Schwarzenegger putting his case

Gov. Arnold Schwarzenegger hit the road Friday to sell his health care plan, telling Los Angeles business leaders he thinks the state will approve a plan to cover 6.5 million uninsured Californians this year and that medical costs could drop as soon as next summer. In a discussion with the Los Angeles Area Chamber of Commerce, Schwarzenegger framed the health care plan as a way to reduce costs for businesses that already offer health care to workers. The Republican governor said existing policyholders bear the costs of expensive medical attention already given to the uninsured, which he called a "hidden tax." "Even though you are insured, don't think that you should not care about this issue," Schwarzenegger said. "Because you should be caring about this issue especially if you're insured because you are paying a 'hidden tax.' And that 'hidden tax' is a lot of money and we can eliminate that and reduce it down if we have everyone insured."

Schwarzenegger's plan would raise $12 billion, including $5.5 billion in federal funds, to extend health coverage to 6.5 million uninsured Californians. Employers with at least 10 workers and who do not provide health care would have to pay 4 percent of payroll to the state, while physicians and hospitals would also have to pay a percentage of revenues. Some Republican lawmakers criticized the proposal last week for placing new mandates on companies and health care providers. They called it a tax, a charge the governor denies.

The Los Angeles Area Chamber of Commerce has been one of the more receptive business groups in response to the governor's plan. The chamber's board president, David Fleming, said his organization supports the governor's efforts. "I think this plan represents a logical solution to a growing and major problem in this state," Fleming said by telephone. "We're the only nation in the world where health care is paid for by businesses, which puts American businesses at a disadvantage with those in other nations. With health care premiums going up every year, it's time to address the problem."

Scott Hauge, president of Small Business California, said employers are open to contributing to health care as long as the state also focuses on driving down specific costs. He said the health care plan should focus on preventive medicine, reducing technology costs and chronic disease management, in addition to examining how to pay for the uninsured.

The governor likened his proposed requirement that all Californians obtain health insurance to existing law requiring all drivers to have auto coverage. "When we say everyone has to have car insurance, there are still some people that don't, but if they get caught, then there will be some penalties," he said.

Schwarzenegger opened the meeting to reporters and broadcast his appearance online after visiting privately with chamber members for about 30 minutes. Besides addressing his health care plan, the governor talked about a legislative proposal to ban parents from spanking a child younger than 4 years old. "I have not looked at it yet," Schwarzenegger said. "I just think that one ought to address that issue. ... We are very fortunate that in America we are in a country where that is not a popular thing. Where I grew up, in Austria -- of course, 40, 50 years ago -- it was a much more common thing. Everyone got smacked, everyone got whacked with the yardstick, in school, by their teacher, by their parents, so it was just a much more cultural thing then."

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British referral management schemes damage patients' interests

Bureaucrats second-guessing a doctor's referrals and sending the patient somewhere else instead??

Referral management schemes pose a serious threat to patients' interests, argues Peter Lapsley, Chief Executive of the Skin Care Campaign, in this week's BMJ.

Referral management schemes are springing up across the NHS as a means of reducing primary care trusts' spending on secondary care services. The justification given for the introduction of the schemes is that they bring services "closer to home" - a mantra repeated often by the government at present. But trust managers admit privately that the true purpose of the schemes is to reduce costs in the face of the budget deficits so many of them are confronting, he says.

Typically, such schemes require that 80% of GPs' referral letters be reviewed in primary care and that 60% of cases should be retained within the trust. In many cases GPs are being offered financial incentives to participate in the schemes. Lapsley firmly believes that these schemes pose a serious threat to patients' interests. They introduce an extra step in the patient's journey, delaying the diagnosis and treatment of often complex and difficult diseases, he writes.

What is more alarming is that some primary care trusts now deliberately delay outpatient appointments, refusing to fund routine paper referrals seen within eight weeks of the date of the referral letter. In contrast, patients who can be booked into clinics directly through the Choose and Book electronic booking service can be seen within two to three weeks, no matter what their complaint. The schemes also remove any vestige of "patient choice," another government mantra, he adds.

In the case of dermatology, about 15% of GPs' consultations in Britain relate to skin disorders, yet the average undergraduate curriculum has only six days of dermatology, and only 20% of GP vocational training schemes include a dermatological component. Practice nurses receive no such training.

Referral management schemes therefore create a real risk that patients with skin diseases will be seen by clinicians who lack the necessary training and experience, greatly reducing the likelihood of prompt and accurate diagnosis, not least in respect of skin cancer, he argues.

The schemes are also insulting to GPs, second guessing their decisions. They undermine the viability of secondary care dermatology, and they remove any incentive for secondary care specialists to support or develop the role of the GP with a special interest in dermatology. The schemes may provide a short term solution to a short term financial problem. The risk, though, is that they will do lasting damage, he concludes.

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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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