Monday, November 23, 2009

Latest political brainwave in Britain: NHS will provide free marriage guidance

Talking therapies are generally useless but so is the NHS on many occasions so I suppose it is a fit. They already support acupuncture. Getting real medicine -- like getting diagnostic tests done -- however, is often too hard. The NHS is run by politics not science or economics

Couples are to be offered marriage guidance counselling for free on the NHS, in a move which has drawn strong condemnation from patients and doctors' groups. Couples with relationship problems will be offered free sessions for up to six months, as part of a £270 million programme to increase the provision of "talking therapies" for the public, Andy Burnham, the health secretary, will announce this week.

Doctors and patients' groups said they were "horrified" by the use of NHS resources for relationship advice when patients with cancer and dementia were being denied treatment they desperately needed.

Mr Burnham will say on Thursday that "when couples hit a rocky patch, a bit of help and support can stop it spiralling out of control". He will instruct GPs to follow new guidance which says that if relationship problems are causing depression, up to 20 sessions of couples counselling can be offered, over the course of six months. Currently, most people seeking help from services like Relate pay between £45 and £60 per session, meaning the free counselling packages will be worth around £1,000 per couple. The NHS is expected to pay existing marriage guidance services, and newly-trained counsellors to provide the therapy.

Doctors and patients groups last night attacked the recommendation, contained in guidance by the National Institute for Health and Clinical Excellence (NICE). NICE has repeatedly come under fire for decisions to reject life-extending drugs for cancer and treatment to reduce symptoms of dementia.

On Thursday, NICE was accused by charities of "condemning patients" to an early death by rejecting the use of Nexavar, a drug which can extend the lives of liver cancer, arguing that its £9 million annual cost – £3,000 a month per patient – could not be justified.

Nick James, professor of clinical oncology at the Cancer Research UK Institute for Cancer Studies said: "I am horrified, in particular because of the way these decisions are taken without public debate. "I think most people would say treatment for those who are sick with cancer should be top of our list, and I would really question whether these kinds of efforts to preserve marriages are a matter for the state."

NICE has previously restricted the use of drugs to limit the effects of Alzheimer's, costing £2 a day, while provoking further controversy in May when it ruled in favour of alternative therapies like acupuncture for back pain, despite admitting there was little evidence they worked.

Michael Summers, Vice-President of the Patients Association, urged NICE and the Government to "get their priorities right". "If we had the luxury of untold sums of money, maybe we would think about paying for couples counselling," he said. "As things stand, people are still waiting for urgent treatment, being denied drugs for cancer, and dementia, and it seems inappropriate at the very least to start using public money in this way".


Indian entrepreneur shows that mass production applied to heart surgery drives costs way down with no loss of quality

HAIR tucked into a surgical cap, eyes hidden behind thick-framed magnifying glasses, Devi Shetty leans over the sawed open chest of an 11-year-old boy, using bright blue thread to sew an artificial aorta onto his stopped heart. As Dr Shetty pulls the thread tight with scissors, an assistant reads aloud a proposed agreement for him to build a new hospital in the Cayman Islands that would primarily serve Americans in search of lower-cost medical care. The agreement is inked a few days later, pending approval of the Cayman parliament.

Dr Shetty, who entered the limelight in the early 1990s as Mother Teresa's cardiac surgeon, offers cutting-edge medical care in India at a fraction of what it costs elsewhere in the world. His flagship heart hospital charges $US2000 on average, for open-heart surgery, compared with hospitals in the US that are paid between $US20,000 and $US100,000, depending on the complexity of the surgery.

The approach has transformed health care in India through a simple premise that works in other industries: economies of scale. By driving huge volumes, even of procedures as sophisticated, delicate and dangerous as heart surgery, Dr Shetty has managed to drive down the cost of health care in his nation of one billion. His model offers insights for countries worldwide that are struggling with soaring medical costs, including the US as it debates major healthcare overhaul.

"Japanese companies reinvented the process of making cars. That's what we're doing in health care," Dr Shetty says. "What health care needs is process innovation, not product innovation." At his flagship, 1000-bed Narayana Hrudayalaya Hospital, surgeons operate at a capacity virtually unheard of in the US, where the average hospital has 160 beds, according to the American Hospital Association. Narayana's 42 cardiac surgeons performed 3174 cardiac bypass surgeries in 2008, more than double the 1367 the Cleveland Clinic, a US leader, did in the same year. His surgeons operated on 2777 pediatric patients, more than double the 1026 surgeries performed at Children's Hospital Boston.

Next door to Narayana, Dr Shetty built a 1400-bed cancer hospital and a 300-bed eye hospital, which share the same laboratories and blood bank as the heart institute. His family-owned business group, Narayana Hrudayalaya Private, reports a 7.7 per cent profit after taxes, or slightly above the 6.9 per cent average for a US hospital, according to American Hospital Association data.

The group is fuelling its expansion plans through private equity, having raised $US90 million last year. The money is funding four more "health cities" under construction around India. Over the next five years, Dr Shetty's company plans to take the number of total hospital beds to 30,000 from about 3000, which would make it by far the largest private-hospital group in India. At that volume, he says, he would be able to cut costs significantly more by bypassing medical equipment sellers and buying directly from suppliers.

Then there are the Cayman Islands, where he plans to build and run a 2000-bed general hospital an hour's plane ride from Miami. Procedures, both elective and necessary, will be priced at least 50 per cent lower than what they cost in the US, says Dr Shetty, who hopes to draw Americans who are uninsured or need surgery their plans don't cover. By next year, six million Americans are expected to travel to other countries in search of affordable medical care, up from the 750,000 who did so in 2007, according to a report by Deloitte. A handful of US insurance plans now give people the choice to be treated in other countries.

Some in India question whether Dr Shetty is taking his high volume model too far, risking quality. "On one level, it's a damn good idea. My only issue with it comes from the fact that if you pursue wholesale volumes, you may give up something -- which is usually quality," says Amit Varma, a physician who serves as president of health-care initiatives for Religare Enterprises, a publicly listed financial services group in Delhi. Religare is part of a conglomerate that also owns Fortis Healthcare., a rival hospital chain.

"I think he has reached the point where if you increase volume any more, you could compromise patient care unless backed up by very robust standard operating procedures and processes," Dr Varma says.

But Jack Lewin, chief executive of the American College of Cardiology, who visited Dr Shetty's hospital earlier this year as a guest lecturer, says Dr Shetty has done just the opposite -- used high volumes to improve quality. For one thing, some studies show quality rises at hospitals that perform more surgeries for the simple reason that doctors are getting more experience. And at Narayana, says Dr Lewin, the large number of patients allows individual doctors to focus on one or two specific types of cardiac surgeries.

In smaller US and Indian hospitals, he says, there aren't enough patients for one surgeon to focus exclusively on one type of heart procedure. Narayana surgeon Colin John, for example, has performed nearly 4000 complex pediatric procedures known as Tetralogy of Fallot in his 30-year career. The procedure repairs four different heart abnormalities at once. Many surgeons in other countries would never reach that number of any type of cardiac surgery in their lifetimes.

Dr Shetty's success rates appear to be as good as those of many hospitals abroad. Narayana Hrudayalaya reports a 1.4 per cent mortality rate within 30 days of coronary artery bypass graft surgery, one of the most common procedures, compared with an average of 1.9 per cent in the US in 2008, according to data gathered by the Chicago-based Society of Thoracic Surgeons....


Democrats battle to keep Barack Obama health reform plan alive

The fate of President Barack Obama’s long-debated healthcare reforms hung in the balance last night as Democratic leaders in the US Senate scrambled to obtain a conclusive majority that would allow a draft bill to go forward. Failure to obtain the 60 votes necessary for the bill to survive would effectively force Obama’s supporters back to the drawing board and would severely set back the president’s hopes of an early resolution of an issue that has become bitterly divisive and has damaged his popularity ratings.

Democratic leaders expressed confidence yesterday that they would win over wavering senators who are worried that the healthcare battle might cost them their seats when they come up for re-election. At least three Democratic senators have expressed their doubts about the bill. It needs the votes of all 58 Democrats and two independents in the 100-member Senate to overcome Republican attempts to talk it out.

The House of Representatives has already passed its own version of the bill and a successful vote would pave the way for further negotiations. These would be on a Senate version to be merged with the lower house bill in a joint committee of both houses, before going to the White House for Obama’s signature.

Senator Ben Nelson of Nebraska is one of several moderate Democrats who was initially reluctant to support the draft bill. He has let it be known that he would vote to allow a full debate but would then insist on further amendments, especially on provisions for government intervention that critics have dubbed as “socialist” medicine.

Another waverer, Senator Mary Landrieu of Louisiana, has been driving a hard bargain as Democratic leaders agreed extra funding of up to $100m for her home state to secure her vote. Landrieu indicated that she was “leaning towards” a yes vote in order to allow further debate.

Senator Blanche Lincoln of Arkansas remained uncommitted and told reporters she might not make up her mind until just before the cliffhanger vote — scheduled for 1am UK time. Lincoln was reported to be nervous that moderate Arkansas voters would turn against her in next year’s election if she supported the $848 billion bill, which is intended to extend health coverage to 31m Americans who are uninsured.

Obama has spent much of his first year in office pressing for action on healthcare. The White House yesterday issued a statement of support calling the bill a “critical milestone in the effort to reform our healthcare system”.


Healthcare bill passes cloture

Health care reform passed its first major test in the Senate tonight, and heads to the Senate floor for debate Nov. 30. President Obama earlier set an end-of-the-year deadline so sign the bill, which -- if you're the betting type -- it seems they'll probably miss. Senate debate is expected to last three weeks.

From the White House, a somewhat subdued statement from press secretary Robert Gibbs: "“The president is gratified that the Senate has acted to begin consideration of health insurance reform legislation. Tonight’s historic vote brings us one step closer to ending insurance company abuses, reining in spiraling health care costs, providing stability and security to those with health insurance, and extending quality health coverage to those who lack it. The president looks forward to a thorough and productive debate."


The Unsustainable Public Option

The Harry Reid-Senate version of ObamaCare will start operating at massive budget-busting deficits starting in 2015, according to an Americans for Limited Government analysis of Congressional Budget Office data. By 2019, the “public option” will have spent some $361 billion more than it took in via new taxes. So, how then does the bill earn the moniker, “deficit-neutral”? The same way the Pelosi-House version does: by rationing health care away from the nation’s elderly—cutting Medicare by some $436 billion.

But that will not pay for this new entitlement—the so-called “public option”—in the long run. Cutting Medicare has its political limits—which is a nice way of saying that cutting it too drastically is a good way for Congressmen to get thrown out on their tails.

Seniors might support entitlement reform where the federal government attempted to figure out a way to fix the broken Medicare entitlement. Under the worst-case scenario, the Medicare Board of Trustees reports that after 2012, the program will lose about $433 billion through 2019. After that, it could be broke as early as 2028.

Economists here is much that could be done to help the situation, including breaking Medicare up into smaller, privatized companies and allowing insurance competition across state lines. But that is not the case being made to the American people in the “HarryCare” bill.

Instead, Congress is attempting to expand health care spending to an additional 36 to 45 million people in an open-ended, taxpayer-financed, government-run takeover. The House version of the legislation goes even further than the Senate, proposing over $890 billion in new spending.

The fact is increasingly clear that Congressional Democrats can only hide the costs in the “public option,” which is what they have done in both versions. But between the numbers, the cover-up comes apart. It took Medicare more than 40 years to run into deficits based on revenue shortfalls. The “public option” will lose hundreds of billions within 5 to 7 years.

As the Independent Institute notes, Florida has tried a similar approach to hurricane property insurance, creating a “public option” to “compete” with private insurers. The proposal also capped how much private insurance companies could charge. This had two predictable results: private insurers fled the state, and the so-called Citizens Property Insurance Corporation “still doesn’t have sufficient reserves to weather a major hurricane. When one comes, Florida taxpayers will be on the hook for the bill.”

In other words, like “public option” health insurance, Florida’s state-run hurricane “solution” proved to be unsustainable and drove Floridians off of private insurance. In the end, it simply created an unfunded liability.

On Saturday at 8PM, the Senate legislation will face an important test vote—on whether or not to proceed to the bill. Reid now admits he is not certain he has the 60 votes necessary to continue pushing the unpopular measure. And if the majority of Americans have their way, by 9PM, the “HarryCare” will have been toe-tagged for the dead room.


The Mandated Health Insurance Outrage

How can they make us buy coverage?

With the introduction of Senate Majority Leader Harry Reid’s 2,074-page health insurance nationalization bill, we can be thankful for one thing at least. It will most likely be the last bill of its kind introduced this year. Who’d have time to wade through another? This doesn’t mean there is anything in the bill to be thankful for. Like its Senate predecessors and House counterpart, it should offend any advocate of liberty and good economic sense.

First and foremost among its defects is the individual health insurance mandate: Every individual would be forced to buy government-defined comprehensive medical coverage (or to have it bought by one’s employer). A fine up to $750 awaits anyone who defies the mandate. As Shikha Dalmia points out in Forbes this week, the individual insurance mandate is the major outrage in the whole “health care reform” scam. I would say it’s the keystone. Remove it and most of the rest crumbles to the ground.

Who do these politicians think they are? Our lives are not theirs to dispose of. Politicians love to sugarcoat their threats of force. So the Reid bill calls the mandate “shared responsibility.” To those who wonder by what authority the government can make us buy insurance against our will, the bill alludes to the Constitution’s Commerce Clause, which gives Congress the power to “regulate … commerce among the several states.” (For a fuller story on the clause, see this.) The bill says, “The individual responsibility requirement provided for in his section . . . is commercial and economic in nature, and substantially affects interstate commerce.”

How would an insurance requirement affect interstate commerce? The bill says that since without the requirement people wouldn’t buy insurance until they are sick, it therefore “will minimize this adverse selection and broaden the health insurance risk pool to include healthy individuals, which will lower health insurance premiums. The requirement is essential to creating effective health insurance markets in which improved health insurance products that are guaranteed issue and do not exclude coverage of pre-existing conditions can be sold.” In other words, for the sake of making the insurance market work better, we must be forced to buy coverage. How’s that for a justification?

It’s amazing how many fallacies can be stuffed into one argument. To begin, medical insurance isn’t really interstate commerce. One of the few sensible things proposed during the public discussion on medical care is that the federal ban on interstate purchase of coverage be repealed. Residents of California are not free to buy less-fancy, less-expensive policies offered in Arizona. They are stuck with policies made more expensive by California’s overbearing regulatory regime. Interstate sales would increase competition and lower prices, but the ruling party shows no interest in that idea. So how can this be about interstate commerce?

There’s more that is wrong with the argument. Typically, the Commerce Clause has been invoked against barriers to the free flow of interstate commerce. The Supreme Court has occasionally upheld the prohibition of activities (such as growing wheat for one’s own use in violation of an acreage-allotment program or dispensing medical marijuana) that were said to adversely affect interstate commerce. But the insurance mandate would represent the first time that individuals were compelled to buy product or service in the name of making interstate commerce more effective. The Congressional Budget Office calls it “unprecedented”: “The government has never required people to buy any good or service as a condition of lawful residence in the United States.”

Even under the most expansive reading of the Commerce Clause, how does compelling the purchase of insurance qualify as regulating interstate commerce?

The nub of the bill’s argument is that if healthy people are not forced to buy coverage, the insurance market won’t work properly. Why not? Because same bill would compel insurance companies to accept all applicants for coverage, sick or healthy, without price discrimination. That is, the bill creates the incentive for people to opt out of insurance until they are sick. Obviously, that would not be good for the insurance market.

The individual insurance mandate, then, is a solution to a problem the bill itself would create. The authors invoke the Commerce Clause to protect interstate commerce from a threat they themselves pose to it. They could avert the threat simply by not imposing guaranteed-issue on insurers. But of course the advocates of nationalized medicine wouldn’t do that. Guaranteed issue is at the center of their scheme. They want to proclaim that they brought universal coverage to America. Freedom must take a back seat to their objective, which is to disguise a welfare program as insurance and put us on the road to government-administered rationing.

The “reformers” are quick to point out that people without insurance go to emergency rooms for medical care and sometimes don’t pay their bills, shifting the costs to the rest of us. But Shikha Dalmia notes that uncompensated care accounts for less than 3 percent of the country’s total medical bill. To save $40 billion a year, we should spend more than $100 billion a year and lose more liberty? No thanks.

One reason for uncompensated care is that emergency rooms are forbidden to turn away patients (even in non-emergencies) who have no means of payment. Who imposed that prohibition? The government, of course. That may sound humane, but one unintended consequence is a likely contraction of charitable care. Why set up facilities for the indigent if they can turn up at any emergency room? Again we see Mises’s Law at work: Intervention begets intervention. Government action creates problems that politicians then use to justify more government action. Undoing the first intervention would help solve the problem, but politicians have little incentive to move in that direction.

Government has suppressed the free market in medical care both on the supply and demand sides. As a result, medical services and insurance are artificially expensive, pricing many people out of the market. Instead of removing the interventions and letting the free market—including mutual-aid associations and philanthropy—lower prices and create more widespread coverage, the politicians propose to pile on more market-suppressing measures. Freedom is the first casualty. But we can also anticipate an aggravation of the current system’s worst features.

Forcing individuals to buy insurance is an intolerable assault on our liberty—not to mention a massive subsidy to the insurance companies. (They’re mad the penalty is not greater.) How many more usurpations can we be expected to tolerate?


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