California: Medicare auditing program halted after it finds abuses

It wasn't supposed to do that: 'Pause' declared after procedure claimed rehab hospitals wasted tens of millions on unneeded care

Medicare officials have declared a temporary "pause" in a controversial auditing program that has put a strain on dozens of California rehabilitation hospitals forced to surrender tens of millions of dollars on allegations that the care they provided elderly patients was medically unnecessary. The pause, announced in a conference call to California hospitals Wednesday by the Centers for Medicare and Medicaid Services, is expected to last at least through October, said Patricia Blaisdell, vice president of medical rehabilitation services for the California Hospital Association, who participated in the call.

The association has been the leading critic of the program and the California contractor, Atlanta-based PRG-Schultz International, because of its rejection of almost all Medicare claims involving elderly patients treated at rehabilitation hospitals after knee or hip replacement.

The decision comes as the first wave of appeals of those cases is hitting administrative law judges for the Department of Health and Human Services. The judges are reversing many, if not all, of those decisions on grounds that it is impermissible under departmental rules for the auditors to call up cases more than a year old without good cause.

Blaisdell called Wednesday's announcement "an encouraging development." "We recognize this as an effort by CMS to step back and take a breath," Blaisdell said. But Rep. Lois Capps, D-Santa Barbara, who has led the state's powerful congressional delegation in complaining vigorously about the way the audit program has been carried out by PRG-Schultz, said she will introduce legislation soon to halt the audit program before it expands nationally by 2010. "We want to put a moratorium on this whole pilot program," Capps said in an interview. "We are not going to allow it to become permanent until all the problems that appear to be developing are fixed." Capps said she expects the legislation to be ready for introduction in a few weeks. Earlier, Capps and Rep. Devin Nunes, R-Tulare, orchestrated a letter signed by three dozen of the state's House members complaining about the way the program has been handled.

The audit program was established as a test by Congress in 2002 in an effort to reduce unnecessary Medicare spending. It took effect in 2005 in three states -- California, New York and Florida, all high-cost Medicare states. But rather than being paid a fee for their work, auditors are paid commissions of between 25 percent and 30 percent of the money they collect from rejecting claims as far back as five years. In the case of PRG-Schultz, its contract permits it to keep the bounty so long as its decisions are not overturned at the first and second stages of administrative review. The reversals, however, are coming in the third stage.

Andrew House, spokesman for Nunes, said PRG-Schultz told CMS that it will relinquish its right to keep its commission on all decisions reversed on appeal. Neither PRG-Schultz nor CMS responded to questions Wednesday. During the pause, CMS will have an independent contractor review PRG-Schultz's work, House and Blaisdell said. "We don't object to audits," said Blaisdell. "What we object to is the way it's being implemented. There are no physician reviews, and there are no individual case reviews. Ultimately, they are denying cases that were appropriate, and it will cause a hardship on providers and create a lack of access for patients."

That already is happening. The Rehabilitation Institute at Santa Barbara is being acquired by Santa Barbara Cottage Hospital in part because of financial problems caused by the audits. Officials at Glendale Adventist Medical Hospital said recently they are turning away Medicare patients because of the financial risk posed by the audits.

PRG-Schultz is struggling financially in its core business operations and is looking at the California Medicare contract and the expanded program as a promising source of continuing business. But in its quarterly financial report last month, the company alluded to problems on the horizon with the federal program, citing risks associated with "changes in the political, legislative and regulatory environment." Among the investors in PRG-Schultz is Blum Capital Partners, headed by Richard Blum of San Francisco. Blum is married to Sen. Dianne Feinstein, D-Calif.

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Australia: It's BYO nurse at collapsing NSW government hospital

But some people see where the problem lies

The family of a dying man was forced to use his credit card to pay for a private nurse in a public ward at Royal North Shore Hospital because there were not enough staff to look after him. Phil Lindsay, 87, a World War II veteran, had less than a week to live when his wife became disgusted with the lack of care. She hired an agency nurse for four nights because the family did not want him left alone.

His cash-for-care story comes amid a wave of complaints about lack of staff and resources at the hospital after Jana Horska, 32, miscarried in the toilets of the emergency department this week. A former doctor at the hospital said funding was cut because "people on the North Shore had money" and could afford private health care. Also yesterday:

* Dr Simone Matousek, a registrar at Royal North Shore, said there was "no commitment to care", and she could do three to four more operations a day "if I did not have to deal with this grossly inefficient system". "Many people work shifts in the hospital and leave when their time is up, not when the patient has been properly cared for," she said. "Fire all the middle management in hospitals who have created this environment and contribute nothing and you will have plenty of hospital funding."

* The federal Health Minister, Tony Abbott, ordered his department to investigate claims the NSW Government steered public funding away from the hospital.

* The Workplace Relations Minister, Joe Hockey, demanded the NSW Government launch a judicial inquiry into the claims.

* The NSW Health Minister, Reba Meagher, was forced to announce that pregnant women attending emergency departments would be transferred to maternity units rather than wait for treatment in crowded waiting rooms.

Budget documents, seen by the Herald, show the Royal North Shore/Ryde Health Service went $18 million over budget in the previous two financial years. Despite this its budget was cut by $13 million from $359 million to $346 million for 2007-08, the Opposition health spokeswoman, Jillian Skinner, said.

Mr Lindsay's case is one of many reported to the Herald. His daughter, Christine Rijks, said he had been suffering kidney failure when he was left in the emergency department for several hours in July 2005. The former Catalina gunner was later admitted to a four-bed ward, "causing my mother and my father more stress than his inevitable death". "It was so difficult to see him waiting," Ms Rijks said yesterday. "We knew he didn't have long to live. We became too frightened to go home at night because we just didn't know if anyone was seeing to him. We hardly saw any staff during the day and we were worried sick about what would happen when we went home."

Her mother, Hilarie Lindsay, said she had been asked to wash her husband, to crush his pills and dress him each day. "It was very distressing. I know the nurses are stressed out of their minds, but I was exhausted by the end of every day because we were the ones nursing him." Mrs Lindsay said she took her husband's credit card and booked an agency nurse, who stayed with him overnight. Ms Rijks said: "My parents were both under a delusion that his war service veteran's gold card would provide the best level of health care in Australia. Of more use was the American Express Gold Card."

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Australia: Another mother miscarries after being ignored by NSW government hospital

Two babies lost in one night

A SYDNEY mother has spoken of the harrowing ordeal of being shunned by nurses at Royal North Shore Hospital while miscarrying - just minutes after a 14-week pregnant Jana Horska miscarried in the waiting-room toilet. The shocking revelation follows a string of horror stories emerging from the hospital, which has been labelled one of the worst in Sydney. The Daily Telegraph can reveal that on the same night Ms Horska miscarried in the emergency department's toilet, another expectant mother was also forced to wait while miscarrying.

Leng Liu and her husband Steve arrived at the hospital emergency ward on Tuesday night not realising the horrific circumstances that had just unfolded only minutes earlier. In acute pain and eight weeks pregnant, Ms Liu, 46, of Chatswood was seen by a nurse at 9.30pm and despite bleeding heavily was told to wait her turn. After an agonising two hour wait, Ms Liu's husband asked the triage nurse why his wife had not been admitted. "We were told we needed an ultrasound but that couldn't happen until the next morning," he said. "I decided to take my wife home and that is where she miscarried. "That nurse would have been happy to keep us waiting till God knows when and had we have not gone home we would have lost the baby there in the hospital toilet."

The couple decided to speak publicly after hearing of Ms Horska's ordeal. The 32-year-old from Mosman miscarried in the hospital's toilet after being forced to wait two hours in emergency. The Daily Telegraph has been inundated with horror stories from patients seeking help at the hospital. Just 18 months ago Angi Milos, 30, was handed a nappy and forced to sit in the waiting room while she miscarried. She was 14-weeks pregnant and crippled with pain when she arrived at RNS. After going to the toilet three hours later, she discovered she had lost her baby in the same toilet Ms Horska lost her baby. "I thought I had been just left there to bleed," she said yesterday. "They could have showed a little bit of compassion."

The State Government is refusing to hold a full investigation into the hospital, instead calling for an inquiry only into Ms Horska's ordeal. In Parliament yesterday, Health Minister Reba Meagher defended her decision not to fully investigate RNS. The hospital's director of trauma Tony Joseph also hit the airwaves yesterday to defend his staff. He said Ms Horska's miscarriage could have happened "in any emergency department in this city, in this state and in this country".

"I feel extreme sympathy for the lady ... and I apologise on behalf of the health system for what has occurred but for us working in emergency it's actually not surprising that this would happen," Dr Joseph said. Dr Joseph refused to apologise on behalf of the hospital, instead blaming a lack of government funding. "We've been telling governments of various levels of this problem for a number of years and we don't see much solution for it," he said.

Ms Meagher's refusal to launch a full investigation outraged Therese McKay, whose husband Don died last May as a result of appalling conditions at RNS. Mr Mackay died the day he left Royal North Shore after being admitted a month earlier for what should have been a routine operation to have his lungs drained. Instead he was exposed to third world conditions and mistakes such as having his breathing monitor switched off. Mrs McKay and her daughter Melissa flew from their Port Macquarie home to confront Ms Meagher. She described Ms Meagher's response to her presence in Parliament as "disgusting".

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The class-war mentality behind the baby deaths

A FORMER senior doctor at Royal North Shore Hospital whose budget was slashed just before a state election says she was told people living in that area could afford to pay more. Dr Linda Dayan, who worked in the hospital's sexual health department for 11 years, said the cutbacks cost her her job. "Last year we had a massive budget cut in our area which was to halve the budget in two years," Dr Dayan told ABC Radio today.

"I called a meeting at the end of last year to speak with the deputy CEO and the woman who was directly under her ... to ask them why our budget was being halved," she said. "One of the women in the meeting said ... 'The new redistribution formula takes into account socio-economic class so everything has been cut in this area.' "She said, 'People in this area can afford to pay more'." [The North Shore is a generally affluent area of Sydney but not everybody who lives there is rich. So why should poorer people living there be discriminated against because some of their neighbouirs can and do use private hospitals? Is it to punish people for living in a somewhat nicer area? It probably is. Leftists think that only they deserve to live the good life. Witness the special treatment given to the "Nomenklatura" in the former USSR]

Dr Dayan, who now works in private practice, has called for a public inquiry into hospital funding. "I wonder if it was part of a political agenda as well - we were coming up to a state election and I was also told ... that maybe they didn't need votes in that area," Dr Dayan told Macquarie Radio shortly after speaking on ABC radio. "Things started to go from bad to worse. (The hospital) couldn't get new positions filled ... and at the last minute before the election those positions were filled so it looked on paper as if there new staff coming on board."

Services at Royal North Shore Hospital have come under the spotlight this week after a 14 weeks pregnant woman went without treatment for two hours and had a miscarriage in the emergency department toilets on Tuesday. Jana Horska was left holding her live foetus in the toilet, sparking outrage among medical groups and the community generally .

Dr Dayan spoke specifically about funding for the hospital's sexual health clinic, but said she was told there was an intention to cut budgets across all services. "Our figures were exactly the same as Western Sydney - they had $4 million, we were slashed to $2 million," she said. "Our figures were the same, our need was the same and yet the figures weren't taken into account. "I was told by an unnamed source that the guts of it was they had to cut $20 million of the budget."

A spokesman for NSW Health Minister Reba Meagher said hospital funding followed strict guidelines set out in the Australian Health Care Agreement, providing equal access to services regardless of where people lived. [Sounds like a barefaced lie]

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Doctor vetting blasted

AUSTRALIANS can't trust medical authorities to hire properly trained doctors, according to Federal Immigration Minister Kevin Andrews. Mr Andrews has made the claim while requesting the Medical Board of Queensland review its procedures for hiring overseas trained doctors. He has insisted on "stringent employment verification checks" before new doctors are employed.

Gold Coast doctor Mohammed Asif Ali was sacked last month for disgraceful conduct after lying on his resume about his medical credentials. In a letter to chair of the Medical Board of Queensland, Dr Erica Mary Cohn, Mr Andrews doesn't refer to the sacking directly. But he says "a recent case" had highlighted to the Australian Government the risk to Australians' quality of health care through "inconsistent registration processes across different jurisdictions".

Mr Andrews also refers to "less than thorough" employment vetting processes. "In order for Australians to have confidence in their overseas trained doctors, they need to have full confidence that these doctors have undergone a rigorous assessment process," he said. "Given this case, I do not believe that Australians can be fully confident in the assessment system that currently exists."

Mr Andrews said the Council of Australian Governments had implemented a new national system for registration of health professionals and the accreditation of their training, to be operational by July 2008. "Until this process is complete, I believe it would be beneficial to review the processes by which employment backgrounds and qualifications of overseas trained doctors are assessed," he said. "As part of this review, I am seeking your assurances that the Medical Board of Queensland is undertaking the most stringent employment verification checks and qualification assessments in order to ensure the integrity of this program."

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How The Swiss Do Health Care

Everyone knows our health-care system, superior as it is in so many ways, is too expensive, too bureaucratic and wasteful. Basically, we hand over about $2.2 trillion each year to hospitals, insurance companies and government paper-pushers -- and then we let them micromanage our health care like we are helpless babies, not rational consumers.

Everyone also knows by now that Canada’s “free” national health care system -- like its sibling socialistic systems in Britain and France -- is a just another Big Government fraud. So can any wealthy, modern country get health care right without resorting to socialism? Yes.

You never hear it touted by the media but Switzerland uses market forces, not government rules and red tape, to create a private, affordable, high-quality health-care system for its 7.5 million citizens. And it spends 40 percent less per capita than we do. Sen. Tom Coburn, an Oklahoma Republican, a fervent fiscal watchdog and a practicing physician, knows all about the Swiss system. Much of his proposed health-care reform bill -- the Universal Health Care and Access Act -- is modeled on it. Coburn’s plan, a major overhaul that can be found at coburn.senate.gov, is complicated, controversial and in no danger of becoming law anytime soon, if ever.

The bill's key elements include achieving universal health-care access by using tax credits to pay for individual or family insurance, phasing out reliance on employer-based insurance, allowing people to choose their own doctors and health insurance and stressing preventive care.

On Wednesday, Sen. Coburn explained why he likes the Swiss system, which operates sort of like our car insurance: You must buy health insurance but you can choose among many plans from many private companies. Since every Swiss is covered, Coburn said, there is no cost-shifting -- i.e., no hidden subsidizing of those who don't have insurance at all or don't have enough. Cost-shifting costs Americans about $250 billion a year, Coburn said. Ending it would save a family of four about $4,000 a year.

Another virtue of the Swiss way, Coburn said, is that it has fostered a range of innovative insurance products. For example, there are five-year policies that reward customers with lower and lower rates if they do the preventive things the company asks. A third virtue, he said, is a national high-risk pool that all insurance companies contribute to that essentially protects companies from suffering heavy losses in a given year.

Fixing America's health care won't take more money, said Coburn, who notes we already "pay too much. ... One out of every $3 we’re spending today didn’t go to help anybody get well and doesn’t prevent anybody from getting sick." "What we need to do is we need to start changing our paradigm to prevention instead of treating chronic disease. That’s what has happened in the Swiss system, and that’s why their costs are not going up."

Switzerland is tiny and doesn't have our social problems. But Coburn says its consumer-driven approach -- which is transparent to consumers in price and quality -- would work here. Coburn knows markets aren't perfect. But he knows why the Swiss system works so well: "It forces people to shop, it forces people to make decisions. ... The point is, markets work -- if, in fact, we’ll trust them."

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NHS rationing rife, say doctors

Rationing of NHS treatments is becoming more widespread, a survey of GPs and hospital doctors suggests. Doctor magazine asked readers about rationing. Of 653 answering questions on consequences, 107 - 16% - said patients had died early as a result. More than half - 349 - said patients had suffered as a result. This compared with one in five in a similar survey conducted nine years ago. The government said decisions had to be made on which treatments to provide.

The magazine asked 12,000 of its readers a variety of questions with between 473 and 857 replying to each one. Doctors said more debate was urgently needed over what should and should not be rationed. They reported not being allowed to prescribe drug treatments including smoking cessation drugs and anti-obesity treatment. They also reported that local NHS trusts had been placing restrictions on fertility treatments, obesity surgery and a host of minor operations, including those for varicose veins.

The magazine said the findings of the latest poll showed rationing was becoming more widespread. A similar survey nine years ago showed that a much smaller proportion - one in five, compared to half - were aware of patients who had suffered due to rationing.

Rationing has become a sensitive subject in the NHS. Independent advisory body, the National Institute for Health and Clinical Excellence, makes recommendations on new, expensive treatments. But with limited budgets, local trusts are often forced to cut back on other treatments to keep pace with the recommendations. Many experts fear the situation will get worse with increasing demands on the health service made by the ageing population and expected advances in medicines.

Richard Vautrey, deputy chairman of the British Medical Association's GPs committee, said: "There is not much honesty and openness about this. "The NHS could spend whatever you gave it, but it obviously works with a limited budget so we urgently need to have a debate about what can be provided. "Trusts are already being forced into this but the political parties are not talking about it."

And Dr Michael Dixon, chairman of the NHS Alliance, which represents NHS trusts, added: "Rationing is the great unspoken reality. "The only people who refuse to mention the 'r-word' are the media and the politicians, who continue to want to promise everything for everyone in order to win elections."

A Department of Health spokesman said it was not trying to avoid the issue. "The NHS has received an unprecedented funding boost in recent years but finance is not endless and hard decisions will always have to be made about which treatments to provide." But he added: "Doctors and nurses make these clinical decisions with patients - not managers or politicians."

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NY: Get a lawyer to deliver your baby

It was one of the saddest decisions of his life. Tamer Seckin, who had spent 20 years working as an obstetrician-gynecologist in Brooklyn, was faced with the prospect of a 14 percent hike in his malpractice-insurance rate, so he decided four months ago to stop delivering high-risk babies. "Just today, I had to tell a woman I'd been treating for years that when she goes into the delivery room, I won't be there," said Seckin, who is the chief of gynecology at Kingsbrook Jewish Medical Center. "This is what I'm trained for, but I can't afford to do it anymore."

And he's not alone. The American College of Obstetricians and Gynecologists and the Medical Society of the State of New York both say that, with malpractice-insurance premiums rising, the dwindling number of OB/GYNs who can afford to practice has become a crisis, particularly for risky patients such as older women or those with medical conditions. "The impact of these rate hikes is tremendous," said Donna Williams of ACOG. "We're seeing many OBs who aren't willing to stay in practice because they just can't afford it."

Nationwide, malpractice-insurance premiums for OB/GYNs constitute about 5 percent of expenses, Williams said. In New York state, they are 36 percent. According to an ACOG survey, in the past four years, rising malpractice premiums have led 8.7 percent of New York state OB/GYNs to stop practicing obstetrics; 12.6 percent have decreased the number of deliveries they perform. And although the total number of births in New York City was down by 6,697 between 1995 and 2003, those requiring a Caesarean section - and a trained obstetric surgeon - rose by more than 3,000. At the same time, the city's supply of practicing OB/GYNs fell by 6 percent.

Edward Amsler, of the Medical Liability Mutual Insurance Co., says most of the blame lies with the tens of millions of dollars New York juries award families of disabled children.

Gov. Spitzer has convened a task force to find a compromise involving the interests of insurers, trial lawyers, doctors and patient-advocacy groups. "The line between a disaster and a happy ending is very thin in the delivery room," Seckin noted. "Events turn rapidly in a way you can't always control, and having an experienced doctor there is the best way to avoid disaster."

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Another public hospital disgrace in Australia

Pregnant woman ignored: Miscarries in hospital toilet

A PREGNANT woman miscarried in a emergency department toilet while waiting for medical help at Sydney's Royal North Shore Hospital, her family says. Despite complaining of acute pain, the 32-year-old woman was not seen by a doctor or given painkillers at the hospital overnight, Macquarie Radio reported today.

The woman's husband, identified as Mark, said his wife, Jana, had already had one miscarriage this year. He said Jana went to the hospital about 6.30pm (AEST) yesterday because she was experiencing similar symptoms to when she had the earlier miscarriage. Mark said that after Jana had been waiting more than an hour at the hospital, he was told by a triage nurse there was nothing they could do, and they should just wait in the queue.

"In the course of our waiting, she's ended up on the floor in a squatting position .. with her hands wrapped around her legs ... directly in view of the administration section of the emergency ward. "She's grimacing in pain and nothing's being done."

Jana then went to the toilet and stayed there for a while, he said. "Next minute, I just hear a scream and a smash, and I jumped up, and I raced into the toilet, and ... I just couldn't believe the scene in front of me. "It is my wife ... sitting on the toilet, screaming ... an image in my mind I'll never be able to get out, the look on her face, screaming, tears, hysterical, pants around the ankles ... holding a live, live mind you, live fetus in her hands ... with blood everywhere."

The woman's husband complained to emergency staff about the pain his wife was experiencing, but was repeatedly told to sit back down and wait, the report said. The man's cousin, identified only as Peter, said on Macquarie Radio that the treatment they received was disgraceful.

"When we weren't looking she walked off into the toilet and had a miscarriage," he said. "People have come running (from) everywhere. "I can't go into the finer details, it's just so gruesome, mate. It's just something I wouldn't say on air. "She's holding the little fetus in her hand, basically, and was wheeled out of the toilet in front of this packed waiting room. "Not only that, but once they found her a bed they left her lying with the fetus between her legs for one hour."

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Walk-in health clinics flourishing, but many doctors skeptical of care

Tatiana Fredericks needed treatment for minor pain last week, only to learn her doctor had the day off. Mary Ann Arman just moved to South Florida from Texas and learned her kids needed more vaccinations to start school. Both ended up at a walk-in clinic in Pembroke Pines, one in a fast-growing but controversial breed of retail health outlets that promise convenience, speed and low prices. Offering a new choice to the uninsured, clinics are trying to carve a niche handling minor care such as infections, colds and burns. But the clinics — often in drugstores, supermarkets and discount stores — have drawn heavy fire from critics who say they undercut a pillar of m edicine: Patients do best seeing a doctor who knows them.

Some doctors argue that they lose touch with patients who go to retail clinics, that most clinics are run by advanced-trained nurses working alone, that they promote superficial care without follow-up and that they bring sick people near healthy shoppers.

Florida, with many uninsured and transient residents, has emerged as a key start-up area for walk-in clinics in retail stores. The concept is so untested that physicians are divided and not sure what to tell patients who want to go. "It's not really well defined when it's advisable to use these places or when it's not," said Dr. William Hazel Jr., a board member of the American Medical Association from Virginia. "We urge caution. We do see problems with this type of medical care. There's no continuity."

Fredericks sees a role for them. The day her regular doctor was gone, the office worker, 23, dreaded going to an emergency room to wait for hours and pay hundreds. For a sudden illness in the past, she had seen a doctor at a free-standing, walk-in clinic called Solantic, so she went back. "I believe in having a regular doctor. But I felt I needed to get this addressed immediately," Fredericks said. "The clinics, they're just an easy way. I waited 10 minutes and the price is right." She paid $50.

Free-standing walk-in centers have been around for decades, but the rapid spread of nurse-staffed clinics in retail stores in the past year has fueled more opposition to the walk-in model. At least 520 walk-in clinics have opened in U.S. retail stores, and their trade group, the Convenient Care Association, predicts more than 700 this year and 5,000 eventually. Florida has licensed 47 with 15 in the works, according to the Agency for Health Care Administration.

CVS is the biggest player with 262 clinics, including 12 in Broward and Palm Beach counties. Wal-Mart has 76 and plans for 2,000. The chain simply leases space to operators, including the tax-assisted North Broward Hospital District, which next month plans to open its first clinics in South Florida stores, in Lauderdale Lakes and Coral Springs. Publix has 33 clinics, including four in South Florida. Winn-Dixie has three in north Florida. Walgreens has 60 and Target 17, none yet in Florida.

Typically, the clinics are open seven days a week until 8 p.m. No appointments are needed and the average wait is 15 to 25 minutes, the trade group reports. Most have sprouted in suburbs where families usually have health insurance, and 50 to 70 percent of clinic users are covered. Insured patients face a co-pay of about $20. Uninsured or cash patients pay $50 for a basic visit and up to $250 for tests or procedures. Services such as vaccinations start at $20.

Clinics may boast service seldom seen in medicine. Some call patients on their cell phones when a nurse is available, so people can shop or get coffee instead of waiting. Some let patients call ahead to get on a waiting list. "They love that. It's kind of like retail applied to health care," said Karen Bowling, chief executive of Solantic, a Jacksonville chain with 10 freestanding clinics and three in Wal-Marts. Operators contend clinics may relieve crowded hospital emergency rooms in South Florida and nationally, where rising numbers of uninsured patients have boosted traffic.

Some walk-in patients have had no prior contact with a doctor and otherwise would not have bothered seeking treatment. Clinic operators said they urge all patients to get a regular doctor. "Patients need more than one access point to the medical system and our clinics are here if people need that access," said Michael Howe, chief executive of the CVS subsidiary MinuteClinic.

But critics — mainly doctors — say clinics fragment medicine as patients see multiple health providers, none of whom has a complete picture of a patient's health. That raises the risk of drug interactions or missed clues to a serious illness.....

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GOVERNMENT HEALTHCARE IN AUSTRALIA

Below are five reports from within the last week. QLD is the State of Queensland; VIC is the State of Victoria; NSW is the State of New South Wales; SA is the State of South Australia

QLD: Ambulance death coverup

A QUEENSLAND Ambulance Service report into the death of a young heart attack victim was shredded, rewritten and a new version given to the Coroner's Office. Sources have told The Sunday Mail the original report into the death of Burbank man Vito Catenaro, 39, was damning of QAS management and its handling of the controversial case. Mr Catenaro died in June last year after his wife Silvana tried in vain to get resuscitation advice from a Triple-0 operator, a nearby ambulance was sent to another address, and eventual medical help was delayed more than 30 minutes.

Mrs Catenaro said one of Commissioner Jim Higgins' assistants admitted to her that the service had bungled at every turn, and apologised. But ambulance insiders said QAS management was now trying to shift blame. "Unhappy with the outcome which revealed a huge system f--- up, the managers ordered that the report be rewritten," a source said last week. "When the ops managers refused, the report was destroyed and a new player brought in to rewrite the facts. "Interestingly, the ethical standards unit rep advised the original investigators to keep copies of the first report handy in the event that it leaked."

The source said management was "in a panic" after new Premier Anna Bligh ordered an audit into the service. The original report was written by highly respected QAS manager Stewart Merefield, an Australia Day Award winner with more than 25 years' ambulance service. Mr Merefield declined to comment yesterday.

A QAS insider said Mr Merefield was ordered by senior ambulance management to rewrite his 60-page report so it was less critical. When he refused, they said someone else would rewrite it and he would be forced to sign. "Mr Merefield refused to play their game because he did not want to perjure himself to the coroner," the source said.

The insider said management and legal counsel ordered that the original Merefield report and all email correspondence be destroyed. Another manager with no paramedic experience was brought in to do the rewrite. The second report was handed to Deputy State Coroner Christine Clements only recently - 15 months after the death - despite repeated requests from the coroner's office, police and Mrs Catenaro to speed the process.

A spokeswoman for Ms Clements said she had not had a chance to read the QAS report to determine whether an inquest would be held. A spokesman for the commissioner admitted a preliminary report was done. "However, the commissioner requested other matters be pursued to ensure all aspects of the investigation were fully canvassed before a final report was submitted to the State Coroner," he said. A spokesman for Emergency Services Minister Neil Roberts said the second report was more in-depth and produced significant recommendations, including counselling and retraining of some staff. He strenuously denied claims that there were orders to destroy the original report.

Mrs Catenaro said she hoped the coroner would investigate so "this sort of failure never happens again".

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VIC: Negligent public hospital treatment of injured woman

An 8-hour wait to deal with a serious head injury is inexcusable and the consequences have been severe

THE family of a critically injured Portland woman, forced to wait eight hours to be admitted to a Melbourne hospital, have joined a campaign for a rescue helicopter for Victoria's southwest. Carolyn Meerbach remains in a coma almost six weeks after she was struck by a car while on her morning walk around Portland with her husband, Joseph. While she was taken by ambulance to the Portland hospital almost immediately after the horror crash, the Melbourne-based helicopter that flew her to the city was not called until almost four hours later.

Her brother-in-law, Keith Meerbach, has joined a 10-year campaign for a rescue helicopter to be based at Warrnambool or Portland. He said he believed Mrs Meerbach's injuries had been worsened by the delay in her undergoing surgery at the Alfred. "There's not a lot of doubt she would be better off is she could have had the pressure in her skull relieved earlier," Mr Meerbach said. He said his 46-year-old sister-in-law had been bleeding into her brain and was now on full life support at the Alfred.

Metropolitan Ambulance Service Chief executive officer Greg Sassella said he was confident Mrs Meerbach's care was not compromised by the air ambulance being based in Melbourne

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NSW: Hospital keeping patients in old storage rooms

ONE of Sydney's busiest hospitals is so under-resourced that patients are being squeezed into storage rooms for treatment. Nurses at the Royal North Shore Hospital at St Leonard's report critical understaffing and that 100 positions for registered nurses and midwives are vacant.

The hospital has launched "treatment rooms'' to relieve the burden on emergency beds. But the new rooms are little more than a hospital bed stuffed into an old storage room. Frustrated nurses are threatening industrial action. They could call an emergency union meeting as early as this week, claiming they are being pushed too hard to pick up the slack. "It's a shambles," said one highly placed nurse, who did not wish to be identified. "There is barely enough room to walk around the beds, let alone treat people properly." The nurse said her colleagues were working up to 19 hours overtime every week to fill the gaps left by the vacant positions. "We are worked off our feet," she said. "We have to do so much overtime to meet targets." The nurse said her colleagues were seriously considering industrial action to improve their working conditions.

Ambulance officers, speaking through the Health Services Union, confirmed that patients were being treated in inadequate rooms with little room to move.

Northern Sydney and Central Coast Health acting chief executive Terry Clout said the hospital was actively recruiting to try and fill the vacant positions. "While international and national nursing shortages are impacting on our ability to fill these vacancies, extensive marketing and recruitment strategies are being put in place to ensure we fill (them) as soon as possible," he said.

Mr Clout confirmed the hospital runs treatment rooms that are used when the emergency department exceeds its capacity. "Clinical treatment rooms in wards at Royal North Shore Hospital are being used to accommodate patients, in response to periods of high-level demand," he said. "The use of these rooms was introduced as a capacity-management strategy in 2000, to prevent patients being kept in the emergency department when its capacity to meet demand has been exceeded."

Opposition health spokeswoman Jillian Skinner said that conditions at the hospital were "disgraceful". "I have had many phone calls and contact from staff about the lack of morale in that hospital. The nurses say the only thing that keeps them there is a commitment to the patients and each other," she said. "Royal North Shore is particularly bad. The place is disgraceful in terms of the physical condition. It's dirty, seedy and rundown."

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QLD: New heart defibrillators are duds

EXPENSIVE new life-saving defibrillators - which cost the State Government more than $1.5 million - do not work. The Queensland Ambulance Service confirmed yesterday the new defibrillators had to be upgraded before they could be rolled out.

It is another major embarrassment for the Government after Emergency Services Minister Neil Roberts boasted in State Parliament this month about the devices. "The message that I want to give to the community is that we need to extend and broaden the range of locations where we have defibrillators... (they) are life-saving equipment. "When you are talking about cardiac arrest, every minute and every second count," Mr Roberts said. He also said $2.5 million had been allocated in the 2007-08 Budget for 240 new defibrillators "to ensure our paramedics are able to access the most modern and reliable equipment for patient care".

A defibrillator, which costs between $10,000 and $20,000, administers electric shocks to try to restart a heart that has stopped. The Sunday Mail revealed in April that faulty defibrillators had been linked to at least three deaths in Queensland since 2005. In March, a 38-year-old Mitchelton man died after the defibrillator in the ambulance taking him to Royal Brisbane Hospital did not work. New devices became a priority and were part of the record funding for the QAS announced by then-treasurer Anna Bligh in her June Budget.

But there have already been problems with the first shipment of defibrillators. Paramedics told The Sunday Mail last week that they had tried to replace their faulty old devices, but had been refused. "People die due to lack of good equipment .... it is locked up... they have pallets of new ones in a warehouse," said a frustrated ambulance officer. A spokesman for Ambulance Commissioner Jim Higgins said: "the QAS has 83 new defibrillators on hold, which are awaiting an external cable upgrade."

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SA: Obstructive paramedic plus hospital delay kills man

Most surprising behaviour from a woman. Is she a lesbian or was she just hormonal?

A female paramedic with a "chip on her shoulder" actively discouraged a critically ill man from going to hospital hours before he died, an inquest has found. State Coroner Mark Johns has strongly criticised SA Ambulance Service officer Jennifer Bell over her dealings with Stefanos Markantonakis, 63, of Goodwood, who had a history of heart disease.

Ms Bell and another paramedic, Sarah Moore, were dispatched to Mr Markantonakis's home at 2pm on March 4, 2004, when he complained of chronic lower back pain. The pair decided he did not need to be taken to hospital and suggested he take painkillers. They returned at 5pm when his family said he had worsened.

Mr Johns said Ms Bell treated him in "a blunt . . . manner more calculated to dissuade him from going to hospital than to encourage him". "I had the impression that Ms Bell is a person with a chip on her shoulder," he said. Mr Johns said this attitude was evident in how she spoke to Mr Markantonakis, his wife and their daughter, Chrisoula, who said she told her it "was a case of poor me".

Mr Johns said Ms Bell left Ms Moore outside when they returned two hours later. "According to Chrisoula she came into the house and stomped through with the attitude she had and said to Mr Markantonakis 'come on we are taking you now'," he said. Mr Johns said Mr Markantonakis was driven to the Flinders Medical Centre, with Ms Bell allegedly telling him to "shut up" before they arrived at 5.24pm.

He waited until about 8pm, when he was examined by a doctor who diagnosed serious internal bleeding from a ruptured abdominal aortic aneurysm. He died soon after during emergency surgery.

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The ABC adds that the bitch: "misdiagnosed the man as having a back ache and then failed to pass on to a nurse vital information about his symptoms. The man died five hours after an ambulance was first called. SA Ambulance medical director Dr Hugh Grantham says, since then, the service has conducted its own investigation and Ms Bell is no longer employed there".

Socialized medicine is broken and can't be fixed

Last week I pointed out that Michael Moore, maker of the documentary "Sicko," portrayed the Cuban health-care system as though it were utopia -- until I hit him with some inconvenient facts. So he backed off and said, "Let's stick to Canada and Britain because I think these are legitimate arguments that are made against the film and against the so-called idea of socialized medicine. And I think you should challenge me on these things."

OK, here we go. One basic problem with nationalized health care is that it makes medical services seem free. That pushes demand beyond supply. Governments deal with that by limiting what's available. That's why the British National Health Service recently made the pathetic promise to reduce wait times for hospital care to four months. The wait to see dentists is so long that some Brits pull their own teeth. Dental tools: pliers and vodka. One hospital tried to save money by not changing bed sheets every day. British papers report that instead of washing them, nurses were encouraged to just turn them over.

Government rationing of health care in Canada is why when Karen Jepp was about to give birth to quadruplets last month, she was told that all the neonatal units she could go to in Canada were too crowded. She flew to Montana to have the babies. "People line up for care; some of them die. That's what happens," Canadian doctor David Gratzer, author of The Cure, told "20/20". Gratzer thought the Canadian system was great until he started treating patients. "The more time I spent in the Canadian system, the more I came across people waiting. … You want to see your neurologist because of your stress headache? No problem! You just have to wait six months. You want an MRI? No problem! Free as the air! You just gotta wait six months."

Michael Moore retorts that Canadians live longer than Americans. But Canadians' longer lives are unrelated to heath care. Canadians are less likely to get into accidents or be murdered. Take those factors into account, not to mention obesity, and Americans live longer.

Most Canadians like their free health care, but Canadian doctors tell us the system is cracking. More than a million Canadians cannot find a regular family doctor. One town holds a lottery. Once a week the town clerk gets a box out of the closet. Everyone who wants to have a family doctor puts his or her name in it. The clerk pulls out one slip to determine the winner. Others in town have to wait.

It's driven some Canadians to private for-profit clinics. A new one opens somewhere in Canada almost every week. Although it's not clear that such private clinics are legal, one is run by the president of the Canadian Medical Association, Dr. Brian Day, because under government care, he says, "We found ourselves in a situation where we were seeing sick patients and weren't being allowed to treat them. That was something that we couldn't tolerate."

Canadians stuck on waiting lists often pay "medical travel agents" to get to America for treatment. Shirley Healey had a blocked artery that kept her from digesting food. So she hired a middleman to help her get to a hospital in Washington state. "The doctor said that I would have only had a very few weeks to live," Healey said. Yet the Canadian government calls her surgery "elective." "The only thing elective about this surgery was I elected to live," she said.

Not all Canadian health care is long lines and lack of innovation. We found one place where providers offer easy access to cutting-edge life-saving technology, such as CT scans. And patients rarely wait. But they have to bark or meow to get access to this technology. Vet clinics say they can get a dog or a cat in the next day. People have to wait a month

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Australia: Public hospital dubbed 'the killing fields'

A KEY Melbourne hospital has been labelled "the killing fields" at a high-level meeting of doctors. The damning indictment on the health system is revealed in a letter from a leading doctor to Premier John Brumby, obtained by the Sunday Herald Sun. In the letter Dr Peter Lazzari reveals how Maroondah Hospital has become known as "the killing fields", as it is forced to rely on under-trained doctors to manage life-and-death cases.

Dr Lazzari, chairman of the medical staff at Angliss Hospital, wrote to the Premier demanding action. In the letter, he says: "All the chairs of medical staff of Victoria's major public hospitals at the August meeting at AMA House were appalled to hear the Maroondah representative speak gravely of his hospital's reputation among doctors on rotation as the "killing fields".

Opposition health spokesman Helen Shardey said: "If we have doctors making these sorts of claims, the Government can no longer turn a blind eye."

But Maroondah Hospital general manager Zoltan Kokai categorically refuted the claims. The hospital was recently been accredited by the Australian Council of Health Care standards and its doctors were credentialed in accordance with Eastern Health policy and registered with the Medical Practitioners Board of Victoria, he said.

But Paul Hoek knows how things can go wrong in the hospital system. The 41-year-old truck driver broke his leg more than a year ago, but is still off work. When his plaster cast was removed 12 weeks after his initial operation at Maroondah Hospital, he was left with a painful, gaping wound near his ankle. Ten months later that wound has not healed. The initial operation saw 18 screws and a plate inserted in his leg but months later Mr Hoek was still complaining about pain in the leg. He says it took more than 30 visits before he was taken seriously and doctors discovered five screws holding his fracture together had broken and the plate was protruding out of his skin. "I am furious," Mr Hoek, of Lilydale, said. He said he was on a disability pension and struggling financially.

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Brits not allowed to prefer British doctors

The threat of unemployment among UK medical graduates is being blamed on the failed computerised recruitment system (MTAS), but an article in this week's BMJ argues that the real problem is government policy on medical immigration.

In the late 1990s UK medical schools produced nearly 5,000 graduates each year, considerably fewer than the NHS needed, writes Graham Winyard, a retired Postgraduate Dean. But in 1997, an expansion of medical school places began and the number of graduate doctors is set to rise to 7,000 in 2010, an increase of 40%.

The planners assumed that UK qualified doctors would replace those from overseas. But Government immigration policies have encouraged thousands of overseas doctors to compete for postgraduate training posts, and it is of course illegal for trusts and deaneries to discriminate on the basis of country of qualification when making appointments. Expanding medical schools makes little sense if extra graduates cannot pursue a career in medicine, says Winyard.

UK trained doctors began to voice concerns about possible unemployment in 2005 and these concerns were dramatically realised this summer, when MTAS was introduced to select doctors for training posts. While there were broadly sufficient posts to accommodate UK applicants, together with those from the rest of the European Economic Area, he argues, the inclusion of thousands of overseas doctors has transformed the prospects for all applicants and has made widespread failure to secure a proper training post inevitable.

The UK urgently needs policy coherence on immigration and medical training, he writes. The direct connection between policy on medical immigration and the likelihood of unemployment for UK medical graduates is inescapable. The most obvious action, he says, would be to suspend the Highly Skilled Migrant Programme - a scheme allowing highly skilled people to migrate to the UK to seek work without a specific job offer - as it applies to doctors, and establish a two stage recruitment process similar to that used in other countries, whereby overseas applications are considered after those of domestic graduates.

The rights of overseas doctors already in the system must be safeguarded, but if decisive action is not taken the situation will be worse next year, he warns. This muddle is in no one's best interests and needs open and honest discussion and clear leadership, however difficult that may be, he concludes.

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Australia: Surgeons say NSW public hospital unsafe

THE head of surgery at Mount Druitt Hospital says the hospital is unsafe and has accused the Health Department of covering up the death of a patient who waited 14 hours to be moved to another hospital because Mount Druitt has no intensive care unit. In a letter obtained by the Herald, Mac Wyllie said the department's claim in an internal report that the delay "did not affect the outcome" of the patient's condition was "'inappropriate" and "deliberately misleading". The 68-year-old man died of acute pancreatitis the day after arriving at Westmead Hospital's intensive care unit from Mount Druitt on March 3. "Our [surgeons'] alternative conclusion is that this delay did affect the final outcome of this patient who eventually died," Dr Wyllie said in his letter to the Sydney West Area Health Service, dated September 5.

Surgeons have been warning for the past three years that Mount Druitt Hospital's emergency department is unsafe because it has had no intensive care unit since early 2004, when it was closed due to staff shortages, and the high dependency unit, where the man waited for the transfer, has no full-time medical staff. They say even "remotely unwell" patients must be transferred to Blacktown or Westmead hospitals. They are concerned that local people, among Sydney's most disadvantaged, wrongly believe the "emergency" sign at the front of the hospital gives the impression it can admit acutely ill patients, which it has not done since October 2004.

The Premier, Morris Iemma, who was then the health minister, promised that patients would not wait for transfers as a result of the intensive care unit closing and that the high dependency unit would have consultant supervision. Apart from cardiology, rehabilitation and pediatric services, Mount Druitt has no acute medical beds and no full-time general staff physician, or even an on-call general visiting physician.

A patient presenting with conditions such as a diabetic complications, breathing problems, chronic arthritis or a stroke must be transferred. Accident and emergency specialists are confined to that department, which is also understaffed. A senior doctor at the hospital, who did not want to be named, told the Herald: "Since 2004 there has pretty much been a whitewashing at Mount Druitt Hospital." He said the man who died "had deteriorated quite significantly" while waiting for the transfer.

Critical cases were not brought to Mount Druitt, but for the "isolated cases" that do end up there, "there is no question that they are in danger - quite considerably - which has been shown by this case and others".

However, local residents are staunchly opposed to closing the emergency department and it would be a political nightmare for the State Government. The Government has ignored its own, independent General Metropolitan Clinical Taskforce, which recommended in a February 2005 report that the department be closed and noted that the community's "perception" that it was a 24-hour, comprehensive service "needs to be addressed". "Mount Druitt Hospital still remains unsafe and the clinicians find it increasingly difficult to fully exercise their duty of care to the patients of Mt Druitt," Dr Wyllie said in his letter, which he addressed to the deputy director of clinical governance at the Health Department, Dr Andrew Baker. Dr Wyllie did not supply the Herald with the letter.

He said the Sydney West Area Health Service Root Cause Analysis (RCA) report on the man's death had "fundamental flaws and omissions". It was more than 15 hours before the man saw an intensive care doctor, Dr Wyllie said. "To say that this delay did not affect the final outcome of the patient is not only inappropriate on the evidence put forward, but could be construed as deliberately misleading," he said. The report failed to take into account that the high dependency unit "has no dedicated residents and it has no direct supervision from either Blacktown or the Westmead intensivists". "I am advised that no intensivist has had a physical presence in the unit to supervise the treatment of patients for over three years."

The RCA report, seen by the Herald, said the man arrived at Mount Druitt Hospital emergency department at 7.30am on March 3, was diagnosed with acute pancreatitis and was to be sent to Westmead Hospital's intensive care unit. However, there were no beds available and he was moved instead to Mount Druitt's high dependency unit and did not arrive at Westmead until 9.45pm. He died early the next morning.

"It is unlikely that this delay altered the course of his illness." the RCA report said. Although the report said there were no intensive care beds at Westmead when nurses checked at 3pm and 5pm, when the man "began to deteriorate", it blamed the delay on "poor communication" within the emergency department.

Another senior doctor at Mount Druitt Hospital, who did not want to be named, said transfer delays were "inevitable" and "unnecessary". "The point is that you can't keep anyone who's even remotely unwell for monitoring at Mount Druitt," he said. "Politically, it's the right thing to say that you've got an emergency department but the fact of the matter is that this hospital has been so downscaled that if a person is really unwell, we can't keep them here.

But one of the authors of the General Metropolitan Clinical Taskforce report, Professor Kerry Goulston, said yesterday that the problem was not a lack of an intensive care unit but understaffing of the emergency department. "We said it was wrong 2« years ago to have a sign saying 'emergency department' and it wasn't functioning as a proper emergency department," Professor Goulston said.

Questions put to the Sydney West Area Health Service on Tuesday - including how it justifies keeping the emergency department open, whether patient transfers have been improved, what it was doing to increase consultant staffing levels, and what were the results of an audit on patient transfers - remained unanswered yesterday.

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Islamic abuse in the NHS

A Muslim dentist made a woman wear Islamic dress as the price of accepting her as an NHS patient, it is alleged. Omer Butt is said to have told the patient that unless she wore a headscarf she would have to find another practice. Later this month, Mr Butt will appear before a General Dental Council professional misconduct hearing, which has the power to strike him off. It is claimed that the 31-year-old dentist asked to speak to the woman in private after she turned up for an appointment at his clinic in Bury. According to the charges, he questioned her on whether she was a Muslim and told her that if he was to treat her she would have to wear Islamic dress. He is also said to have read out a number of religious rules to her. He then told his nurse to give the patient her own headscarf to wear, the accusation says. It is not known whether the woman was a Muslim.

The charges to be heard by the General Dental Council say that Mr Butt undermined public confidence in his profession by discriminating against a patient and failed to act in her best interests. Mr Butt is the older brother of former Islamic extremist Hassan Butt, who once declared he had 'no problem' with terror attacks on Britain and who said that September 11 "served the pleasure of Allah". He has since recanted and now calls for all Muslims to abandon violence.

The dentist also featured in immigration hearings involving an asylum seeker suspected of providing a safe house for Kamel Bourgass, an Algerian terrorist jailed for life for stabbing PC Stephen Oake to death in Manchester in 2003. Mr Butt, the immigration hearing was told, was introduced by his brother to the asylum seeker, who at various points claimed three different identities. The tribunal was told that Mr Butt was "a respectable and responsible person who wishes to help devout and practising Muslims in difficulty". He "did not regard the use of false names as unusual for asylum seekers".

The headscarf incident is alleged to have happened in 2005, at a time when between 4,000 and 8,000 people in Bury were unable to find an NHS dentist. According to the charges, Mr Butt "asked to speak to Patient A in private. "In the course of conversation with Patient A you: (a) asked whether she was Muslim; (b) told her words to the effect that, in order to receive treatment from you, she needed to wear appropriate Islamic dress; (c) quoted to her parts of the Ahadith."

The Ahadith is a series of instructions on behaviour attributed to Prophet Mohammed but not written as part of the Koran. The charge continues: "You told Patient A that, if she did not wear a headscarf, she would need to register with another dentist. You instructed your dental nurse to give Patient A her headscarf. "The dental nurse took Patient A to another room where she was given the nurse's headscarf to wear. "In seeking to impose an Islamic dress code on Patient A in order for treatment to be provided you undermined public confidence in the profession by discriminating against Patient A."

If the charges are upheld, the Porsche- driving dentist will be found guilty of serious professional misconduct. Penalties can range from a public warning to suspension and being struck off.

Tory MP Sir Paul Beresford, a former minister and a dentist, said: "When a patient comes to see me I have no concern with their religion. I do not ask Muslim patients to read the Bible. "My practice tries to respect religious belief. For example, during Ramadan we try to help Muslim patients by making sure they do not have to swallow water when they are fasting. We do not ask patients to become Christians."

Women staff at Mr Butt's Bury practice do not routinely wear headscarves while at work. One female patient said: "I think it is a pretty outrageous thing to ask but I have never felt as if I am being discriminated against at this practice as a Western woman. "If I was then I would certainly make a full complaint. If it is true then it shows a reverse prejudice bordering on racism."

Mr Butt was involved in another controversial incident earlier this year when police stopped his Porsche 911 and said they could not read its customised number plate. The dentist recorded the subsequent search of the car on his mobile phone and passed the video to the BBC, which broadcast it on a local news bulletin. It shows Mr Butt asking an officer: "Are you a racist?" The dentist was then arrested for racially aggravated behaviour. There were no charges, and a complaint against the police by Mr Butt is still being considered. Mr Butt was unavailable for comment yesterday. Staff at his practice said he was on holiday.

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HillaryCare's New Clothes: Different means but the same political destination

Hillary Clinton has been blasted for months by her Democratic Presidential rivals because, until Monday, she hadn't delivered her formal campaign promises for "universal" health care. But John Edwards and Barack Obama were unfair. She beat them to the punch by at least 13 years. The former first lady's 1993-94 health-care overhaul ended disastrously. Still, it poured the philosophical and policy foundations of the current health-care debate. As she unveils HillaryCare II, Mrs. Clinton likes to joke that it's "deja vu all over again"--and it is, unfortunately. Her new plan is called "Health Choices" and mentions "choice" so many times that it sounds like a Freudian slip. And sure enough, "choice" for Mrs. Clinton means using different means that will arrive at the same end: an expensive, bureaucratic, government-run system that restricts choice.

Begin with the "individual mandate." The latest fad after Mitt Romney's Massachusetts miracle, it compels everyone to have insurance, either through their employers or the government. Not only would this element of HillaryCare require a huge new enforcement bureaucracy, it is twinned with a "pay or play" tax on businesses that don't, or can't afford to, provide health insurance to their employees.

The plan also creates a new public insurance option, modeled after Medicare, and open to everyone, regardless of income. To keep insurance "affordable," HillaryCare II offers a refundable tax credit that limits cost to a certain percentage of income. Yet the program works at cross-purposes, because coverage mandates always drive up the price of insurance. And if the "pay or play" tax is lower than a company's current health insurance costs, a company will have every incentive to dump its employee plan and pay the tax.

Meanwhile, the private insurance industry would be restructured with far more stringent regulations. Mrs. Clinton would require nationally "guaranteed issue," which means insurers have to offer policies to all applicants. She would also command "community rating," which prohibits premium differences based on health status.

Both of these have raised costs enormously in the states that require them (such as New York), but Mrs. Clinton says they are necessary nationwide to prevent "discrimination" that infringes "on the central purposes of insurance, which is to share risk." Not quite. The central purpose of insurance is to price, and hedge against, reasonably predictable risks. It does not require socializing every last expense and redistributing wealth.

No liberal reform would be complete without repealing the Bush tax cuts of 2001 and 2003; Mrs. Clinton would foot the bill for her plan with this tax increase. The rest of the estimated $110 billion per year in new government spending would be achieved by "modernizing" health-care delivery and "promoting wellness," though this $35 billion in savings is speculative, if not fanciful. Further tax hikes would be required: That $110 billion is a back-of-the-envelope calculation, and Team Hillary is keeping the specifics in its pocket.

Given how poorly "universal" policies fared the last time around, who can blame them? Mrs. Clinton and Ira Magaziner headed a health-care task force with more than 500 members that eventually produced 1,342 numbing pages of proposals. It's hardly surprising this boondoggle died without so much as a Congressional vote.

Yet Mrs. Clinton insisted that the public had been spooked by Rush Limbaugh, an article in a marginal political journal and advertising campaigns such as "Harry and Louise." In other words, the lessons she learned were political, not substantive. She thought she had overreached with too-sweeping changes. So she and her husband began to slice their universal health-care ambitions into smaller initiatives like the 1997 State Children's Health Insurance Program (Schip).

This is her strategy now. HillaryCare II is designed to cause minimal disruptions to current private insurance coverage in the short run, while dressing up the old agenda with slightly different mechanisms and rhetoric. Rather than fight small business, this time she is trying to seduce it with tax credits for small companies that provide insurance. Only later when costs rise will the credits shrink or other taxes rise. To court large manufacturers, like the auto and steel industries, she'll offer another, "temporary" tax credit to subsidize their health-care liabilities. Her plan, in short, is HillaryCare I in better clothes--a transitional platform to shift people to the default option, which is government insurance.

What's striking about all this is how little new thinking there is. Like the other Democratic proposals, HillaryCare II would mark another major government intrusion into health care. It would keep all of the system's current problems, most of them created by government policies, and entrench and expand them. The creativity is all in the political repackaging.

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Snake Oil Medical Reform

Hillary Clinton's latest campaign pledge on health care reform is another of the chicken-in-every-pot variety we get from almost all politicians: Everyone in the United States will have top-flight, affordable medical care and it won't cost us more (unless one includes taxpayers, and those deemed "affluent" by Democrat standards).

This Plan covers every American - finally addressing the needs of the 47 million uninsured and the tens of millions of workers with coverage who fear they could be one pink slip away from losing their health coverage - with no overall increase in health spending or taxes.

She proposes tax subsidies to individuals and small employers to offset the costs of insurance, which will be required of all. She doesn't mention the high penalties that would be needed to enforce mandated coverage.

She proposes that Bush's tax cuts be rolled back, but doesn't mention the corresponding roll back in productivity and tax revenues that results from reduced incentive to succeed.

She proposes expansion of existing government programs to guaranteed coverage for all, but doesn't mention that the states that have instituted guaranteed coverage regardless of health condition, and community rating to provide the same premium regardless of age, location or condition, have seen sharp escalation in premiums for the younger and healthier, increased government costs, and have not reduced the number of uninsured. (See this multi-year study.)

She proposes that costs of health care won't increase because she will accomplish more than the current major efforts to increase efficiencies and effectiveness of health care delivery:

Most Savings Come Through Lowering Spending Due to Quality and Modernization: Over half the savings come from the public savings generated from Senator Clinton's broader agenda to modernize the heath systems and reduce wasteful health spending.

She proposes that all this will not come at increased government regulation, but ignores that her proposals would gut the private insurance industry while placing the remainder under tight government controls, in effect establishing a semi-private sham for nationalized health care.

She, also, doesn't mention the uniformity, sluggishness in keeping abreast of the latest developments and the squelching of the incentives to develop them, and ultimately treatment rationing that is inevitable when the overwhelming costs come due of the promises. But, by then, the promises' hollowness although seen and suffered will be virtually irreversible as the private market no longer exists.

Oh, and she doesn't mention that her and others' figure of 47-million uninsured is inflated by at least double, as it includes a majority who are here illegally or who can afford coverage but choose not to be self-responsible. Even nationalized health care apologist Ezra Klein notes that all her promises almost sound like she "washes your car."

The devil will be in the details, if Hillary, and others, ever get down to presenting complete honest analyses rather than stump rhetoric. Hillary keeps repeating the word "choice" in describing her plan. The New York Times' politics blog comments:

Her choice of words also reflects her evolution and her recognition that she needs to appeal to a broad spectrum of people who don't want their most personal decisions to be decided for them, and to try to assuage (or at least hold at bay) some critics. The "choice" word will be perceived as code, in an effort to address the absolute balking of people who don't want their personal physicians - even in the wake of health-maintenance organizations and beyond - taken from them.

The question is whether voters will choose to be fooled by her.

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Republicans Can Win on Health Care

A market-based system can give us freedom, innovation and health security

All around America, families are grappling with health-care concerns. They wonder if they'll have insurance at a price they can afford. They worry about how much out-of-pocket health costs take from the family budget. They question if they'll be able to pick their own doctor. Some feel trapped in jobs they don't like out of fear of losing their health insurance.

As the latest government-heavy plan announced by Hillary Clinton yesterday once again shows, the answers politicians offer on health care highlight the deep differences between liberals and conservatives. This is a debate Republicans cannot avoid. But it is one we can win--if we offer a bold plan. Conservatives must put forward reforms aimed at putting the patient in charge. Increasing competition will ensure greater access, lower costs and more innovation.

Liberals see the concerns of families as a failure of private insurance, and want the U.S. to move toward a government-run, single-payer model. This is a recipe for making problems worse. Socialized medicine inevitably leads to poor quality, inefficiency, rising taxes and rationing. The waiting lines and poor care that cause people from other countries to come here for treatment are not the answer.

Government can help poorer and older Americans get quality health care without sacrificing what everyone wants--the ability to choose their own doctor and health coverage that meets their family's particular needs. What reforms will do that?

* Level the tax playing field. People who work for companies get a tax break on the health insurance they get from their employer. Many small business employees, farmers and the self-employed are unable to benefit from the same tax advantage, because they or their employers can't afford health insurance. It's not fair or wise to penalize people who have to pay for health insurance out of their own pockets. They should benefit from the same tax advantage employees from bigger companies get.

The mortgage interest deduction made it easier for people to own a home and all America benefited. Similarly, every worker should get a deduction for health-insurance premiums. This would ease the burden on working families and make it possible for millions more Americans to own health insurance. Some Republicans in Congress support a tax credit rather than a deduction: that's reasonable, too. A deduction or a credit puts patients in charge by helping them get private coverage that meets their needs.

* Tax-free savings for health costs. We are encouraged to save tax-free for retirement and college; we should make it easier to save tax-free for out-of-pocket medical expenses, too. Tax-free savings accounts, paired with low-cost catastrophic health insurance, make coverage affordable for working families. For example, a youth minister told me his Health Savings Account (HSA) gave his family peace of mind because they now had insurance coverage for big emergencies and could save tax-free for everyday health expenses. That's why, in less than three years, more than 4.5 million families have set up HSAs. Some Democrats want to rein in HSAs because they fear HSAs put the individual--not government--in charge and once someone gets to pick a plan that meets their needs, they won't like being dictated to by government.

And when people see they can save money by eating better, exercising and making healthy lifestyle choices, guess what? They do. I met with workers at Wendy's Headquarters in Ohio who were eagerly taking steps to lead healthier lives because it saved them money.

* Portability. When you change jobs, you don't have to change auto insurance, but you may have to change your health insurance and even your doctor. That's important in a world where young Americans are likely to have 10 jobs before they are age 36. Too many people are locked into jobs they don't like out of fear they'll lose health coverage. The solution is obvious: People should be able to take their health insurance with them when they change jobs.

* Arming consumers through more competition. Rep. John Shadegg (R., Ariz.) argues that people should be able to buy health insurance issued by a company based in another state. Lack of interstate competition helps to explain why the same health policy costs $8,334 in North Dakota but $10,312 in South Dakota. If consumers in South Dakota could buy that North Dakota policy, prices for health insurance would go down.

* Pool risk, lower costs. Large companies get purchasing power and savings because they share risk across large numbers of employees. Sen. Mike Enzi (R., Wyo.) and Rep. Sam Johnson (R., Texas) believe small businesses should be able to join together to pool risk, too. It would mean more competition and lower costs, and more people able to afford coverage.

* Greater transparency.Today, patients rarely know what a procedure will cost or how good a clinic or hospital is, except by reputation and word of mouth. For example, a study of metropolitan hospitals found prices for services varied widely--by as much as 259%--even after controlling for geographic variations in the cost of doing business. Putting information about cost and quality in the hands of patients would lower the cost and improve the quality of health care. Patients making informed choices would create market pressures for lower prices and better care.

* Stop junk lawsuits. I've heard sad stories from doctors and patients. The doctor who had to close her clinic in her hometown and move across the state to work at a hospital that would pay her rising liability insurance premiums. The head trauma specialist afraid that when he retired, his community in one of the poorest regions in the country couldn't attract a replacement. The pregnant woman who drove 80 miles from home in Las Vegas to get prenatal care.

Communities are losing talented health-care professionals who simply can't afford the bigger liability premiums caused by frivolous lawsuits. More than 48% of all counties in the U.S. have no ob-gyn physicians. Hospitals are finding it tougher to provide obstetrics, emergency room care or neurosurgery because of frivolous lawsuits. And doctors, afraid of lawsuits, practice "defensive medicine," ordering unnecessary tests and procedures which add to the cost of health care. Whose interest does that really serve? If we want richer trial lawyers, let them keep filing junk lawsuits we all pay for. If we want better health care, curb frivolous lawsuits.

* Build on the progress already made by putting patients in charge and letting competition work. When Congress considered prescription drug coverage under Medicare, Democrats tried to have government set prices and deliver the drugs. When the Congressional Budget Office estimated the first year's monthly premium for seniors would be $35, Democrats tried to lock in that price.

Republicans disagreed, arguing competition would lower prices and provide more choices. They were right: Competition led to more options and an average monthly premium of around $23--an annual savings of $144 in the first year. Competition continues to save seniors (and taxpayers) money. When the bill passed, independent actuaries estimated the monthly premium for 2008 would be $41. Recently, Medicare officials announced that the 2008 average monthly premium will be around $25. Seniors would have paid over $4 billion more in prescription drug premiums the first two years of the program had Democrats mandated a $35 monthly premium. Taxpayers are saving also: This past January, the actuaries projected that the prescription drug benefit will cost $113 billion less over the next 10 years than estimated the previous year, primarily because of competition and low bids

In short, the best health reform proposals will be those that recognize and build on the virtues of our market-based medical system. Sick people around the world come here because they can't get quality care in their home countries. Many health-care professionals come here to practice, leaving behind well-meaning health-care systems where government is in charge, bureaucrats make the decisions, and where the patient doesn't have the choice he or she does in the U.S.

Mrs. Clinton may think Americans want to trade freedom and innovation for the illusory security of government regulation and surrender control of their health decisions to government bureaucrats. My bet is 2008 will teach us something different if Republicans make health care a centerpiece issue.

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Socialized medicine is already here

Congressional Democrats are trying to expand government health insurance to children who don't need public assistance, while their party's presidential hopefuls are concocting even grander schemes to achieve "universal coverage." "That's socialized medicine!" cry the Republicans. President Bush asks whether we want a government-run health care system or a private system. Republican presidential hopeful Rudy Giuliani accuses Democrats for lusting after the socialized systems of Europe, Canada, and Cuba. In a recent television appearance, Sen. Hillary Clinton (D-N.Y.) emphatically denied the suggestion that she supports socialized medicine. Was Clinton being disingenuous, or are Democrats really trying to foist socialized medicine on the American people?

The question seems silly once you consider how socialized our health care system already is. Government already finances about half of Americans' medical care, so you might say our system is already half-socialized. Yet we are much farther along the road to socialized medicine than even that would suggest.

Consider two distinguishing features of socialist economies. The first is that the government decides what individuals may produce, what they consume, and the terms of exchange. That is largely true of America's health care system. Government controls production and consumption by determining the number of physicians; what services medical professionals can offer and under what terms; where they can practice; who can open a hospital or purchase a new MRI; who can market a drug or medical device; and what kind of health insurance consumers may purchase. Government bureaucrats even set the prices for half of our health care sector directly, and indirectly set prices for the other half. When you read about Medicare over-paying imaging centers and hospitals, or that it's impossible for Bostonians to get an appointment with a general practitioner, it's largely because the bureaucrats got the prices wrong, and those rigid prices do not automatically eliminate shortages and gluts like flexible market prices do.

A second feature of socialist economies is that there is little incentive to make careful economic decisions, because government has put everyone in the position of spending other people's money. Canada may have the most heavily socialized health care system in the advanced world. Yet America's system is as much a tragedy of the commons as the Canadian system, where health care is ostensibly "free." In each country, only about 14 cents out of every dollar of medical spending comes directly from the patient. How can America's health care system be "socialized" when we rely on the private sector more than any advanced nation? Because it doesn't matter whether the dollars and the hospitals are owned publicly or privately. What matters is who controls how they are used.

In 2007, the average family of four will pay $25,000 for health insurance - nearly 30 percent of their income. About $14,000 represents taxes that fund health programs for the elderly and the poor. In other words, the government controls the lion's share. The remaining $11,000 purchases the family's own coverage, usually through an employer. Though we count that as "private" spending, the government largely controls that $11,000 as well.

Congress provides a substantial tax break for employer-controlled health insurance. That sounds nice, but it means that workers who want to control their coverage themselves face a tax penalty. That penalty often forces such workers to pay twice as much for less coverage. That benign-sounding "tax break" effectively requires Americans to let someone else control a large chunk of their incomes and their health care decisions. We may call that "private" spending. But notice the hallmarks: government denies individuals control over their economic decisions, and encourages them to act as if they were spending someone else's money - in this case, their employer's.

How can our system be "socialized" if we don't force patients to wait for care, as other nations do? America does ration by waiting - just ask any Medicaid patient - though we do so less often than nations where governments arbitrarily limit medical spending. But that's because we commit the opposite sin: our government encourages unlimited health care spending, which causes enormous waste.

For example, the federal Medicare program essentially makes an open-ended commitment to pay for whatever medical care seniors and their doctors demand. That may be why researchers at Dartmouth Medical School have estimated that Medicare purchases $60 billion in useless services every year. That's nearly one-fifth of all Medicare spending. It also may explain why we spend 50 percent more on medical care than other advanced nations without making ourselves noticeably healthier.

Surely, America doesn't have socialized medicine of the Canadian or British variety, or socialized medicine borne of some deliberate plan. But American politicians should stop pretending that socialized medicine is some far-off dystopia. To paraphrase Keyser Soze, the greatest trick that advocates of socialized medicine ever played was to convince the American people that we don't already have it.

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Canadian official refuses Canadian health care

Post below lifted from Don Surber. See the original for links

The woman who would-be prime minister of Canada had her breast-cancer surgery done in? A. Ottawa, B. Toronto, C. Montreal, D. Alberta, E. California.

Of course Liberal PM candidate Belinda Stronach went to California. The Canadian liberal elite (she is a billionaire’s daughter) do not wait in line like commoners for Canadian health care. The liberal elites travel to the United States for their medical treatment. The Toronto Star reported:

Stronach, diagnosed in the spring with a type of breast cancer that required a mastectomy and breast reconstruction, went to California in June at her Toronto doctor’s suggestion, a spokesperson confirmed.

“Belinda had one of her later-stage operations in California, after referral from her personal physicians in Toronto. Prior to this, Belinda had surgery and treatment in Toronto, and continues to receive follow-up treatment there,” said Greg MacEachern, Stronach’s assistant and spokesperson.

Speed was not the issue, MacEachern said – it was more to do with the type of surgery she and her doctor agreed was best for her, and where it was best performed. The type of cancer Stronach had is called DCIS, ductal carcinoma in situ, one of the more treatable forms.

If Canada’s health care is so good, why is it not doing this sort of surgery? Mind you, this happened in June and is only being made public in September. Her spokesman said the liberal elite loves the Canadian health system.

“In fact, Belinda thinks very highly of the Canadian health-care system, and uses it when needed for herself and her children, as do all Canadians. As well, her family has clearly demonstrated that support,” MacEachern said.

“This was about a specific health-care procedure, unrelated to any views about the quality of Canadian health care, a decision based on medical advice and a referral from her Toronto physicians, and just one part of several areas of treatment. Belinda has nothing but praise for the community of health-care professionals in Toronto who supported and treated her throughout the last six months.”

Sure, pal, sure. Whatever.

People like Stronach want the power to run a health system that they would never, ever use. The reason Canada does not have this sort of care is it devotes only 10% of its GDP to health care. America devotes 15% of its economic power to medical care. You get what you pay for.

NHS getting desperate about superbugs

Useless bureaucrats to be bypassed -- and there's nothing more desperate than that for socialists

THE health secretary, Alan Johnson, is to bypass hospital managers to give nurses and matrons the power to report directly to hospital boards in the fight against superbugs in the National Health Service. Nursing staff will be made accountable for infection control on their wards and promised a “hotline” to the top if management refuses to take ward cleanliness seriously.

Johnson will admit this week that poor infection control in hospitals has displaced waiting lists as the biggest problem facing the NHS and that tackling superbugs is now his priority. His decision to bypass the chain of command reflects frustration at the failure of many trusts to get to grips with infection control. More than 1,600 people die from MRSA, or methicillin-resistant staphylococcus aureus, in England and Wales every year. In addition, more than 3,800 people die from clostridium difficile.

Johnson believes matrons lack the power to take full responsibility for the state of their wards, because they must rely on management for resources. Nurses complain that their pleas for hygiene to be taken more seriously are ignored. Nursing staff will be told to inform trust boards directly if the hospital needs more isolation wards or cleaning equipment. They will be asked to update boards on cleanliness four times a year.

Johnson will make the announcement ahead of a public consultation on Tuesday in which more than 1,000 people across England will be asked how to improve the NHS. He will say fear of catching a hospital superbug has overtaken waiting times as the public’s most pressing concern about the NHS.

The consultation is part of a review being carried out by Lord Darzi, the health minister, at the request of Johnson and Gordon Brown. Darzi has also identified hospital superbugs as a serious problem. Darzi, a world-renowned surgeon at St Mary’s hospital, London, said: “We cannot avoid the challenge of better cleanliness and infection control in hospitals. I know, as a surgeon, that cleanliness and infection control are crucial to quality of care. “It is already clear from what I have found in the past eight weeks that this is a major issue of public concern, too. “We want to send a clear signal to patients that doctors, nurses and other clinical staff take their safety seriously. We want to give more responsibility to matrons and nurses.”

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Health "Rights"

By Theodore Dalrymple

Public affairs, said Doctor Johnson, vex no man: by which, I suppose, he meant that, if we are honest, only those matters which touch us directly and personally have the power genuinely to move us. The rest is ersatz or assumed emotion that we fake or exaggerate in order to appear more concerned with public affairs than we really are; and true it is that an argument with my wife causes me more genuine upset than a distant war, however bloody, though I am perfectly aware that in the scale of human history the war weighs a million, or a trillion, times more heavily.

This means, or ought to mean, that I should by now have reached such a state of serenity that even the weekly arrival of the medical journals should not upset me. After all, my personal situation is about as satisfactory as it will ever be. I please myself, more or less, what I do; my work is also my pleasure. I am indeed fortunate.

And yet The Lancet in particular, once one of the world's greatest medical journals, never fails to irritate me. Its sanctimony makes Elmer Gantry seem like a self-doubter. It propounds abject nonsense with the self-conceit of the assuredly saved preaching to the assuredly damned. Dickens would have loved to satirise it.

For example, it published a paper at the end of July entitled, "Is access to essential medicines as part of the fulfillment of the right to health enforceable through the courts?" The paper discussed whether, if individuals were denied access to important medicines, they could seek redress via the courts, particularly in Latin America, on the grounds that their rights were being denied.

The right to health was accepted in this paper as if it were a straightforward natural fact, like the roundness of the earth, for example, and no more disputable than the roundness of the earth. Yet the notion of a right to health is plainly ridiculous, at least until man becomes immortal. A man who is dying of incurable cancer is unfortunate, but his rights are not being infringed.

Perhaps the authors of the paper meant by the "right to health the "right to health care." But this is scarcely any better. A right to a material benefit implies someone else's duty to provide it, irrespective of whether he wants to do so or indeed is actually able to do so. This is not to say, of course, that the world would not be a better place if everyone who needed it were able to obtain health care; but the world would not be a better place because everyone's rights had been observed or complied with, but because avoidable suffering had been avoided. There are more and better reasons, after all, to treat people medically than that they have a right to such treatment.

I could not help but notice that among the drugs deemed so essential that not to make them freely available to people who need them amounts to a breach of their rights was buprenorphine, a drug prescribed by doctors to opiate-addicts in the hope that they, the addicts, will thereafter stop talking opiates of their own, and take those of the doctor instead. In a way this was odd, because there was an item in the very same edition of The Lancet entitled "Designer drug Subutex [buprenorphine] takes its toll in Tbilisi [the capital of Georgia]." There, at least, there was no danger that the people's right to burenorphine was being infringed.

The article starts with the following dramatic paragraph: "Crushed on pavements, tossed by the road, or in the corners of apartment-block entrance halls, the used syringes tell a story of rising addiction. The needles seen across Tbilisi are discarded by the addicts of Subutex, a treatment for opiate abuse that has ironically become the country's mostpopular drug."

The drug is manufactured in Britain and exported to France, where gullible doctors prescribe it to addicts who pretend to need it, and who then sell it on to dealers who smuggle it into Georgia at a profit of 600 per cent. Seven tablets in France cost $20, and $120 in Georgia. Among the smugglers of buprenorphine was the honorary consul of the Cote d'Ivoire in Georgia, who brought it into the country in his diplomatic bag. According to The Lancet, the problem is not a small one: 39 per cent of addicts treated in clinics in Georgia were addicted to buprenorphine, and the total number of drug addicts in Georgia was 250,000, which is to say one in twenty of the entire population. This represents an 80 per cent increase since 2003, and is largely due to the importation of buprenorphine.

Five pages later in The Lancet, the very same author wrote an admiring, even hagiographical article, about Dr Vladimir Mendelevich, a doctor who is trying to introduce the treatment of drug addicts in Russia, Georgia's neighbour and historical suzerain, with yes, you've guessed it, buprenorphine (among other drugs). Dr Mendelevich is described as a hero by the author without any hint of irony, or even of awareness of what he had written only five pages previously, or that to introduce yet another drug into a country notorious for its corruption and administrative chaos, contiguous with Georgia, is an idea that needs very careful consideration.

Just how essential is buprenorphine that, not to make it available to all who feel they need it constitutes an attack on their fundamental human rights? This question was in part answered by a paper in the New England Journal of Medicine that appeared in the same week as The Lancet that I have cited. The authors, who practised at Yale, wanted to establish whether extra counselling had any effect on the abstention of addicts who were prescribed a tablet containing both burpenorphine and naloxone.

This tablet is an extremely clever one. Naloxone when taken by mouth has no effect, but when taken by injection acts as an antagonist to opiates, and precipitates withdrawal symptoms. Thus its inclusion with buprenorphine discourages buprenorphine abuse (though I have little doubt that, before long, addicts and their acolytes will devise something to circumvent this precaution).

The researchers recruited 497 addicts for their study, but excluded 296 of them because (as addicts in real life tend to do) they took alcohol or other drugs as well as opiates, or behaved in a dangerous and antisocial way. A further 35 dropped out at preliminary stages, leaving only 166 of the original 497 for the experiment.

The 166 were divided, like Gaul, into three: those who received the drug on a once weekly basis, those who received it on a three-times weekly basis, and those who received it on a three-times weekly basis plus extra counselling. In the event, there was no difference in the outcomes between these three groups at 24 weeks.

What was most striking was that only 75 continued the experiment to the 24th week, which is to say that 422 addicts of the original addicts did not get that far: and 24 weeks is not exactly an eternity. The average maximum duration of abstinence from illicit opiates among the 166 sterling citizens who were treated was between five and six weeks. More than half their urine specimens tested positive for the presence of illicit opiates.

Nor is this all. It is well known that the results of clinical trials are better than results obtained in a "natural" environment, that is to say you cannot expect the same degree of success when you transfer a treatment that has been tried experimentally to normal, everyday practice. This is for several reasons, among them the enthusiasm and dedication of the staff involved in the trial, enthusiasm that often communicates itself to the patients who are therefore more optimistic and compliant with treatment than they would otherwise be.

It might well be that the very low compliance rate of the patients was caused by an awareness of the presence of naloxone in the tablets they received. It was precisely because the medication could not be abused, at least until someone devised a method of abusing it, that the compliance rate was so very low. But if so, it must cast in doubt on the motives of the addicts for seeking and accepting treatment in the first place. And it should be borne in mind that the patients were selected among 479 addicts for their relatively "good" behaviour: namely, their absence of additional substance abuse and lack of threatening, violent and criminal conduct. In other words, their prognosis was already better than average among the addicts.

Had the patients been prescribed buprenorphine alone, I think they might well have "complied" with treatment better, but only because it would have had some economic or abuse value to them. The criteria for completion of the study were not exactly stringent: those who did not miss more than three counselling sessions or missed their medication for more than a week were deemed to have completed it.

In short, the whole business was an elaborate and sordid farce, from which the authors drew the conclusion that there is "a need both to measure adherence in future research and to monitor and encourage adherence in practice in order to reduce the potential misuse of the medication and to improve the treatment outcomes." The idea that the whole notion of treatment in a voluntary condition such as addiction might be inappropriate was quite beyond the authors.

But let us return briefly to the question of the supposed right to health. Can it be the right of anyone to obtain a treatment that is marginally effective, if it is effective at all? In fact, this is often the case in modern medical treatment. The chances of anti-hypertensive treatment doing you good rather than harm are small, though the harm it can do you is slight and the good it can do you is enormous. How certain does the good that treatment does you have to be before it becomes a right enshrined in, and actionable at, law?

I am astonished at how quickly the doctrine of rights has colonised minds, like bacteria on a Petri dish. Not long ago, I asked a young patient what she was going to do with her life (I am sufficiently interested in my patients to ask such things). She said she wanted to study law. Any particular branch, I asked, thinking she might want to do criminal law, which is the most interesting, if least lucrative, branch? "I want to go into human rights," she said, with that semi-beatified smile with which a girl of her age might once have claimed to have a vocation.

"Oh yes," I said, "and where do human rights come from?" "What do you mean?" she asked. "I mean, are they just there, like America, waiting to be discovered by someone going out and looking for them, or are they conferred by mere human agency, in which case they can be repealed at the drop of a law?"

She looked appalled, as if I were a deeply wicked man who had suggested that, for example, racial discrimination was just the thing. "You can't ask that," she said.

I didn't explore the question of why not, because a medical consultation is not a dialogue by Plato. But after that, I did begin to think that there was something to Richard Dawkins' conception of a meme, namely an idea that enters minds and spreads from mind to mind as a gene favourable to survival in a population.

The problem with memes, of course, is that they don't have to be good ideas, only ideas that are in someone's, or some group's, advantage. And the ever-expanding concept of human rights is of advantage to regulatory bureaucracies, of course, for how can positive rights be enforced without them? Not coincidentally, the paper in The Lancet with which I began this article emerged from that bureaucracy of bureaucracies, that meta-bureaucracy, the World Health Organization in Geneva.

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Doctors for auction in Australia

Yet more of that wonderful government "planning". There are plenty of would be doctors but a very limited number of places in medical schools (Which are all run by Leftist State governments). The result: Much more dangerous circumstances for patients

A CRISIS in public hospital emergency departments has reached the point where they are forced to bid against each other for casual doctors who are already paid as much as triple the award rate. Doctors say patient care is at risk because emergency departments are forced to rely on often inexperienced locums with a "nine-to-five mentality" to plug gaps in the system. The Herald has obtained an email from one large NSW locum agency that describes 26 NSW hospitals as being at crisis point, 21 of them public hospitals, with some unable to fill shifts for senior emergency doctors the next day.

NSW Health estimates it costs $35.2 million more a year for locums than it would for permanent staff, but refuses to fund more permanent senior specialists. Rates for locums generally vary from $90 to $180 an hour depending on experience and type of shift, but can reach $250 for a senior doctor required at the last minute in a regional area or on a public holiday, or when the hospitals bidding against each other push up the price.

The vice-president of the Australasian College for Emergency Medicine, Sally McCarthy, said the use of locums was at "phenomenally high levels" and NSW Health did not support more permanent positions. "But the health service is happy to compete against other hospitals for locums, bidding up the price," Dr McCarthy said.

When the Herald contacted heads of emergency departments, they were highly emotional - one even tearful - and some called out of hours or while on holiday to express their frustration and desperation. They all refused to go on the record, fearing repercussions from NSW Health.

On Tuesday, vacancies emailed by Australia Wide Locum Placement included 41 shifts in the emergency department at Nepean Hospital from now to September 25, and 70 shifts at Blue Mountains Hospital to November 30 - 16 of which are in emergency just for this month. Camden Hospital had 85 emergency shifts to fill over the past month, all for senior doctors.

Royal North Shore Hospital needed 20 shifts filled in emergency up to October 14 and Fairfield needed 25 up to the end of next month, 13 of which were for senior emergency doctors to work overnight this month to fill vacancies every few days. Other public hospitals listed as in "crisis" - with shifts needing to be filled within 48 hours - included Concord, Mona Vale, Fairfield, Sutherland, Campbelltown and several regional hospitals.

Locums are often junior doctors, lured by the pay and far less stressful working conditions.

The emergency departments at Camden and Campbelltown hospitals are among the busiest in the state but are understood to have the heaviest use of locums. Of all doctors in Camden's emergency department, about 70 per cent are locums.

The director of Australia Wide Placements, Terry Keenan, said his company would fill "less than half" of the crisis shifts at public hospitals. His agency sought to fill 800 shifts in Sydney public hospitals on any given day. "The demand is enormous," he said. Hospitals are so desperate that they even offer a higher rate than is necessary, he said. "We sometimes get hospitals saying 'we can give up to $140 an hour', and we say we think we can fill it for less." He also said some doctors did not commit to a shift until the last minute, "thinking that if you don't the price might go up".

The use of locums in public hospitals has "increased alarmingly" in recent years, said a NSW Health report published in The Medical Journal of Australia last year. The head of a big Sydney metropolitan emergency department said it spent $1 million on locums last financial year. "It's virtually impossible to check how well they're going to perform, whether they're really as senior as they say they are and whether they can do all they say they can do and . you never have the organisational knowledge or the commitment," he said. "You end up with the more inexperienced, lower-quality employees . we regard it as a bit of a crisis."

A medical registrar at a Sydney public hospital emergency department said the use of locums could be "life-threatening for a patient". "You've got the people who are the least skilled, the least loyal and the least oriented who are the ones that are making more money than even the directors of the department. And you're sending them off to life and death situations." The head of emergency at a big regional hospital said he had to "fight tooth and nail for every doctor" employed there. "They just say no, no money. When you talk about safety they don't want to know about it."

The State Government blamed the doctor shortage on the Federal Government, saying it was not funding enough university places [But the universities are run by STATE governments!]. A spokeswoman for NSW Health said: "Clearly it is better to have full-time medical staff than to rely solely on the use of locums to backfill vacancies," she said.

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