Sunday, December 13, 2009

Patients with a crippling gut condition 'could be made ill under British government plans to remove their drugs'

Something for Americans to look forward to under Obamacare

The National Institute for Health and Clinical Excellence (Nice) wants to restrict how long patients are given the drugs, which stabilise their illness and have been credited with allowing many to live a normal life. Under new proposals patients with Inflammatory Bowel Diseases (IBD), which includes Crohn's disease, will be guaranteed the treatment for just one year. They will only receive the drugs again if their condition worsens.

At the moment many patients are given the drugs permanently, to prevent relapses in their illness. But Nice insists that the drugs are too costly for the benefits that they provide to continue to prescribe them indefinitely. The new proposals come only a year after Nice sparked outrage by proposing to stop prescribing the drugs entirely if a patient’s condition appeared to stabilise, without even guaranteeing a year of treatment.

Michael Addelman, from Manchester, whose seven-year-old son Jake currently takes one of the drugs involved, Infliximab, said that to remove his son’s medication would “cruel”. “It would be immeasurably cruel to force somebody back into this hellish life,” he said. “The prospect of my son going back to a life of intense pain is extremely worrying.”

Richard Driscoll, chief executive of the National Association for Colitis and Crohn's Disease (NACC), said that the proposals were “madness”. He said: “We really don’t think the NICE Committee understands what this will actually mean for patients’ lives. “The treatment that has been keeping (patients) well and able to lead a near normal and productive life at college, or in work or in caring for their family will suddenly stop. “For many, their symptoms will then start to recur, interrupting work, education and family life. “They will be attending hospital again for assessment and treatment, and this will continue until they get ill enough to ‘requalify’ for the treatment.”

He added: “Just imagine how it would feel for a university student whose treatment has enabled them to complete their course, only to find that it is to stop a couple of months before their final exams – this is madness. “And is it really more efficient and cost-effective for the health service to have someone getting steadily more ill and needing a series of appointments and tests or even admission to hospital compared to having them on a planned programme of care that keeps them well?”

The two drugs involved are Infliximab, which Nice estimates costs £12,500 a year to prescribe, and Adalimumab, which costs £10,000 a year.

There are an estimated 250,000 sufferers of IBD in Britain. Symptoms often include severe weight loss, because the disease makes it difficult for patients to eat. Other signs can be extreme pain, diarrhoea, vomiting, and associated diseases like arthritis.

A spokesman for Nice said: "In making their provisional recommendations, the appraisal committee was unable to recommend adalimumab and infliximab in people with severe active Crohn’s disease for continuous treatment after 12 months due to a lack of long-term data and insufficient evidence identifying a patient group at high risk of relapse. "A further course of treatment with adalimumab or infliximab for another 12 months was recommended as an option for people whose disease relapses”.


Mother died after NHS doctors missed infection

Civil servant Sarah Stitt, 36, went to her GP complaining of chronic earache and was given antibiotics for her pain. But another infection causing meningitis was missed despite further medical examinations - and spread to attack her brain. Mrs Stitt, mother to two sons, died from the brain virus just four weeks after first going to her doctor.

Ear specialist witness Desmond Nunez told the inquest: "Some things could have been done, it might have made a difference."

Mrs Stitt began suffering earache in January 2007. She visited her GP, spoke to an out-of-hours healthcare worker and went to hospital as she struggled to cope with the pain. Doctors diagnosed an infection and prescribed antibiotics and eardrops. But the inquest heard a second "extremely rare" infection called masked mastoiditis was missed before developing into meningitis.

Her husband, Sean, then took her to the Royal Gwent Hospital in Newport, South Wales where she died. Gwent coroner David Bowen yesterday recorded a narrative verdict, saying diagnosing the second infection would have pointed towards meningitis. He added: "Mrs Stitt wasn't a lady who easily complained. She had a very high pain threshold."

Speaking outside court, Mr Stitt, 40, of Magor, Gwent, said: "Sarah was so friendly, loving and generous. "I can't believe no-one spotted she was seriously ill until it was too late. "She was in extreme pain. The doctors failed to recognise the symptoms and just treated her for an ear infection."

Mr Stitt added: "I'm glad the coroner recognised there was a missed opportunity to save Sarah's life. "My family and I will have to live with the consequences of that missed opportunity for the rest of our lives. "I've lost a loving wife and my children have lost a devoted mother who can't be replaced. "Harry doesn't even remember his mum - he was only three when she died. Joseph still finds it painful."

A spokesman for Aneurin Bevan Local Health Board, which runs the Royal Gwent Hospital, said: "We fully accept the coroner's verdict in this tragic case. "There are lessons to be learned in respect of clinical management of such cases and appropriate action has already been taken." [Like what?]


British hospitals 'face funding squeeze'

Hospitals face a four year long squeeze on their funding with the announcement that ministers will freeze the income they receive for procedures, in effect a real terms cut. Ministers insisted that the move would increase efficiency within the NHS. But health experts warned that the freeze, coupled with a goal to reduce management costs by almost a third, could mean cuts.

Ministers have committed to a freeze next year, but have said that there will be a “maximum” increase of naught per cent for the three years after that – suggesting that the payment rate, or tariff as it is known, might actually be cut.

Mr Burnham, the Health Secretary, insisted that the move would improve productivity within the health service, as he published a roadmap for the NHS for the next five years. He said: “There is no doubt and getting away from it, (this) is challenging, it is tough and let’s be honest about that. “But there is time to plan. “There are lots of things that we can do to spend money better and more wisely in the NHS.”

But health experts warned that the plan could lead to cuts which affect patients. Dr Jennifer Dixon, director of the Nuffield Trust, the health policy charity, said: ‘The scale of the challenge will be intense. “Without significant increases in productivity – the likes of which have not been achieved in the past – the health service will inevitably face real terms cuts in its budgets from 2011 onwards.”

The document also lays out plans for family doctors to be asked to make one per cent efficiency savings across the board. Hospitals’ incomes will also be linked to patient satisfaction for the first time. The NHS has previously set a target to make between £15 and £20 billion of efficiency savings by 2014.


Public option’s rotten replacements

Sarching for an acceptable alternative to the controversial "public option," Senate Democrats on Tuesday night adopted three bad ideas instead. Having tried and discarded the "robust" public option, the opt-in and opt-out approaches, co-ops and the "trigger," Senate Majority Leader Harry Reid proposed a program similar to the Federal Employees Health Benefit Program, which covers government workers, including Congress members. Reid's plan would also expand Medicare and Medicaid.

The FEHBP offers a variety of private insurance plans under a program managed by the US Office of Personnel Management. Each year, OPM uses the federal procurement process to solicit bids from insurance firms to be one of the plans offered. Premiums can vary, but participating plans operate under stringent rules.

Moderates like Connecticut Sen. Joe Lieberman like the FEHBP model because the insurance plans are private rather than government entities. Liberals like Sen. Charles Schumer like it because it is government-regulated and managed.

In using the FEHBP as a model, however, Democrats have chosen an insurance plan whose costs are rising faster than average. FEHBP premiums are expected to rise 7.9 percent this year and 8.8 percent in 2010. By comparison, private-insurance premiums will rise on average by 5.5 to 6.2 percent annually in the next few years, the Congressional Budget Office predicts. In fact, FEHBP premiums are rising so fast that nearly 100,000 federal employees (who pay 30 percent of their plans' premiums) have opted out of the program.

FEHBP members are also finding their choices reduced. Next year, 32 insurance plans will either drop out of the program or reduce their participation. Some 61,000 workers will lose their current coverage.

Moreover, the government can't simply allow non-government workers to buy into the FEHBP. According to the Robert Woods Johnson Foundation, such an approach would result in substantial "adverse selection" — that is, new enrollees would be much sicker than the current pool of workers, driving premiums higher for current plan participants. A similar proposal in Tennessee several years ago nearly destroyed the state-employee health system.

So the plan would authorize a parallel program replicating the FEHBP. But former OPM director Linda Springer doubts that the agency has the "capacity, the staff or the mission" to manage the new program, saying, "ultimately, it would break the system."

And an independent FEHBP-like system ultimately also would suffer from the same adverse selection, making its premiums unaffordable for most Americans without government subsidies. So even this "nonpublic" public option would wind up being a drain on taxpayers.

But the expansion of Medicare and Medicaid are even worse ideas.

Medicare is now $50 trillion to $100 trillion (yes, that's trillion with a "T") in debt, depending on which accounting measure you use. But Democrats now want to allow individuals age 55 to 65 to be able to "buy in" to the program.

The plan initially calls for enrollees to pay actuarially valid premiums if they elect to participate in the program. But history suggests that such funding mandates are likely to fade over time. Medicare Part B was originally supposed to support 50 percent of its costs through premiums. Premiums now pay for less than 25 percent of the program's cost.

Plus, Medicare under-reimburses doctors, especially in rural areas. Thus, expanding Medicare enrollment would threaten the viability of rural hospitals and other providers and also result in more cost-shifting, driving up private insurance premiums.

Democrats may also raise Medicaid eligibility to 150 percent of the poverty level — even though that program is one of the biggest threats to the solvency of the federal and state governments' budgets.

Medicaid now costs more than $330 billion a year, a cost that grows at a rate of about 10.7 percent annually. The program spends money by the bushel, yet reimburses providers even worse than Medicare. The Medicare Payment Advisory Commission says only 69.5 percent of doctors are willing to accept new Medicaid patients. So Medicaid patients have a tough time finding adequate primary care. The number of Medicaid beneficiaries who use emergency-department services for non-emergency care is higher than the rate for any other payer group, including the uninsured.

It's easy to understand why Senate liberals would support this "compromise": It expands government health-care programs and further squeezes private insurance. But why would self-professed moderates sign on to a proposal that raises costs, results in higher insurance premiums and provides a lower quality of care?


The Democrats' Assault On Seniors: Wrecking Medicare To Save Obamacare

by Hugh Hewitt

In an interview on my radio show Wednesday, Arizona Senator Jon Kyl underscored the fact that Senate Democrats do not have the 60 votes they need to pass Obamacare, and that reports about the inevitability of Obamcare passing are part of the Democrat's strategy. (The transcript of the interview is here.) Kyl asserted that Harry Reid routinely announces, and then the MSM echoes, statements about the inevitability of the bill's passing, but then reality catches up.

This is happening again today as the premature reports of an agreement to expand Medicare to those 55 and older are exposed as more puff talk from a disappointed and reeling left that has seen its dream of a public plan take some serious blows in the past few days. David Drucker's and Emily Pierce's report in Roll Call (subscription required) conveys the difficulty facing Reid:
Democratic Senators involved in crafting what Majority Leader Harry Reid (D-Nev.) described as a “broad agreement” on health care policy appear to be at odds over both the policy proscriptions and the notion that they had even reached such a deal.

Though Reid announced late Tuesday that negotiations among a group of 10 liberal and moderate Democratic Senators had largely resolved the intraparty standoff over the public insurance option, participants in the group said their “agreement” had been mischaracterized and that they agreed only to send the proposal to the Congressional Budget Office for a cost estimate, saying more information was necessary before making any firm decisions.

Seniors especially have to hope that the new deal falls apart as it represents a savaging of Medicare. The Obama-Pelosi-Reid assault on Medicare has three parts now.

First, Obamacare proposes to loot Medicare of about a half trillion dollars in benefits. Obamacare enthusiasts dismiss the devastating impacts to Medicare Advantage enrollees as necessary to rebalance the system, but the loss of benefits to those senior citizens will be huge. So too will the cutbacks for hospitals treating the elderly if the bill passes.

Second, Medicare payroll taxes are raised in the Senate bill, but that massive flow of new revenue isn't going to secure the financial future of Medicare, but to instead pay for new entitlements, thus crowding out a source of future funding for Medicare when it hits the rocks in a very few years.

And now, third, Democrats are proposing the expansion of the nearly insolvent Medicare program to millions of new enrollees 55 and older. This enormous mistake will not only quickly drain the program of its remaining resources, it will accelerate the trend of doctors heading into concierge practices, abandoning the low-paying Medicare patients for the much more equitable payments provided by the dwindling number of privately covered patients.

All of the versions of Obamacare are radical assaults on seniors, but the latest version is a recipe for disaster for Medicare, and seniors know it. The seniors' political punishment of all Democrats will come in 47 weeks, but right now they have to act to alert the few Democrats on the fence that voting for this reckless scheme is political suicide.

Here are the five steps that everyone should take, but especially those already or soon to be covered by Medicare.

Readers should also take a moment to review the Democrats' plan on the debt limit --lifting it by nearly $2 trillion!-- which is every bit as reckless as their gamesmanship with Medicare. This is another transparent political trick, one that will further undermine the dollar and lock in future inflation that will destroy the savings of seniors that are in fixed investments.

Two days ago, Rupert Murdoch wrote in the Wall Street Journal about the failures and future of journalism. The very first thing that journalists must do to have their enterprises survive, Murdoch wrote, is to "give people the news that they want."

This doesn't mean the lowest common denominator of news such as sensational tabloid stories, but it most certainly does mean news about how readers' lives are going to be impacted by what D.C. does. Right now I am devoting most of every show to Obamacare because the audience is huge and very dialed in to how the Democrats' massive scheme will change their health care and thus the arc of their lives. Incredibly, MSM is not covering this aspect of the story --is not talking to seniors or doctors or hospital execs. Instead the Beltway-Manhattan media elite is covering Obamacare like a game of whether or not Harry Reid can get to 60 votes. Not surprisingly Reid announces he is going to win and the MSM scurries off to report that Reid is on the verge of winning. Almost nothing is being written about what the proposed deal will do to seniors' health care, just as the impact on the dollar of the massive hike in the debt ceiling is also largely unreported.

If Obamacare was fully and fairly explained, it would have been dead long ago, and the opinion polling shows that despite the best efforts of MSM to ignore the realities of the bill, it is deeply unpopular in the country and is triggering a massive blowback for Democrats, as it should.

Never have so many reporters produced so little in the way of accurate meaningful coverage of so important a bill. Perhaps they are simply not up to the complexity of the story, but the failure of MSM to get the story straight or the facts right or even to ask moderately difficult questions of so-called Democratic centrists like Indiana Senator Evan Bayh and Pennsylvania Senator Bob Casey is remarkable.

New media will continue to report the reality of the Democrats' assault on older Americans, and all the AARP propaganda and MSM misdirection will not obscure the growing recognition that Obamacare is a massive bait-and-switch that is not going to help Americans get better medical care but will instead hasten the collapse of Medicare and the arrival of rationing.


Perverse Health Care Incentives

Ronald Brownstein of The Atlantic is the only mainstream reporter I am aware of who glimpses what the debate over health care economics should be about.

Last month he wrote, “To save costs, Democrats mostly want to change the incentives for providers. Republicans mostly want to change the incentives for patients by shifting toward a model where insurance covers only catastrophic expenses and people pay for more routine care from tax-favored health savings accounts. In essence, the Republican view is that the best way to hold down long-term costs is to directly expose patients to more of them. Few Democrats accept that logic though and it has little influence on either chamber’s legislation.”

Brownstein gives the Republicans too much credit, but my focus is on the contending ideas, not who may or may not hold them. The economic issue is incentives (no slight intended toward the moral issue), and the choice is between having government micromanage incentives and letting the free market’s natural incentives work.

If we have to sum up the problem of the American health care system in a single phrase, it would be: perverse incentives. Tax and other government policies make it look smart for each individual to do socially stupid things, such as abandoning cost-consciousness under the influence of apparently low-cost comprehensive coverage and having “insurance” for uninsurable things like pregnancy, abortion, contraception, well-baby care, physical and dental exams, eyeglasses, and more. Few if any people would find it worth the price to buy such “insurance” in a free market since the premium would include the cost of the future services plus administrative overhead. I find it hard to believe that companies would offer policies with such coverage, since the actions giving rise to the “need” for the services are largely discretionary. (A lot of other coverage we are used to, such as for diseases brought on bad habits, might also become extinct.)

Yet government policies that make employer-based coverage preferable to independently purchased coverage induce us to do things we would not do in the absence of those policies. The system hides the true costs, encourages consumption, and turns active consumers into passive patients. We end up paying higher (though hidden) prices than we would find in a free market. That’s why the current system has so many bad features, which people have erroneously blamed on the marketplace.

Spending Too Much

As a result of the constellation of perverse incentives, Americans spend more than other populations on “health care.” And because the incentives are perverse we may safely say that we on the whole pay too much. How much is hard to say. Surely one reason our medical bill is so high is that we are a rich society and there are many new and valuable services to buy that were unavailable even ten years ago. But that does not exhaust the explanation for why we pay so much or why the price of “health care” rises faster than the price the average product. We have been taken for a ride. From the perspective of the average person’s well being, the system is irrational. But it is not irrational from the perspective of those making money off it, or of the politicians who benefit one way or another.

So we have an incentive problem. What do we do about it? The dominant view in Washington is, as Brownstein notes, that provider incentives must be changed. That’s why there is so much talk about abolishing traditional fee-for-service and going to a system where doctors are rewarded for the quality not the quantity of care. That’s also why there are plans for new commissions that will issue advisories—and perhaps ukases—regarding “best practice.”

In other words, the prevailing thinking is that doctors ought to be induced or ordered to practice medicine they way politically anointed “experts” think they should practice it. Consumers would still be passive observers, and those who wanted a different form of practice would be out of luck.

The problem with this is not that fee-for-service is sacred. Maybe it’s as bad as the planners say. The point is that the best provider-incentive arrangement(s) will be the outcome of a competitive—not bureaucratic—process. Competition is a discovery process, F. A. Hayek taught. Doctors, health economists, and bureaucrats sitting around a conference table in front of a whiteboard and PowerPoint presentation may agree unanimously that some new arrangement is optimal. But we really can’t know if it is as good as they think until it’s tried out in a competitive environment with real people. However, if bureaucrats impose their scheme and it comes a cropper, we’ll all suffer. Bureaucracies are slow to admit mistakes.

Consumer Incentives

That brings us to the other way to change incentives: on the consumer side. People choose differently depending on whether they face the full costs of their actions or, instead, artificially depressed (and therefore shifted) costs. If public policies make services look cheaper than they are to those lucky enough to have comprehensive coverage and encourage overconsumption and cost-obliviousness, then it stands to reason that abolishing those policies would bring down real prices and introduce consumer responsibility. We don’t need government to create incentives to lower costs. It just needs to back off and let the market work. “Back off” is shorthand for a long list of repeals, including the protectionist regulatory regime for the insurance industry and medical profession, and subsidized consumption through Medicare and Medicaid.

The common impulse for “health care reform” is entirely honorable. It is distressing to know that so many people are vulnerable to bankruptcy-threatening medical bills or to raw deals from State-cartelized insurance companies. Who wouldn’t change that if he could? The question is: Which approach has a better chance of changing it? Centralized bureaucratic decision-making by self-serving politicians and their “private sector” patrons? Or decentralized, cooperative, entrepreneurial efforts to satisfy cost-conscious, freely choosing consumers?

It’s time we junked the intolerable system we have, rejected further state control, and tried freedom.


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