Tuesday, April 08, 2008

Privacy or “Free” Health Care?

Many liberals are up in arms these days over the USA PATRIOT Act and other recent assaults on our civil liberties. Hurray! Alas, many of these same liberals are chomping at the bit to implement even more intrusions upon our privacy. They want the government to know about your every throat swab, hemorrhoid exam, and AIDS test. That is, they are calling for some form of socialized medicine. Message to liberals: please reconsider!

Seriously, do you really want people like Dick Cheney to have access to your medical records? With any form of single-payer healthcare they will. You are probably envisioning single-payer healthcare as part of an overall victory by your party, and it would be – temporarily. But even if the Republicans get a drubbing this fall, at some time they will be back in power, and then they will have access to records of every psychiatric exam, birth control prescription and abortion. Is that what you want?

Worth the risk, you say? Better to lose some privacy than to continue our current heartless and inefficient healthcare system? You might be right if those were our only two choices. They aren’t. Alternatives exist. If we so desire, we could have a healthier nation, with affordable, patient-driven healthcare. But it does require opening our minds to many different ideas. The solutions to our dilemma consist of many tweaks to the existing system.

U.S. healthcare is bad for many reasons: drugs and doctors are expensive, insurance and managed care are fraught with moral hazards, poor people fail to get cheap early care and then clog the emergency rooms, and Americans in general are unhealthy. That’s right; our healthcare system is bad in part because we are unhealthy – not the other way around. Better diet and exercise would do much to reduce the incidence of heart disease, depression, diabetes and other expensive to treat maladies. Reduce the incidence of expensive diseases, and the cost of insurance goes down. Cut he cost of insurance and more poor people could afford insurance, which would unclog the emergency rooms. (Read my column from last month for ideas on how to improve America’s diet.)

But even if insurance costs go down by a factor of two, health insurance would still be expensive for many. One solution would be a tax credit for getting health insurance. Unlike a tax deduction, a tax credit would be valuable to the poor, the very people most need health insurance. Such a tax credit could go to the individual instead of the employer, putting an end to corporate wage serfdom. The tax credit should be a fixed amount. If you can find adequate coverage that costs less than the credit, you get to pocket the difference. This gives consumers and incentive to shop, which is very important to reducing moral hazards.

But we wouldn’t be thinking so much in terms of insurance if doctors and drugs were cheaper. Doctors are so expensive because we have a cartel in place; doctors are required for many tasks that could be done by health practitioners with lesser degrees. Imagine if it required a Ph.D. in computer science to put up a web page.

Drugs are so expensive in the U.S. because our FDA is far more cautious than equivalent agencies in other First World countries. We could cut drug prices by simply approving drugs that have been approved in other First World countries. If we wish to be cautious, we could require that such other country approvals be in place for several years to take advantage of their post-market monitoring.

Healthcare in the United States can be fixed without resort to a single-payer plan. But healthcare advocates have to want it. Otherwise, we are stuck with the choice between big corporations and Homeland Security having access to our medical records.

Let me end by conceding one advantage to single-payer healthcare: Roe v. Wade becomes moot. If the federal government has a record of every healthcare transaction, no one can argue with a straight face that medical decisions are a matter of personal privacy. Whether abortion is a legitimate medical procedure becomes a matter for legislatures to decide. What? You don’t like this feature of single-payer healthcare? Too bad. The Religious Right will be aware of the line of reasoning above the moment single-payer gets implemented. I will make sure of it.


Your regulators will protect you -- again

Crooked and incompetent German doctor allowed to practice in Australia for years -- despite complaints and at great cost to the community

One of Australia's most senior trauma surgeons faces the sack for incompetence and a possible criminal investigation for billing for operations that never occurred. The stellar career of Thomas Kossmann, the head of the nation's busiest and most prestigious trauma unit at The Alfred hospital in Melbourne is in tatters after a three-month investigation by an expert panel into his surgical and administrative practices. The panel's damning findings are contained in a confidential report obtained by The Australian.

The scandal once again raises serious questions about the ability of medical authorities to properly assess doctors before allowing them to work in this country. The panel reports that more attention needs to be paid nationally to how specialist doctors are credentialled to practise in the public health system.

The key findings against Professor Kossmann are that he performed unnecessary surgery and undertook surgery he was incapable of doing. The panel found he invoiced Victoria's Transport Accident Commission, the WorkCover Authority and Medicare Australia for operations that were not performed, surgery he did not carry out and surgery that was unnecessary. The panel found that in his billing he used multiple Medicare item numbers that are mutually exclusive and used item numbers not in the spirit of funding agreements. They found he did not have the required expertise to practise or teach spinal and pelvic surgery - something he was routinely doing at The Alfred. He was found to have misrepresented his surgical experience on his curriculum vitae by overstating his level of experience and training in the area of orthopaedic surgery. And he was found to have performed surgery that had not been performed in Australia or overseas before and which was flawed in its conception and harmful in its effect.

The expert panel's final assessment of Professor Kossmann is scathing. In relation to his invoicing habits, it concluded: "The professor failed to perceive a problem, almost to a level where he seemed to have no concept of what constituted a moral approach to patient billing." The panel recommends that the TAC - Victoria's publicly funded traffic accident compensation system - Medicare Australia and the WorkCover Authority conduct audits of Professor Kossmann's entire billing history.

He told the panel his billing practices were no different to those of his colleagues. He said that because the TAC had never questioned his billing, he assumed he was billing appropriately.

The panel was also critical of Professor Kossmann's clinical performance. It called his surgical practices and decision-making inappropriate, unnecessary and beyond the accepted norm. "The nature of these practices and decision-making was beyond any level of acceptable behaviour and standard of care, and was flawed in its conception and harmful in its effect," the report states. It dismisses Professor Kossmann's defence that if such an audit were conducted of other surgeons a comparable rate of incidents would be found. Professor Kossmann argued to the panel that the cases where he was found to have exercised wrong clinical judgment reflected differences of medical opinion. The panel disagreed.

The investigation was established by Bayside Health, which runs The Alfred hospital, after four surgeons lodged complaints against Professor Kossmann last August. Respected Victorian child orthopedic specialist Bob Dickens led the panel. The other members were Brisbane orthopedic surgeon John Tuffley and Sydney orthopedic surgeon Stephen Ruff. The panel examined 24 cases raised by the four doctors in their complaints against Professor Kossmann. In all but seven of the cases, the panel substantiated the complaints. It randomly reviewed a further 31 of Professor Kossmann's cases and, of these, found three where there were significant concerns about his clinical and/or administrative practices.

During the investigation, Professor Kossmann was interviewed by the panel members - two of whom are examiners in orthopedics for the Royal Australasian College of Surgeons - to test his understanding of basic science. He failed dismally. "All panel members are of the opinion that if an orthopedic candidate in his/her final exam had given the answers which the professor had given, they would have seriously considered failing that candidate," the report states.

It is understood the hospital has sent the final report to Professor Kossmann. He has two weeks to respond. Professor Kossmann has taken legal action in the Victorian Supreme Court against the hospital following its suspension of him on full pay last November after adverse preliminary findings were made against him in a draft report.


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