and ask medical staff to double-check dosages and names of all medications given. "I'd demand it," she said.

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Australia: Another disastrous public hospital

New hospital worse than the old one

THE new $98 million Bathurst hospital is so dysfunctional it is dangerous, doctors say, forcing the Health Department to halt demolition of the old one and raising serious concerns about the future of all hospital redevelopments. Surgeons have indefinitely suspended routine elective surgery at the new Bathurst Base Hospital, warning that serious design and construction flaws - such as an inadequate emergency alarm system and a pipe that leaked raw sewage into the maternity ward - are putting patients at risk.

It is the latest in countless public hospital blunders that have forced the Health Minister, Reba Meagher, to call a Special Commission of Inquiry into acute care services in NSW, which began last week. "The minister has sought urgent advice from the area health service about the issues from the redevelopment. This number of issues with a brand new hospital is unacceptable and we are getting to the bottom of that," a spokeswoman for Ms Meagher said yesterday. She said medical staff had been extensively consulted during the planning stage. But the Opposition and doctors say the debacle raises wider concern about the consultation process on all of the state's hospital redevelopments, including the $702 million Royal North Shore facility.

Significant problems with the new Bathurst hospital include possible hanging points and access to sheer drops outside the mental health unit - which has remained empty - and major communication failures with pagers and mobile phones. Medical Staff Council chairman Chris Halloway said areas in intensive care, operating theatres and accident and emergency were also too small. Dr Halloway said the hospital, which opened three weeks ago, was unsafe. "It's mainly accident and emergency and the surgical features that are the problem. The reason that we had to cut off elective surgery is simply . so we could cope with the dysfunction," he said. "We can't deliver a proper standard of patient care . the community in Bathurst don't have the health care facility that they had a couple of months ago."

The inadequate alarm system was "a pivotal safety issue" but also only half of the intensive care beds could be seen from the nurses station due to poor design, he said. "[It] seems to us to be clinically crazy."

Dozens of patients have had their surgery postponed. One Bathurst hospital doctor, who did not want to be named, said developers had decided to "shrink-fit the facility". "They didn't consult us and what consultation there was they didn't pay attention to," he said.

A spokeswoman for the Greater Western Area Health Service did not dispute the safety concerns. A team of technical experts had been at the hospital all weekend attempting to rectify the problems, she said. A fire and safety audit had been ordered as well as an audit on room sizes. "This is a really serious issue for us and we're working extremely hard to try and assess the issues," she said. She said area health service agreed to doctors' demands not to demolish the old hospital yet. "It was down to start tomorrow. It has been deferred until Wednesday," she said.

"It's just another case of the Iemma Government and Reba Meagher failing to listen to frontline health workers," the Opposition Leader, Barry O'Farrell, said. The GWAHS spokeswoman said clinicians were engaged in "extensive consultation".

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18 February, 2008

NHS patient starved to death

A hospital trust will have to pay damages after a patient who had undergone a successful operation for cancer was then inadvertently starved and poisoned to death. Roy Hodgson, 66, a retired pub landlord, underwent a surgical operation to remove a tumour in his throat at the Cumberland Infirmary, in Carlisle, and was given a good chance of making a full recovery. But he suffered weeks of starvation after a nurse failed to insert a feeding tube correctly into his stomach, and senior medical staff failed to spot the mistake.

Mr Hodgson, a father of three grown-up children who ran the Three Tuns pub in Cleator, West Cumbria, for 20 years, suffered such hunger pangs that he attempted to flee the hospital and was discovered near its entrance clutching his stomach.

It emerged at his inquest that several days after his operation on October 16, 2004, the feeding tube came out and the nurse put it back in the wrong place. A radiologist who examined a scan of the area did not spot the error. When nurses fed him through the tube with liquid nourishment, they were effectively poisoning him. He died two weeks later after developing peritonitis.

At the time Karen Hodgson, his daughter, described how her father kept asking for something to eat and drink, and showing them how swollen his stomach was. He would have to write notes to explain his hunger. She said: "A couple of days before he went back into intensive care, the nurses found him in the hospital foyer with his coat on, crouched by the wall and holding his stomach."

The National Health Service Litigation Authority, which handles major claims against NHS hospitals, has written to the family's lawyer confirming that the trust accepts medical negligence. There is yet to be an assessment of the level of damages. Markus Nickson, the family's solicitor, said that the hospital had admitted that staff failed to give Mr Hodgson the care he needed and that he died as a result. He said: "What Mr Hodgson and his family have gone through was appalling."

The hospital, part of the North Cumbria Acute Hospitals NHS Trust, has insisted that it has learnt the lessons of Mr Hodgson's death. The hospital has changed its protocols and any reinsertion of a feeding tube is now only carried out by specialist staff.

Mark Hodgson, 28, the dead man's son, said that the family had not pursued legal action for the money but said that they did not want a similar thing happening to anyone else. He said: "We have been told that they have changed the procedure nationwide. That is the best thing we could have got from this."

Mr Hodgson, an electrical engineer, described his father as a happy, outgoing and caring man who had every hope of a recovery. "What happened was an absolute disgrace," he said. "We wanted justice. We had no idea that he was not being fed properly."

The family's grief was compounded at the time by having to leave the pub that was also their home. They said that the brewery had asked them to leave if they could not open the pub for business. The family, which was running the pub, were forced to raise money through a garage sale of their possessions. Mr Nickson said: "Not only did they lose a loved father because of a ghastly mistake, they were told by the brewery which owned the pub that they would have to get out within a week."

At the inquest last November, John Taylor, the Coroner for West Cumbria, concluded that Mr Hodgson had died as a result of an accident. The coroner was assured by medical staff that procedures at the hospital had been changed in the light of the patient's death. Feeding tubes are no longer put in after surgery, but between diagnosis and the start of any treatment. Nurses would no longer reinsert feeding tubes so soon after an operation when the hole in a patient's stomach was not properly established.

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Massachusetts pain

Pretty much as predicted by skeptics

To hold down state costs, officials are considering raising premiums as much as 14 percent and doubling some copayments for the subsidized insurance program that is at the heart of healthcare reform. State officials said they want to ensure that the program, called Commonwealth Care, does not collapse under the weight of soaring costs or under a potential influx of residents whose employers drop coverage because the program offers a better deal for their workers. "If we're not only trying to insure the uninsured, but insure the previously insured, that's going to blow the doors off," said Leslie Kirwan, the state's top budget officer and chairwoman of the Commonwealth Health Insurance Connector Authority board that oversees Commonwealth Care.

But advocates and some members of the authority board that reviewed the proposed increases yesterday said the hikes would price people out of the program. In addition, advocates called them unfair when compared with the 5 percent premium increase the state expects for unsubsidized insurance plans. "We think it undermines the very principle on which the reform stands, to provide access to quality, affordable healthcare and to protect the poor and the most vulnerable," said the Rev. Hurmon Hamilton, president of the Greater Boston Interfaith Organization, a group of congregations that advocates for healthcare access.

The proposed increases might be modified or avoided if insurers lower their prices for covering enrollees in the next fiscal year or if the state finds other sources of revenue. The state is currently negotiating with insurers who are seeking far more than the state wants to pay. Neither side would disclose the size of the gulf.

As proposed, the increases would affect about half of the 170,000 low-income people now enrolled in Commonwealth Care. The premium increases would apply to those whose income is above 150 percent of the federal poverty level and the copayment increases to those above 100 percent of the poverty level. State residents are eligible for the program if their income is at or below 300 percent of the poverty level and they do not have access to work-based insurance. Under the proposal, the lowest premium would rise from $35 to $40 a month, a 14 percent increase.

Jon Kingsdale, executive director of the connector, defended the proposed Commonwealth Care premium increases of $5, $10, or $15 a month as fair, adjusted for income, and far lower than most premium increases in private insurance. Kingsdale said that the subsidized program and the private insurance plans are completely different and that comparing the increases was like comparing apples and oranges.

Connector staff members, who proposed the increases, said they could help prevent the state plan from becoming so attractive that employers drop coverage for their workers and send them to Commonwealth Care. The state is already predicting that enrollment and costs for Commonwealth Care could double over the next three years. "If we're going to preserve political support and keep it economically viable, we've got to maintain some comparability between the benefits and contributions in Commonwealth Care and in the private market," Kingsdale said.

Several connector board members opposed the increases, while others said they seemed reasonable and might be necessary to sustain the program. The board is expected to vote in two weeks on whether to impose any increases, after it reviews insurers' bids. "It's too extreme," said Celia Wcislo, a board member and assistant division director of Local 1199 of the SEIU. She said the state should look to insurers and hospitals instead to foot more of the cost.

In addition to the premium increases, copayments for office visits and prescription drugs could rise by $5 or $10, and some enrollees could see an increase in the total amount of out-of-pocket costs they must cover.

A Brockton mother of five children said those increases could make the plan unaffordable for her family. Mona Divers pays $37 a month in premiums for herself; the rest of her family has other insurance. With a heart condition, high blood pressure, high cholesterol, and a thyroid problem, she needs regular care and racks up copayments for office visits and prescriptions. Her husband's income of about $23,000 doesn't go very far, she said. The family is also paying off about $4,000 in medical bills run up before she enrolled in the state plan. "Back in September, when I signed up, I thought, 'Thank God I have Commonwealth Care to help me,' " she said. If the cost increases, she added, "I don't know if I'm going to be able to keep it up."

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17 February, 2008

NY's Cuomo: How To Drive Up The Cost Of Insurance

New York's Attorney General Andrew Cuomo, aspiring to the governorship once held by his father, finds a handy populist target, health insurers. Cuomo, borrowing from an earlier New York City district federal court suit and one in New Jersey, charges that insurers underpay out-of-network claims by lowballing the reasonable-and-customary charges of doctors against which health plan members' coinsurance (% payable by insured) is applied. The database, Ingenix, is owned by United Healthcare but shares the data of all major insurers in order to arrive at reasonable-and-customary charges for medical procedures. The first problem is that Cuomo appears to exaggerate:

Mr. Cuomo said his office had compared the prevailing market rate for a routine doctor's visit with the amount Ingenix had calculated as reasonable and customary. While doctors in the metropolitan New York City area typically charged $200 for an office visit, he said, Ingenix calculated the rate at only $77. Under a typical plan, the insurer would pay 8o percent of the $77, or only $62. The patient would be responsible for covering the remaining $138 balance.

UnitedHealth disputes the numbers Mr. Cuomo provided, saying Ingenix calculates the range of prices for those office visits as $125 to $300. The company said it did not know how Mr. Cuomo's office came up with its figures. Members of Mr. Cuomo's staff declined to describe the method.

The second problem is that Cuomo refuses to be transparent, while accusing insurers of not being transparent:

"There is no disclosure; there's no transparency; there's no accountability," said Mr. Cuomo, saying his office began investigating the matter after receiving complaints from consumers.

The third problem is that Cuomo charges as illicit the common statistical method of discarding extreme outliers in calculating reliable averages:

The company rejects charges that seem far from the norm and subjects the information to a "strong validation process," according to a UnitedHealth spokesman, Don Nathan. The information gives insurers "a snapshot of current charges in a geographic area" that they can use to determine what is a reasonable and customary fee for a service, he said.

The fourth problem is that Cuomo disregards the cost impact of his charges. If extreme charges are included in calculating reasonable-and-customary, then the costs of insurance must rise.

Acknowledging what he called the headline risk, Doug Simpson, a Merrill Lynch analyst, predicted in a research report Wednesday that consumers would end up paying more, no matter the end result of the investigation. "We believe to the extent that regulators wish to raise provider payments for out-of-network care," Mr. Simpson wrote, "there will be a corresponding increase in the cost of coverage."

In that vein, to keep premiums down, insurers can increase the percentage of out-of-network charges the insured is responsible for, and can apply that percentage against the discounted charges paid network doctors, resulting in both cases in higher out-of-pocket costs to care users. The fifth problem is that Cuomo, coming from the pro-government-run healthcare camp, wouldn't mind that at all. Cuomo asks:

Individuals generally pay higher premiums for the privilege of being able to select doctors or hospitals outside the network, Mr. Cuomo said. "You could have paid less and be limited to the in-network doctors," he said.

For in-network doctors, substitute lower-paid government-run healthcare doctors. Also, expect the long waits and rationed treatments that accompany. New York State's health insurance premiums are already near $500 more a month higher than the average state for family coverage, reflecting primarily New York's relatively expansive coverage laws and mandates.

For decades, sane people and states elsewhere in the country have marveled at New York's excesses, and sought to avoid them. The result is a highly taxed, stagnant, aging population in New York and its one-legged economy's reliance on Wall Street's booms-and-busts (including bust the economy). Tort lawyers seeking class-action payoffs, and ambitious attorney generals elsewhere seeking populist platforms for their ambitions may follow Cuomo's lead, but the rest of us will suffer.

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Major Australian regional hospital could not handle miscarriage

This hospital serves an area approximately the size of England

Bree Steele's shocking experience at Cairns Base Hospital is another tragic example of why the Far North is long overdue for a new, better-equipped hospital. Mrs Steele went to the Cairns Base Hospital emergency department the week before Christmas, with symptoms of an undiagnosed miscarriage. She was 13 weeks pregnant but was later told by her doctor that the fetus had died at eight weeks.

The mother of Adelaide, 1, said she was forced to wait six hours at the hospital and was eventually told to go home. She then spent another two days trying to get medical help through the hospital. Later she was told the hospital could not provide the treatment she required to remove the fetus, she told The Cairns Post. Eventually, on the advice of a midwife at the hospital, she went to Townsville for the surgery, which took only 15 minutes a day later.

"I didn't realise there was a problem with the hospital until I had to use it," Mrs Steele, 22, said. "It was traumatic event that was made worse. "I was in a totally desperate situation and no one could help me."

Queensland Health last night confirmed Mrs Steele had experienced a long wait, and had been told she would have to wait until the following week for an appointment to have the miscarried fetus removed. "Queensland Health deeply sympathises with Ms Steele's loss, and recognises what a deeply distressing experience this would have been for her," a Queensland Health spokesman said. "Queensland Health regrets that her experience with the health system was not to her satisfaction.

"While we appreciate how difficult it would have been for Ms Steele, the emergency department at Cairns Base Hospital was extremely busy that night, seeing 135 patients, which is more than the average daily attendance of 110 patients."

Mrs Steele said staff at the Cairns Base Hospital had their hands tied by a lack of facilities and resources. "I really hope this campaign comes to something because there would be other women out there like me," she said. "The hospital needs the services to cope with special needs." "They can't just rebuild the same hospital at a different location because we need more than that."

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Government drug manufacturers at work: "At least 115 Panamanians died after drinking toxic cough syrup in 2006, investigators said on Thursday, as the slow probe into the health disaster turned up more cases. Jose Oro, a spokesman for the Ministry of Public Affairs, said recent clinical tests had shown at least 115 people died after taking cough syrup that was adulterated with diethylene glycol, a poisonous substance normally used in engine coolant. The Chinese-made toxin was mistaken for a sweetener by government drug manufacturers, who made low-cost medicines for Panama's poorest people. Investigators previously estimated the drug had killed 94 people, mainly from kidney failure or related ailments. Investigations are only slowly turning up new cases because of the number of people involved. Only around 20 percent of the 763 people tested to date have actually shown traces of the deadly drug, according to a government study."





16 February, 2008

Mouldy NHS hospital kills a baby

A hospital has closed its neonatal unit to new admissions after a baby died from a rare fungal infection and another was found to be suffering from it. A premature baby, described as having been very sick, died at Salford Royal Hospital in late December. It was discovered that the child had aspergillus, a common airborne fungal infection, which can attack the very young. The infection was also found on the skin of a second baby, who is now being treated. As a precautionary measure, the hospital has stopped admitting preterm babies while the cases are investigated.

Michael Robinson, the senior consultant neonatologist, said: “Preterm babies are more susceptible to developing infections because of their immaturity and we continue to do all that we can to reduce these. “When a second infection occurred within two months of the first, we took further advice and are embarking upon a range of investigations and precautionary measures to ascertain whether there are any common contributory factors. “As a temporary measure, we have closed the unit to admissions of preterm babies and are currently monitoring the situation closely.”

The disease is a common airborne fungus that is found in homes and buildings and favours damp or flood-damaged properties. It is usually harmless but can develop in people with asthma or weakened immune systems such as leukaemia patients or those undergoing chemotherapy.

The hospital remains open to women giving birth. There were 17 babies on the neonatal unit and they are still being cared for by specialist staff. The hospital is a regional centre for premature babies and has received the highest rating of the Healthcare Commission.

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Australia: A totally mismanaged public hospital

A QUEENSLAND hospital forced to close its cardio-thoracic unit due to staff infighting refused surgery to an Aboriginal man due to his race, it has been alleged. Surgical services at Townsville Hospital ceased last November, after doctors claimed patient lives were at risk because of feuding between staff. The state's Crime and Misconduct Commission (CMC) has been called in to investigate the infighting, as well as claims hospital management failed to properly intervene.

Opposition Aboriginal and Torres Strait Islander partnerships spokesman Rob Messenger said he had heard serious allegations from hospital whistleblowers. They allege that an Aboriginal man was refused surgery because of his race, and a surgeon whose patient death rate was three times the national average was allowed to operate, while whistleblower doctors were not.

One whistleblower tried to meet with Health Minister Stephen Robertson 10 months before the unit's closure, but was refused, Mr Messenger said. He said an independent inquiry was needed to shield whistleblowers from "vindictive bureaucrats". "I've asked the CMC to support my call for an independent public inquiry ... in order to find out the truth, and to protect and engender confidence in whistleblowers and witnesses," Mr Messenger said.

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15 February, 2008

NHS pays back millions in overcharges

The NHS is being forced to pay out at least 180 million pounds to people wrongly charged for nursing care. Patients charged for long-term nursing and social care from 1996 to 2004 have been able to have their cases reviewed. More than 12,000 cases have been examined, resulting in around 2,000 payouts at a total cost of 180m to date.

It comes after NHS chiefs were told to fund care packages where the main area of need was health-related rather than just personal care, such as aid with bathing or dressing. But the rules were interpreted differently across England, meaning some people ended up paying more than they should.

In 2003, a report by the Health Service Ombudsman said the Government's guidance on the eligibility of patients for NHS-funded care places had been "misinterpreted and misapplied" by some health authorities. The result was that some elderly and disabled patients suffered "hardship and injustice" by wrongly being asked to pay for their care needs.

Earlier, in 1999, Pam Coughlan won a test case against the closure of her NHS care home in Exeter. The judgment made clear that if the needs of the patient were primarily health needs, the health authority was responsible. Applications had to be submitted to primary care trusts by November last year for the payouts, which can take distress into account.

A Department of Health spokesman said: "The NHS has paid restitution to the affected individuals or their families, totalling œ180m to date. It is not possible to estimate the level of restitution that will be paid following the review of the remaining cases."

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Unjust Deserters

Trial lawyer Andy Birchfield is suing for peace. He is co-lead counsel of the Plaintiffs' Steering Committee for the federal Vioxx litigation, a select group of trial lawyers who have negotiated a "Settlement Agreement" with pharmaceutical giant Merck, Inc. The agreement is meant to end between 50,000 and 60,000 lawsuits alleging that Vioxx--Merck's bestselling pain reliever for arthritis sufferers--caused unwitting users to suffer heart attacks and strokes. Though it may be a good deal for Birchfield and for Merck, it's not good for every Vioxx plaintiff. Like many "mass torts"--lawsuits alleging that a single defendant harmed many people in a similar way--the Vioxx litigation includes a small core of relatively strong cases and a huge infestation of nuisance suits filed by plaintiffs hoping to cash in on an eventual settlement. If the Settlement Agreement works as intended, it will pay off the nuisance plaintiffs--and their lawyers--by pressing plaintiffs with stronger suits to settle for much less than their claims may be worth.

Even the relatively strong Vioxx cases are no walk in the park for plaintiffs' lawyers. The trickiest part is proving that the drug actually caused a stroke or heart attack; arthritis sufferers are generally not young, and while evidence suggests that prolonged use of Vioxx can double the risk of heart attack, everyone agrees that many of the heart attacks in cases now pending in state and federal trial courts would have occurred anyway. Indeed, Merck has won 10 of the 14 Vioxx trials that have reached final judgment so far, according to the website On Point. In the other four cases, however, the plaintiffs were awarded an average of $24 million each--meaning an average payout for all 14 cases of almost $7 million, sufficient reason for Merck to come to the negotiating table, where the Settlement Agreement was born.

The Settlement Agreement is not, as its name suggests, an agreement between Merck and the plaintiffs to settle their suits. Rather, it is an agreement between Merck and many of the plaintiffs' lawyers: Merck agrees to offer take-it-or-leave-it settlements to the lawyers' Vioxx clients only if the lawyers agree to advise all their clients to accept Merck's offer and to drop any clients who don't take that advice. Moreover, the lawyers must forfeit any payment from plaintiffs who choose to walk--a provision designed to prevent participating lawyers from, in effect, selling highly valuable clients to lawyers operating outside the settlement (in such cases, the old and new lawyers ordinarily split the eventual fee). These terms are intended to prevent trial lawyers from trying the strongest cases while settling the hundreds or thousands of nuisance claims.

But lawyers are ethically bound to offer candid, independent advice to each client about whether or not to settle. So Vioxx lawyers, most of whom handle many such cases, shouldn't settle a single case under the Settlement Agreement unless they honestly believe that every Vioxx client ought to accept Merck's offer. Birchfield claims that the agreement really is "in the individual best interest of each and every individual client." But the agreement can't possibly offer each claimant a similar percentage of the expected value of his claim, because it ignores differences in the substantive law of each state. Under the agreement, plaintiffs in West Virginia, which does not limit punitive damages, will find themselves advised to settle so that otherwise similar plaintiffs in Michigan, whose claims are actually barred by law, can recover just as much as they do. Because the agreement is redistributive between these groups, it can't be an equally good deal for everyone.

Is the Settlement Agreement nonetheless so generous that well-situated plaintiffs with strong cases can't reasonably refuse? I entered basic demographic and medical information about the 14 Vioxx users whose cases have already been tried into the online "Vioxx settlement calculator" provided by the Plaintiffs' Steering Committee, which yielded offers ranging from almost nothing to a maximum of $1.3 million, with most offers clustering in the $100,000 to $400,000 range. (Final amounts will depend to some extent on how many claims settle.) These sums don't impress. True, most people would gladly take much less than the $7 million average of the 14 cases already litigated if doing so would settle their cases quickly, eliminate their chance of losing an appeal, and thus avoid the very large risk of getting nothing at all. But some claimants are being offered less than 10 percent of what experience suggests their cases are worth.

The agreement is, however, a good deal for Merck and for the trial lawyers suing it. Merck needs to limit its risk to a sum certain in order to pacify the equities markets, and the $4.85 billion that it commits in this settlement is dwarfed by the estimated $15 billion that it would spend to litigate every Vioxx case. The lawyers, for their part, have never intended to take most of their cases to trial. Anticipating a settlement, they gorged their portfolios with claims so weak that they would cost much more to litigate individually than they would yield in fees. To get a positive return on these nuisance suits, lawyers are now flocking to an agreement that sells out the interests of those clients who actually have viable claims.

Lawyers like Birchfield, whose firm represents about 7,000 Vioxx plaintiffs, have supersized the lawyer-client conflict that is always potentially present when the two parties undertake a contingent-fee agreement. Lawyers are more interested in settlement than their clients because trials cost clients very little additional money--direct costs are fronted by attorneys and customarily are not collected from unsuccessful clients--while they cost lawyers a great deal of time. Though lawyers have an ethical obligation to resist the incentive to settle cases against their clients' interests, lawyers who file money-losing nuisance suits must settle them to remain in business. Mass-tort defendants like Merck are learning how to take advantage of this need by offering to settle the nuisance suits only if the trial lawyers also deliver up their strongest cases at bargain rates. The plaintiffs with strong cases lose out, while the trial lawyers and the dubiously injured benefit.

There are two kinds of cases in every mass tort: the ones that are strong enough to justify the cost of trying them, and the ones that aren't. A loser-pays rule in American civil litigation--requiring the loser of a lawsuit to pay the winner's legal fees--would eliminate lawyers' incentive to clutter dockets with cases of the second kind. This sensible reform would free lawyers and courts to focus attention on the parties most likely to have been seriously harmed, and could head off a burgeoning ethical crisis among mass-tort lawyers who are selling out clients with strong cases in order to settle suits that they should never have filed in the first place.

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14 February, 2008

British senior citizen flies to India for knee op because he 'didn't trust NHS after bungled surgery'

A great-great-grandfather flew a 10,000 mile round trip for knee surgery because he did not trust the NHS after he lost a leg when they bungled a previous operation. Battling Ken Austin, 80, refused to go through the NHS again after a knee replacement on his right leg ended up with him losing the limb completely because the surgeons had mistakenly severed an artery. When faced with a similar operation on his other leg, the pensioner from Halifax, West Yorkshire, decided to spend his savings on flying to India for the procedure instead.

Mr Austin, who has just returned from the trip, said: "It's a sad case that you pay all your taxes and then don't get the service. I realise it was a tricky operation I had, but I did not trust them." He added: "It is strange to think that I have gone to a poor country for an operation."

The former foster carer's knees have been deteriorating due to his age for years and he had his first knee replacement operation on his right leg in 1993. When the pain in his right leg came back last year, he was told he needed another knee. He was told by surgeons at Bradford Royal Infirmary that it could be risky cutting through old scar tissue but decided to go ahead because he considered himself to be in the best hands. But the decision ended up costing him his leg after surgeons blundered and severed an artery.

Mr Austin said: "While I was in theatre, an artery was severed, cutting off the blood supply through my leg and foot, and what should have been an eight-day stay turned into an eight-month nightmare. "The flesh on my right leg began to die and turn black. "When ulcers started appearing all over my leg, maggots were used to try to fix the problem but eventually I was left with little choice but to have the leg removed, which was done in January last year." He added: "I couldn't believe this had happened to me. I was always an active chap, I like to travel, do a spot of gardening and I love to get out in the car for a drive. It really hit me hard. "I knew that the operation may have been a bit tricky, but what was my alternative, a wheelchair, in pain for the rest of my life? There was no way I was going to do that."

Mr Austin had to have a false leg and to walk with a stick after the failed operation. The horrific experience meant that when his left knee started to go seven months later, the pensioner began to look at other options. He said: "I couldn't go through the heartache I had been through before... "I'd heard of people going to India for surgery so I started asking around and found out a friend, who lives in Greece, had been to India for surgery without the wait of the NHS and the cost of going private. "He said he had such a great experience that I decided that is what I would do. I dare not trust the NHS with my last leg, I could not lose everything"

The wait for an operation in India is shorter and it only costs 5,000 pounds, including travel, compared to 9,000 pounds in England. Mr Austin contacted the Bharathi Raja Hospital in Chennai and by the end of the year, was in the operating theatre receiving treatment from Dr AK Venkatachalam, a UK-trained consultant orthopaedic surgeon.

He said: "I'm delighted with the results. I am completely fine now and on my way home did a detour and visited my friend in Greece to show off my new knee. I'm off to Cuba too this year." He now says that if he ever has more problems with his knees, he would not think twice before going back to India instead of using the NHS. "I'm lucky because I can afford it with my savings, others may not be so lucky," he said.

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Swedish minister: healthcare guarantee 'not working'

Health Minister Goran Hagglund has criticized the lack of progress made toward shortening wait times in Sweden's health system. He made the comments in an opinion article published in Dagens Nyheter in which he stated that the 250 million kronor spent by the government on lowering wait times has apparently had a little effect. The criticism comes in response to a report by the National Board of Health and Welfare (Socialstyrelsen) showing that nearly 45 percent of patients have longer wait times than are supposedly guaranteed by the healthcare system. "These figures are not satisfactory. They show that we haven't approached the problem of availability with the level of force needed," said Hagglund to news agency TT.

Since 2005, Sweden's health system has been governed by a "healthcare guarantee" (Vardgarantin) between the national and regional governments. The guarantee states that county councils, which have primary responsibility for healthcare administration, promise to treat patients within 90 days. If treatment cannot be administered by the patient's primary hospital within 90 days, the county is to then help the patient find an alternative location within the county or even recommend the patient to a hospital in another county.

Wait times for service were also found to vary greatly from one county to another. In Jamtland county, for example, four out of ten patients couldn't even get through to their local clinic by telephone on the day they become ill.

Hagglund asserted that people are generally satisfied with the care provided-when the receive it. "But the wait to receive attention-be it a telephone call to a local clinic or a first visit to a physician-is simply too long," he said.

Hagglund concludes that the voluntary guarantee provided by county councils isn't good enough, and suggested that a guarantee mandated by legislation may be required. "County councils do a shabby job of informing patients of the fact that they can travel to another county [for care]," said Hagglund. "I believe that any new legislation will take the question of [care] availability into account." Another measure may be creating a ranking system for county health systems, in hopes that counties would be motivated to not end up last in the rankings.

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13 February, 2008

The nastiness engendered by a socialized medicine system

A 101-year-old Briton may be kicked out of New Zealand after immigration bosses rejected his plea to spend his final years living with his son, his only living relative. Despite savings of 145,000 pounds and a 33,000 a year pension, the widower may have to pack his bags after being told his circumstances "do not make him special." A retired research chemist whose son is a university professor, the man, who has not been named, had pleaded to stay in New Zealand after arriving in 2006.

Details of his case emerged yesterday, just three days before the arrival of 102-year-old Eric King-Turner, from Hampshire, who will be New Zealand's oldest ever immigrant. Mr King-Turner has been allowed to move with his Kiwi-born wife, Doris, 87, and has spent the last weeks sailing from Southampton to his new home.

But although the unnamed man told the country's Residence Review Board that he, like Mr King-Turner, is hale and hearty, officials have been unmoved by his plight fearing he may be a drain on health resources.

The centre of gravity of my immediate family is very clearly in New Zealand," wrote the man in a letter reported in a New Zealand newspaper yesterday. Hard-nosed bureaucrats, however, said if they wanted to stay in touch his son should make the 24,000 mile round trip to visit him in Britain. "Overall the appellant's age, his financial resources, the fact that the appellant has no family in Great Britain, do not make him special," the board said in a written decision. "The board appreciates the submission made that the appellant's son is the only living family member the appellant has, but for many years the appellant has lived in Great Britain, apart from his son and alone. "Presumably his son has visited him in that time and there is no evidence as to why his son could not continue to do this in the future."

The decision has drawn fire from New Zealand's opposition spokesman on immigration, Dr Lockwood Smith. "I don't think we have a very smart policy when it comes to old folk," he said. "To just say no is not good enough. "I know there are concerns that elderly people become a drain on society but where people are of significant means and they have assets and a pension it ought to be possible." More than 10,000 Britons were granted New Zealand residency permits last year, nearly 25 per cent of all immigrants.

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Australia: Queensland's public hospitals fail health tests

QUEENSLAND'S beleaguered public hospitals are putting lives at risk by failing to deliver adequate care across a range of key areas. A new report into the performance of the state's 40 hospitals in 2006-07 has measured their outcomes according to 29 specific "clinical indicators". Across the indicator categories of surgical, medical, gynaecological/obstetric and mental health, the report found 26 instances where the outcomes were substandard.

An analysis of the overall performance of the state's public hospitals, released separately to the report, also identified areas where there were inferior outcomes compared to their private counterparts. Across 15 areas where comparisons were possible, the analysis found outcomes in the public sector were significantly worse than the private. It said there was a much higher stroke in-hospital mortality rate in the public sector while complications from prostate and hysterectomy surgery occurred far more frequently. The only area where private hospitals were significantly worse than public was in the frequency of patients catching pneumonia.

While similar data is not available from most other states, Health Minister Stephen Robertson this week insisted Queensland's hospitals were performing as well, and in some cases better, than those elsewhere in Australia. "However, this report highlights areas where individual hospitals need to do better in a particular category," he said. "In every case, where a hospital recorded an unfavourable result, it was investigated and where necessary a management plan was put into place to improve performance."

The report found nine instances where public hospitals failed one of the 13 surgical indicators, with the Gold Coast Hospital responsible for three of these. There were seven failures across the medical indicators with three hospitals - Redland, Townsville and Ingham - found to have unacceptable rates of in-hospital heart failure. Redland was also one of three hospitals that failed one of the gynaecological/obstetric indicators. Across the mental indicators, five hospitals recorded patients getting depressed during long stays at a rate twice that of the state average.

Coalition health spokesman John-Paul Langbroek said the Government's multi-billion-dollar plan to fix the state's public hospitals was failing. "The Bligh Government's band-aid solutions are not working," he said. "This Government is not treating patients and they are failing to fix Queensland's beleaguered public hospitals."

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12 February, 2008

The Real FDA Scandal

So Members of Congress and the press are working up another panic about the state of the Food and Drug Administration. The place is a mess all right, but as usual the most alarming news is receiving almost no attention. Washington is responding to a series of investigations concluding that the FDA cannot "adequately" monitor America's food supply and medical products. One of the FDA's outside advisory panels, the Science Board, reports that the agency is in "a precarious position," in part because it is chronically underfunded. The Government Accountability Office chimes in that, at the FDA's current pace, it would take 13 years to inspect every foreign drug plant exporting to the U.S. and 1,900 years to inspect every overseas food factory.

That last factoid may be true, or not, but it does raise the question of whether such a crackdown is possible, never mind desirable. Monitoring 100% of foreign imports -- or 10%, or whatever -- would be so onerous that it might as well be a ban. Yet lapses like adulterated Chinese toothpaste are exceedingly rare, mainly because companies have every incentive to police themselves. (Ask Mattel about its toy import nightmare.)

Still, it's generally agreed that the FDA could use more cash, and the White House's 2009 budget requests a 5.7% increase. But what no one reports is that the Science Board says these shortfalls crop up because Congress hasn't increased FDA funding in proportion to its burgeoning regulatory demands. Over the last two decades, Congress has expanded the FDA's reach more than 127 times; it now oversees about 25 cents of every dollar spent in the U.S.

The Science Board's most important, and distressing, finding is that the FDA bureaucracy "cannot even keep up with the advances in science" -- and not solely due to a lack of funding. While "the world of drug discovery and development has undergone revolutionary change," the authors write, the FDA's "evaluation methods have remained largely unchanged over the last half-century." Think about that: We live amid a revolution in biology, but the FDA still thinks like it did when Sputnik launched.

The observation comes on page three, which leads us to suspect that Congress's hand-wringers haven't even read the study. Here's a refresher: "The mission of getting safe and effective drugs to patients in a timely manner is currently threatened by inadequate expertise and capabilities," the Science Board notes. Particularly in complex and specialized fields like genomics and biotechnology medicine, the FDA lacks the basic competence "to understand the impact of product use, to maintain ongoing currency with their evolution or to evaluate the sophisticated products produced" and "to support innovation in the industries and markets that it regulates."

The Science Board authors propose that the FDA "modernize current regulatory pathways," especially the narrowness with which it balances risk and benefit for the most promising new therapies before they are allowed to reach the public.

The FDA uses rigid statistical techniques to evaluate developmental drugs, even when the lives of terminally ill patients are at stake. Many advanced immunotherapies for cancer, for instance, are held hostage to the FDA's old models, which still insist on crude mortality rates and the large average effects detected in clinical trials. Better metrics would include improving the quality of life or slowing the progression of tumors, or focusing on targeted populations. The Science Board says that "there is an urgent need for developing . . . new statistical methods that are most appropriate for the data generated by new areas of science."

Take Junovan, a medicine for a rare pediatric bone cancer. Junovan's successes in a clinical trial were "only" demonstrated with a 94% level of statistical certainty, instead of the FDA-mandated 95%. Avastin, a revolutionary biologic currently used against lung and colorectal cancers, also looks like it will get a thumbs-down as a treatment for metastatic breast cancer. While the evidence shows that patients lived longer before their symptoms got worse, they didn't live longer on average. Refusing to consider "progression-free survival" as a drug benefit is not only unscientific, but morally hideous.

The real scandal is that these policies are the product of the FDA's institutional culture, which puts political incentives and bureaucratic procedure above patient results. Congress and the press could do some good if they investigated that problem, but it's so much easier to say, "spend more money." Perhaps that's why the Science Board ends on a mordant, but all too accurate, note: "Finding: Recommendations of excellent FDA reviews are seldom followed."

Source




NHS reforms 'in full retreat’

Reform of the National Health Service is stalling as Britain continues to fall behind comparable countries in Europe, a report from the influential Reform think-tank concludes. While the Government claims that the overhaul of the NHS continues, it is in denial about what is happening on the ground, according to Professor Nick Bosanquet and his co-authors, Andrew Haldenby and Helen Rainbow.

The reform programmes remain “embryonic, and in some cases in full retreat”, the report says. As a result, the NHS is facing “a perfect storm” created by the combination of an ageing population, expensive new technology and a more informed society. Without successful reform, the report says, the NHS will decline, providing substandard quality and access. An outflow of talented staff would increase the difficulties.

Mr Haldenby, the director of Reform, said: “In his major speech on the NHS in January, the Prime Minister said that reform was all but in place . . . In fact, reform has barely left the starting gate.”

Andrew Lansley, the Shadow Health Secretary, said: “This report highlights Gordon Brown’s mismanagement of our NHS. He has spent a lot but achieved too little.”

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11 February, 2008

Mandate Update

To hear some of the presidential candidates, you'd think that health-insurance companies are the driving force behind the growing cost of health insurance. The more likely culprits are our politicians and the laws they pass. Since the early 1990s, the Council for Affordable Health Insurance (CAHI) has tracked state health-insurance mandate legislation in all 50 states, and our actuarial team estimates the impact of those mandated benefits on the cost of a policy.

A health-insurance "mandate" is a legislative requirement that an insurance company or health plan cover (or offer coverage for) common -- but sometimes not so common -- health- care providers, benefits and patient populations. They include:

- Providers such as chiropractors (mandated in 46 states) and podiatrists (35 states), but also massage therapists (four states) and naturopaths (four states);

- Benefits such as mammograms (50 states) and drug abuse treatment (34 states), but also morbid obesity treatment (four states) and wigs for cancer patients (10 states);

- Populations such as dependent students (30 states), but also grandchildren (four states).

Although there were only a handful of state mandates in the 1960s, CAHI's just released "Health Insurance Mandates in the States, 2008" has identified 1,961 nationwide -- up from 1,901 a year ago.

For almost every health-care product or service, there are at least two groups that want insurance to cover it: those who sell the products and services so they can get more business, and those who use the products and services to lower their out-of-pocket costs. Both of these highly motivated groups push state legislators -- and increasingly members of Congress -- to require insurance to cover the care. As a result, government interference in and control of the health-care system is steadily increasing -- and so is the cost of health insurance.

Mandate proponents often claim that covering a particular medical product or service actually lowers health-care costs, because either the proposed coverage costs less than the standard of care (for example, a chiropractor or podiatrist usually charges less than a medical doctor), or the service will reduce or avoid future medical costs.

To be sure, some health-care services such as vaccines and mammograms can be very cost effective, especially when targeting certain at-risk groups and individuals. And many of the mandates we identify would normally be included in a comprehensive health-insurance policy. But the fact is that mandates almost always raise the cost of health insurance. That's because mandates require insurers to pay for care that consumers previously funded out of their own pockets, if they purchased it at all.

Although most mandates will have a relatively small impact when taken individually, it's the cumulative effect that drives up the cost of coverage. It's like telling people they must have a "Cadillac plan" loaded with options. Cadillacs are nice, but not everyone can afford one. And when people can't afford coverage, they join the ranks of the uninsured. Mandates also limit choices. Why should an older couple nearing retirement pay for maternity coverage, or a teetotaler pay for drug and alcohol abuse counseling?

One of the things you notice when tracking mandates over time is that some mandate legislation catches on. For example, over the past several years we have seen a steady increase in the cervical cancer/human papillomavirus (HPV) vaccine mandate. In the last state legislative session, at least 41 states introduced legislation to mandate coverage for this vaccine, and 24 states introduced legislation to mandate the HPV vaccine as part of the school entrance vaccine list.

Another trend is the "eligibility" mandates. Health insurance typically allows dependents to stay on a policy during their college years. But some states are increasing dependent eligibility up to age 30, regardless of student status. As a result, some commonly refer to this mandate as the "slacker mandate." In addition, we are seeing new eligibility categories emerging, such as "domestic partner," "legal alien," "elderly parent," "grandchild" and "U.S. armed services personnel." All of these are attempts to force insurers to cover people under someone else's existing policy.

Such micromanaging of benefits is unique to health insurance. State legislators aren't nearly as aggressive in controlling life, property and casualty, and even auto insurance. As a result, those insurance markets function better and provide consumers with more choices.

Fortunately, a few states are recognizing that mandates make health insurance more expensive. At least 10 states now permit mandate-lite policies, which allow individuals to purchase a policy with fewer mandates and so are more tailored to their needs and financial situation. And there are now at least 30 states that require a mandate's cost to be assessed before it is implemented.

Mandates aren't the only things driving up the cost of health insurance. States that require insurers to accept any individual who applies, regardless of their health status, are imposing costly burdens on health insurance. And those costs get passed on to consumers -- if they decide to keep their coverage.

Before politicians jump on the anti-health-insurance bandwagon, they should look at the role they are playing in driving up costs. Making health insurance more affordable would be a lot easier if they would stop legislating what it has to cover.

Source




Inquest jury blames NHS hospital for unlawful killing of mother

The "chaotic" storage of drugs at a hospital led to a woman who was in labour being given a powerful epidural anaesthetic in her arm instead of a saline drip. An hour after giving birth to a son, Mayra Cabrera complained of feeling dizzy and soon afterwards she suffered a fatal heart attack. Her husband was in the room as doctors fought in vain to save her life. More than a year after her death, the Great Western Hospital in Swindon, Wiltshire, admitted that there had been a mix-up with bags of intravenous saline solution and Bupivacaine. The painkiller should have been administered direct to her spine.

An inquest jury found the Swindon and Marlborough NHS Trust responsible yesterday for unlawful killing. It is believed to be the first such finding against an NHS trust, rather than a named person. Senior staff at the hospital face a possible prosecution after Wiltshire police said that they would reopen the investigation into her death.

After the verdict Arnel Cabrera, Mrs Cabrera's widower, called for a prosecution against the midwife who made the fatal error. In a statement he said: "Mayra was my love and my life. However, our life together was ripped apart by the action of a midwife who failed to check the fluid she gave to my wife. "The midwife's failure to accept responsibility or show any remorse for her actions has made me very bitter and angry. I cannot forgive her and now hope that the police and Crown Prosecution Service will prosecute her for manslaughter."

The NHS trust apologised unreservedly for the mistake and said that it had learnt its lesson. It supported a call by the coroner for improvements to the labelling and storage of drugs and for other measures to prevent a recurrence.

Mrs Cabrera, 30, was a Filipina midwife at the Great Western Hospital, where she gave birth to Zachary in May 2004. The handling and storage of drugs there was described as chaotic. David Masters, the Wiltshire Coroner, said that he would be writing to the Health Secretary recommending stricter controls on the handling and administration of drugs.

After 17 hours' deliberation at the end of the four-week inquest in Trowbridge the jury returned a majority verdict. It stated: "Mayra Cabrera was killed unlawfully - gross negligence/manslaughter - storage and administration."

The midwife accused of the mistake, Marie To, repeatedly denied having made the fatal blunder and said that she was unable to explain how the Bupivacaine had been connected to Mrs Cabrera's drip. Gerwyn Samuel, for Mr Cabrera, told her: "It is because you are blocking from your mind the blindingly obvious - that you put up that bag and that it was Bupivacaine."

Mr Masters said that he would be writing to the Health Minister, the Midwifery Council, relevant royal colleges and the General Medical Council to recommend that staff training and the storage and administration of drugs should be overhauled. He also wants the connectors for epidural drugs to be changed so that a mix-up would be unlikely to recur. He said: "The nettle needs to be firmly grasped. It is quite clear that what is needed is a firm and radical approach to tackle the problems raised. "Firstly we need equipment which can be only used for epidural use - giving sets, syringes, and infusion bags which can only be attached for epidural use. Because we are in a global market place the manufacturers have to look to Europe and not just UK requirements. This is something the Minister for Health should tackle."

Detective Inspector Ian Saunders, of Wiltshire Police, who led the original investigation, said that the evidence presented to the inquest would be reviewed. "The CPS will carefully review what has been said in these proceedings to see if any new evidence has come to light."

Lyn Hill-Tout, chief executive of Swindon and Marlborough NHS Trust, apologised for the blunder that killed Mrs Cabrera. She promised that the trust had learnt its lesson. "I want to reiterate our sincere and unreserved apologies to Mr Cabrera and Zac. The trust admitted liability for Mrs Cabrera's death as soon as possible. We sincerely hope that other hospitals will be able to learn from the bitter lessons that we have learnt. This tragic case should not have happened and one death is one too many.

"We wholeheartedly support the coroner in his call for better labelling of drugs by the manufacturers and most importantly the introduction of new special fittings which do not allow for drugs to be connected to the wrong route. "We can never bring Mayra back but we can do all in our power to ensure that there are no similar tragedies. We have been criticised for a number of failures, failures which we accept, deeply regret and from which we have learnt important lessons."

Mr Cabrera, whose work permit expires at the end of this month, is to ask the Home Office for permission to stay in Britain on compassionate grounds. His request was backed by the coroner, who criticised the way in which his case had been dealt with up to now.

Mr Masters said: "I find it quite extraordinary that this man has not had the benefit of knowing that he can stay in this country for the foreseeable future. I would wholeheartedly support his right to stay, had I any say in the matter. It seems to me that the red tape should be cut and thrown away and that should done quickly, sooner rather than later."

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10 February, 2008

British Dentists 'under pressure to treat fewer children'

Dentists are under pressure not to treat children as the NHS cannot afford to fund their care, it was claimed yesterday. Health trusts want dentists to concentrate on targeting adult patients who have to pay for treatment, according to a pressure group. The claims, to a Commons health select committee, come as figures show that one in three children has not visited a dentist for up to two years.

Eddie Crouch, a founding member of dental pressure group Challenge, said: "There is a danger that children will be turned away because of undue pressure from primary care trusts to get revenue from dentists. This money obviously comes from adult patients who pay for treatment." He added: "The new arrangements have failed to provide many of the important benefits that the Department of Health wished to achieve. "There are growing inequalities in access to care, and the quality assurance mechanisms are woeful."

Early last year many dentists were forced to stop treating children until April after local health trusts ran out of money at the end of the financial year. The trusts faced budget shortfalls after the Government overestimated how much would be raised from dental fees.

Mr Crouch's comments were backed by the London Regional Group of Local Dental Committees. In a statement to the committee it said there was increasing pressure to treat more adults and that people from deprived backgrounds would suffer. "Children and adults who are exempt from NHS charges are among the most in need of dental help," it said. "Yet PCTs require dentists to ensure that a certain proportion of the patients they treat are sufficiently well off to pay for their own NHS treatment, in order to maintain the PCT's financial balance. "We know of dentists who have been told that unless they see a higher proportion of paying NHS patients, they will have their contract capacity curtailed."

Other experts told the committee that dentists would actually be better off financially if they pulled out children's teeth rather than go through the time-consuming process of attempting to save the tooth with a root canal filling.

The Government set up the select committee to investigate the state of NHS dentistry after it emerged that 250,000 fewer patients saw a dentist in the year since the introduction of the new contract in April 2006. The number of children seeing a dentist within the previous two years has fallen by 19,000 from the figure in 2006 and only half of adults have seen a dentist within the past 24 months. With an average patient list of around 2,500, that would mean 1.25million patients have lost access to a dentist.

Source




Australia: NSW hospitals to knock back 'mildly ill' patients

Hospitals on the New South Wales north coast will begin turning away people with minor ailments, in a bid to make beds available for those who are more seriously ill. The North Coast Area Health Service says about 80 beds from 14 different public hospitals will be classified as "surge beds" which are mainly to be used during periods of high demand. It says if people with mild or chronic illnesses are treated in outpatient clinics or at home, then the "surge beds" will not be needed all the time.

Health Service chief executive Chris Crawford says the policy is not about cutting costs by reducing the number of beds that are available. "This means that rather than the beds being used for these mildly ill patients, we'll keep them and have them available for very seriously ill patients when you get high peaks in activity," he said.

The State Opposition says more hospital beds are needed across the state to help deal with the crisis. Opposition Leader Barry O'Farrell is concerned about the policy. "Clearly a major contributing factor to the state's hospital crisis is a shortage of beds and the pressure that places upon our hospitals, particularly in being able to recruit and retain staff," he said. "Taking further beds out of the fastest-growing region in the state doesn't seem to make sense."

Source





9 February, 2008

The Wages of HillaryCare

Hillary Clinton and Barack Obama agree on most policy issues, but that makes their rare differences all the more revealing. To wit, their running scrap over Mrs. Clinton's "individual mandate" for health care, which Mr. Obama has now had the nerve to expose for its inevitable government coercion.

Mrs. Clinton's proposal requires everyone to buy health insurance, along with more insurance regulation, a government insurance option for everyone and tax hikes. Mr. Obama likes all that but his mandate would only apply to children. He argues that the reason many people aren't insured is because it's too expensive, not because they don't want it. Mrs. Clinton counters that coverage can't be "universal" without a mandate.

But then Mr. Obama had the impudence to defend his views. His campaign distributed a mailer in key primary states that claimed the Clinton plan "forces everyone to buy insurance, even if you can't afford it." It also featured an image of an anxious couple at a kitchen table. The Clinton apparat went apoplectic, claiming the flyer evokes the famous "Harry and Louise" commercials. A common article of liberal faith is that this "smear campaign" doomed HillaryCare in 1994 -- as opposed to, say, its huge cost and complexities. But never mind.

Yet if Mrs. Clinton's plan is better because it has a mandate, how does it work in the real world, where some people still won't be able to afford insurance, or would decline to acquire it? At a recent debate, the Illinois Senator drove the point home, asking Mrs. Clinton, "You can mandate it but there will still be people who can't afford it. And if they can't afford it, what are you going to fine them? Are you going to garnish their wages?" And in an interview with ABC's George Stephanopoulos on Sunday, Mrs. Clinton conceded that "we will have an enforcement mechanism" that might include "you know, going after people's wages."

Well, well. In other words, HillaryCare II isn't all about "choice," but would require financial penalties for people to pay attention, including garnishing wages. To put it more accurately, the individual mandate is really a government mandate that requires brute force plus huge subsidies to get anywhere near its goal of universal coverage.

Mitt Romney's mandate program in Massachusetts is already expected to reach $1.35 billion in annual costs by 2011, up from $158 million today. And that's with only half of the previously uninsured currently enrolled; no less than 20% didn't qualify for subsidies and were granted exemptions because the costs were too much of a hardship.

Most experts calculate that a national mandate with subsidies like Mrs. Clinton's would enroll about half to two-thirds of the uninsured, less for a voluntary plan and subsidies alone. But such guesswork is pointless without the basic enforcement assumptions, which Mrs. Clinton refuses to provide. She's more interested in wielding what she calls "a core Democratic principle" against Mr. Obama. "My opponent will not commit to universal health care," she said Saturday.

The logic of Mr. Obama's approach is that policy makers should target those who are priced out of coverage. The Census Bureau says 38% of the uninsured earned more than $50,000 in 2006, 19% above $75,000. They aren't a major public policy problem -- except that a big reason they lack coverage is because it is more expensive than it needs to be thanks to government market interference. And 29% earn under $25,000, which means they probably qualify for existing subsidy programs like Medicaid or Schip but haven't enrolled.

The news here is that all of this is being exposed now, and by a fellow Democrat. Many Americans are uncomfortable with the coercion of the mandate -- and not all of them are Republicans. The California health-care overhaul was recently done in by liberals concerned about its consequences for the working poor.

The political lesson that Mrs. Clinton learned in 1994 wasn't about compromise or market forces. It was that a government health-care takeover can only be achieved gradually and by stealth. Her individual mandate is an attempt to force everyone to buy into a highly regulated and price-controlled system where government redistributes income and dictates coverage. We assume the McCain campaign is paying attention.

Source




Britain: Foreign doctors face competence inquiry

Britain's medical regulator has launched a major inquiry into the competence of foreign doctors after it emerged that they are now twice as likely to face disciplinary hearings as UK medical graduates. Figures seen by The Times also reveal that triple the number of doctors who trained abroad were struck off the UK medical register last year compared with 2005.

The findings, part of a report compiled by the General Medical Council, have prompted the profession's regulator to commission seven research projects, which will cover issues including the competence of foreign doctors and whether they are subject to institutional racism within the health service. More than 5,000 cases were dealt with by the GMC in 2006, 303 of which culminated in fitness-to-practise hearings and 54 doctors were struck off. Of these, nearly two thirds - 35 doctors - had trained outside the UK.

The range of offences included sexual misconduct, dishonesty and failing to provide an adequate level of care for patients. Among the cases in the past three months have been a Hungarian doctor struck off for dishonesty, a Nigerian for clinical incompetence and misdiagnosis and an American-trained doctor who had sexually harassed a nurse. One Spanish-trained psychiatrist was found to have abused his position over the use of prescription drugs.

Last month Gordon Brown pledged to tighten checks on medical staff who trained overseas after three NHS doctors were charged in connection with the attempted car bomb attacks on London and Glasgow.

But medical regulators suggest that patient safety may be compromised by current procedures, which require some doctors to produce no more than a degree certificate and a letter of reference before they can start work. The GMC said there was a growing number of complaints about GPs and hospital doctors, but a "disproportionate" number of overseas-trained doctors were appearing before its disciplinary panels. Strikingly, 30 per cent of complaints against foreign doctors came from other health professionals or the police, who were the source of less than 15 per cent of complaints against UK-trained doctors.

The GMC has commissioned researchers to look into the pattern, for which there is currently "no good explanation", it said. It added that doctors were only struck off when it would endanger patients and the wider public to do otherwise.

One of the projects coordinated by the Economic and Social Research Council is already under way, while six others are due to start in the next few months. They include proposals from academics at the London School of Economics and the universities of Newcastle and Leicester to investigate how doctors come to work in the UK and set out which of them might present a particular risk to patients.

Under current rules, doctors from Europe can register and treat patients in Britain but are not tested for clinical competence and do not have to prove they can speak English, unlike those from Australia or elsewhere who are naturally fluent. The GMC and other regulators fear that patient care may be at risk , and have called for a change in the law to test doctors from the EU.

This week The Times revealed that hundreds of junior doctors who took up posts this month have not been vetted by the Criminal Records Bureau. Hospital trust managers complained that they could not check the criminal records of some applicants because they received the names too late.

Of the 5,085 complaints lodged against doctors last year, a rate of almost 100 a week, nearly 40 per cent referred to overseas-trained doctors - roughly in proportion to their numbers in the NHS workforce. A far greater number of international medical graduates were referred to hearings compared with UK graduates (34 per cent as against 16 per cent last year).

Paul Philips, director of standards and fitness-to-practise at the GMC, said: "The number of fitness-to-prac-tise cases we deal with is going up year on year. Doctors with a primary medical qualification from overseas or within the EU are disproportionately represented, and more are being referred to us than we should be see without a good explanation." The British Medical Association said that the pattern might be accounted for by a culture of institutional racism within the NHS. A Department of Health spokesperson said all NHS doctors were subject to stringent pre-employment checks.

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8 February, 2008

Massachusetts: RomneyCare costs to double

The subsidized insurance program at the heart of the state's healthcare initiative is expected to roughly double in size and expense over the next three years - an unexpected level of growth that could cost state taxpayers hundreds of millions of dollars or force the state to scale back its ambitions. State projections obtained by the Globe show the program reaching 342,000 people and $1.35 billion in annual expenses by June 2011. Those figures would far outstrip the original plans for the Commonwealth Care program, largely because state officials underestimated the number of uninsured residents.

The state has asked the federal government to shoulder roughly half of the program's cost from 2009 through 2011, but there is no guarantee of that funding. Commonwealth Care provides free or subsidized insurance for low- and moderate-income residents. "The state alone cannot support that kind of spending increase," said Michael Widmer, president of the Massachusetts Taxpayers Foundation, a business-funded budget watchdog group.

Even with federal backing, the state may not be able to afford the insurance initiative as designed, because the law did not make any attempt to trim wasteful health spending, said Alan Sager, a Boston University professor who specializes in healthcare costs.

Currently, 169,000 people have enrolled in the program, which is expected to cost $618 million in the fiscal year ending June 30. When it authorized the program in 2006, the Legislature estimated that about 215,000 people would eventually be enrolled at a cost of $725 million. State officials in late 2006 reduced that estimate to between 140,000 and 160,000 - a number that was surpassed last year. "We're paying the price of our own success," said Widmer.

The administration of Governor Deval Patrick produced the new estimates to launch negotiations for federal funding, and has shared them with some state health leaders at closed-door meetings. Patrick is seeking about $1.5 billion over three years, half the cumulative cost for Commonwealth Care. The administration declined to discuss the numbers or the assumptions behind them, citing the ongoing negotiations.

In a statement, however, the governor's spokesman, Joseph Landolfi, said, "It is clear that paying for healthcare reform will pose a much greater fiscal challenge than was anticipated by the previous administration. We are committed to making health reform a success by aggressively pursuing cost savings and efficiencies in the healthcare system, as well as working with legislative leaders to review options for additional state revenues so that we can continue to afford this important initiative."

The expanding need for new state and federal money is in sharp contrast to the statements made by former governor Mitt Romney, when he proposed the initiative in 2004 and as he campaigns for president. He has repeatedly suggested that the state could insure low-income residents largely by reallocating money paid to hospitals and health centers that serve the uninsured. "The bill that I submitted to the Legislature didn't cost $1 more than what we were already spending," he said Wednesday night during a GOP debate. "However, the Legislature and now the new Democratic governor have added some bells and whistles."

In fact, Romney signed the law in 2006 as modified by the Legislature, approving most of the changes, but vetoing a few provisions that were overridden. Lawmakers then estimated that the initiative would cost the state only a small amount of new money in the first few years. It is now apparent that both Romney and lawmakers underestimated the cost of insurance subsidies as well as other parts of the initiative, largely because they based their projections on low estimates of the number of uninsured and the rising price of insurance. When the law was passed, neither Romney nor the Legislature estimated the costs beyond next year because they believed the enrollment growth would be all but complete.

From the beginning, many health policy specialists said the initiative would cost the state more than expected. Now, some say, the benefits of reaching near-universal insurance coverage may counterbalance the financial pain. "I wouldn't say there's an imminent danger that the whole thing is going to collapse," said Robert Seifert, senior associate at the Center for Health Law and Economics at the University of Massachusetts Medical School. "It's challenging, but if it's a priority for the administration, then I think it's doable. There are benefits that don't appear in the budget numbers," including healthier residents, who are less of a financial drain in the long run.

Government-funded costs of another part of the insurance initiative - expansion of the state's Medicaid program, called MassHealth - are also projected to grow significantly. The state is also seeking federal reimbursement for half of those expenses. MassHealth covers the poor and disabled who have minimal financial assets. Commonwealth Care provides free or subsidized insurance to those who don't qualify for MassHealth but have low to moderate incomes and no access to insurance through work.

Overall, spending on the healthcare initiative will total about $1.95 billion this year. Slightly less than half of that will be funded by the federal government, with the rest coming from state taxpayers and other sources. If the state doesn't get all of the federal funds it is seeking, policy makers could face difficult choices: spend more state money or cut back the two programs by reducing enrollment, cutting subsidies, or eliminating benefits.

More here




Non-EU doctors barred from UK posts

An overdue burst of intelligence. Bringing in poorly trained Indian doctors when British-trained doctors could not get jobs was crazy

New immigration rules will stop doctors from outside the EU applying for postgraduate training posts in the UK, it has been announced. The Home Office has laid out new regulations to prevent overseas doctors applying for foundation and speciality training posts. It follows criticisms that homegrown doctors are unable to find jobs once they graduate from UK medical schools.

The rules, which will first affect recruitment in 2009, would see a drop of between 3,000 and 5,000 overseas applications next year, official estimates suggest. The rules apply to doctors currently not resident in the UK - it will not affect doctors with medical jobs already here on the Highly Skilled Migrant Programme. The Government estimates that around 10,000 non-EU medical graduates are currently in the UK.

Figures suggest that up to 1,100 UK doctors could still miss out on a training post in 2009 and beyond owing to the number of overseas doctors. The Government said therefore it was launching a consultation on guidance which says doctors currently in the UK on HSMP can only get a job here if there is no UK or EU doctor suitable for the role.

The Court of Appeal ruled in November that such guidance was unlawful. The Government appealed against that decision and the case is due to be heard by the House of Lords, with a decision expected in May. Around 1,300 UK graduates missed out on a training post last year.

Source





7 February, 2008

McCain versus Romney on socialized medicine

Post below lifted from New Editor . See the original for links

Jeff Jacoby makes the conservative case for John McCain. He's correct that McCain is someone a true conservative can support, though you may not agree with all his positions. I would add to that that Mitt Romney is someone that a true conservative cannot. Not because he took socially liberal positions on things like abortion and gay rights when he ran in 1994 and 2002. It's because on health care, Mitt Romney is a socialist.

Conservatives may be backing Mitt Romney more so than McCain, but remember that while Hillary Clinton and Barack Obama argue about who can do a better job socializing medicine, Mitt Romney has already done it. He supported and signed a law that would fine people who don't buy health insurance, which is something Hillary Clinton can for now only dream about.

"It's a conservative idea," says Romney, "insisting that individuals have responsibility for their own health care. I think it appeals to people on both sides of the aisle: insurance for everyone without a tax increase."

Conservative? Romney explains further in a 2006 piece in The Wall Street Journal:

Some of my libertarian friends balk at what looks like an individual mandate. But remember, someone has to pay for the health care that must, by law, be provided.

That's a canard liberals have used for years. Someone's got to pay for it! But the conservative message has always been that, well, you should pay for your own things. Romney implied that those without health insurance are "free riders."

''No more 'free riding,' if you will, where an individual says: 'I'm not going to pay, even though I can afford it. I'm not going to get insurance, even though I can afford it. I'm instead going to just show up and make the taxpayers pay for me,' " Romney told reporters after a healthcare speech at the John F. Kennedy Library.

In other words, if you can afford to buy something, you should be forced to buy it. And who are all these people who can afford health insurance but don't buy it, but then don't pay for the health care they do receive? I've chosen to be without health insurance in the past; it was simply more cost effective for me when I owned my own business to go to the doctor and pay out of pocket. It's insulting, and I believe factually incorrect, for Romney to blame the working uninsured-by-choice for the high cost of government-paid health care.

Jacoby mentions in his piece that he wishes McCain better understood that liberty is important. But Romney confuses responsibility with government mandates that don't work. Also, as one would expect, the mandate plan hurts small businesspeople the hardest. And it obviously takes away personal choice, that is, liberty. Why it's not a deal-breaker for people who call themselves conservative is beyond me.




Poor NHS leadership and chasing targets `hampers patient care'

Patient care has suffered repeatedly because of poor management and bureaucracy in the NHS, according to a report by the healthcare watchdog. A lack of leadership, inadequate team-working and focusing too much on government targets emerged as common themes in the Healthcare Commission's review of its 13 major investigations between 2004 and 2007. It concluded that some boards were focused on mergers between organisations after a shake-up of NHS trusts, or on meeting targets at the expense of patient care.

At Maidstone and Tunbridge Wells Hospitals NHS Trust, appalling hygiene standards contributed to more than 90 deaths from the bug Clostridium difficile, and at Sutton and Merton Primary Care Trust serious neglect of people with learning disabilities was found. In areas such as mental health services, the number of managers and administrators has doubled since 2000, hindering patient care and wasting resources, said Sir David Goldberg, an emiritus professor of psychiatry.

Writing in the British Journal of Psychiatry, Sir David said that there were 6,275 managers and administrators in mental health services, and 99,052 other staff - a ratio of one manager/administrator for every 15 staff. "Something is seriously wrong. The Department of Health is constantly introducing new regulations that require a report." He said that medical staff spent a growing proportion of their time attending meetings with managers, clinical governance meetings and carrying out audit activities.

Gill Morgan, of the NHS Confederation, said: "Organisations must be given the real autonomy necessary to enable them to take ultimate responsibility, rather than . . . being dominated by central targets."

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6 February, 2008

Hillary Weighs Garnishing Wages to Pay for Universal Health Care

Sen. Hillary Clinton, D-N.Y., this morning left open the possibility that, if elected, her government would garnish the wages of people who didn't comply with her health care plan. "We will have an enforcement mechanism, whether it's that or it's some other mechanism through the tax system or automatic enrollments," Clinton said in an appearance on "This Week with George Stephanopoulos". Clinton went on to say, though, that such mechanisms would not include penalties. "They don't have to pay fines … We want them to have insurance. We want it to be affordable. And what I have said is that there are a number of ways of doing that. Now, there's not just one way of getting to that."

Sen. Barack Obama, D-Ill., has raised questions about how Clinton intends to pay for and implement her universal health care plan. Clinton responded to her opponent, saying "The misleading information that Sen. Obama's campaign is putting out, that I will force people to do it even if they can't afford it, is absolutely untrue." "It's so reminiscent of old 'Harry and Louise' talking about how, 'Oh, the sky will fall if we try to have universal health care.' He's playing right in to all of the arguments against this core value of the Democratic Party," she said in response to a recent Obama campaign mailer criticizing her plan.

Source




Australia: State health system worse despite cash injection

Surprise! surprise! There's no cure for malignant bureaucracy other than abolishing it and starting again

QUEENSLAND'S health system continues to struggle and is getting worse in some areas despite a multibillion-dollar cash injection. A new report has found many patients are still waiting longer than recommended for critical surgery while record numbers are presenting to emergency departments. Queensland Health's Public Hospital Performance Report for the 2007 December quarter shows the department has already spent $5.5 million in 2007-08 outsourcing surgery to the private sector in an attempt to clear the backlog.

Health Minister Stephen Robertson yesterday said the report showed the system was performing more surgery, treating more patients and providing more outpatient services than ever before. "Now I am not for a second suggesting all of our problems are fixed," Mr Robertson said. "We still have a lot of work ahead of us to build a first-class health system for Queensland."

However, Coalition Health spokesman John-Paul Langbroek said the Government's $10 billion promise to fix the system was failing. "More Queenslanders are waiting longer for their surgery than ever before. We have never seen the situation this critical."

The report found the percentage of Category one patients who had waited longer than the recommended 30 days for surgery had almost doubled to 13.9 per cent in 12 months. The percentage of Category two patients overdue for surgery was 22.5 per cent while Category three was 29.9 per cent. Overall, 28,579 patients were waiting for elective surgery, slightly more than the number who were waiting a year earlier.

Some of the hospitals with the biggest percentage waiting lists across the elective surgery categories were Princess Alexandra (38.6 per cent), Royal Brisbane and Women's (37.6 per cent) and Mater Adult (34 per cent). The report found a record 842,725 patients were admitted to public hospitals in 2007, a 9.2 per cent increase on 2005.

Mr Robertson said the increasing number of emergency department patients was hurting the system's ability to reduce elective surgery waiting lists. "The same surgeons, the same nurses, the same operating theatres that you use to perform elective surgery are the ones where emergency surgery is performed," he said.

However, Mr Langbroek said the Government constantly had different excuses. "It begs the question about all the extra resources we keep hearing about and what is happening to it?" he said. [Most of it goes on more and more clerks and "administrators"]

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5 February, 2008

Extraordinary NHS mismanagement of their funding

It's only the taxpayer's money so who cares?

NHS hospitals have paid more than 120 pounds ($240) an hour for agency workers to fill staffing gaps during the past year, according to figures obtained under the Freedom of Information Act. The payments included 96.75 an hour for a GP in Wolverhampton, 100 an hour for a human resources manager in Blackburn, and 121.59 an hour paid for a nurse in a Berkshire hospital.

The figures, which were obtained by the Conservative Party, form part of a bill for NHS agency staff that totalled 1.18 billion in 2005-06, the last year for which the Department of Health has released figures. The total amount was down from the 1.45 billion that was recorded in 2003-04, but more than double the 540 million spent in 1997. Average hourly pay rates for NHS employees are 15.66 for a nurse, 24.14 for a junior doctor and 60.31 for a consultant, based on the 37.5-hour standard working week, the Tories said.

Andrew Lansley, the Shadow Health Secretary, said: "Labour's chaotic short-term planning has let down NHS staff. Some stability for them is the least we would have expected from the billions that the Government has poured into the NHS." He added that it was incredible that agencies could be paid such high hourly rates for staff at a time when jobs were being cut.

The Conservatives asked NHS trusts to reveal the top hourly rates that each had paid for agency staff during the previous 12 months. The highest figures also included 121.10 an hour for a nurse at Chesterfield and Royal Hospital NHS Trust and 111.96 for a nurse at Salisbury NHS Foundation Trust. The highest hourly rate for a non-clinical worker was 119 for a turnaround director at Coventry Teaching Primary Care Trust, followed by 110 for financial staff at Heatherwood and Wrexham Park Hospitals NHS Trust and 106.66 for a director of healthcare and procurement at Havering PCT.

Some trusts appeared to have kept agency costs more strictly under control. Bath and North East Somerset PCT said that the most it paid was 31.15 per hour for a nurse, while the South Western Ambulance Service NHS Trust's most expensive agency worker was a temporary deputy finance director at 33.33 an hour.

Temporary staff are employed across the NHS to meet fluctuations in activity levels and to cover vacancies and short-term absences. Trusts obtain temporary workers from their own nursing bank, from private agencies or from the NHS-run temporary staffing service, NHS Professionals. A 2007 report by the House of Commons Public Accounts Committee said: "Properly managed, temporary nurses play an important role in helping hospitals achieve flexibility. "Excessive use can be costly, particularly when trusts are heavily reliant on agency nurses. High use of temporary nurses can also have a negative impact on patient care and satisfaction."

Source




More on the RomneyCare failure

As he campaigns across the country this week in anticipation of the Super Tuesday primaries, Mitt Romney probably won't say much about the storied health-care plan he signed into law as governor of Massachusetts. For one thing, it is hard to portray yourself as the ideological heir to Ronald Reagan when your health-care plan is virtually indistinguishable from the one proposed by Hillary Clinton. But another reason Romney may not want to talk about his plan is that it has been a dismal failure.

The Massachusetts plan was supposed to achieve universal health coverage while controlling costs. As Romney wrote in The Wall Street Journal, "Every uninsured citizen in Massachusetts will soon have affordable health insurance and the costs of health care will be reduced." Or not.

The Massachusetts plan might not have achieved universal coverage, but it has cost taxpayers a great deal of money. Before RomneyCare was enacted, the number of uninsured Massachusetts residents was estimated at 618,000. Under the new program, about 300,000 previously uninsured residents have signed up for insurance. But of these, 169,000 are receiving subsidized coverage, proving once again that people are all too happy to accept something someone else is paying for. Another 70,000 people have also been enrolled in Medicaid, meaning a total of 239,000 people are receiving taxpayer-funded health insurance. Of those who have signed up for insurance since the plan was implemented, slightly more than half have received totally "free" coverage. Only 60,000 unsubsidized residents have bought insurance in order to comply with the mandate.

And though the subsidies have increased the number of Massachusetts citizens with insurance, as many as 300,000 Massachusetts residents have failed to buy the required insurance. Thus, half of those who were uninsured before the plan was implemented remain so.

The Massachusetts plan might not have achieved universal coverage, but it has cost taxpayers a great deal of money. It was originally projected to cost $1.8 billion in 2008, but it is now expected to exceed those estimates by $150 million to $400 million. Over the next decade, projections suggest that RomneyCare will cost $2-$4 billion more than was budgeted. Given that Massachusetts is already facing a projected budget deficit this year, the pressure to raise taxes, cut reimbursements to health-care providers, or cap insurance premiums will likely be intense.

The cost of the Massachusetts plan is also likely to continue rising, because it has failed to hold down the cost of health care. When Gov. Romney signed the bill, he claimed "a key objective is to lower the cost of health insurance for all our citizens and allow our citizens to buy the insurance plan that fits their needs." In actuality, insurance premiums in the state are expected to rise 10-12 percent this year - twice the national average.

A major cause is that the new bureaucracy the legislation created - the "Connector" - is not allowing Massachusetts citizens to buy insurance that "fits their needs." For example, the Connector's governing board decrees that by January 2009, no one will be allowed to have insurance with a deductible higher than $2,000 or total out-of-pocket costs of more than $5,000.

In addition, every policy will be required to provide prescription drug coverage, a move that could add 5-15 percent to the cost of insurance plans. A proposal to require dental coverage failed narrowly, but the dentists - and several other provider groups - have not given up the effort to force its inclusion. This comes on top of the 40 mandated benefits the state had previously required, ranging from in vitro fertilization to chiropractic services.

Romney now says that he cannot be held responsible for the actions of the Connector board, because it's "an independent body separate from the governor's office." But many critics of the Massachusetts plan warned him precisely against the dangers of giving regulatory authority to a bureaucracy that would last long beyond his administration.

Executives often blame others for the failures of their own policies, but that's not a tendency one looks for in a candidate. Romney claims he is a "true conservative" with the business expertise to "get things done." Judging by his experience with health-care reform, far from it.

Source





4 February, 2008

More on the problematic narrowness of thinking among some medical practitioners

I put up yesterday an article by the excellent Arnold Kling in which he bemoaned the narrow vision of many doctors under the present system. I reproduce below an email that I have received in response from an American anesthesiologist -- in which he highlights current medical training as the problem

Concerning your column about the man looking at his father's medical care and "specialists not looking at the whole patient", let me tell you about my experience.

Surgical Residents (trainees) where I trained - were GREAT DOCTORS. There was a tradition of being harassed if they missed a lab value or physical sign - it's called PRIDE AND COMPETITION. They would be harassed at Grand Rounds if they missed something basic - like a skin rash or an abnormal lab value.

It's just nonsense to believe that SPECIALIZATION makes doctors too focused - it's the individual training program.

In another location, surgeons are "sloppy" - they are more concerned about what they are cutting, and less about the patient. Some specialists are the worst offenders. They have a stunning disregard for "the whole patient". Shameful.

In contrast, the best "real doctors" I have worked with in surgery were trained in a central Texas institution. All were good "doctors" and I miss them; I have yet to come across surgeons who have such a grasp of the "whole patient". But these are proof that it doesn't take a "family doctor" to act like Marcus Welby.

Anesthesiologists often "bail out" surgeons who are completely unaware of some of patients' serious medical problems. We are often called the "Internists of the Operating Room". We look at the "whole patient" as much as anyone, despite being "specialists.

It's not about IQ, or "specialization" - it's about the ATTITUDE of the director of the training program.

PS - My wife had surgery at this same central Texas institution; the recommendation of my colleague who trained there was good enough for me. Knowing the "inside" "is one of the perks of being "In the business".




Fatally negligent government X-ray service in Australia

A Gold Coast breast cancer sufferer who sued Breast-Screen Queensland over botched mammogram readings has died, but her grieving husband has vowed to fight for answers about the bungle. Philippa Naismith was diagnosed with aggressive breast cancer in July 2005 - 11 months after being given the all-clear by the state's breast-screening service. The cancer spread to her bones and she died at home on January 18, aged 54, with her husband Paul at her side.

Before she died, Mrs Naismith won a confidential out-of-court settlement from BreastScreen Queensland. Another Gold Coast victim's claim is still being finalised. The settlement followed revelations that Queensland Health had been forced to review 9300 women's mammograms after five radiologists contracted to BreastScreen had failed to detect some cancers.

Mr Naismith said yesterday that he was determined to ensure those responsible were held accountable. "Philippa died an absolutely horrendous death - she was coughing up lung tissue in the end - and I feel very angry," he said. "Presumably, these people are still working in the health system but they are not being made accountable for the lives they are supposed to protect. I'm not saying they gave my wife cancer but I am saying they took away any chance she had."

Source





3 February, 2008

When Health Care Becomes Personal

By Arnold Kling

"Despite a rapidly growing elderly population, the number of certified geriatricians fell by a third between 1998 and 2004. Applications to training programs in adult primary-care medicine are plummeting, while fields like plastic surgery and radiology receive applications in record numbers. Partly, this has to do with money-incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, most doctors don't like taking care of the elderly." --Atul Gawande

Over the past eight weeks, I have been spending a lot of time with my father, who has developed some acute medical problems. For the most part, my focus is day-to-day (or hour-to-hour) on the issues and stresses that arise.

But I have also come around to some different points of view about our health care system. I no longer think of Medicare and health care regulation as inefficient. I now think of them as pure evil.

My Father's Case

My father has benefited from America's health care innovations and research. He had heart bypass surgery 17 years ago. His use of diet and medications to control blood pressure and an irregular heartbeat have enabled him to live to almost ninety, whereas his own father died of heart problems in his fifties. When told eight weeks ago that he had terminal cancer, thinking back on his heart issues my father said, "I'm lucky I've lasted this long."

In late November, my father started having episodes where he could not eat without throwing up in the middle of a meal. His doctor sent him for an endoscopy, which found an advanced malignant tumor in his esophagus. The survival rate for esophageal cancer tends to be extremely low, because it is rarely diagnosed early enough. In my father's case, the cancer is viewed as inoperable. Instead, he underwent a course of radiation.

On the evening of January 10, my father experienced severe pains near his right ankle. The next day, he went to see his internist, who diagnosed the problem as cellulitis, meaning an infection. He prescribed antibiotics, and also sent my father for a precautionary X-ray.

While standing near the entrance to the building for the X-ray, my father slipped and fell, fracturing his hip. He was taken nearby to the emergency room of BJC hospital in St. Louis, admitted to the hospital, and operated on that Monday. His hip required a reinforcement (screws) rather than replacement.

From an orthopedic perspective, he was supposed to begin rehabilitation the day after surgery. However, the operation had required stopping his heart medication, and his heart rate rose above safe levels. He spent more than a week as a cardiology patient, getting no rehab. Finally, he was transferred to the nearby St. Louis Rehabilitation Institute. I believe that he has the strength to eventually be mobile with a walker. However, statistically when people his age suffer hip fractures, 25 percent of them never make it out of the hospital, and with his cancer and heart problems he is probably not above average for his age in terms of overall health.

Health Care Complaints

I do not expect health care to be perfect. I do not expect someone with cancer to have an enjoyable experience. I am not threatening to sue anyone, or even to suggest that the care my father received was anything other than far above average. But I do think that there were serious flaws, and that these flaws are systemic.

When Atul Gawande says that "most doctors don't like taking care of the elderly," I think he is including my father's internist and virtually every other doctor that he saw at BJC. None of the doctors touched my father with their hands. Many of them used a stethoscope. The internist looked at the cellulitis. Otherwise, they never examined him. And each specialist was only concerned with his or her particular area--the heart doctors only worried about his heart, the orthopedists only cared that the screws were in correctly, the internist only worried about the cellulitis. Nobody noticed problems with my father's veins or his skin that were caused by having too many IV's and spending too much time on his back.

I do not blame my father's internist for failing to detect the esophogeal cancer earlier. However, it is a fact that for years my father had been coughing after meals, and he had asked the internist about this symptom. The internist treated it as an allergy.

I probably should not blame the internist for sending my father for an unnecessary X-ray, on the way to which he broke his hip. But the X-ray was unnecessary, because the internist already had made his diagnosis.

A Better Way

However, having seen the doctors at the Rehabilitation Institute, I know that there is a better way to practice geriactric medicine. The doctors there were hands-on. They changed dressings themselves. They looked at his entire body. They took their time. They found a number of problems that had slipped through the cracks of the specialists at BJC. And they figured out why my father has difficulty with balance.

It really was quite simple. The doctor at the Institute held each of my father's feet and asked him to make some specific motions. It was obvious to me just watching that my father has some neuromuscular deficits, which he has clearly had for at least a year. For example, he cannot feel his feet well enough to control whether his toes point up or down. These are issues that can be dealt with--but only if someone knows about them. And doctors who do not like to touch old people are not going to know.

The real key to preventing my father from falling and breaking his hip would have been to identify and treat his deficits. But it takes a hands-on doctor to do that.

Integrated Medicine

Our health care system is widely criticized for its fragmentation, specialization, and lack of incentives for quality. For example, Shannon Brownlee's highly-regarded book Overtreated makes a strong case that specialist-driven health care is more expensive and less effective than the best-of-breed integrated care systems. My guess is that the Saint Louis Rehabilitation Institute comes closer to this integrated care ideal than does its bigger BJC brother.

Atul Gawande points out the key issues with geriatrics. The elderly are particularly ill-served by narrow specialists who deal with issues piecemeal and in haste.

The Saint Louis Rehabilitation Institute offers a glimpse of a better way to care for the elderly. There, more of the care is driven by the needs of the patient than by the habits of specialists. However, best practices, whether at that Institute or elsewhere, are not going to spread to the medical profession as a whole. That is because our main policy objective in health care is to insulate people from having to pay for it.

Government is the Customer

When consumers are in the driver's seat, best practices tend to spread. In a market economy, if you fail your customers, you go out of business. BJC, which is regarded as one of the best hospitals in the country, should go out of business. It should be driven out by hospitals that function more like its subsidiary, the Rehabilitation Institute.

Internists and specialists who do not like to touch old people should be driven out of business. They should be driven out by hands-on doctors and by gerontologists who take a more holistic view of patients.

The reason that medical care works the way it does is that government is the customer. Government pays health care providers for time and materials. Shannon Brownlee and others believe that government could come up with better compensation schemes that would help promote quality. I doubt this.

Trying to influence medical care from a government bureaucracy sets up a game between bureaucrats and doctors. The object of Medicare Administrators will be to get the largest change in behavior with the least increase in compensation to health care providers. The object of the health care providers will be to get the biggest increase in compensation for the least change in behavior. The health care providers are bound to win. They control the information flows ("you want to see reports that demonstrate quality? we'll give you reports that demonstrate quality.") More importantly, they have the most organized lobbyists, so that any "pay-for-performance" schemes that do not work in doctors' favor will be shut down.

Medicare is wonderful for relieving the elderly from the burden of worrying about health care expenses. By the same token, it is wonderful for relieving doctors of the burden of worrying about the elderly as customers. You get paid for understanding the billing system, not for understanding your patients.

State and local governments do their part to harm our health care system. Licensing regulations serve to entrench and protect the specialist system and fragmented health care. In other industries, business owners decide how to train their employees to do their jobs. Competition leads firms to adopt training methods that foster customer satisfaction. In health care, training methods are dictated by government licensing boards, and they foster high prices and inefficient staffing. A recent story tells you which side the regulators are on.

Mayor Thomas M. Menino embarked on a highly public campaign yesterday to block CVS Corp. and other retailers from opening medical clinics inside their stores, an effort that exposed a rift between Menino and the state's public health commissioner, a longtime ally.

...The decision by the state Public Health Council, "jeopardizes patient safety," Menino said in a written statement. "Limited service medical clinics run by merchants in for-profit corporations will seriously compromise quality of care and hygiene. Allowing retailers to make money off of sick people is wrong."

In a separate letter, Menino urged members of the city's Public Health Commission to consider barring the clinics from Boston.

I believe that our health care system could be a lot better. Unfortunately, the politicians who claim to be our friends are in fact our worst enemies.

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2 February, 2008

British maternity services now at breaking point

Your article detailed the Healthcare Commission's first review of mothers' experiences of maternity services, "the most comprehensive assessment of maternity services to be conducted in England" (Mothers-to-be get guide to the best and worst NHS care, January 25). Thirty-one hospital trusts were categorised as "least well-performing", which has become a euphemism for a lack of resources.

You reported "inadequate checks on whether staff intervene effectively to prevent unnecessary caesareans", and that "too many trusts do not adequately support mothers in breastfeeding and too few offer comfortable delivery rooms to encourage natural birth".

I was quoted in response to the prime minister's acknowledgment that "an extra 1,000 midwives were needed". But this number needs putting into a wider context. Ambitious guarantees were made last April in the government's new strategy, Maternity Matters, which aims for England to have a first-class maternity service by the end of 2009. However, the review highlights a shrinking maternity service and an overworked midwifery workforce - without pointing a finger at the maternity funding crisis.

The Royal College of Midwives has calculated that England needs 5,000 more full-time midwives to deliver the government's maternity strategy in the light of the current birth rate, the highest since 1993. In 1997 there were the equivalent of 18,053 full-time midwives in the NHS. The most recent figures, however, saw only a 4.5% rise by 2006. Meanwhile, between 2001 and 2006 the number of births rose by 12.7% - in short, midwives in 2006 coped with 71,935 more babies than five years earlier. The furore this week over the pressures that immigration poses for maternity services rams our point home - not that we are against immigration, but the government has to ensure there are enough midwives to cope.

Your article is correct in pointing out that "hospitals in the north scored particularly well and those in London did badly, with 19 of the capital's 27 trusts relegated to the bottom division". But in the capital the number of births increased by 16.1% over five years.

Moreover, there has been a drop of 16% in student midwife places over the past two years. Health secretary Alan Johnson did acknowledge that "more had to be done to modernise the service". But he needs to do his maths. Our members tell us that the gaps in service are basic. There aren't enough midwives or beds, and they hate that they don't have time to give the care and reassurance they want to provide for expectant mothers. They are reinforcing the review's findings of a "failure to recruit enough midwives for one-to-one care during labour".

We feel that maternity services are now at breaking point. Given the staffing shortfalls, we need real figures underpinned by the demographic changes facing this country - rising birth rates and the retirement of baby-boomer midwives - if the government is to honour its guarantees for maternity care. Otherwise we will be failing mothers, babies and their families.

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The failure of RomneyCare may have killed HillaryCare

On Monday, California Gov. Arnold Schwarzenegger's "universal" health-care plan was shot down by a committee in the state's Senate, 7-1. The most vociferous opponents were not fiscal conservatives, but labor unions that launched a last-minute revolt against its most crucial feature: an individual mandate that would have forced everyone to buy coverage.

This defeat has national political implications. Hillary Clinton, for example, has denounced Barack Obama for refusing to include an individual mandate in his health-care plan. Yet many California unions argued that a mandate would force uninsured, middle-income working families to divert money from more pressing needs toward coverage whose price and quality they cannot control.

The unions are correct: This is exactly what is happening in Massachusetts, where Mitt Romney enacted a similar plan two years ago as governor. (And Mr. Romney's plan is the inspiration for both the Schwarzenegger and Clinton plans.) The experience in the Bay State deserves a lot more scrutiny than it has been getting.

Massachusetts uses a sliding income scale to subsidize coverage for everyone up to 300% of the poverty level -- or a family of four making around $60,000. Everyone over that limit is required to pay for their own coverage if their employers don't provide it. All this has inflated demand, which, combined with onerous regulations on insurance suppliers, has triggered premium increases of 12% for this year -- double last year's national average.

No one is escaping the financial sting. The state health-care bill for fiscal 2008-2009 is expected to touch $400 million -- 85% more than originally projected. Still the state won't be able to fully shield those it subsidizes from the premium increases. But uninsured folks who don't qualify for government help really get pounded. Before the hike, the cheapest plan for uninsured couples in their 50s cost $8,200 annually. Now, unless government bureaucrats hand them an exemption, they might well find it cheaper to pay the penalty -- up to half the price of a standard policy -- than purchase insurance. That is, pay to remain uninsured. This is legalized extortion: TonySopranoCare.

The government response to rising premiums is, unsurprisingly, price controls. The Commonwealth Health Insurance Connector Authority -- the bureaucracy created to oversee RomneyCare -- is considering prohibiting underwriters from raising premiums more than 5% for unsubsidized plans, meanwhile requiring them to cover 40-odd benefits from hair prostheses to chiropractic services. If companies can't scale back coverage, they'll have to compromise care; and the Connector is perfectly willing to assist.

As reported in the Boston Globe, the Connector is encouraging insurance companies to include only a limited network of cheaper physicians and facilities in some plans to hold down premiums. Patients who wish to see more expensive providers will have to dig into their own pockets. Dr. Steffie Wollhandler, a professor of medicine at Harvard University, worries that the Connector will revive Gov. Romney's original idea of enrolling poor people in plans that only offer access to neighborhood health centers ill-equipped to treat anything beyond routine ailments. Forcing people to buy substandard care they cannot afford is not universal care, she says. "It is a hoax." And so Massachusetts is marching toward a system of two-tiered medicine -- the alleged market inequity that universal care is supposed to cure.

How about enforcing the mandate? In Massachusetts, non-compliers lose their personal tax exemption -- about $220 -- the first year, followed by fines in subsequent years. California was planning to garnish the wages or impose liens on the mortgages of the uninsured to pay for coverage. "This bill was like telling someone who is in need of help, 'I'm going to give you food, but I'm going to take away your clothes," Leland Yee, a Democratic senator from San Francisco, told the California Chronicle.

The problems with RomneyCare have prompted Mr. Romney himself to abandon it. And Mr. Obama is surely correct that part of the reason 45 million Americans are uninsured is not that no one is forcing them to buy it, but that they can't afford it. It may be too much to hope that Mr. Obama would embrace market-oriented measures -- such as deregulating insurance markets, giving patients more control over their health care dollars, and fixing the federal tax code to let individuals, like employers, buy health coverage with pre-tax dollars -- to bring down insurance costs. But unlike Mrs. Clinton, he at least seems to understand the perverse side effects of an individual mandate.

Should Hillary Clinton ever be in a position to bully people into buying coverage, a coalition of labor and fiscal conservatives might well do to HillaryCare what it just did to GovernatorCare.

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1 February, 2008

California nonsense dies

In handing Gov. Arnold Schwarzenegger his biggest legislative setback, members of a Senate panel expressed concerns Monday that his plan to cover most Californians without health insurance was inadequately funded and would worsen the state budget crisis.

But the legislation negotiated by the Republican governor and Assembly Speaker Fabian Nunez, D-Los Angeles, was unable to surmount several political hurdles beyond the annual tab, now estimated at $14.9 billion. A proposed tobacco tax drew high-powered opposition. The fact that raising taxes takes a two-thirds vote in the Legislature made finding financing a complicated exercise. Republicans never supported the measure. Democrats weren't on the same page. "It's really a misnomer to term this as a bipartisan effort," Sen. President Pro Tem Don Perata, D-Oakland, said after the Senate Health Committee voted to block the bill, AB X1 1.

Because the plan to provide coverage for 3.7 million of the 5.1 million permanently uninsured Californians was backed by the governor and Nunez, proponents tried to emphasize its bipartisan support. During a yearlong campaign for his No. 1 priority, however, Schwarzenegger was unable to persuade even one Republican lawmaker to join him.

Meanwhile, the Democrats on the Senate Health Committee who voted for AB 8, another bill to expand health care that Schwarzenegger vetoed last year, were unable to hold together after Nunez pushed AB X1 1 through the Assembly. Only one member of the 11-member panel – Sen. Mark Ridley-Thomas, D-Los Angeles – voted for it. Seven members voted no, including Sen. Dave Cox, R-Fair Oaks, and three abstained, including Sen. Darrell Steinberg, D-Sacramento.

Democrats who voted against the bill cited a report released last week by the Legislative Analyst's Office that concluded the plan could be underfunded by billions of dollars. They also expressed concern it would add to the state's projected $14.5 billion deficit. "You can say you're going to cover 800,000 more children, but if there's no money, you're not going to do that and it's cruel to raise such expectations," Sen. Sheila Kuehl, the panel's chairwoman, told reporters.

Schwarzenegger and Nunez maintained the plan would raise enough money to pay for itself. Their plan called for mandatory employer and employee contributions, a fee on hospitals, an additional $1.75 tax on a pack of cigarettes and leveraging the money to increase matching federal funds. Democratic opponents said the provision requiring most workers to contribute to the cost of their coverage would be unaffordable for some families. Republicans, meanwhile, warned that requiring most employers to contribute to their workers' coverage would force many small businesses to close.

In a statement, Schwarzenegger vowed not "to give up trying to fix (the state's) broken health care system." "If it were easy, California would have gotten universal coverage 60 years ago – that's when Governor Earl Warren's reform plan fell short by a single vote," the governor said.

Anthony Wright, executive director of Health Access, a statewide health care consumer advocacy coalition, noted the only significant new funding in AB X1 1 that was not in AB 8 was the proposed tobacco tax. Although some panel members said the bill did not have enough ways to raise revenue, "it seems it had one too many that raised additional opposition from the tobacco industry to kill it," Wright said.

The tobacco industry spent millions of dollars in 2006 to defeat a $2.60-a-pack tax increase for health care. There is no direct evidence the industry played a role in Monday's vote, but Nunez previously charged that tobacco had targeted some Democrats in the Assembly with unflattering mailers.

Betsy Imholz, special projects director for Consumers Union, the nonprofit publisher of Consumer Reports, said it's "really easy to kill health care reform because it's complicated." "So many interests were involved that when they began to fight among each other, it was easy for the plan to fall apart," Imholtz said. "We're disappointed to see it go down."

In a brief statement to the Senate committee, Nunez urged the panel to propose its own solution for California's health care crisis. "I would challenge the members of the Senate to come up with a plan that's doable, that can withstand the same type of scrutiny that (AB X1 1) was put through in this committee," the speaker said.

Perata, who advised members of the Senate panel "to vote their conscience," said the mounting budget deficit made it difficult to sell the bill to constituents. "There are going to be layoffs in this state," Perata told reporters. "There are going to be layoffs in school districts." The legislation, he noted, would have required a simple majority to clear the Legislature. Voters would have had to approve the financing. But it takes a two-thirds majority to increase taxes in the Legislature, which Perata said would be needed if there were a shortfall. A two-thirds vote requirement, he noted, already makes it difficult for the Legislature to pass a state budget on time.

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Australia: A corrupt government health boss with a bad memory

There seems to be an epidemic of bad memories among West Australian officials and politicians

THE return of WA Inc was felt with full force yesterday when Australia's highest-paid public servant was forced to resign following a damning corruption report linking him to former premier Brian Burke. The West Australian Government is now bracing itself for nine reports, to be released in the next three months, by the Corruption and Crime Commission, all involving Mr Burke's lobbying activities.

The CCC yesterday recommended that the Director of Public Prosecutions consider legal action against Neale Fong, the state's $565,272-a-year director-general of health. Dr Fong resigned shortly after the report was made public, saying he was embarrassed that he had not recalled 33 emails between himself and Mr Burke, but that they had been "totally innocuous". Dr Fong had told the CCC under oath that there was no personal or professional business relationship between himself and Mr Burke and that he had no recollection of any of the 33 emails.

The CCC recommended that consideration be given for Dr Fong to be prosecuted "arising from his representation of his relationship with former premier, Mr Brian Burke". The CCC claimed Dr Fong had engaged in three cases of misconduct, the most serious being that he disclosed to Mr Burke that the CCC was investigating a fellow senior officer in the department.

Corruption authorities have recorded and listened to about 13,000 phone conversations of Mr Burke related to several major lobbying deals. The calls were intercepted for 18 months from the beginning of 2006. Mr Burke himself was unaware all his phone calls and computer traffic was being monitored until he called before the CCC last year to give evidence under oath....

Yesterday's report stated that Dr Fong engaged in serious misconduct by disclosing a restricted matter to Mr Burke, namely that the commission was investigating a senior Department of Health official, Michael Moodie. The health chief was also reported to have engaged in misconduct by telling his minister, Jim McGinty, that he had no recollection of any emails between himself and Mr Burke and that he had no personal relationship with Mr Burke. The commission found evidence to the contrary. The report also found Dr Fong engaged in misconduct by failing to report the disclosure to him by Mr Burke of what the former premier claimed to be confidential cabinet information.

Commissioner Len Roberts-Smith QC said it was inconceivable that Dr Fong had not, could not and did not recall that there were any emails between himself and Mr Burke. A statement by the CCC said: "Although the investigation concerned the facts of Dr Fong's relationship with Mr Burke, there was no allegation against Mr Burke, his conduct was not the subject of the inquiry and the commission expresses no opinion about it in this report."

Dr Fong said: "I am embarrassed that I did not recall the emails from Mr Burke. However, I receive approximately 2000 emails and send 650 emails per month. I receive thousands of text messages, telephone calls and messages and pieces of correspondence every month."

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