Many fake doctors in Pakistan

Most English-speaking countries have recruited substantial numbers of doctors from Pakistan and many of those in Britain's NHS have been found to be poor performers. Could the report below be relevant to that? Australian bureaucrats have certainly often been very lax in checking the credentials of overseas doctors

SOME 70,000 quacks with bogus medical degrees are said to be endangering lives across the country. But the recent news of a fake doctors’ recruitment scam at the District Headquarters Hospital in Rawalpindi raises new concerns about the infiltration of such charlatans into our public healthcare institutions. Several senior health officials have already been arrested for the hiring of at least four people — three of them brothers — whose medical certificates were found to be bogus. One was taken on by the hospital as a neurosurgeon no less. While all those found guilty ought to be prosecuted and punished, more comprehensive preventative measures are also in order.

For starters, the Pakistan Medical and Dental Council could ask all public and private hospitals in the Rawalpindi-Islamabad area to send a list of their doctors for verification. The PMDC needs to introduce a multi-tiered checking and monitoring system which should include routine degree verification in all hospitals. Fake doctors are either not registered with the PMDC or hold phoney registration certificates, and as such unqualified doctors can be weeded out without harassing genuine practitioners. Hospitals which fail to verify credentials with the PMDC before hiring new doctors should be appropriately penalised. Detecting fake doctors requires diligent regulation as well as public awareness and prompt reporting by medical professionals who are suspicious of a colleague’s credentials. Not many people perhaps know that the PMDC’s website allows the general public to check if their doctors are registered with the council and are thus licensed to practise medicine. The PMDC and the health authorities should encourage the general public, through advertisements and posters, to be involved in exposing fake doctors in this manner. After all it is the public that will benefit most, in terms of safer healthcare, by the eradication of bogus physicians.

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A cure worse than the disease

With Democratic support coalescing around Sen. Max Baucus’s (D-Mont.) health care reform proposal, passage of a comprehensive overhaul now appears more likely than ever. One reason is the Congressional Budget Office’s (CBO) preliminary cost estimate for the bill suggesting that it would cost $829 billion over the 10-year budget window, but actually reduce the federal deficit by $81 billion.

On paper, the plan looks affordable, because it contains several features intended to reduce long-term health care costs. However, there is good reason to believe these proposals will not cut costs substantially, and could reduce the quality of care for patients. Most of the alleged cost-cutting measures merely shift costs from the federal government onto the states or private payers, without affecting long-term health care inflation. The only measures that could reduce the annual rate of growth in health care costs would erect government barriers between patients and their doctors, while jeopardizing long-term medical innovation.

Bringing millions of currently uninsured Americans into public or private health plans will not be cheap. That is why White House Chief of Staff Rahm Emanuel has said that the administration’s first priority is “getting health care costs under control.” And, in an August New York Times op-ed, President Obama wrote that the Democratic proposals “will finally bring skyrocketing health-care costs under control” by cutting “hundreds of billions of dollars in waste and inefficiency in federal health programs like Medicare and Medicaid.”

In order to keep the bill’s reported net costs down, Sen. Baucus’s plan relies on $397 billion of new taxes and other expected revenue and on accounting and cost-shifting gimmicks. For example, to help increase health care coverage, the bill would expand Medicaid eligibility, a move that shifts an estimated $33 billion of spending to the states. The CBO’s analysis notes this, but because it is not a federal expenditure, does not account for it in the bill’s budget score.

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American healthcare fascialism

Some time ago I invented the phrase "fascialism" to describe the American system of political economy. Fascialism means an economy is part fascist, part socialist. Economic fascism has nothing to do with dictatorship, militarism, or bizarre racial theories. Fascism is a brand of socialism that was the economic system of Germany and Italy in the early 20th century. It was characterized by private enterprise, but private enterprise that was comprehensively regulated and regimented by the state, ostensibly "in the public interest" (as arbitrarily defined by the state).

Socialism started out meaning government ownership of the means of production, but it came to mean egalitarianism promoted by "progressive" taxation and the institutions of the welfare state, as F.A. Hayek stated in the preface to the 1976 edition of The Road to Serfdom. The problems of the American healthcare system are caused entirely by the fact that the government subjects the system to massive interventions, some of which are fascist in nature, while others are socialist.

In 1992, the Hoover Institution published an essay by Milton Friedman titled "Input and Output in Medical Care," in which Friedman documented how, at the beginning of the 20th century, about 90% of all American hospitals were private, for-profit enterprises. State and local governments then began taking over the hospital industry. So, by the early 1990s only about 10% of all American hospitals were private, for-profit enterprises. Socialism characterizes at least 90% of all hospitals. Many other hospitals have received government subsidies, and with the subsidies come reams of regulation, making them fascist by definition.

The effect of this vast government takeover of the hospital industry, Friedman documented, is what any student of the economics of bureaucracy should expect: the more that is spent on hospital care, the worse the quality and quantity of care become, thanks to the effects of governmental bureaucratization. According to Friedman, as governments took over an ever-larger share of the hospital industry (being exempt from antitrust laws), hospital personnel per occupied hospital bed quintupled, as cost per bed rose tenfold.

Friedman concluded that "Gammon's Law," named after British physician Max Gammon, "has been in full operation for U.S. hospitals since the end of World War II." Gammon's Law states that "In a bureaucratic system, increases in expenditure will be matched by a fall in production.… Such systems will act rather like 'black holes' in the economic universe, simultaneously sucking in resources, and shrinking in terms of … production." Dr. Gammon surely knew what he was talking about, having spent his career in the British National Health Service.

"The U.S. medical system, in large part, has become a socialist enterprise," Friedman ended. Friedman also once suggested a syllogism to explain the bizarre spectacle on display today of responding to problems caused by healthcare socialism with even more healthcare socialism. The syllogism goes as follows:

1. Socialism has been a failure everywhere it has been tried;

2. Everyone knows this; and

3. Therefore, we need more socialism.

Layers of regulation plague every aspect of medical care and health insurance in America. In the health-insurance industry, for instance, each state imposes dozens of regulatory mandates on health insurers, requiring them to include coverage of everything from massage therapy to hair implants. The reason for mandates is that the message-therapy and hair-implant industries (and many others) hire lobbyists to bribe state legislators to require insurers to cover their particular practice if they want to sell insurance within a state. Among the states with the largest number of mandates as of 2009 are Rhode Island (70), Minnesota (68), Maryland (66), New Mexico (57), and Maine (55). Idaho has the fewest mandates (13), followed by Alabama (21), Utah (23), and Hawaii (24).

Each mandate increases the cost of health insurance and probably increases the typical health-insurance policy by hundreds, or thousands, of dollars yearly. This is a good example of healthcare fascism.

Government policy in the health-insurance industry applies both the brakes and the gas at the same time. While imposing onerous and cost-increasing regulations, government also limits legal liability in some cases where an insurer refuses to pay for a particular procedure or treatment that costs a patient his life. The state also creates state-wide cartels with laws prohibiting the portability of some aspects of health insurance. (For example, my employer-provided health insurance covers pharmaceuticals in Maryland, where I reside, but not in other states.)

Getting back to pure socialism, Medicare, Medicaid, and the Veterans Administration hospitals socialize a very large portion of healthcare in America, with the same predictable results as the socialization of hospitals: runaway costs for decade after decade, coupled with massive fraud, as is often the case when politicians are enabled to spend other people's money. Even the federal government admits that there is currently about $60 billion in Medicare fraud. Since government always understates the cost of everything it does, it is likely that the real number is at least two or three times that amount.

Having taken over most of the hospital industry, government-run or government-subsidized hospitals have created regional monopoly power for themselves with so-called "certificate-of-need" (CON) regulation. How this regulatory scam works is that an existing hospital in an area will give itself the legal "right" to decide whether there is a legitimate "need" for more hospitals. They have given themselves, in other words, the right to veto new competition in the hospital industry. It is as if the Microsoft Corporation had a legal right to veto new competition in the computer industry.

Not surprisingly, research has shown that CON regulation has increased hospital costs. CON regulation is also used to block competition in various healthcare professions as well, from nursing to home healthcare. (I was once asked to assist several nurses in obtaining a CON license from the Fairfax County, Virginia government so that they could start up their own home healthcare business. The county government was already in the business itself, and vetoed their application, naturally.)

Physicians have long enjoyed a degree of monopoly power derived from state legislatures that delegate to the American Medical Association (the doctors' union) the "right" to limit entry into medical schools through accreditation. Only graduates of accredited (by the AMA) medical schools are licensed to practice medicine. The AMA has used these state-granted privileges to limit both the number of medical schools and the number of medical-school graduates. The reduced supply of doctors drives up the price of medical care and the income of AMA members. Hundreds of other health professions limit entry with the help of occupational licensing regulation, the primary effect of which is to create monopoly profits, not to ensure quality of care.

Government regulation of pharmaceuticals and medical devices, primarily by the Food and Drug Administration (FDA), increases healthcare costs, denies the benefits of myriad helpful drugs and devices, and creates monopoly power. It has literally been responsible for the premature death of thousands of Americans who have been deprived of drugs that were long available to people in other countries.

FDA bureaucrats are extremely risk averse: On the one hand, it costs them nothing personally to delay a life-saving drug for years, if not decades, by demanding test after test. On the other hand, if they permit a drug to enter the marketplace that turns out to be dangerous, it is a public-relations disaster for the agency, which it does not want to be associated with. Consequently, the entrance of new drugs and medical devices onto the market is often delayed by years, costing many lives and inflicting much needless pain on those already suffering, while driving up prices.

The FDA also makes the market for pharmaceuticals less competitive by restricting what advertising may say for myriad drugs — even aspirin. New drugs do consumers no good if they do not know about them. Advertising restrictions imposed by the FDA, therefore, prop up the profits of incumbent drug marketers at the expense of newcomers in the industry and of consumers.

The government's legal system is also responsible for what used to be called "the liability crisis." The genesis of this crisis began in the 1960s. The government courts began accepting the Chicago School Law and Economics argument that assigning all liability in product-liability cases to manufacturers would be a good way to minimize the "social costs" of accidents. Manufacturers know more about products such as medical devices than anyone else, the argument went, so contract law and shared responsibility for accidents with the users of the products were thrown out the window.

So, when accidents occur, slick trial lawyers have had an easy time convincing dumbed-down juries to award millions, or hundreds of millions, of dollars in liability lawsuits. These lawsuits have bankrupted the manufacturers of many medical devices, while convincing others that the devices are too risky to make. The effect on the healthcare consumer is poorer healthcare and higher prices.

There are thousands of other government regulations and controls on all aspects of healthcare, even (or especially) the nursing-home industry. Like most regulation, it has little or no beneficial effect for the public. More often than not, it is part of a cartel arrangement by some group of medical practitioners who are in cahoots with federal, state, or local politicians who are always more than willing to sell their "constituents" down the river for a generous campaign "contribution."

The only sensible approach to healthcare "reform" would be massive privatization of America's socialized hospitals, combined with deregulation of the medical professions to introduce more competition, and deregulation of the health-insurance industry. Free-market competition would produce medical "miracles" the likes of which have never been seen, while dramatically lowering the cost of healthcare, just as it has done in every other industry where it is allowed to exist to any large degree.

This is not likely to happen in the United States, which at the moment seems hell-bent on descending into the abyss of socialism. Once some states begin seceding from the new American fascialistic state, however, there will be opportunities to restore healthcare freedom within them.

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Congress' health care bills leave millions uninsured

The high cost of health insurance premiums would continue to put coverage out of reach for millions even if Congress approves legislation President Obama says is intended to ensure "that every American has affordable health care."

The number of people who remain uninsured will depend on how House and Senate leaders reconcile separate versions of health care legislation to arrive at a final bill. The factors include the size of government subsidies to help low-income families pay for insurance and the scope of penalties that would be charged for those who don't buy a plan.

"A lot of this really depends on affordability," said Diane Rowland, executive vice president of the Kaiser Family Foundation. "As they put these bills together, one question is, 'Are the subsidies ... going to be sufficient to make coverage affordable?' "

The non-partisan Congressional Budget Office estimates 17 million Americans would remain uninsured under the Senate Finance Committee's 10-year, $829 billion health care bill. Health experts such as Rowland say that number would include families who earn too much to qualify for Medicaid but not enough to pay for insurance.

Others who could remain uninsured under the Finance Committee bill include people who choose to pay a proposed $750-a-year fine rather than buy coverage and those who are eligible for Medicaid but don't enroll.

Senate Majority Leader Harry Reid, D-Nev., is working behind the scenes to merge the Finance Committee bill with one passed in July by the Senate health committee.

The Finance Committee's bill would expand coverage to 29 million Americans who wouldn't otherwise have it, ensuring that 94% of U.S. residents are covered, according to the Congressional Budget Office. An early analysis found that a proposal being developed in the House would cover an additional 6 million to 7 million people, said Brendan Daly, a spokesman for House Speaker Nancy Pelosi, D-Calif. The speaker is leading negotiations in her chamber to combine three House bills into one.

Details of the House and Senate proposals are evolving. Lawmakers, including Senate Finance Committee Chairman Max Baucus, D-Mont., have said that no matter how the legislation is crafted, not everyone will have coverage. Those who could remain uninsured include:

•Those who can't afford it. All of the health care bills would mandate that individuals have health insurance and would provide subsidies to help low-income families pay for premiums. The Finance Committee bill would allow people to opt out of buying coverage if the lowest-cost plan available equals 8% or more of their income after subsidies.

A Center on Budget and Policy Priorities study estimates a family of three earning $27,465 a year would pay 4.5% of its income for insurance under the Finance panel's bill, more than four times the amount the same family would pay under the health committee's bill. "A family ... at that level is stretching it every day to make ends meet," said Judith Solomon, a senior fellow at the center.

•Individuals and families who choose to pay a penalty instead of buying insurance. The Congressional Budget Office has not said how many people it believes would make the decision, but it estimates the government would collect $900 million in penalties in 2016.

About 48% of those penalties would come from people earning between 100% and 300% of poverty, or between $18,310 and $54,930 for a family of three, according to the budget agency. About 29% of the money would come from people earning more than five times the poverty line.

•People who are eligible for Medicaid and other programs but do not enroll. Marc Cohan, director of litigation for the National Center for Law and Economic Justice, said one reason eligible people do not apply is because of the bureaucracy involved. "A lot of people ultimately throw up their hands in despair and walk away," he said.

Sen. Jim Bunning, R-Ky., criticized the Finance Committee's bill this month for adding "hundreds of billions of dollars more in new taxes ... and yet 25 million people will still remain uninsured." The number includes 8 million illegal immigrants who would not be covered under any of the bills in Congress.

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Health reform written behind closed doors

By day, Democrats tout how open they have been while crafting a bill to reform the nation's health care system. By early evening, they're behind closed doors. Three times last week, White House officials went to Capitol Hill to meet in closed sessions with top Senate Democrats to put together a health bill. They left with not much more than a thumbs up or a "we're making progress"-type comment to the reporters waiting outside. It's not exactly the level of transparency that President Obama promised during the campaign, when he said health care talks would be aired live on C-SPAN.

"I'm going to have all the negotiations around a big table," he told a town hall audience in Chester, Va., in August 2008. "We'll have the negotiations televised on C-SPAN, so that people can see who is making arguments on behalf of their constituents and who are making arguments on behalf of the drug companies or the insurance companies. And so, that approach, I think, is what is going to allow people to stay involved in this process."

The small group of White House officials and three senators met in Senate Majority Leader Harry Reid's office three evenings last week to discuss what kind of bill to send to the Senate floor. The negotiation team includes Mr. Reid, Finance Committee Chairman Max Baucus of Montana, and Christopher J. Dodd of Connecticut, who led the work on the Health, Education, Labor and Pensions (HELP) Committee bill.

White House officials seen leaving the meetings include Chief of Staff Rahm Emanuel, Health and Human Services Secretary Kathleen Sebelius, health care "czar" Nancy-Ann DeParle, and Peter Orszag, director of the Office of Management and Budget.

It's hardly unexpected that major legislation on Capitol Hill, particularly on an issue as complex as health care reform, would be done in a small group and behind closed doors. The reform debate is now at a particularly sensitive stage, as House and Senate leaders have to make major political and policy decisions on what kind of legislation to send to their chambers' floors.

But Mr. Obama's campaign promises have provided Republicans and other opponents of the Democrats' reform plans with an easy criticism of how he's crafting the legislation. "They're writing a health care bill in secret, even though the president called for all of this to be out on an open table and have C-SPAN cameras in the room," House Minority Leader John A. Boehner of Ohio said last week. "We're about to significantly alter one-sixth of the economy, and if there was ever a need for transparency it is now," Sen. Mike Johanns of Nebraska warned in a recent Republican address.

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