Wednesday, January 06, 2010

British patients being tube-fed 'to save time'

Patients are having their health put at risk by staff who feed them through tubes unnecessarily because they are too busy to help them eat normally, a report has warned. Putting a tube into the stomach to give nutrition artificially should be a last resort but busy hospital wards and care homes are using them inappropriately, the report from the Royal College of Physicians said.

Experts said that there could be a "hidden agenda" for fitting feeding tubes due to staffing issues and costs. Care homes are refusing to take some patients without a tube in a widespread practice which was condemned by the working party who compiled new guidelines for clinicians. Dementia patients are often tube fed but evidence has shown it does not prolong their life and may be harmful, the report said. Dr John Saunders, co-chairman of the working party and experts in medical ethics, said: "In the demented patient it does not prolong life, the treatment is inappropriate and futile. It is actively unethical and dubious."

Concerns over artifical feeding have been raised after palliative care experts warned that food and water were wrongly being withdrawn from some terminally patients on the Liverpool Care Pathway.

Feeding tubes may be inserted directly into the stomach through a small hole in the abdomen and liquid feed administered by carers or the patient themselves. It is done if the patient cannot safely swallow food without choking or inhaling it but in many cases this can be overcome with specialist nursing care. Patients who have had a stoke, those with other brain injuries, multiple sclerosis and Huntingdon's may require tube feeding and some will also be able to eat some food orally if helped and may recover.

In other cases patients may be fed artificially at the end of life and in these cases clinicians should consider if the treatment is to improve their condition and if not it is futile, the report said.

Around six per cent of patients who have a feeding tube will die within 30 days while 10 per cent will suffer a complication such as an infection or bleeding. It is thought up to a fifth of patients with feeding tubes have them inappropriately because either they are futile or they could eat normally if given appropriate help, Dr Rodney Burnham, co-chairman of the working party said.

He said there was a "growing problem" of care homes refusing to take patients unless they have a feeding tube fitted. "We come down very strongly on any blanket refusal on those grounds," he said. "They may cite patient safety but there could be a hidden agenda on grounds of staffing or costs."

A survey found there was an 11 per cent increase in the number of people being fed artificially outside hospital in just one year to reach 39,000 people in Britain in 2008. Every hospital or nutrition team will have experienced a care home refusing to take a patient unless a tube is fitted, Dr Burnham said. "The reasons can be surmised as being ostensibly for patient safety but it is an invasive procedure with a risk. "Where institutions have a laissez-faire approach the 30 day mortality has been well over 30 per cent. It is not appropriate to be done unless it is in the patient's best interests," Dr Burnham said.

In deciding whether to feed patients artificially who cannot communicate or do not have capacity to make decisions for themselves, doctors should consider what the objective is for the treatment, what it is in their best interests and if it will be tolerable, the report said. Where patients have given advance directives or so-called living wills, to refuse artificially nutrition those decisions should be respected. The courts may be called on to decide in cases where family members and medical staff disagree, the report said.


NHS cash won’t cure health inequalities

[British Conservative leader] David Cameron will pledge today to divert billions of pounds to healthcare in the most deprived parts of the country if he forms the next government.

This decision on health funding, I am told, is the first in a series of policy statements by the Conservatives aimed at countering claims that the party is intent on slashing core public services, and countering 'class war' claims that they are a party of the rich. So I can see why 'Dave' (as his spin-doctors prefer him to be called) wants to do this. I just think it will be an ineffective policy, and therefore a waste of our money – money that is pretty short right now, and could be used to better effect.

If health outcomes reflected the amount of money we spent in different areas, then the fittest, sprightliest, longest-living folk would be in the Calton area of Glasgow, and the sickest ones with the rottenest teeth would be in Wokingham. The fact is, of course that although residents of leafy Wokingham can expect to live comfortably longer than the national average (75 for men and 80 for women), a male in Calton cannot expect to see his 54th birthday. (That is 13 years shorter than Iraq, even after a decade of sanctions, and 16 years less than North Korea, likewise.)

In the Calton, a quarter of the population say their health is not good and over half smoke. Two-fifths are on incapacity benefit. Calton residents suffer from their drink, drugs, and poor diet. Alcohol abuse is far above the national average. Heart disease, diabetes, and hospital admissions with drug overdoses are high.

Would more money from the NHS change that? Not a chance. Of course, Dave's health supremo, Andrew Landsley, says that he is going to turn the NHS from a sickness service to a health service, concentrating more on prevention rather than cure. He would still have his work cut out to make an impact on statistics like these. No, Calton residents are already the victms of too much government spending – poor-quality public-sector housing, a social benefit system that encourages family break-up and makes it almost impossible for people to get back into work, and a state school system that leaves inner-city kids underqualified and devoid of any hope of improving themselves. Yet more of the same will not help. We need to think much more radically if we are to change ill-health – and the causes of ill-health.


Medicare and the Mayo Clinic

by Jeff Jacoby

PRESIDENT OBAMA is a great admirer of the Mayo Clinic. Time and again he has extolled it as an outstanding model of health-care excellence and efficiency.

"Look at what the Mayo Clinic is able to do," the president proclaimed at a rally in September. "It's got the best quality and the lowest cost of just about any system in the country. . . . We want to help the whole country learn from what Mayo is doing." A few months earlier, in a letter to Senator Max Baucus of Montana and the late Senator Ted Kennedy, the president had singled out the Mayo Clinic and the Cleveland Clinic for praise. They "offer the highest quality care at costs well below the national norm," he wrote. "We need to learn from their successes and replicate those best practices across our country." On the White House web site, you can find more than a dozen other instances of Obama's esteem.

So perhaps the president will give some thought to the Mayo Clinic's recent decision to stop accepting Medicare payments at its primary care facility in Glendale, Ariz. More than 3,000 patients will have to start paying cash if they wish to continue being seen by doctors at the clinic; those unable or unwilling to do so must look for new physicians. For now, Mayo is limiting the change in policy to its Glendale facility. But it may be just a matter of time before it drops Medicare at its other facilities in Arizona, Florida, and Minnesota as well.

Why would an institution renowned for providing health care of "the best quality and the lowest cost" choose to sever its ties with the government's flagship single-payer insurance program? Because the relationship is one it can't afford. Last year, the Mayo Clinic lost $840 million on its Medicare patients. At the Glendale clinic specifically, a spokesman told Bloomberg, Medicare reimbursements covered only 50 percent of the cost of treating elderly primary-care patients. Not even the leanest, most efficient medical organization can keep doing business with a program that compels it to eat half its costs.

In breaking away from Medicare, the Mayo Clinic is hardly blazing a trail. Back in 2008, the independent Medicare Payment Advisory Commission reported that 29 percent of Medicare beneficiaries -- more than 1 in 4 -- have trouble finding a primary-care doctor to treat them. A survey by the Texas Medical Association that year found that only 38 percent of that state's primary-care physicians were accepting new Medicare patients.

But if you think things are bad now, just wait until Congress enacts the president's health care overhaul. A central element in both the House and Senate versions of ObamaCare is that Medicare reimbursements to hospitals and doctors -- already so low that many providers lose money each time they treat a Medicare patient -- will be forced lower still.

The Centers for Medicare and Medicaid Services, a branch of the US Department of Health and Human Services, estimated last month that the Senate bill would squeeze $493 billion out of Medicare over the next 10 years. As a result, it cautioned, "providers for whom Medicare constitutes a substantive portion of their business could find it difficult to remain profitable and . . . might end their participation in the program (possibly jeopardizing access to care for beneficiaries)." In short, the Democrats' idea of health-care reform -- more government power to set prices, combined with reduced freedom for individuals -- will only make medical care harder to come by: an Economics 101 lesson in the pitfalls of price controls.

Nearly six months ago, the Mayo Clinic tried to sound an alarm. Instead of making American health care better and more affordable, it warned, the legislation working its way through Congress "will do the opposite" and "the real losers will be the citizens of the United States."

Each year Medicare loses tens of billions of dollars to fraud and abuse. The program's long-term deficit is a staggering $38 trillion. Its expenditures have raced ahead of inflation from the day it was created: Medicare's price tag has skyrocketed from $3 billion in 1966 to an estimated $453 billion this year. Yet its reimbursement of medical providers is so meager that more and more of them cannot afford to treat Medicare patients. Whatever else Medicare might be, it is no model for rational reform.

Obama says he want the country to "learn from what Mayo is doing." What Mayo is doing is trying to provide high-quality medical care in the face of Washington's compulsively misguided interference. As 3,000 Mayo patients have just learned, government interference can hurt. Ratchet up that interference with ObamaCare, and the pain will only grow worse.


Obama and the Vampire Congress

by Michelle Malkin

Meet the Beltway bloodsuckers. They convene in the dead of night, when most ordinary mortals have left work and let their guard down or are lying asleep in bed. Pale-faced and insatiable, the nocturnal thieves do their nefarious business in backrooms and secret chambers. Their primary victims? Taxpayers, the free market and deliberative democracy.

Democratic leaders have been promising the most ethical, transparent, open and engaged administration for years. Instead, they have delivered a bleak and creepy legislative environment that could double as a “Twilight” movie set.

Skulking Senate Majority Leader Harry Reid rammed the government health care takeover package through under the cover of darkness before Thanksgiving and Christmas. House Democratic leaders forbade debate on all but one amendment not authored by themselves. The Senate Finance Committee killed a GOP amendment that would have required Demcare to be available online for 72 hours before the committee voted. Reid and his Volterra-style henchmen cut last-minute cash-for-cloture deals behind closed doors.

And now House and Senate Democratic leaders are reportedly preparing to cut dissenters out of the reconciliation process by bypassing the formal conference committee.

In Hill parlance, this legislative shortcut is called “ping-ponging.” A better game analogy: dodgeball. With mounting opposition from both conservative Republicans and progressive Democrats, President Obama’s water-carriers must use every trick in the book to speed the final merging and passage of the bill before the end of the month.

The hypocrisy reeks stronger than rotting garlic. In 2006, House Democrats asserted that “House-Senate conferences are a critical part of the deliberative process because they produce the final legislative product that will become the law of the land.” That same year, Reid railed on the Senate floor against informal deal-making that circumvented the conference committee process -- and he attacked the use of manager’s amendments to avoid public scrutiny:

"Of course, nobody can see the manager’s amendment. It is composed of over 40 amendments. How could anyone vote for a piece of legislation such as that -- a manager's amendment with 42 separate amendments? Now, these amendments were not put in a conference committee. People complain about that. But at least in a conference committee, you have people working together, sticking things in. … Here, you have one person making a decision as to what is going to be in the manager’s amendment. There is no way to know what is in it."

But four years later, it was Reid who snuck his 383-page manager’s amendment -- stuffed with payoffs, special breaks and concessions on health care -- into the Senate hopper on the Saturday before Christmas break. Four years later, it is Reid stifling the open, collaborative conference committee process he so fiercely championed.

Where’s Barack Obama? As a candidate, he promised repeatedly to broadcast legislative negotiations on C-SPAN “so that the American people can see what the choices are” and “so that the public will be part of the conversation and will see the choices that are being made.” But the most transparent presidential administration ever is shrugging its shoulders. On Tuesday, White House press secretary Robert Gibbs pooh-poohed C-SPAN’s request to allow electronic media coverage of the Demcare negotiations.

Instead, Gibbs thinks Americans should be grateful for what they got last month: “The Senate did a lot of their voting at 1:00 and 2:00 in the morning on C-SPAN. … And I think if you watched that debate -- I don't know -- I wasn't up at 1:00 or 2:00 in the morning for a lot of those votes, but I think if the American public had watched … you'd have seen quite a bit of public hearing and public airing.” And if you missed the middle-of-the-night broadcasts, tough noogies.

Team Obama’s contempt for meaningful transparency has been on display from Day One. A year ago this month, Obama broke his vaunted open government pledge with the very first bill he signed into law. On Jan. 29, 2009, the White House boasted that the Lilly Ledbetter Fair Pay Act had been posted online for review. Except: Obama had already signed it -- in violation of his “sunlight before signing” pledge to post legislation for public comment on the White House website five days before he sealed any deal.

From the stimulus to the health care takeover to holiday bailouts for bankrupt financial behemoths Fannie Mae and Freddie Mac, it’s been all backrooms and blackouts ever since. The Prince of Darkness at 1600 Pennsylvania Ave. is perfectly happy with his Vampire Congress. Wraiths of a sunshine-evading feather flock together.


Obama prods Congress to pass health bill quickly

President Barack Obama is prodding House and Senate Democrats to get him a final health care bill as soon as possible, encouraging them to bypass the usual negotiations between the two chambers in the interest of speed.

Obama delivered the message at an Oval Office meeting Tuesday evening with House Speaker Nancy Pelosi and House Majority Leader Steny Hoyer. Senate Majority Leader Harry Reid and his No. 2, Sen. Dick Durbin, D-Ill., joined in by phone.

They agreed that rather than setting up a formal conference committee to resolve differences between health bills passed last year by the House and Senate, the House will work off the Senate's version, amend it and send it back to the Senate for final passage, according to a House leadership aide, speaking on condition of anonymity in order to discuss the private meeting.

Obama himself will take a hands-on role, convening another meeting with congressional leaders at the White House on Wednesday, the aide said. The aim is to get a final bill to Obama's desk before the State of the Union address sometime in early February.

Facing the need to maintain a tenuous 60-vote coalition in the Senate, House Democrats will probably have to give up on starting a new government insurance plan to compete with the private market, something that's a nonstarter with Senate moderates. In its place they hope for more generous subsidies for lower-income families to buy health insurance.

Obama agreed at Tuesday evening's meeting to help strengthen affordability measures beyond what's in the Senate bill, the aide said.

Pelosi suggested Tuesday that House members wouldn't insist on the government plan as long as the final bill provides "affordability for the middle class, accountability for the insurance companies, ... accessibility by lowering cost at every stage." "There are other ways to do that, and we look forward to having those discussions," she said.

House Democrats want the Senate to agree to language revoking insurers' antitrust exemption as a way to hold insurance companies accountable in absence of direct government competition, said Rep. Chris Van Hollen, D-Md., a member of the House leadership.

The bills passed by the House and Senate both would require nearly all Americans to get coverage and would provide subsidies for many who can't afford the cost, but they differ on hundreds of details. Among them are whom to tax, how many people to cover, how to restrict taxpayer funding for abortion and whether illegal immigrants should be allowed to buy coverage in the new markets with their own money.

Concerns about affordability are paramount. Major subsidies under the bills wouldn't start flowing to consumers until 2013 at the earliest. Even with federal aid, many families still would face substantial costs. The House bill would provide $602 billion in subsidies from 2013-2019, covering an additional 36 million people. The Senate bill would start the aid a year later, providing $436 billion in subsidies from 2014-2019, and reducing the number of uninsured by 31 million. "Affordability is a critical issue," Van Hollen said.

But sweetening the deal for low- and middle-income households could require more taxes to pay for additional subsidies. And the House and Senate are also at odds over whom to tax. The House wants to raise income taxes on individuals making more than $500,000 and couples over $1 million. The Senate would slap a new tax on high-cost insurance plans. Although the Obama administration supports the Senate's insurance tax as a cost-saver, labor unions, which contribute heavily to Democratic candidates, are against it.

The House may end up accepting the insurance tax if it hits fewer people than the Senate's design now calls for. There also could be common ground in a Senate proposal to raise Medicare payroll taxes on individuals making more than $200,000 and married couples over $250,000.

Democrats reacted defensively to criticism that they are taking the final, most crucial stage of the debate behind closed doors, contending they've conducted a transparent process with hundreds of public meetings and legislation posted online. Republicans seized on a newly released letter from the head of the C-SPAN network calling on congressional leaders to open the final talks to the public, and cited Obama's campaign trail pledge to do just that. Asked about that promise, Pelosi remarked, without elaboration, "There are a number of things he was for on the campaign trail."


Why the White House Is Wrong - Again - On Health Care Spending

Nancy-Ann DeParle, the Director of the White House Office of Health Reform, posted a note – ironically titled “Reality Check” – on the White House blog this morning claiming that a new report from the federal government’s health actuaries supports the administration’s position on health care reform.

But all that report says is that U.S. health care spending continues to increase – even though the rate of increase actually hit a historic low in 2008 (the latest year for which figures are now available). DeParle’s argument is basically this: We spend too much on health care, therefore the reform proposals currently in Congress will fix everything.

However, DeParle seems to have missed the actuaries’ earlier report on what those reform proposals will actually do – which is, to make health care spending grow faster, not slower. In particular, actuaries estimate that if the Senate health reform bill becomes law, total U.S. health care spending would increase by 0.7%, or $234 billion through 2019. And that’s after taking into account what little savings would be achieved by cutting Medicare benefits and encouraging employer to cut health benefits by taxing private insurance plans that are “too generous.”

In other words, the primary source of “savings” in the Senate bill comes not from making the health care system more efficient, but from (1) denying health care services to seniors under Medicare, and (2) from encouraging private insurance companies and employer to deny health care services to everybody else. Even after taking account of that so-called “savings,” total health care spending would still increase faster than it would without reform!

The inescapable conclusion is that reform proposals currently in Congress will take an inefficient health care system and make it even more inefficient than it is now. One does not have to be one of what DeParle dismissively calls “defenders of the status quo” to oppose a reform plan that will produce a result clearly even worse than the status quo.

DeParle claims that if “opponents of reform get their way,” health care spending will continue to increase. The fact is, if the administration gets its way, health care spending will increase faster than it does already and we’ll get less health care for our money. If opponents get their way, we might instead have real reform that gives patients more choices, gives providers incentives to give the best treatment instead of the most expensive treatment, and ultimately better health care at a lower cost. Unfortunately, that’s the opposite of the outcome the bills in Congress would give us.


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