Thursday, October 01, 2009

British dentists threaten mass walkout over stupid new NHS contracts imposed by government

They object to becoming bureaucrats first and dentists second. They really do want to fix teeth

The move could see thousands more patients being denied an NHS dentist - a decade after Tony Blair promised everyone would have access to free care. The British Dental Association, the dentists' trade union, is opposed to a new draft contract because it says it will lead to delays in payments for their NHS work and even more red tape. The contract is supposedly an attempt to improve access to NHS dentistry.

It comes three years after a bungled deal saw hundreds of practitioners quitting the Health Service, leaving a million fewer with an NHS dentist. But critics say the deal is another example of botched health staff contracts and will mean even fewer dentists agreeing to do NHS work. The new system requires dentists to follow a complex matrix of burdensome 'key performance indicators', developed by a large accounting and management firm. Adding to the extra work, no computer process has been developed to manage the procedure, so it will all have to be completed by hand, until a system can be built - and paid for.

One dentist, who did not want to be named, said: 'Far from simplifying things, the new contract keeps all the current contract targets, and actually adds many more. It even includes 22 separate information schedules. 'It also adds a vast number of new "quality" measures, creating an additional bureaucratic nightmare.' He added: 'This contract is essentially a system developed by pen-pushers who have no experience of how a dental service is actually run. Dentists are being thrown into a live-fire exercise.'

The row threatens to overshadow today's speech at the Labour conference by Health Secretary Andy Burnham.

Conservative health spokesman Mike Penning said: 'These contracts are simply repeating the Government's past mistakes, and ministers have again completely failed to engage with the dental profession to broker a workable solution to the problems they have created. 'Patients and dentists around the country will be rightly concerned.'

Some primary care trusts are already asking dentists to sign the draft contract. If dentists do not sign, it will leave thousands of people without access to NHS dentistry - forcing them to go private or without treatment altogether.

The British Dental Association says the Department of Health has spent the past six months developing its own new contract system in isolation from the profession itself. In an extraordinary development, the BDA has publicly advised its members not to sign the contracts - a refusal that could see many dentists walking out on the NHS. Yet the Health Department has refused to stop trusts using the contract and would not deny that it will subsequently be imposed.

Dr John Milne, chairman of the BDA's general dental practice committee, said: 'The version we have seen is not, in our opinion, fit for purpose. We are lobbying the department hard for a number of significant changes to its content. 'Unfortunately, the draft has been released by a number of primary care trusts. As it stands, we do not believe the contract is suitable and are advising members not to sign it.'

Barry Cockcroft, Chief Dental Officer, said: 'The Department of Health is working with the British Dental Association and the NHS to develop this contract. 'We intend to robustly pilot potential changes with existing providers. We have already had many expressions of interest from dentists and PCTs to be involved in piloting and we will involve stakeholders as fully as possible.'


The "Public Option," or Bust

Barack Obama's entire presidency is now hopelessly tethered to the success of the cornerstone of his health care policy: the so-called "public option." Without it, his administration will have failed inside of its first year pursuing a policy that most Americans find to be a monstrous growth of government into a sector that works well for the more than 280 million Americans who have health coverage.

Today, the Senate Finance Committee is expected to take up the controversial proposal, an amendment being put forward by Democrat Senators Chuck Schumer and Jay Rockefeller that would add the government-run insurance plan to the so-called Baucus bill. The plan is already a part of the House version, H.R. 3200.

This massive government-run system, as proposed in the House of Representatives, would put an additional 45 million people on the government health-care rolls. ALG estimates this will cost some $2.1 trillion over ten years.

And Barack Obama, whether he cares to admit it, has stuck his reputation out there to achieve this unseemly takeover of what will be by 2018 one-fifth of the nation’s economy. Recently, in Cincinnati, he said, “I continue to believe that a public option within the basket of insurance choices would help improve quality and bring down costs.” Obama’s position is perfectly clear. And the only question is whether his party in Congress will stand by him in the face of incredible public opposition to the takeover. According to Rasmussen Reports, a full 56 percent of voters oppose the plan, with only 41 percent in favor.

The fact is, the Democrat Party has been pursuing a national takeover of the health care for decades now. It is their top agenda item. And anything less, when they have 60 Senators and 256 Representatives, enough to command the national agenda, will be an overwhelming—and much-deserved—defeat for the freshman Administration and his increasingly hard left party.


Escape to Montana

Canadians seek a private option

A bipartisan majority of the Senate Finance Committee defeated the health-care "public option" yesterday, though in our view Max Baucus's bill will still reach the same destination, albeit more slowly. With that in mind, we offer as today's commentary a cautionary tale from the land of the original public option, Canada. Here are the opening paragraphs of Sunday's Los Angeles Times dispatch:
"VANCOUVER, CANADA: When the pain in Christina Woodkey's legs became so severe that she could no longer hike or cross-country ski, she went to her local health clinic. The Calgary, Canada, resident was told she'd need to see a hip specialist. Because the problem was not life-threatening, however, she'd have to wait about a year. So wait she did.

In January, the hip doctor told her that a narrowing of the spine was compressing her nerves and causing the pain. She needed a back specialist. The appointment was set for Sept. 30. 'When I was given that date, I asked when could I expect to have surgery,' said Woodkey, 72. 'They said it would be a year and a half after I had seen this doctor.'

So this month, she drove across the border into Montana and got the $50,000 surgery done in two days. 'I don't have insurance. We're not allowed to have private health insurance in Canada,' Woodkey said. 'It's not going to be easy to come up with the money. But I'm happy to say the pain is almost all gone.'

Whereas U.S. healthcare is predominantly a private system paid for by private insurers, things in Canada tend toward the other end of the spectrum: A universal, government-funded health system is only beginning to flirt with private-sector medicine.

Hoping to capitalize on patients who might otherwise go to the U.S. for speedier care, a network of technically illegal private clinics and surgical centers has sprung up in British Columbia, echoing a trend in Quebec. In October, the courts will be asked to decide whether the budding system should be sanctioned. More than 70 private health providers in British Columbia now schedule simple surgeries and tests such as MRIs with waits as short as a week or two, compared with the months it takes for a public surgical suite to become available for nonessential operations.

'What we have in Canada is access to a government, state-mandated wait list,' said Brian Day, a former Canadian Medical Assn. director who runs a private surgical center in Vancouver. 'You cannot force a citizen in a free and democratic society to simply wait for healthcare, and outlaw their ability to extricate themselves from a wait list.'"

In other words, while Congress debates whether to set U.S. medicine on the Canadian path, Canadians are desperately seeking their own private option. At least Ms. Woodkey had the safety valve of Montana and private American medicine. Once Congress passes a form of Medicare for all, with its inevitable government price controls and limits on care, Americans might not be so lucky. Let's hope that by then Canada has expanded its own private option, so Americans will one day be able to visit Alberta for faster, better care. Unless Congress bars that too.


Anti-abortion campaigners attack Barack Obama health care plans

An alliance of Roman Catholic bishops, pro-life Democrats and conservative Republicans has claimed that taxpayers’ money could be used to buy abortions. A group of Democrats in Congress claims it has enough votes to block reform unless it is given the chance to include a ban on public funds being used for abortions. They want any new law to include a provision that women whose health care is subsidised by central government to any degree will have to pay for abortions themselves.

More than 30 Democratic members of Congress have written to the party’s leadership urging a vote on restrictions for abortion funding, joining 100 Republicans who submitted a similar letter on Monday, according to the New York Times.

Federal law forbids using taxpayers’ money for abortions. Supporters of abortion rights say it is possible to separate federal money from private money for subsidised patients, and prevent the use of any federal funds for the procedure.Pro-choice groups also worry that private insurers would drop plans that include abortions for fear of losing subsidised clients. Currently nearly half of women whose insurance is provided by their employers have abortion included.

The injection of abortion, the most explosive and divisive social issue in the US, could make the health care debate even more heated. Abortion was legalised by the 1973 Supreme Court Roe v Wade judgment and has motivated conservatives and religious groups since.

The emergence of another hurdle to the drawn-out health debate came as the Senate finance committee considered its version of a health care bill yesterday. Senators on the powerful committee defeated Mr Obama by ruling out the creation of a government-run insurance company to offer an alternative to private insurers by a vote of 15 to eight.

The White House has conceded that it might not get the public option, although it is clinging to the hope that the provision could be added when various draft bills from the Senate and the House of Representatives are merged into a final bill.

Mr Obama’s plans have run into much stronger than expected opposition as he has attempted to provide health insurance to 47 million people currently without it. Republicans have questioned how reform will be financed.


Why Medical Malpractice Is Off Limits

A few thousand trial lawyers have a lock on Democrats, who refuse to consider any legal reform

Eliminating defensive medicine could save upwards of $200 billion in health-care costs annually, according to estimates by the American Medical Association and others. The cure is a reliable medical malpractice system that patients, doctors and the general public can trust.

But this is the one reform Washington will not seriously consider. That's because the trial lawyers, among the largest contributors to the Democratic Party, thrive on the unreliable justice system we have now.

Almost all the other groups with a stake in health reform—including patient safety experts, physicians, the AARP, the Chamber of Commerce, schools of public health—support pilot projects such as special health courts that would move beyond today's hyper-adversarial malpractice lawsuit system to a court that would quickly and reliably distinguish between good and bad care. The support for some kind of reform reflects a growing awareness among these groups that managing health care sensibly, including containing costs, is almost impossible when doctors go through the day thinking about how to protect themselves from lawsuits.

The American public also favors legal overhaul. A recent Common Good/Committee for Economic Development poll found that 83% of Americans believe that "as part of any health care reform plan, Congress needs to change the medical malpractice system."

Congress now realizes it can't completely stonewall legal reform. But what has unfolded so far is a series of vague pronouncements and token proposals—all of which assiduously avoid any specific ideas that might offend the trial bar. Here are some examples:

• On July 31, Rep. Bart Gordon (D., Tenn.), a Blue Dog Democrat, introduced an amendment to the House health-care reform bill (H.R. 3200) to fund pilot projects for liability reform, including pilots for "voluntary alternative dispute resolution."

What happened? According to the online newsletter Inside Health Policy, "While Gordon's amendment originally had seven policies that states could implement in order to receive federal funding, the other five suggestions were crossed out . . . due to the agreement with the trial lawyers."

• On Aug. 25, at a town-hall meeting in Reston, Va., Howard Dean, former chair of the Democratic National Committee, was asked why there is nothing in the health-care proposals about liability reform. Mr. Dean replied: "The reason that tort reform is not in the bill is because the people who wrote it did not want to take on the trial lawyers. . . . And that is the plain and simple truth."

• On Sept. 9, President Obama made a commitment in a speech before Congress to fix the problem of defensive medicine. On Sept. 17, his secretary of Health and Human Services, Kathleen Sebelius, announced an initiative that will allow states to test a variety of programs to "put patient safety first and let doctors focus on practicing medicine." But in the initiative's statement of goals made no mention of defensive medicine, or of pilot projects such as special health courts. The funding for the initiative is a tiny $25 million. According to Katharine Seelye on the New York Times's Prescriptions blog, "the comparatively small budget seems commensurate with the administration's level of interest in the subject."

The upshot is simple: A few thousand trial lawyers are blocking reform that would benefit 300 million Americans. This is not just your normal special-interest politics. It's a scandal—it is as if international-trade policy was being crafted in order to get fees for customs agents.

Trial lawyers are agents, and their claims are only as valid as those they represent. They argue, of course, that they are champions of malpractice victims. As Anthony Tarricone, president of the trial lawyers association (called the American Association of Justice) put it: "Trial attorneys see first-hand the effects medical errors have on patients and their families. We should keep those injured people in mind as the debate moves forward." But under the current system, 54 cents of the malpractice dollar goes to lawyers and administrative costs, according to a 2006 study in the New England Journal of Medicine. And because the legal process is so expensive, most injured patients without large claims can't even get a lawyer. "It would be hard to design a more inefficient compensation system," says Michelle Mello, a professor of law and public health at Harvard, "or one which skewed incentives more away from candor and good practices."

Trial lawyers also suggest they alone are the bulwark against ineffective care, citing a 1999 study by the Institute of Medicine that "over 98,000 people are killed every year by preventable medical errors." But the same study found that distrust of the justice system contributes to these errors by chilling interaction between doctors and patients. Trials lawyers haven't reduced the errors. They've caused the fear.

An effective justice system must reliably distinguish between good care and bad care. But trial lawyers trade on the unreliability of justice. It doesn't matter much whether the doctor did anything wrong—a lawyer can always come up with a theory of what might have been done differently. What matters most is the extent of the tragedy and that a case holds potential for pulling on a jury's heartstrings.

Former Sen. John Edwards, for example, made a fortune bringing 16 cases against hospitals for babies born with cerebral palsy. Each of those tragic cases was worth millions in settlement. But according to a 2006 study at the National Institutes of Health, in nine out of 10 cases of cerebral palsy nothing done by a doctor could have caused the condition.

Unreliable justice is like pouring acid over the culture of health care. One in 10 obstetricians have stopped delivering babies, unable to pay malpractice premiums on the order of $1,000 per baby, according to the American College of Obstetricians and Gynecologists (ACOG). Some hospitals, including Methodist Hospital and Chestnut Hill Hospital in Philadelphia, have stopped delivering babies altogether; and the number of unnecessary caesarian sections have increased to the detriment of the health of mothers, according to the ACOG.

Trial lawyers scoff at the idea of special health courts. "First you have a court for doctors," a spokesperson for the trial lawyers, Linda Lipsen, recently said, "and then what? A court for plumbers?" But America has a long tradition of special courts for situations where expertise and consistency are important—bankruptcy courts, tax courts, workers compensation tribunals, vaccine liability tribunals, Social Security tribunals, and many more.

Trial lawyers often claim that any alternative to the current medical malpractice justice system, such as specialized health courts, will only make it more difficult for injured patients to seek justice. But that's why you start with a pilot project. If these courts are unfair they will be rejected. But if they succeed—that is, are fairer to patients and doctors—they could provide a solid foundation for rebuilding an effective, less costly health-care system than we have today.


Health Co-Ops Aren't the Answer

Insurance competition across state lines is a better idea

Congress is now backing away from creating the government health-insurance program, better known as the "public option." Instead, Montana Democratic Sen. Max Baucus is proposing to spend $6 billion to create government sponsored health-care co-operatives that he believes will create needed competition with private insurers.

Mr. Baucus is wrong about co-ops. They aren't likely to drive down costs or compete with private insurers on a level playing field.

Co-ops have a long history in America. They are not-for-profit organizations that are owned and run by their members. They've been used to sell farm products, provide electricity to rural areas, start credit unions, and much more. There are even health-care co-ops that have been reasonably successful. One of them is Group Health Cooperative of Puget Sound, in Washington State.

But health co-ops represent only about 1% of the health insurance market, and it won't be easy to raise that number quickly.

Private health insurers perform many complex and hard-to-replicate functions. They issue policies and accept financial risks associated with the costs of providing care. They perform actuarial analyses to track costs and price policies. They design different benefit structures to meet varying needs. They select, contract with, and monitor the quality of thousands of hospitals and doctors and other professionals who provide the services covered by their policies. They assess evidence for which technologies and treatments provide value, and provide information to assist millions of individuals and employers with a range of health-care and health coverage issues

Most plans, especially the best ones, assist with coordination of care and management of chronic conditions, and help consumers save money and time by guiding them to better health decisions. Typically, all of this is facilitated by highly sophisticated and expensive information systems, and many trained nurses and physicians.

Any effort to create a new health-care co-operative for five, 10 or 50 million Americans would be an extraordinary undertaking. It took decades and billions of investment dollars, with some of the most sophisticated business minds, to build today's major health insurance companies.

The many insurance functions these companies perform would need to be constructed from scratch by the proposed health co-operatives. It would require years to build them, and where would the expertise be found? This expertise resides—you guessed it—at health-insurance companies.

Further, the main way co-operatives could be cost-competitive with existing private plans would be by the billions of taxpayer subsidies envisioned by co-op proponents and by paying doctors and hospitals at Medicare rates, which often do not even cover costs. The price tag for such a start-up would be billions of dollars with years of work. Can anyone recall the startup of a government-subsidized company sent into the marketplace to compete fairly with private firms? Fannie Mae? Freddie Mac?

If we want greater competition for today's health plans to drive down costs, let's instead revise the ground rules and create a competitive landscape across the nation for existing companies.

We could start by allowing health plans to compete across state lines. Because of restricted competition, in a large number of states only one or two plans dominate the market. We should also reduce the number of mandated benefits states impose on plans. They drive costs 20%-30% higher than they might be. And we might encourage health plans to negotiate more aggressively than they do now with hospital monopolies that exist in many local areas.

Finally, we could promote benefit designs that offer more affordable coverage, such as policies with higher deductibles and health savings accounts that foster greater consumer engagement and healthy behaviors.

A "public option" by any other name—including health-care co-op—just won't fly. The real competitive force will come from putting more dollars into individuals' hands and fewer into insurers' hands, and by fostering true competition among existing insurers.


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