Wednesday, June 10, 2009

Health Care Bill Is the Ball Game

You might suppose that President Obama has his hands full running two wars, administering General Motors, "rescuing" the banking system, attempting to empower unions over management, hushing up whispers about hypocrisy regarding Guantanamo detainees, managing the mortgage crisis, imposing "clean energy" on the nation, handling nuclear North Korea and nearly nuclear Iran, "stimulating" the economy, reviving the "peace process" between Palestinians and Israelis, inaugurating a new relationship with Russia and with the Muslim world, and reversing the rise of the world's oceans, but no, he has one more agenda item -- overhauling U.S. health care.

The administration is hoping that a health bill will be voted on by early August, which may be overly optimistic but still means that this summer will be dominated by the health care debate. Its outcome will determine the overall success or failure of Obama's effort to torque America toward the European model of statism. It isn't just that the health care sector accounts for 17 percent of the U.S. economy. It is also the case that if enacted, a nationalized health service -- no matter how crushingly expensive or bureaucratic -- will vitiate arguments about the proper scope of government. All future pleas for reducing the size of the state will run into the accusation that the small government advocate is eager to take antibiotics from the mouth of a child or insulin from a diabetic.

Whereas the Clinton administration advertised the overhaul of American health care primarily as a means of covering the uninsured, President Obama is making the bolder claim that revamping health care is a way to save money. Really? Medicare is already the program that ate the government, scheduled to go into bankruptcy itself in 2019. As the trustees report put it, "while Medicare's annual costs were 3.2 percent of Gross Domestic Product (GDP) in 2008, or about three quarters of Social Security's, they are projected to surpass Social Security expenditures in 2028 and reach 11.4 percent of GDP in 2083." Or consider the Massachusetts health care reform introduced by Mitt Romney. Like every other government health care program, Romney's has vastly exceeded cost projections. Initially projected at $125 million per year, the program actually cost taxpayers $133 million in 2007, $647 million in 2008, $869 million in 2009, and could top $1.1 billion next year.

"Health care costs," President Obama intoned as he kicked off a summit on the subject, are "causing a bankruptcy every 30 seconds." Cord Blomquist on observed that in 2008, a big year for bankruptcies, there were a total of 1.1 million bankruptcies. Adding up Obama's numbers -- 120 bankruptcies per hour times 24 hours in a day and 365 days in a year equals 1,051,200 bankruptcies per year -- would suggest that only 100,000 of those were for non-medical expenses. Does that make sense in the midst of a collapsing housing market? The study Obama based his numbers on was flawed in other ways as well, as ABC's Gary Langer posted on the ABC News website.

Beware of politicians bearing statistics. But what is even more galling than misleading (or outright false) statistics is to watch politicians rail about the expense of health insurance without once acknowledging their own role in jacking up the price. Health care is expensive of course -- though it also delivers value (improved quality and length of life). But our jerry-built system has made buying insurance much more expensive than it should be. State mandates require insurance companies to cover a variety of specialized medical services (usually at the behest of lobbyists for the relevant service providers) including: in vitro fertilization, marriage therapy, smoking cessation classes, hormone replacement therapy, chiropractor visits, and so on. That makes it impossible for companies to offer cheap, no-frills, high-deductible plans for the young and healthy. As Sally Pipes notes in "The Top Ten Myths of American Health Care" (Pacific Research Institute), there were only 252 mandates in force 30 years ago. Today there are 1901, an average of 38 per state.

Government involvement in the health care system, through mandates, reduced competition (such as forbidding shopping for insurance across state lines), and a skewed tax deduction that permits only employers and not employees to deduct the cost of health coverage, has made health care more expensive than it ought to be. Yet President Obama proposes that hair of the dog -- vastly more government involvement -- will bring down costs and improve quality.

If he follows the lead of Great Britain, Canada, or other systems he admires, he can definitely bring down costs. He can do it the way they have, by rationing care. But Americans should bear in mind this summer that when the president promises to get health care costs under control he is really promising less care. There is a better way. More competition, not less. More market discipline, not less. This will affect every American for generations to come. The stakes could hardly be higher.


Patients with suspected cancer forced to wait so NHS targets can be hit

Patients rushed to hospital with suspected cancer are having their treatment delayed so that managers can meet Government targets, an NHS investigation has found. And an appalling case of negligence below. Getting anything seriously wrong with yourself sure is risky in Britain

People arriving at Accident and Emergency departments with symptoms which could indicate the aggressive spread of the disease are waiting weeks for diagnosis and treatment while “routine” cases are prioritised. Hospital managers told researchers that treating desperately sick patients more quickly would “reflect badly” on their performance against Government cancer targets which only cover those referred to specialists by GPs. Doctors, patients groups and politicians were appalled by what one described as a “breathtaking admission” which confirmed their “very worst fears” about how far the NHS target culture has gone in distorting clinical priorities.

Although most people with suspected cancer are referred to hospitals by their GPs, more than 30,000 people diagnosed with the disease each year are first alerted to tumours by violent symptoms, such as seizures, vomiting and jaundice, which cause such alarm that patients go straight to their local A&E departments.

The report by the NHS Institute for Innovation and Improvement, an official health service agency which issues advice to hospital managers, says that many of these emergency patients waited six weeks or longer for basic tests. It said they were “often” not given the same priority as patients who had been referred by GPs, who were covered by two targets, ensuring that they see a specialist within two weeks, and start treatment, following diagnostic tests, within two months. “As a result, they can end up with a very poor experience before finally receiving a diagnosis and the right care,” it warns. The report, due to be published tomorrow added: “Many trusts recognised the need to get some patients in this group onto the same pathway as people on the cancer two week wait [target] but were concerned this would reflect badly on their cancer figures”.

Some A&E departments failed to recognise the risk of cancer in seriously ill patients. In cases where the disease was suspected, patients were sent home to wait six weeks or longer for diagnostic tests. Others waited weeks on wards before seeing a specialist or having scans, the report, which is endorsed by the Government’s cancer tsar, found.

Nigel Beasley, the NHS Institute’s lead for cancer, and head and neck surgeon from Nottingham University Hospitals said: “Targets are very effective, but they do have side-effects. The risk is that these patients are not being prioritised because of the focus on the two-week target for patients referred by GPs.” He said anxious patients admitted as an emergency were often trapped in hospital for weeks waiting for scans, and to see a specialist, and should learn from good hospitals, who carried out investigations quickly, often using outpatients appointments. Mr Beasley said: “Patients can be stuck in hospital for a long time, waiting for scans, and other diagnostic tests. Once they are in hospital, they can end up waiting two, three, or even four weeks before there is a diagnosis and any decision to treat.”

The admission about the effect Government targets were having on emergency cancer patients horrified clinicians and patients groups. Shadow health secretary Andrew Lansley described it as “one of the clearest examples yet of how Labour’s tick-box targets are failing NHS patients”. He said decisions about which patients should be seen first must be taken by doctors, based on the patient’s clinical needs, not by managers following Government diktats.

Katherine Murphy, from the Patients Association, said the report provided “breathtaking” evidence of a confidence trick being played on the public, repeatedly told that waiting times for patients with suspected cancer are falling, while desperate cases were forced to the back of the queue. She said: “This confirms our very worst fears, and exposes the scandal of what pernicious targets are doing to patients. We have seen other targets being used in ways that damage patient care, but of everything we have seen, this really is the cruellest of the cruel”.

Leading cancer specialist Prof Karol Sikora said: “I think it is absolutely horrifying that hospital managers are playing around with targets that can delay treatment for people who may well be at an advanced stage of the disease.” “I know of many cases where people who have been admitted to NHS hospitals as an emergency have languished for weeks before even seeing an oncologist,” added Prof Sikora, Medical Director of independent company CancerPartnersUK.

The British Medical Association said many trusts were bullying doctors into delaying urgent referrals. Dr Jonathan Fielden, chairman of the BMA’s consultants committee, said: “A number of our members have already expressed fears about the two-week cancer target, because it means all the cases referred by GPs are given the same priority, regardless of whether they are expected to be benign or high risk. When this same target is delaying patients who have been admitted as an emergency that is an even greater cause for concern”.

Several oncologists said they supported two-week waiting time targets for cancer patients referred by GPs, but called for the target to be widened to include all patients.

Ian Beaumont, from charity Bowel Cancer UK said it “beggared belief” that anyone would value statistics over efforts to save lives. Dr Jane Maher, chief medial officer at Macmillan Cancer Relief described the revelation in the report as worrying, but said the biggest obstacle to getting the right care for patients admitted to hospitals as an emergency was getting the right diagnosis, as cases were often complex, meaning cancer could be mistaken for other conditions.

Among those who have experienced the problem is Melissa Matthews was 28 when she went to the Accident and Emergency department of her local hospital. For several days, she had been suffering abdominal pain which had left her feeling so uncomfortable that she was unable to eat. She told her family doctor, who advised her not to worry, unless she began vomiting, in which case she should go immediately to A&E.

When she began being sick, her partner took her to the casualty unit of Norfolk and Norwich Hospital. The couple mentioned concerns about bowel cancer, having recently watched a programme about its symptoms, but the doctor reassured her: “You are far too young to have bowel cancer; when the blood tests come back they will show that”. The tests did not indicate a problem; Miss Matthews was sent home to Norwich and told she was probably suffering from irritable bowel syndrome.

But the pain and vomiting continued. A week later, when she was unable to even swallow water, she returned to A&E, and was admitted to a ward for five days, but sent home once more. One week later, after she collapsed in agony at home, she was admitted to hospital again. This time, X-rays revealed a blockage. During an eight-hour operation, surgeons found a tumour so large they were forced to remove her womb and 36 inches of her bowel. The blood tests which Miss Matthews had undergone in A&E, she later found out, were not a clear indicator of bowel cancer, or its absence after all.

Six months of chemotherapy followed Miss Matthews’ operation, after which she was given the all-clear. However, since then the cancer has returned. On Tuesday, Miss Matthews, now 30, will undergo a second operation to remove a tumour. The mother of two girls, aged 11 and 13, says her focus now is on survival. “I don’t feel angry about this any more, my concern is about what happens next, but I did feel very frustrated, and frightened. I thought going to A&E was the safest place to be, but I was just fobbed off”.

A hospital spokesman said patients were encouraged to complain if they were not satisfied with their care, and added that bowel cancer was rare in patients of Miss Matthews’ age.

More than 4,900 people have backed The Sunday Telegraph’s Heal Our Hospitals campaign, which is calling for a review of hospital targets to make sure they work to improve quality of care.


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