SCREWY U.S. REGULATIONS

Two years ago, the University of Washington School of Medicine paid the government $62 million to settle a Medicare billing dispute. In addition to its legal expenses, the medical school paid more than $750,000 for a high-powered, outside committee to review what happened and write up a report. Obviously, the medical school learned an expensive lesson. But will the lesson help improve patient care? We doubt it.

The title of the 111-page report summarizes the emphasis: "Achieving Excellence in Compliance." The document uses the word "compliance" 620 times, and recommends a new objective for the school: achieving "a culture of compliance" in addition to the more traditional medical school goals of research, teaching and patient care. To implement the recommendations of the report, the school is spending money for more lawyers, more layers of staffing, re-educating physicians and more oversight of who bills for what and how.

Unfortunately, the process is eerily like that for many businesses where the Sarbanes-Oxley law has resulted in complicated, expensive and difficult-to-comply-with rules. Once upon a time, an organization could be successful by ethically providing goods and services to customers and clients. The ethical guidelines for this behavior were ultimately based on underlying and universal moral rules, such as those prohibiting stealing or cheating. Understandable and enforceable laws and contracts often reflected those ethics. Over time, many lost sight of the underlying moral code but still followed the ethical codes set up by business or professional organizations.

More recently, complicated laws governing business and professional behavior are causing increased emphasis on compliance to the often arbitrary rules, sometimes leaving common sense and ethics behind. Judges agreeing with new ideas put forth by trial lawyers or government prosecutors often defeat rather than fulfill justice. Many enterprises, probably now including the UW medical school, visualize these exceedingly complicated rules as an impenetrable briar patch. It's easy to understand why they now concentrate their compliance resources in the areas targeted by government enforcers. Because it's impossible to consistently comply with all the myriad rules, the goal becomes damage control; the modus operandi becomes risk management. Instead of being a uniform and solidifying bedrock underpinning civilization, law enforcement has become an unmarked minefield destroying lives and enterprises almost willy-nilly.

In medicine, Congress is now considering "pay for performance" and "best practices" incentives that would reward doctors for following government guidelines (i.e., rules) on how to treat patients with particular conditions or diseases. One difficulty with this government micromanagement is that the scientific studies used to establish the "best practice" rules typically include patients with a given condition, such as congestive heart failure and a narrow range of possibly complicating factors. Researchers do not further analyze patients with a significant complicating factor because it would take too many such patients to generate a statistically significant result. For these patients, there's no "best practice" science to unerringly guide the doctor in treatment. For example, a patient with heart failure might have a past history of a previous stroke and also come down with pneumonia on top of the heart failure. It would be rare for an up-to-date scientific study to account for even this relatively simple set of complicating factors. And, medical advances quickly outdate these studies.

In addition, research funds for promising but politically-incorrect treatment methods, such as chelation therapy and hyperbaric oxygen therapy, is cut off by the medical-political complex controlling almost all research grants.

Most people want doctors with experience in treating their condition rather than a technician treating them based on a printout from the best-practices computer.

There's a huge disconnect between the goals of compliance and excellent patient care. "Compliance" implies there's something to comply with, such as government billing and practice rules. But successful patient care often depends on creative insight. The practice of medicine is as much an art as a science. If it were only science and technique, we'd have high-school-graduate best-practices technicians following computer printouts rather than medical doctors taking care of patients. Why waste all that time and money for college plus five to ten years of medical training?

We agree that doctors should be moral, honest and ethical. But "compliant" as a primary motivation? Ethical should cover that base. The more energy and costs expended on compliance, the less is left over for patient care. The alternative is for increased costs of medical care, without any added patient benefit. Ironically, although the government insists that Medicare recipients get first class medical care at the same time it clamps down on medical costs, the result of more compliance efforts will be decreased access and higher costs.

If the University of Washington succeeds in "achieving excellence in compliance," it may avoid further government penalties, but patients will ultimately pay the price, both in the quality of care and dollars.

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Queensland hospital bed crisis continues despite political hot air

There seems to be NOTHING they can do to make their public medicine system work properly

As Premier Peter Beattie announced on Thursday that Queensland's health system had "turned the corner", 49 Queenslanders were on hospital gurneys in emergency departments statewide, waiting for proper beds. This was in spite of Queensland Health data showing that during the last six months of 2005 the five Brisbane public hospitals admitted fewer patients than in the same period in 2004. Admissions to the Mater General, for example, were down almost 20 per cent. The data shows all five hospitals have been operating at peak capacity for most of the past week. Statewide, this has contributed to dozens of patients every day being forced to wait in hospital emergency departments while staff struggle to find beds for them. Yesterday 64 people were waiting for beds; on Wednesday (the day before Mr Beattie's declaration) 72 were in limbo across the state.

So urgent has the demand for beds become that management at Queensland's largest hospital, the Royal Brisbane and Women's, has told staff to move discharged patients into a transit lounge to free beds, and that beds are not to stay vacant longer than 30 minutes. The situation is not confined to Brisbane, with most regional hospitals also forced to accommodate people in emergency departments while staff look for beds.

The number of public hospital beds in Queensland dropped from 10,115 in 1994-95 to 9340 in 2004-05. In this time Queensland's population grew by 25 per cent. The bed shortage is likely to hit the politically sensitive issue of elective-surgery waiting lists harder. Two new studies to appear tomorrow in The Medical Journal of Australia have found hospital and emergency department overcrowding to be associated with increased mortality; and show the hospital bed closures have resulted in hospital occupancies over 95 per cent.

Mr Beattie yesterday continued to defend his proclamation that the state's health system had "turned the corner". He said securing new pay deals for doctors and nurses was "absolutely fundamental" to turning the corner to improve health. "If you haven't got doctors and nurses it doesn't matter how many beds you've got you'll never reduce waiting times," he said. "The core issue here was to get a pay package that satisfied our doctors and satisfied our nurses. They were the two big challenges - and to make sure, we trained more doctors for the future." Mr Beattie said hospital bed numbers and waiting lists were among the "longterm, systemic" issues that would take time to resolve because of Queensland's population growth. "That's why we had a five-year plan," he said.

Queensland Opposition health spokesman Bruce Flegg said all of Queensland's major hospitals "are suffering serious bed shortages that is causing a critical situation of access-block in emergency departments". "Clearly Queensland Health has not turned the corner, and Mr Beattie should be ashamed of himself for trying to pull the wool over the eyes of Queenslanders," Dr Flegg said. Australian Medical Association Queensland president Steve Hambleton said yesterday that "the health system is nowhere near fixed yet". He said the $1 billion pay rise over the next three years, given to nurses this week, was "recognition of their value to the system, but the money was not a solution alone". "Fixing Queensland's health system will depend on the co-operation of all those in the health profession," Dr Hambleton said.

Source

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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