Thursday, January 21, 2010


Two current articles below -- from two different Australian States

Doctors highlight a cancerous medical bureaucracy in Queensland

Medicos wage war on billions wasted on bureaucrat jobs

AUSTRALIA'S peak medical group will demand Queensland Health stop hiring bureaucrats as part of a new name and shame campaign targeting the hundreds of millions of dollars it claims are being wasted in hospitals. The Australian Medical Association will today unveil a "War on Waste" campaign in a bid to highlight problems in the beleaguered health system, ahead of proposed reform by the Rudd Government later this year.

AMA Queensland president Mason Stevenson last night told The Courier-Mail the campaign would attempt to pressure both the state and federal governments to act on health reform, given an estimated $4 billion was being wasted nationwide. The group claims, for example, one in 10 surgery patients is admitted to hospital and prepared for surgery but discharged before their operation because of a lack of theatres. "The wastage is widespread and is costing lives," Dr Stevenson said.

The move comes amid a heated debate over a proposed federal takeover of hospitals, with the Rudd Government still considering recommendations from a top-level report.

But the Bligh Government last night produced a letter written last year by Queensland Health director-general Mick Reid asking to consult with the AMA about red tape. It claimed that request has been met with silence from the AMA.

The AMA campaign includes a list of questions Queensland Health will be asked to answer within two weeks, including how much extra hospital floor space bureaucrats have been given in the past decade. The AMA has also called for a moratorium on hiring bureaucrats, saying department figures showed the number of administration jobs had swollen from 5060 to 13,645 positions since 1995. Doctor jobs, meanwhile, had risen from 3095 to 6715 positions.

But Health Minister Paul Lucas defended the administration staff, saying they were crucial to taking paperwork from doctors and nurses who had been hired in record numbers. He instead accused the AMA of trying to introduce its own red tape and waste. "The AMA criticises Surgery Connect now but this is just sour grapes from an organisation that in 2006 supported the initiative and wanted to charge the State Government a $1.7 million 'management' fee to administer the program," he said. "Every hour of paperwork taken out of doctors' hands by booking clerks and patient liaison officers is an extra hour spent treating patients."

But Dr Stevenson said a moratorium was necessary to stop wastage.


A "Soviet style" hospital bureaucracy in NSW

Over the past 18 months I have spent an inordinate amount of time in public hospitals in NSW, not as a patient but as a witness to the ordeals of family members. There were multiple trips to the emergency department - where elderly people were piled up in corridors - and wards in which four very sick people crammed in one room managed to be pleasant to each other while overstretched nurses remained cheerful and the doctors adept.

There was the hand clinic with an inexplicable waiting time every week of four to six hours, but with world-class doctors fixing broken fingers for free, and the deserted endocrinology clinic, which a specialist opens by himself on Saturdays so his sickest patients don't have to wait.

I walked along deserted corridors at night and marvelled at how such a massive, ingenuity-sapping bureaucratic institution somehow still manages to save lives and bring out the best in people who work there. Two things were notable: first, the professionalism, expertise and good humour of most doctors and nurses; and second, the extent to which they must work around a government bureaucracy of Soviet-style ineptitude. Their successes are in spite of the system, about which they are openly scathing.

How did our hospitals become so remote from the needs of patients and the good sense of medical professionals? Two doctors with a combined total of more than 80 years in the NSW public hospital system, and a passion for public service, are speaking out about their experience of the "chaos, tragedy and sometimes downright farce" they have encountered in the second half of their careers.

Dr John Graham, the chairman of the Department of Medicine at Sydney Hospital and Sydney Eye Hospital, and Dr X, a staff specialist physician at a large hospital in the Northern Tablelands, (who cannot give his name for fear of being sacked) say the problem is not a lack of funding but the dead hand of bureaucracy. They have prescribed the remedy to restore public hospitals to their former place among the most trusted and well run institutions in the country: to reinstate local autonomy, with independent hospital boards taking full control of the budget.

Dr X, who is also a senior officer in the army reserve who served in Rwanda, Afghanistan and Banda Aceh after the tsunami, knows a thing or two about organising medical teams. "I have an appreciation of organisations, of command and control, of man management and of assessing clinical priorities and planning for them," he says. "In criticising the Department of Health, I am not an anarchist or privateer; I believe in our public institutions."

He says the amalgamation in 2004 of the Hunter and New England Health services into one giant administration was "an absolute disaster". "I can honestly say that in my three decades here I have never seen the system more dysfunctional. It just gets more and more bloody difficult."

His hospital is so stretched for doctors he has been without a day off and on call every second night since November. In an impassioned letter written on New Year's Eve while he was on call, he stated: "At the moment I have no resident medical officer, no registrar or secretary. I am expected to be all of these. "Meanwhile, in hospital I have patients waiting for investigations and treatment which will not be available for several weeks [due to holiday closures]. I am being pressured to discharge patients before they are ready, and to not admit patients who should be admitted.

"I am supposed to compromise patient care in order to save the hides of non-clinical incompetents who make irresponsible decisions without any consultation or consideration of the likely consequences. "Such a situation would never have occurred when communities had 'ownership' of their local hospitals and governed them though their local hospital boards . . . "And it is not as though the Hunter-New England Area Health Service is short of money; with a budget of $1 billion dollars, you could be forgiven for thinking that the staffing of its hospitals with appropriately experience doctors would be a priority."

Like Dr X, Dr Graham traces the rot back to the 1980s and 1990s when local hospital boards were replaced with area health services. In a policy paper for the Centre for Independent Studies in October, he argued that "the disastrous reorganisation of public hospital administration over the past 25 years needs to be reversed". Decision-making in hospitals used to be quick and effective, but now "funding is not spent optimally and trust, co-operation, morale and institutional loyalty has been sapped . . . Resource misallocation involving extraordinary growth in the size and cost of the bureaucracy has led to a massive waste of taxpayer's money."

The bimonthly department meetings that he attends at Sydney Hospital show how dysfunctional the system has become. "The department's time is mainly occupied in dealing with centralised directives issued by the South Eastern Sydney and Illawarra Area Health Service and NSW Health . . . Doctors and nurses these days are forever wasting time and energy complying with the new sets of orders issued by an intrusive, arbitrary, and seemingly unaccountable bureaucracy." For instance, there are new rules issued to medical staff every day about everything from handwashing to how to write a blood test request or talk to the grieving relatives of a patient. "They're constantly telling you your business," Dr Graham says.

And if you buck the system, "there is a lot of heavy-handed pressure brought to bear, especially on younger doctors and nurses. NSW is really like what it would have been in Moscow 20 years ago." Dr Graham, who is semi-retired, says that he is able to speak out because he is in the "lucky situation where they can't hurt me".

In an indication that the deteriorating state of our hospitals will be a major election issue, the Australian Medical Association this week called for wide-scale health reform in its submission to the 2010 budget. It's about time someone listened to the doctors.


Barack Obama has learnt nothing

Barack Obama will attempt to push through health care reform despite the shock loss of a previously safe Democrat senate seat in Massachusetts, aides have said. Advisers said tactics would have to be rethought but the president remained determined to stick to his political agenda.

Little-known Republican Scott Brown triumphed in one of the most liberal states in the country, which had delivered landslides to the late Edward Kennedy for 47 years.

On what was a grim first anniversary of Mr Obama's inauguration, Democrat leaders in Congress held urgent meetings to assess how they could salvage health legislation. The election defeat cost them their 60-vote majority in the Senate which was needed to see off Republican threats to filibuster the bill.

David Axelrod, a senior adviser in the White House, said: "We'll have to think through this next year from the standpoint of tactics but in substance the mission can't change. It's not an option simply to walk away from a problem that's only going to get worse."

David Plouffe, the president's former campaign manager, said that passing what was meant to be the cornerstone of the administration's domestic agenda would demonstrate strong leadership. "We have a good health care plan," he said on ABC. "We need to pass that. We have to lead and then explain it. We can't cut and run, it would be devastating for the country."

Republican leaders in Congress called for a reworking of the bill, which would provide near universal coverage and aimed to bring down long-term costs. But Nancy Pelosi, the Democratic House Speaker, argued that because Massachusetts already had near-universal health coverage under a state law, the vote should not be seen as a referendum on the issue. "We don't say a state that already has health care should determine whether the rest of the country should. We will get the job done. I'm very confident," she said.

Others in the party fear that their own seats are now at risk in November's midterm elections, and are convinced that the message from Massachusetts, a state Mr Obama won by 26 points in 2008, is that they must go back to the drawing board on health care.

At a raucous victory rally on Tuesday night Mr Brown said: "We won because of a shared conviction with voters that the people do not want a trillion dollar health care plan that's being forced on the American people. "The bill hasn't been debated openly and it will raise taxes and destroy jobs and drive the country deeper into debt. We need to start afresh and work together to do the job better."

Jubilant supporters at a Boston hotel ballroom compared his victory to the uprising against the British in the same city in 1773. "The revolution started here 230-something years ago, the same thing is happening tonight. Last time it was George III, now it's Washington we're going for," said Dave Knight, who volunteered for the Brown campaign.

With the Democrats' filibuster-proof majority gone, plans to introduce a cap and trade system for carbon emissions are also now at risk. A bill passed the House of Representatives but has been stuck in the senate for months.

The trial of five September 11 suspects at criminal court may also be in jeopardy. The proposal to move them from Guantanamo to the mainland for trial needs approval by Congress and Senator-elect Brown is fervently opposed to the notion. "Giving new rights to terrorists is wrong for our country," he said. "Our tax dollars should be spent on weapons to attack them, not lawyers to defend them."

Mitch McConnell, the Republican leader in the Senate, said the result should encourage Mr Obama to be more accommodating. "If he turns to govern in the middle we would be happy to meet him there," he said. But given a near complete breakdown in either side's ability to work with the other, observers said that seemed an unlikely scenario.

The Republican beat his Democratic rival and Massachusetts attorney general Martha Coakley by 52 per cent to 47 per cent.


Did the Dems secret deals on health care elect Brown?

During this morning's press conference, newly elected Massachusetts Senator Scott Brown discussed what he had heard from voters driving while driving around Massachusetts. He said that voters were tired of "business as usual," and he specifically cited anger over Nebraska Senator Ben Nelson's shady "cornhusker kickback" in the health care legislation as an example of why Massachusetts voters produced a stunning upset by voting for him the previous evening.

Brown isn't the only one who thinks that the populist backlash against these secret deals on health care reform is major reason why Democrats are in big trouble right now. In a memo yesterday that losing Democrat Martha Coakley gave to the press, her campaign blamed Washington Democrats for losing. The memo observed that Coakley declined steadily in the polls immediately following the Christmas eve passage of the health care bill. Further, the Coakley campaign's internal polls showed Brown's argument that the health care legislation and cap-and-trade were effectively tax increases were the most effective arguments with voters.

"We Democrats had to explain to Massachusetts voters and other Americans why non-Nebraskans and nonunion members have to pay more taxes, while Nebraskans and union members get to pay less. Those two deals seem to have alienated most people across the political spectrum. That’s not easy," wrote former Clinton Special Counsel Lanny Davis in the Wall Street Journal this morning.

And yesterday, The New York Times quoted one Massachusetts voter saying, "I'm just devastated by what Obama’s doing. I don’t think he cares enough about anything other than his own personal agenda or this foolish health care bill." The same voter also specifically cited the unfairness of the union tax exemption the health care bill as unfairly punishing her daughter and her husband who worked at a non-unionized business. It's also worth noting that Massachusetts has the highest average health care premiums in the country at almost $14,000 annually per family -- as such, the "cadillac" tax that unions received their exemption from would unduly hit Massachusetts residents. The unfairness of the union deal was likely not lost on them.


With new GOP strength in Senate, will Obamacare die in House?

Throughout the Massachusetts Senate race, we heard the number "41" repeated over and over -- as in Scott Brown would become the 41st Republican senator, whose presence would deprive Democrats of a filibuster-proof majority and stop President Obama's national health care plan. But now that Brown actually is the 41st GOP senator, the most important number in politics is 218 -- as in, can House Speaker Nancy Pelosi amass a majority of 218 votes for House Democrats to pass the health care bill already approved by the Senate, thus sending it to Obama's desk to be signed into law.

That is the essence of what's known as Plan B. The Senate is out of the game, now that Democrats no longer have their 60-vote majority. Any new version of a bill combining elements of the House and Senate versions won't be able to get through a Senate with 41 Republicans united against it. So the only course of action available to Democrats is to have the House pass the Senate bill verbatim, and then promise to quickly make changes to satisfy the objections of lawmakers in both houses.

But to do that, House Speaker Nancy Pelosi will need 218 votes to pass the Senate bill. And all across the House, Democrats and Republicans are doing the math.

When the House passed its version of the health care bill last November, the margin was 220 to 215. But the House has changed since then. First, Democratic Rep. Robert Wexler, a strong supporter of national health care, has quit to become president of a Washington-based think tank. That leaves Democrats with 219 votes. Then Republican Rep. Joseph Cao, the only GOP lawmaker to vote for the bill, announced that he would vote against it the next time, leaving Democrats with 218 -- the bare majority needed to pass the health care bill.

In addition, the House Republican leadership calculates that 11 Democrats who voted for the health care bill will likely vote against the Senate version because it lacks the House bill's tighter language on the subject of abortion. These are Democrats who voted for the so-called Stupak amendment and then voted for final passage of the health care bill because it contained the Stupak amendment language. If 11 of them do indeed defect, Democrats will be down to 207 votes -- 11 short of the number needed for passage.

How to close that gap? Well, three Democrats who voted against the bill -- Reps. Brian Baird, Dennis Moore, and John Tanner -- have decided to retire. No longer facing voter wrath over health care, they might be convinced to change their votes. If they all changed their position, Democrats would get to 210. But after that, what? Pelosi would still need eight more votes.

It is widely believed that the Speaker held some votes in reserve when the House passed the health care bill last November. That is, there were some Democrats who really wanted to vote against the bill but could have been arm-twisted to vote for it if it were absolutely necessary. Since Pelosi had the votes needed for passage, she let those lawmakers vote against the bill. Now, she could lean on them to change their vote.

That will surely happen -- but the question is, will it happen at least eight times? No one knows. But Republicans expect the Speaker to pull out every stop, to make every deal, to go to any length to pass the bill. "They have so much riding on this, I think they'd do almost anything to pass it," says a highly-placed House GOP source. "If it failed, Pelosi would have to acknowledge that they were wrong, and we've seen no indications that they believe that anything they've done on this health care bill is wrong."

Look for Democrats to enter into intense negotiations in coming days. They might not move immediately -- and they don't have to, because the Senate bill has already been passed, giving the House the freedom to vote on it tomorrow, next week, or six months from now. But it's likely that the President's Day recess, scheduled for the week of February 15, will emerge as a self-imposed deadline for a deal. "Their natural break is President's Day," says the GOP source. "If you go home for a week and you haven't finished this, it gets even harder."


Does Mass. Health Law Cover Fewer People Than Believed?

More dubious statistics

As Massachusetts held a de facto referendum Tuesday on Democrats' national health plans, a new study says the state's own health overhaul law hasn't been as successful as its backers claim. Republican Scott Brown has vowed to be the 41st vote to block a health care overhaul if elected to the U.S. Senate. But as a state senator, he voted for landmark legislation in 2006 seeking to cover virtually all residents.

In 2006 the Census Bureau reported that 10% of Massachusetts residents were uninsured. In 2008, it had fallen to 3.8% . But that understates the uninsured by at least 45%, according to Michael Cannon, director of health policy studies at the libertarian Cato Institute. "The official estimates overstate the health coverage gains in Massachusetts in part because residents are concealing their coverage status," said Cannon, who co-authored a study with Aaron Yelowitz, an economics professor at the University of Kentucky.

The law's supporters accuse Cato of "sloppy research." "Cato has a far-right libertarian point of view, and they opposed reform even before it passed," said Brian Rosman, research director of Health Care For All, a liberal advocacy group in Massachusetts.

The state requires people to buy insurance or pay a fine. That may affect how people answer Census questions about their insurance status, Cannon argues.

Nondenial Denials? Some respondents don't answer questions on insurance status. The Census tries to correct for that by comparing them with people with similar characteristics who did answer the question. "We find evidence that these imputations rose in Massachusetts, not just after the law passed but relative to other New England states," said Cannon. "Using those other states as controls, it shows that nonresponse to the health insurance question is growing in Massachusetts for some reason that is unique to the Bay State."

Cannon and Yelowitz find that the uninsured rate could be closer to 5.1% vs. the official 3.8%. "And that's only one strategy for concealing your health insurance status from the government pollster," said Cannon. "You can refuse to participate in the survey or you can lie."

Rosman isn't buying any of it. "When confronted with numbers that don't support their conclusion, Cato makes up a reason why people are lying," he said. "No one goes to jail here for not having insurance. It's no different than other issues on your taxes." He adds that reports looking at people — not samples — are "completely consistent with each other."


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