Wednesday, June 17, 2009

Obama health care plan cuts funds to hospitals

Treat more people with less money? Sure!

The White House said Saturday that President Barack Obama intended to pay for his health care overhaul partly by cutting more than $200 billion in expected reimbursements to hospitals and other medical facilities over the next decade – a proposal that is likely to provoke a backlash from cash-strapped medical institutions.

The high-stakes struggle over medical care is heating up as Obama declares the status quo unacceptable. Obama has insisted that his plan will not add to the federal deficit, and he had already set aside in his budget what he calls a $635 billion "down payment" toward the overall 10-year cost of the overhaul, which is expected to top $1 trillion. But Republicans and some Democratic legislators have been pressing him to provide details on how he would cover the rest. On Saturday, he used his weekly Internet and radio address to do so.

Obama said he had identified "an additional $313 billion in savings that will rein in unnecessary spending and increase efficiency and the quality of care," bringing the total to nearly $950 billion. "These savings will come from common-sense changes," Obama said in his address. "For example, if more Americans are insured, we can cut payments that help hospitals treat patients without health insurance." He added: "If the drugmakers pay their fair share, we can cut government spending on prescription drugs. And if doctors have incentives to provide the best care instead of more care, we can help Americans avoid the unnecessary hospital stays, treatments and tests that drive up costs."

Saturday's announcement came during an intense push by the White House to sell Obama's health care plan, his highest legislative priority. Broadly speaking, Obama wants to extend coverage to the nation's 45 million uninsured, preserve consumer choice and cut rising health care costs. He has argued that fixing the nation's health care system is crucial to the economic health of the U.S.

But as Congress contemplates the details of the legislation, the question of how to pay for the plan is among the thorniest it will face. Already, one of Obama's early proposals – limiting tax deductions for high-income people – has run into major roadblocks on Capitol Hill.

The administration expects to achieve the lowered hospital payments in two major ways. First, said Obama's budget director, Peter Orszag, payments to hospitals will be reduced to try to encourage them to work more productively and efficiently. These "productivity adjustments" would account for $110 billion in savings.

Secondly, the administration expects to lower payments to hospitals that treat large numbers of low-income patients. Medicare and Medicaid make special extra payments to these hospitals, but Orszag said those payments would become less necessary over time, as more of the nation's 45 million uninsured acquire coverage through the new program.

But hospital administrators, already nervous about lowered reimbursements, are likely to oppose such cuts. Less than 24 hours before Obama's radio address, the president of the American Hospital Association, Richard Umbdenstock, issued a call to action to his members across the country, warning that Congress might cut provider payments. Umbdenstock asked hospitals to "push back" against the proposed cuts. "Payment cuts are not reform," he said, denouncing "blunt cuts that cripple hospitals' ability to do better for their patients."

Dr. Patricia Gabow, chief executive of the Denver Health and Hospital Authority, which operates a 477-bed public hospital, said it would be "pretty risky" for Congress to cut payments to safety-net hospitals before knowing whether new legislation actually reduced the amount of uncompensated care they must provide. "What about homeless people, the chronically mentally ill, substance abusers and people with low literacy?" Gabow asked.

Congress ultimately will shape the new laws. Sen. Max Baucus, D-Mont., chairman of the Finance Committee, intends to introduce his plan this week. Aides said it would include a proposal to tax some employer-provided health benefits, a notion that Obama sharply criticized during his campaign for the White House. Workers might, for example, have to pay income tax on the value of family coverage exceeding $15,000 a year. Labor unions, many employers and many House Democrats oppose such a tax.


A British Liberal politician goes to an NHS hospital

Even though he got VIP treatment he could still see lots of problems

Last weekend, when the heart was being ripped out of Gordon Brown’s Government by angry voters, I was having bits of my insides cut out by surgeons. Fortunately, my bits were less essential - merely an appendix. And the voters seemed angrier than the appendix.

The unplanned, emergency hospital visit to St Thomas’s, London, did, however, do me a valuable service - providing first-hand experience of what the NHS now calls ‘the patient journey’ (though much of it was actually second-hand, via my family, as I spent a fair proportion of my time unconscious).

Overall, I came away very impressed and reassured. I was released in good shape 36 hours after surgery under general anaesthetic. I had benefited from recent advances in diagnostics - the acute appendicitis was picked up on a CT scan - and keyhole surgery techniques. The consultants and hospital doctors were highly professional. Nursing care was meticulous and friendly. Staff repeatedly cleaned their hands with MRSA disinfectant. I even enjoyed good hospital food. [They must have sent out for it]

This positive experience reflects, I think, a bigger change. A decade ago, as a newly elected MP, I was deluged by complaints about NHS hospitals. Long waiting times. Slapdash treatment. Bolshie nurses.

Dirty wards. Local and national surveys showed that health care was top of voters’ concerns. Health remains an issue, of course, especially around such big, intractable problems as mental illness and geriatric care. But with a few dramatic, recent exceptions, such as Stafford General Hospital, the sense of crisis which centred on the country’s hospitals has lifted.

One reason is that vast amounts of taxpayers’ money have been spent, and it shows. The worry is that the taps will now be turned off again as we head for a new era of cuts. Last week there were warnings of severe financial curbs as Government tries to rebalance the budget after the terrible damage inflicted on public finances by the collapse of the banking system and recession.

My short experience told me that there is now excellent quality care in the NHS provided by some first-class people. I also sensed that the services are potentially fragile if put under financial stress.

My own adventure began when I collapsed in a heap several times after dinner at a friend’s house. The initial theory was food poisoning - a House of Commons crayfish sandwich eaten earlier in the day was chief suspect.

When the ambulance team arrived, within seconds of the predicted time, they were worried about the fainting and wanted me checked out at the nearest hospital. I hadn’t appreciated ambulance staff have advanced paramedic skills. When you are feeling half dead it is reassuring to know that the first contact with the NHS is with people who really know what they are doing.

There followed the almost obligatory long wait on a trolley in a cubicle in A&E. I am told this violates one of the numerous targets hospitals have to meet. But it wasn’t a problem. There were higher priorities: desperately ill old people and victims of assaults guarded by the police. I was safe and comfortable and the medical staff were calm, efficient and kind.

I was fortunate to have my wife with me who spotted details that the system somehow overlooked - such as dirty toilet floors and missing loo rolls. As morning broke I discovered that my lab tests showed a worrying abnormality and I must stay.

It also transpired that someone had recognised the grey-faced, middle-aged man in the cubicle. A smart lady appeared with a clipboard - Management - and I was taken to a beautiful room with a view. I was getting five-star treatment and felt too weak to insist on equality. My wife later overheard a conversation: ‘I can’t believe it! We’ve actually got an MP here on the NHS.’ It is quite possible that my favourable experience owes something to this observation. But I think the outstandingly good practice I encountered ran much deeper. As did the inefficiencies.

While I was waiting for surgery the next day, long after the appointed hour, my son and daughter were waiting for me, chatting to the surgeons and anaesthetists.

They waited and waited. There was a problem. No porter. No manager to sort it out. I discovered that such waits occur constantly. There aren’t enough porters. But we are in a recession and there are alarming levels of unemployment in Inner London which provides the hospital with its staff. So why is there a porter shortage?

I also discovered that a new multi-million-pound building next door had been poorly designed so that doors are too narrow for porters to take trolleys through.

The underlying problem seems to be a preoccupation with the glamorous ‘frontline’ roles rather than the equally essential backroom systems. Or perhaps funds are rationed in ways which starve these less visible activities. Armies win battles, however, not just because of brave soldiers but because someone is organising supplies of ammunition, lorries, food and drink. Good businesses also understand logistics.

Public services are often woefully deficient in this area. The problem is called management. In the NHS, management seems to mean highly-paid officials sitting in big offices, attending meetings, burnishing their mission statements and issuing edicts to operational staff based on Government targets.

In St Thomas’s I gathered management was insisting on commandeering a doctors’ rest area for new offices - alienating the very people who make the NHS so remarkable.

The problem, as I saw it, is a lack of the NHS equivalent of hands-on supermarket floor managers, factory fore- men and Army sergeant majors: the cogs who make the machine work.

When I was ready to leave, my worries were confirmed. I was told there was a three-hour wait for straightforward drugs from the pharmacy. I was happy enough reading a book but my bed and room, and nursing staff, were likely to be immobilised for a morning. Someone made a fuss and this cut the wait to three minutes. But when my wife visited the pharmacy there were harassed staff too busy to answer the phone, attend the front desk or supervise distribution. Management was nowhere.

In numerous, passionate debates about the future of the NHS I have never heard mention of porter shortages, pharmacy management, hospital transport or trolley logistics. But unless the inefficiencies are sorted the cuts will reverse the NHS improvements of the past decade.

We have been here before. The financial screw tightens. Hospitals are told to make economies. There are cuts in ‘beds’ (in other words medical staff). Key vacancies aren’t filled. Non-emergency cases are pushed back (and their condition deteriorates). Then someone decides that the hospital isn’t ‘viable’.

Protests, barricades, petitions. In the battle for resources, valued local community hospitals and less glamorous bits of the NHS are trampled underfoot. But it needn’t be like that. Sensible steps have to be taken now to ensure the high-quality people who work in the NHS are properly used.


Australia: Victorian government hospital gives woman fatal overdose

Mogadon is well known as a powerful sleeping pill. Why would anybody be given three of them? This sounds deliberate, not accidental. It's not even indicated for depression

A family say they could only watch their mother slowly die after staff at Casey Hospital allegedly gave her an accidental overdose of a sleeping pill. The coroner is investigating the March 30 death of Elsinor Mitchell, 74, who was allegedly given three Mogadon tablets on March 27 when she was not supposed to receive any medication. Ms Mitchell's family say that within 15 minutes of the medication she fell into a coma while being transferred in an ambulance, and they could only watch as her organs shut down over the next three days because doctors were powerless to reverse the damage.

Victoria police have prepared a brief for the coroner, who is reviewing medical records and referring the information to the clinical liaison service for a medical opinion. Southern Health, which runs Casey Hospital, yesterday declined to comment on the incident, saying it was standard procedure not to discuss matters before the coroner. Other medical sources have told the Herald Sun it would typically require a greater dose of Mogadon to overdose.

Ms Mitchell's brother, Alf Hulland, his sister's power of attorney while in hospital, said Ms Mitchell was diagnosed as suffering depression by Casey Hospital doctors and given medication just before being placed in an ambulance to travel to a Heatherton clinic. He claims the hospital's doctors later admitted they realised the mistake only while Ms Mitchell was in transit, but she had already slipped into a coma before they could alert paramedics to the problem.

The Narre Warren mother of five adult children was later rushed to Monash Medical Centre but could not be saved. "A doctor took her youngest son into a room and told us somebody had made a terrible error at Casey Hospital," Mr Hulland said. "She said there would be a big inquiry and it would not be covered up, but apart from that there was nothing more she could do and her organs would shut down so she had 24 to 48 hours at the most to live.

"It is the most distressing thing I have ever had to endure in my entire life - to sit there and watch her die. I think it is absolutely disgraceful. "They had told me that within a fortnight she would be home and back to her normal self again. There was no reason for her to die. "A doctor came over from Casey Hospital the next day and apologised. It is the first time I have seen a doctor cry." Mr Hulland said he could barely recognise his sister in her final hours because her transformation was so severe. "She was a bubbly, happy-go-lucky person who always helped anybody," he said. "She absolutely had a heart of gold."


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