Tuesday, May 31, 2005

Consumers Lose Round in Battle over Specialty Hospitals

Government monopolies must be defended! No matter how inefficient and costly they are

On March 8, the Medicare Payment Advisory Commission (MedPAC)--ignoring its own research and new studies showing the benefits of competition and specialization--recommended to Congress that it extend the moratorium on development of new specialty hospitals until January 2007. The moratorium, passed in late 2003, will end in June of this year if Congress takes no action. Passed as part of the Medicare Modernization Act of 2003, the moratorium law also asked MedPAC to study the pros and cons of specialty hospitals and report back to Congress with its findings and recommendations.

Congress included the moratorium in the Medicare reform measure amid concerns that specialty hospitals threatened the ability of community hospitals to provide essential services to patients and that physician ownership of specialty hospitals created incentives for doctors to recommend unneeded care. The MedPAC study largely refuted those concerns.

Members of Congress and policy experts were quick to weigh in on MedPAC's report and recommendations. Dr. Alan Pierrot, an orthopedic surgeon and past president of the American Surgical Hospital Association, told the Senate Finance Committee on March 8, "No proof of harm to general hospitals, risk to patients, or abuse of the Medicare program because of excessive or unnecessary surgery has been found. There is no justification to continue the moratorium beyond the legislated expiration date."

Pierrot's views were not shared, however, by Senator Max Baucus (D-MT). "When it comes to physician ownership of specialty hospitals, I'm not sure the playing field is level," he said.

The MedPAC study compared profit margins at community hospitals in markets that have specialty hospitals with the profit margins of such hospitals in markets that don't. In both markets, profit margins declined modestly between 1997 and 2002, but the decline in profits was greater for community hospitals that did not face competition from specialty hospitals. The study also found little that would suggest physicians with ownership stakes in specialty hospitals were performing unnecessary treatment. The research showed there were slight differences in utilization of heart procedures between markets with specialty heart hospitals compared to those without them, but most of the differences were not statistically significant.

MedPAC researchers also visited several specialty hospitals. The report notes that in their discussions with physician-owners, "the primary issue ... was greater control of hospital operations." Frustration with the bureaucracy at general hospitals was given as a key reason many physicians established specialty hospitals.

Addressing the criticism from physicians that they had unsuccessfully tried to enact changes at community hospitals, some administrators admitted they had been "slow to react to their physicians' demands for changes," according to the report.

Physician-owners at specialty hospitals also described to MedPAC how greater control over their facilities results in improved productivity. Among the factors they cited were fewer disruptions to schedules, less down time between surgeries, and better control of operating room staff.

More -- much more -- here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Monday, May 30, 2005


North Carolina's Medicaid program offers such top-of-the-line coverage that officials worry patients are moving here to take advantage of it. The state's Medicaid program, which covers the disabled, poor and aged who qualify, pays for more services than 33 other states provide to their Medicaid patients. North Carolina pays for psychologists, private-duty nurses, dentures, personal care services and other benefits not offered by many states. The state also pays doctors more than 44 other states.

The N.C. Senate earlier this month passed a budget proposal, now being reworked in the House, that makes cuts in both services and physician reimbursements. It's an attempt to temper the program's rising costs in the state budget. "North Carolina has been spending far more on Medicaid than the rest of the Southeast," Democratic Senate leaders said in a recent budget briefing paper, "which has encouraged people from other states to come here under false pretenses for services."

State and local Medicaid officials can't confirm or dispute that argument, because they don't record a patient's previous address. It's a contention that periodically rises up, especially among border counties. "It's something we hear about anecdotally," said Keith Moon, social services director in Gaston County.

North Carolina's Medicaid budget has ballooned from $4.6 billion six years ago to $8 billion this year. The state's share of that has grown from $1.3 billion six years ago to $2.3 billion this year, and helped fuel steady growth in the state budget. Medicaid is health care coverage for certain groups of poor people, mainly the disabled, elderly and single-parent families who fall below certain income levels. The federal government carries 66 percent of the cost, the state's share is 29 percent and the counties pay 5 percent. Legal aliens or refugees are eligible for Medicaid but only after a certain period of residency or for a limited time. Illegal aliens are eligible only for emergency medical services.

By 2010, Medicaid is projected to consume 30 percent of the N.C. budget. "You're serving a group of people with benefits that exceed, in many cases, what they would receive on a private (insurance) policy," said Senate President Pro Tem Marc Basnight, a Democrat from Manteo. "The care level is rightfully generous in this state, but something that we can't afford. ... We're unable to pay at the rate that we're paying."

Lanier Cansler, a Republican who recently stepped down as the No. 2 official in the N.C. Department of Health and Human Services, said, "Everyone is beginning to understand that Medicaid isn't going to be sustained as it is." ...

The General Assembly in 2001 commissioned an extensive review of the state's Medicaid program by The Lewin Group, a Virginia-based consulting firm. Lewin's report said North Carolina included several benefits "not offered by an overwhelming number of state Medicaid programs." One of Lewin's primary recommendations was considering "whether North Carolina should pare back where it exceeds the `average' state Medicaid program."....

The state budget passed by the Senate, and now being rewritten by the House, made several cuts in Medicaid, including: Reducing personal care service from 60 hours per week to 40; Dropping physician payments from 95 percent of the Medicare rate to 90 percent; Lowering payment for private-duty nurses from a maximum of more than $300,000 to about $80,000 annually; Shifting 65,000 aged, blind and disabled Medicaid patients who are eligible for Medicare to that program.

More here

Illinois: Conscription for pharmacists: "The American Center for Law and Justice (ACLJ), which specializes in constitutional law, today filed an amended complaint in state court in Illinois adding four additional pharmacists to its lawsuit challenging Illinois Governor Rod Blagojevich's emergency amendment to the state code requiring pharmacists to dispense medication even if filling the prescriptions violate their conscience and religious beliefs. The ACLJ initially filed suit in mid-April on behalf of two pharmacists and today's action brings the total to six pharmacists who contend the Governor's order is unenforceable. 'The Governor's directive continues to cause concern for a growing number of pharmacists who don't believe they should have to put their religious beliefs aside to keep their jobs,' said Francis J. Manion, Senior Counsel of the ACLJ, which is representing the pharmacists."


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Sunday, May 29, 2005


Thousands of Australians continue to die unnecessarily in public hospitals despite the federal and state governments spending millions of dollars to improve patient safety. Ten years after a groundbreaking study revealed 18,000 people died every year from adverse events, experts involved in the study said safety standards had not changed. "If we did the study again we would find just as many preventable deaths," said Fiona Tito-Wheatland, the former chairwoman of the Professional Indemnity Review who commissioned the 1995 report. "We haven't changed the system fundamentally, so why would the results differ?" Ms Tito-Wheatland and senior hospital staff say the Australian Council for Safety and Quality in Health Care - set up by the federal and state governments in 2000 - was overly bureaucratic. "In 10 years we haven't even collected the national data we need to know what's going wrong," Ms Tito-Wheatland said.

Bill Runciman, head of Royal Adelaide Hospital's department of anaesthesia and intensive care and one of the authors of the 1995 report, said changes that could save lives were not being implemented. He said the use of catheters impregnated with antibiotics could reduce the rate of bloodstream infection - which killed up to 1000 people a year - tenfold. "The catheters are more expensive which is why hospitals won't buy them," he said. "Our hospital uses them but I know of a lot of hospitals that don't."

The council, which received $55million over five years from the federal and state governments, is under review. Council chairman Bruce Barraclough said the council should be replaced with a body that had regulatory powers. However, hospital staff say the council has failed to raise awareness of safety procedures. "We believe that despite the initiatives of both commonwealth and state quality councils, there has been rather limited impact on the practice of healthcare at the grass roots level in public hospitals," said John McNeil, head of Monash University's department of epidemiology and preventive medicine. A Monash University study of public hospitals in four states found medical staff at all levels had "little systematic involvement in quality and safety-related activities".

Health groups claimed the council also failed to improve doctor-patient communication. "Open disclosure hasn't gone very far at all and it's been a disappointment," said Prue Power, head of the Australian Healthcare Association. But Professor Barraclough said the council was committed to open disclosure. "It took about two years to develop a national standard for open disclosure and ministers endorsed it in 2003," he said. "If you are running a health system you need to understand the complexities of doing this, rather than just saying, 'yes this is good thing, let's just do it'."

Former NSW Health Care Complaints Commissioner Merrilyn Walton disagrees, saying: "Patients should always be told when something goes wrong. Why do you need rules about it?"


Tenncare cuts approved: "A federal appeals court panel has approved Tennessee’s procedures for kicking people off TennCare, the state’s expanded Medicaid program. The ruling, which overturns a lower court decision, means the state does not have to hold a hearing for each TennCare recipient before removing them from the program. A three-judge panel of the 6th U.S. Circuit Court of Appeals heard arguments in Columbus, Ohio, on Tuesday and handed down a decision Friday. The court said decisions on how to run TennCare were up to the elected officials in Tennessee, "so long as the State’s disenrollment process satisfies the requirement of the Medicaid regulations and statute, any relevant consent decrees and the Constitution." Gov. Phil Bredesen has proposed removing up to 323,000 adults from TennCare to save money, but he recently released a plan to keep the cuts at only about 225,000 people. The appeals court overturned a decision by U.S. District Court Judge William J. Haynes, who said all TennCare enrollees deserved a neutral hearing in case they had been wrongfully terminated. The state had argued that hearings for every TennCare recipient cut from the program would be impractical, and that the disenrollment procedure met all legal requirements".


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Saturday, May 28, 2005


Top legislators on Wednesday announced a bipartisan agreement for a $500,000 limit on "pain and suffering" damages against Illinois doctors. With leaders of both chambers behind it, the Legislature could pass the measure as early as this week. Gov. Rod Blagojevich is on board, which all but guarantees that malpractice awards in the state will be capped - unless opponents can undo it later with court challenges. The landmark measure, meant to make Illinois' court system friendlier to doctors, includes a $1 million limit on noneconomic damages against hospitals. It also contains provisions to prevent frivolous lawsuits from being filed in the first place; new disciplinary tools and public disclosure to weed out bad doctors; and more oversight and competition among the companies that provide malpractice insurance for doctors. "It's a great day to be a physician in Illinois again . . . and a great day for patients," said Dr. Craig Backs, president of Illinois State Medical Society, marking victory in his group's epic battle with the state's trial lawyer lobby.

The state's leading trial lawyer lobby, frustrated at the apparent defection of the Chicago Democrats who have backed them until now, said they aren't surrendering. "We'll be repeating to legislators who are voting what we've been saying forever, and that is, caps won't solve the problem," said Keith Hebeisen, president of the Illinois Trial Lawyers Association. Hebeisen said his group will fight the bill in the Legislature "up until a vote takes place," and then challenge it in the courts if it becomes law. In the mid-1990s, court challenges overturned state caps on lawsuit damages.

For now, at least, the agreement apparently ends a two-year political war, centered in the Metro East area, that has dominated the Legislature, fueled statewide advertising blitzes and helped decide a state Supreme Court election. Both sides in the debate have generally agreed that the malpractice insurance premiums that doctors in Illinois pay have become unreasonably high and have forced many doctors to leave the state. Doctors and their Republican allies have blamed out-of-control litigation for the excessive rates. Lawyers, backed by many Democrats, have said the culprit is the insurance industry, for allegedly gouging doctors and then blaming the court system for the high premiums.

Wednesday's agreement is a bitter pill to the Chicago Democrats who run the Legislature and who were ultimately forced by public pressure to agree to a concept they have steadfastly opposed. The agreement relied on the capitulation of House Speaker Michael Madigan, Senate President Emil Jones and Blagojevich - all Chicago Democrats who have long stood against caps.....

More here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Friday, May 27, 2005


(Post lifted from the Adam Smith blog)

It's now clear the way that National Health Service reform is going in Britain. The new Health Secretary, Patricia Hewitt, is announcing today that she is doubling the volume of medical and surgical procedures that are contracted out to the private sector.

Think-tankers don't often make good ministers, as Hewitt, who once ran the smug and irrelevant Institute for Public Policy Research, demonstrated at the Department of Trade and Industry. But they are slick at finding their way around blockages.

The fact is that the Old Labour part of Mr Blair's own party hate the idea of NHS reform, to which he and the moderates are committed. They forced him to water down his plans to make state hospitals more independent, and even then very nearly killed them, slashing his 160-plus majority to just 17. With a post-election majority in the mere 60s, how could he possibly get through further reform.

The answer is, as Hewitt spots, he doesn't have to. She already has the power to contract out NHS work, rather than give it to state employees. We already sent cataract patients to Norway and hip-replacement cases to France. Foreign healthcare companies have come in offering treatments up to eight times cheaper than state hospitals, using new techniques like mobile operating theatres. Do more of that, then more again, and pretty soon you have made healthcare provision entirely private. Once everyone has got used to it, and has seen the merits of competition, you can start devolving the funding down from the state to the individual, using private and social insurance or medical savings accounts.

It's a solution which the Adam Smith Institute proposed more than 15 years ago. Don't try to reform an unreformable, intractable, unmanageable state service. Build a dynamic new one and let the sclerotic old system, and its sclerotic supporters, fade away. Next stop: education.


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Thursday, May 26, 2005


IT took only one semester for Dr. Jacques Chaoulli to flunk out of a Montreal law school a few years ago after he incessantly challenged professors in the classroom and in exams with his novel legal interpretations. But Dr. Chaoulli, a family physician, never lost his taste for legal argument, or his distaste for Canada's publicly financed health care system. He has taken what was once regarded as a nuisance case, challenging the constitutionality of the system all the way to the Supreme Court - serving as his own lawyer, rolling his cardboard boxes stuffed with files into the chamber and paying for his efforts with a half million dollars out of his own pocket and that of his tolerant Japanese father-in-law.

It has been a year since the Canadian Supreme Court heard the case, a rare delay that is raising eyebrows in legal circles. Scholars studying Dr. Chaoulli's challenge say the court is either badly divided or waiting for the appropriate political moment to release a bombshell. They speculate that the justices may agree outright with Dr. Chaoulli (pronounced cha-OOH-li), or are working out instructions to the government to find a way to fix what many agree is an ailing health care network - where doctors are in short supply and patients wait months for diagnostic tests and elective surgeries like cornea transplants and knee replacements. "If I win, everything will be turned upside down," Dr. Chaoulli said with a smile, sipping a cup of tea in the living room of his modest stone house in Montreal. "One constitutional expert told a friend of mine, 'Chaoulli, is he a crazy man or a genius? We will know after the judgment of the Supreme Court.' "

A diminutive man who has trouble keeping his wire-rim glasses on straight, Dr. Chaoulli, 53, hardly looks like the "freedom fighter" that Canada's conservative news media have called him. But if he wins his case he will tear up the third rail of the nation's politics and raze what many Canadians consider to be the bedrock of their national identity. He argues that regulations that create long waiting times for surgery contradict the constitutional guarantees for individuals of "life, liberty and the security of the person," and that the prohibition against private medical insurance and care is for sick patients an "infringement of the protection against cruel and unusual treatment."

He believes that Canada is disallowing the basic contract rights of doctors and patients, and that the country would serve the sick much better if it had a parallel private health care system, as in France and many other industrialized countries. "His argument is credible," said Patrick Monahan, dean of the Osgoode Hall Law School of York University in Toronto. "The issue of waiting times does raise constitutional issues."

More here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Wednesday, May 25, 2005


During the welfare-reform debate, the Left predicted that scaling back federal cash assistance to the poor would be similarly disastrous. The most hysterical predictions were that one million children would be thrown into poverty and that the poor would be starving in the streets.

Welfare reform produced exactly the opposite of what the Left expected. Caseloads plummeted and poverty decreased — often dramatically — for every racial category and age, including children. Poverty remains lower today than at any point prior to welfare reform, going back to 1979. Many who opposed the 1996 law have since admitted that it accomplished a large measure of good. And evidence stemming from part of that law suggests that with regard to Medicaid, the Left is again misreading the tea leaves.

Though wholesale Medicaid reform was thrown overboard in 1996, the welfare-reform law contained a little-noticed provision that eliminated Medicaid eligibility for non-citizen immigrants. One person who did notice was Harvard economist George Borjas. He discovered that the result of this “draconian” measure was exactly the opposite of what many would predict: coverage among non-citizen immigrants increased.

Borjas explains, “The immigrants most likely to be adversely affected by the new restrictions significantly increased their labor supply, thereby raising their probability of being covered by employer-sponsored insurance. In fact, this increase in the probability of coverage through employer-sponsored insurance was large enough to completely offset the Medicaid cutbacks.”

The robust economy of the late 1990s cannot explain these results, Borjas argues, because states that offered coverage to those cut from the Medicaid rolls saw coverage levels for this group decrease, while states that did not saw coverage levels increase. As author Jason DeParle has written, “When welfare was there for the taking, they got on the bus and took it; when it wasn’t, they made other plans.”

Borjas notes that immigrants responded not just to the Medicaid cuts, but to all the changes in the 1996 law. Nonetheless, a natural experiment has demonstrated that Medicaid cuts produced exactly the opposite of what opponents would predict, and that — by at least one measure — the cuts were more compassionate than the program’s previous (supposed) generosity.

More -- much more -- here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Tuesday, May 24, 2005


Waiting lists for surgery at Queensland hospitals were growing, the state Opposition said today. The lists included 209 children waiting for surgery at Brisbane's two children's hospitals, Opposition Leader Lawrence Springborg said. Mr Springborg said figures released by the Government showed that waiting lists for elective surgery across the state had more than doubled in the past year.

But Premier Peter Beattie later countered Mr Springborg's claims by saying the figures were old. "These waiting list figures have been around for ages. They were released earlier in the month," he said. He said the most urgent categories had shown a marked improvement when compared with the same quarter a year ago. "The facts are that our system is improving in many senses but there are problems, systemic issues that need to be addressed, and they will be addressed," Mr Beattie said.

Mr Springborg said there were 21 people waiting for urgent surgery at the state's largest hospital, the Royal Brisbane and Women's Hospital, 338 for semi-urgent surgery and 2077 waiting for surgery classed as non-urgent. Of the 209 waiting for elective surgery at the Royal Children's and Mater Children's hospitals, three were classed as urgent, 71 as semi-urgent and 135 as non-urgent. "These latest surgery waiting list figures are a sad indictment on Peter Beattie and the state Labor Party's administration of Queensland Health," Mr Springborg said. "There has been more than a doubling of those people that are waiting for life-saving elective surgery, and of those in the semi-urgent category there has been a fourfold increase. "One of the most disturbing figures that have been dug up by the Nationals is that some 209 children at the two children's hospitals have been waiting for more than the required time for surgery." Mr Springborg called on the Government to provide "several million dollars at least" as well as better administration and management of public hospitals to ensure that people got their surgery on time.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Monday, May 23, 2005


Even lifesaving procedures are sometimes not available in time

A nine-year-old boy has died after an operation to treat his severe epilepsy was cancelled because Britain's top children's hospital had run out of money. Peter Buckle, from Evenwood, in County Durham, had a massive seizure and died last Monday. He had been waiting to undergo surgery at Great Ormond Street Hospital for Children in London.

The brain operation which might have saved his life had been cancelled twice. The first time, on March 15, Great Ormond Street cut back its operation lists after finding that it had treated more children than its budget allowed for. The operation was rescheduled for April 22, but cancelled three days beforehand when a ward was closed after staff contracted a viral infection. It had since been rescheduled for June 10.

Peter's mother, Judith, 42, said: "We will never know if the operation would have saved him - that is the most awful thing about this. I was very bitter, just like any mother would be, but it has been a long road. We are devastated. But that's life, isn't it? We will remember him for all the wonderful memories he has given to us. He was our special little boy."

Great Ormond Street has pioneered the relatively new field of epilepsy surgery for children, which has a good success rate. However, recent investigations by The Sunday Telegraph have highlighted how the dire state of NHS finances can affect patient care. Earlier this year this newspaper revealed that hospitals and primary care trusts have accumulated debts of an estimated £1 billion between them. In March, it was made public that Great Ormond Street was running a £1.7 million deficit. As a result, it cancelled 100 operations and closed up to a fifth of its beds.

A spokesman for the hospital confirmed that the initial cancellation of Peter Buckle's operation could be attributed to the hospital's "financial situation", but said: "We regret cancelling on any patient. The first thing we do is reprioritise [operations] according to clinical need. We offer our deepest sympathies to the family." The hospital declined to comment further until a coroner's investigation had been completed.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Sunday, May 22, 2005


In the 40 years since it was created to provide medical care to the needy, Medicaid has metastasized beyond this narrow purpose. According to the National Association of State Budget Officers, in 2004 Medicaid surpassed elementary and secondary education as the largest item in state budgets, consuming an estimated $309 billion of tax revenue.

This would be less of a problem but for the significant portion of its budget that provides coverage to those who could obtain it elsewhere. The problem is not merely (or even principally) fiscal. Like other components of the old welfare system, Medicaid harms many purports to help by lulling them into dependency. And it constantly draws more Americans toward dependency through an ever-increasing tax burden and higher health-care costs.

For the sake of the truly needy and everyone else, Congress and the states should pare this behemoth down to a flexible program focused solely on those who cannot help themselves. The Left's predictable response presents only a minor obstacle to reform. Still intent on expanding the program to cover all Americans and thus deepening the crisis, Medicaid's apologists have nothing to offer but echoes of the dire and famously inaccurate predictions the Left made about welfare reform ten years ago. The real obstacles to reform are Republicans who are willing to accept the status quo.

Medicaid's Perverse Incentives

Medicaid operates much like other components of the old welfare system, notably the now-repealed Aid to Families with Dependent Children (AFDC) cash-assistance program. In each program, Congress created: a legal entitlement to benefits for anyone who meets the eligibility criteria; a scheme where the more money a state spends, the more it receives from Washington; and centralized control over how states run their programs. Each feature creates perverse incentives that increase Medicaid spending, overall health-care costs, and dependency on government.

Medicaid typically offers services to beneficiaries free of charge, which creates the program's first perverse incentive: encouraging beneficiaries to consume medical care without regard to cost. Requiring the truly destitute to contribute to the cost of their care is of course impossible, not to mention undesirable. Yet allowing 50 million Americans to consume care as if it were free brings its own raft of undesirable consequences.

As the RAND Health Insurance experiment demonstrated, removing price-sensitivity induces patients to consume more medical care — 43-percent more under the conditions tested — but fails to produce measurable health gains. Though few data exist for Medicaid, leading researchers at Dartmouth College estimate that 20 percent of Medicare expenditures purchase care that provides no clinical value.

Medicaid's second perverse incentive is that it discourages private efforts that provide for those who are eligible. Anyone who meets federal eligibility criteria (regarding age, income, assets, etc.), or a particular state's broadened criteria, is entitled to benefits, which encourages many to enroll even when they could obtain care and coverage elsewhere.

Researchers at the Robert Wood Johnson Foundation surveyed 22 leading studies on whether "free" government coverage crowds out private coverage and concluded that crowd-out "seems inevitable." While the scale is uncertain, over half of these studies found that expansions of public coverage were accompanied by reductions in private coverage. Some even found that enrollment growth in public programs was completely offset by reductions in private coverage. The lure of "free" medical care is a powerful draw, and an entitlement makes it impossible for states to focus resources on the truly needy.

The states' open-ended entitlement to more federal funding creates Medicaid's third perverse incentive. States receive an average of $1.30 from Washington for every dollar they spend. This encourages states to broaden their programs beyond what is necessary to assist the truly needy. According to the Urban Institute, close to one-fifth of Medicaid-eligible adults and children have private coverage, which strongly suggests that states have expanded Medicaid well beyond its original purpose.

Inflating Health-Care Costs

Medicaid undermines private health insurance in more ways than just giving some people a "free" alternative. It also makes private health insurance more expensive by shifting part of its costs onto private parties.

Price controls enable Medicaid to pay below-market rates, and providers make up the difference by charging private payers more. Mark Duggan of the University of Maryland and Fiona Scott Morton of Yale University estimate that Medicaid increases the price of non-Medicaid prescriptions by 13.3 percent. So if Grandma's medications cost her $1,000 per year, upwards of $110 of that is her contribution to Medicaid. When unleashed market-wide, this mix of inflated demand and cost-shifting makes private health coverage less affordable, particularly for low-income Americans who are already Medicaid-eligible or on the cusp of eligibility.

A convention among health policy writers is to hail Medicaid as the white knight that rescues the uninsured when employers find they can no longer afford private coverage. As Jonathan Cohn wrote in The New Republic this February, "If Medicaid hadn't grown to fill the yawning gaps in private coverage over the last decade, today we would probably have 50 million uninsured Americans instead of 45 million." It's a convention that turns reality on its head. Medicaid is a prime culprit behind rising health-insurance premiums.

Promoting Dependency

Because Medicaid is a means-tested program, many beneficiaries become or remain eligible by avoiding constructive behaviors — such as earning, saving, and purchasing private insurance — that would make them ineligible.

Jonathan Gruber of MIT and Aaron Yelowitz of the University of Kentucky found that Medicaid beneficiaries save less and consume more in order to remain eligible. They estimate that in 1993, Medicaid reduced asset holdings among those eligible by the equivalent of $1,600 to $2,000 in today's dollars. Those disincentives are even greater today, thanks to subsequent expansions of eligibility and benefits.

The program also discourages private insurance for nursing home and other long-term care expenses. Jeffrey Brown of the University of Illinois at Urbana-Champaign and Amy Finkelstein of the National Bureau of Economic Research found that 60 percent to 75 percent of the benefits from private long-term care insurance "are redundant of benefits that Medicaid would otherwise have paid." They estimate that Medicaid by itself discourages 66 percent to 90 percent of seniors from purchasing such insurance. Even seniors with considerable means are able to avoid tapping those resources; gaping loopholes in asset tests make them eligible for Medicaid as well.

A Familiar Ring

The congruity with to the old welfare system could not be more striking. Medicaid encourages the poor — and the not-so-poor — to become dependent on government. It encourages people to behave in ways that increase the cost of government and of health care, which makes self-reliance more difficult for their neighbors. And it encourages states to get more people to behave that way.

With so many similarities, many have proposed reforming Medicaid along the same lines as welfare: end the entitlement to benefits; eliminate open-ended entitlement to matching federal funds by capping federal payments to the states; and give states greater flexibility to pursue a few broad goals. This was the Republican plan in 1996 before President Clinton threatened to veto welfare reform if it included Medicaid reform. Perhaps wisely, Republicans sacrificed Medicaid reform and reformed welfare.

Yet if Republicans were intent on enacting meaningful Medicaid reforms ten years ago, and welfare reform was an enormous success, why are we no closer to Medicaid reform today?



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Saturday, May 21, 2005


The Morris inquiry into Dr Death will go far beyond events in Bundaberg and investigate claims of bullying, lying, cover-up and vilification of Queensland Health staff in hospitals across the state.... Mr Morris, who has criticised Queensland Health over its attempts to suppress a damning report about reckless and unsafe care of patients at Hervey Bay Hospital, said investigators were focusing on claims of bullying, lying, cover-up and vilification of staff in the health bureaucracy.

Mr Morris foreshadowed recommendations of "possibly sweeping changes" to the administration of Queensland Health. Key issues included allegations of a culture which involved "active discouragement of complaints and reports and bullying of medical and nursing staff to prevent them from making such reports". Mr Morris also added vilification of medical and nursing staff who did complain, concealment of bad news, obfuscation of the truth, use of creative or falsified statistics, and use of "spin" to distract attention from adverse media reports. He said there was a question as to whether Mr Nuttall and his predecessors "have themselves been the victims of this culture - whether they have been prevented from or hampered in discharging their ministerial responsibilities by a department which has consistently lied to them or withheld the facts from them".

The commission, which starts public hearings in Brisbane Magistrate's Court on Monday, will determine the truth of the allegations during an examination of issues surrounding Bundaberg Base Hospital's former director of surgery, Dr Jayant Patel. Dr Patel, who was trained overseas, had been struck off in New York State and Oregon for botched surgery which harmed patients. His shocking track record was not checked or known to Queensland Health authorities until The Courier-Mail last month discovered findings against him published on the Internet.


Welfare reform's unfinished business: "In the 40 years since it was created to provide medical care to the needy, Medicaid has metastasized beyond this narrow purpose. According to the National Association of State Budget Officers, in 2004 Medicaid surpassed elementary and secondary education as the largest item in state budgets, consuming an estimated $309 billion of tax revenue. This would be less of a problem but for the significant portion of its budget that provides coverage to those who could obtain it elsewhere. The problem is not merely (or even principally) fiscal. Like other components of the old welfare system, Medicaid harms many it purports to help by lulling them into dependency. And it constantly draws more Americans toward dependency through an ever-increasing tax burden and higher health-care costs."


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Friday, May 20, 2005


Authoritarian medicine in Britain. Only the law is keeping this guy alive -- and that may change. The Brits have been told that they pay for lifetime care through their taxes. This shows that what they think they have paid for and what they get can be two different things

The National Health Service should not have to give life- prolonging treatment to every patient who demands it because that would mean a crippling waste of resources, the Government said yesterday. A lawyer for Patricia Hewitt, the Health Secretary, said that a ruling granting a patient the right to request life-prolonging care had serious implications for the NHS.

The dramatic intervention came as lawyers for the General Medical Council challenged a High Court ruling that supported a terminally-ill man’s wish to be kept alive artificially. Leslie Burke, 45, who suffers from cerebellar ataxia, a degenerative brain condition, won a landmark case last May granting him the right to stop doctors withdrawing artificial nutrition or hydration (ANH) treatment until he dies naturally. The Department of Health, backing the GMC’s attempt to reverse the ruling, said that if that right were established, patients could demand other life-prolonging treatments. The department argues that this will create a culture in which patients request treatments “no matter how untested, inappropriate or expensive, regardless of doctors’ views”.

Philip Sales, for the Health Secretary, told a panel of three appeal judges, headed by the Master of the Rolls, Lord Phillips of Worth Matravers: “A general right, as identified (in the High Court), for an individual patient to require life- prolonging treatment has very serious implications for the functioning of the NHS. “It may be interpreted as giving patients the right to demand certain treatments, contrary to the considered judgment of their medical team, that would lead to patients obtaining access to treatment that is not appropriate for them, and to unfairly skewed use of resources within the NHS.”

Under current GMC guidelines, a competent patient could decide between treatment options offered by a doctor. “But the patient cannot require his doctor to offer him any treatment option which, in the doctor’s view, is not clinically appropriate or which cannot be offered for other reasons — having regard to the efficient allocation of resources.” Mr Sales said that the ruling had led to a confusion of the roles of doctor and patient — decisions over treatment were for doctors, not patients.

Doctors’ leaders said the precedent won by Mr Burke had created a minefield of unresolved issues over appropriate treatment and use of NHS resources. The GMC’s arguments — that the ruling is unclear and puts doctors in an “impossibly difficult position” of having to pursue treatments of no clinical benefit — has widespread support within healthcare. Intensive care beds, where patients can receive lifesaving care such as ANH, cost £1,500 a day to run while high-dependency beds for patients who require close monitoring cost up to £800 a day.

The Government put £300 million into critical care beds after the flu epidemic of 1999-2000, increasing the number of intensive care beds from 1,496 to 1,677 and high- dependency beds from 847 to 1,208. by January 2001. But since then the number of high-dependency beds has risen by only 206, the Intensive Care Society says. Figures from 2000 revealed that the NHS had four critical-care beds per 100,000 — compared with 25 in Germany and 24 in the US. No figures are available on how many patients in Britain are in long-term intensive care.

Mr Justice Munby ruled last year that if a patient is competent, or has made a request before becoming incompetent, doctors have a duty to provide ANH. Mr Burke, from Lancaster, was in court in his wheelchair yesterday listening to the arguments for overturning the ruling, which he believes will save him if ANH was withdrawn after he loses the ability to communicate. Richard Gordon, QC, for Mr Burke, argued that the GMC case was based upon a misunderstanding of the role of doctors in relation to the legally competent patient. The hearing continues.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Thursday, May 19, 2005


Paul Krugman has been using his space on the New York Times op-ed page for weeks now to discuss America's "real crisis"--not Social Security but health care. ... But government-run health care didn't make sense for America in 1994, and it still doesn't. Krugman's arguments are enticing. But they gloss over basic facts. Consider:

Americans tend to believe that we have the best health care system in the world. . . . But it isn't true. We spend far more per person on health care . . . yet rank near the bottom among industrial countries in indicators from life expectancy to infant mortality.

Krugman's error here is a common one: assuming that universal health insurance and good health go hand-in-hand. But life is not so simple. Take infant mortality. According to the National Center for Health Statistics, Mexican-American and white babies in the United States have a lower infant mortality rate (about 6 in a thousand live births) than Native Americans or blacks. Yet Mexican Americans also have the least access to health insurance of any of these groups. In fact, it's even more complicated: A study in the Journal of the American Medical Association suggests that Mexican-American babies are twice as likely to be born outside a hospital as babies of all other groups. Infant mortality statistics--like life expectancy--reflect a mosaic of factors, such as diet, marital status, drug use, and cultural values. Dismissing American health care on the basis of such statistics is like declaring Cuban democracy stronger than America's based on voter turnout.

Krugman again: Amazing, isn't it? U.S. health care is so expensive that our government spends more on health care than the governments of other advanced countries, even though the private sector pays a far higher share of the bills. . . . What do we get for all that money? Not much.

Actually, if we measure a health care system by how well it serves its sick citizens, American medicine excels. Comparing breast cancer statistics in Germany, Britain, France, Spain, Italy, and the United States, market analyst Datamonitor finds that 95 percent of American women are diagnosed in early stages (I or II). In contrast, a full 20 percent of European women are diagnosed in late stages. WHO data on five-year survival rates for various types of cancers bear this out. For leukemia the American survival rate is almost 50 percent; the European rate, just 35 percent. Esophageal carcinoma: 12 percent in the United States, 6 percent in Europe. Say what you want about the problems of American health care, but for those stricken with disease, there's no better place to be than the United States.

Like many critics of American health care, Krugman argues that the costs are just too high: "In 2002 . . . the United States spent $5,267 on health care for each man, woman, and child." Health care spending in Canada and Britain, he observes, is a fraction of that. He also zeroes in on the troubles of General Motors, which spends $1,500 on health care for every car produced. Even more problematic: "Medical costs are once again rising rapidly."

No one would dispute that American health care is expensive. But a bargain isn't always a good deal. Britons spend a fraction of what Americans do--and wait for practically every test, surgery, or specialist consultation. This spring, the story of Margaret Dixon, an English pensioner awaiting a risky surgery, caused a political storm. She was prepped for the procedure and, expecting the worst, said goodbye to her family--only to be bumped by a more urgent case. Again she waited, again she was prepped, and again she said goodbye to her family--and she was bumped again. In all, she says, her surgery has been canceled seven times. (National Health Service officials dispute her account, arguing it's "only" been four times.) Such stories are all too common under public systems. Data from the Commonwealth Fund show just 5 percent of American patients wait longer than four months for an elective procedure, as do 23 percent of Australians, 27 percent of Canadians, and 36 percent of Britons.....

For Krugman and like-minded pundits, the solution is simple: junk "ideology" and the "obsession" with the private sector in favor of the Utopian ideal of socialized medicine--which, incidentally, can't be made to work in any country that has subscribed to it. But a better and less radical approach would start by asking: Why are health costs rising so dramatically in the first place?

The central problem is the way Americans pay for their care. Rather than paying directly, most people get their health insurance from their employers. Someone else foots the bill. This odd financing arrangement developed because of World War II wage controls. Employers began to provide health benefits as a disguised form of income, and their incentive to do so only increased when the IRS ruled that, unlike income, these employer-provided benefits would not be taxed. The resulting accidental system is wasteful and bureaucratic. With Americans paying directly just 14 cents for every health dollar they spend, there is much incentive to spend first, and ask questions later. Health managers, meanwhile, create bureaucratic hurdles in an attempt to constrain patient choice (and thus costs). During the 1990s-heyday of managed care, for instance, HMOs attempted to dictate whether and when their patients were tested.

An answer to the predicament? American health care needs to evolve along a third way--not the rationing of public systems, or the bureaucracy of HMOs. Instead, Americans should be more involved in their health care decisions. Consumer-driven health care attempts to do exactly this. In 2003, Congress created health savings accounts (HSAs) in the Medicare Modernization Act, a major breakthrough. HSAs marry high-deductible insurance (that is, real insurance, for unusual, out-of-the-ordinary expenses) with a tax-free savings account for smaller health expenses. HSAs thereby encourage consumers to shop around and ask providers tough questions. The Miami Herald recently ran a story on a Fort Lauderdale woman who shopped around for physiotherapy--and saved herself a thousand dollars a session.....

There is still much work for Congress to do. Health care is badly over-regulated. Some on the Hill have sought to address this; Rep. John Shadegg of Arizona, for example, has proposed legislation allowing people to buy health insurance from out-of-state providers, thereby fostering national competition in what is currently a badly Balkanized industry regulated state by state. President Bush and the Republican leadership have invested little political capital in such initiatives. The return of HillaryCare to the national debate should give them incentive to act.

More here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Wednesday, May 18, 2005


The fleecing of many Third World nations of their best doctors and nurses is causing a “major emergency” in developing countries and the British Medical Association is calling on the British government to undertake some urgent action. Today in a joint statement both the BMA, and the Royal College of Nursing (RCN) warned that deaths in third world countries will increase if action is not taken now. In a "statement of principles" the organisations say that sound though billion-dollar efforts to tackle global health problems like HIV and Aids are, they are were being severely undermined by the skills drain from developing countries.

The NHS today relies on a seemingly unending influx of migrants from Africa, Middle East and east Asia due to problems recruiting and retaining indigenous home grown staff. The reasons are many fold but poor working conditions, an over reliance on bureaucratic styles of management and low morale within the Service are frequently cited reasons for low retention. Another less obvious factor is that many staff recruited from overseas see working in the NHS as a stepping stone to working elsewhere in the developed world, with the USA an attractive and sought after career move, thus a need to replace those that move on to bigger and better things.

Rather than address the fundamental issues, the Government’s short-termist policy of rapidly increasing the numbers of ‘front-line’ medical staff working in the NHS has led to large-scale recruitment from overseas. In 2002/03, over 40 per cent of the 31,775 nurses joining the NHS register were from abroad whilst in 2003, nearly three quarters of the 15,549 doctors who joined the register qualified outside the UK. The consequences for those countries in Africa in particular are of course easy to see with continued disease and suffering, high infant mortality rates and short lifespans.

In addition there has to be a serious assessment of the risk of communicable diseases brought in by those health care workers who have come straight from high risk areas of HIV/AIDS, tuberculosis and Hepatitis B being of particular concern. At present there is no obligatory screening process carried out on overseas medical staff for these communicable diseases which leaves colleagues, patients and hospital visitors at significant risk of contagion. It is incidentally obligatory for domestic students to be tested for Hep B prior to admission to a British medical school. Migrationwatch have published figures, in turn reproduced from the General Medical Council which show that, in the years 2002/3 3,200 doctors and 1,300 nurses arrived from South Africa, where the HIV rate is 1 in 5. South Africa also has a high incidence of TB and Hepatitis B yet none of these recruits were tested for any of these communicable diseases. The same applies to nearly 500 nurses from Zimbabwe. In addition, nearly 4,000 doctors and 8,000 nurses were recruited from countries with high rates of TB.

More here


By Darren Giles

Our public health crisis deepened yesterday as Health Minister Gordon Nuttall admitted he could not guarantee the state's hospitals are safe. Speaking after alarming revelations about Hervey Bay Hospital, Mr Nuttall was unable to reassure Queenslanders that medical incompetence had been contained. Mr Nuttall s comments came after health inquiry commissioner Tony Morris released a damning report into orthopedic services at Hervey Bay Hospital. The report, by two senior surgeons, identified two overseas-trained doctors whose surgical skills were "seriously flawed".

Mr Nuttall yesterday said he could understand public concern, but was assured by his department it was safe to get surgery at Hervey Bay Hospital. Asked if he could give the same commitment for all other hospitals, the Minister was hesitant. "I can only go on the advice supplied by my department", he said. "My department has advised me that to the best of their knowledge, things are operating in a proper manner. "I am not going to stand here and say that it is perfect - I can't say that. I can't give those assurances.

Mr Nuttall said the latest report was "disturbing" and that the commission of inquiry would investigate the findings. The Minister said the two doctors under scrutiny, Dinesh Sharma and Damodaran Krishna, continued to work under strict supervision at Hervey Bay Hospital.

Queensland Health received the report on May 6 but kept it hidden. Mr Nuttall denied a cover-up and questioned why the authors had not contacted Queensland Health last year when they first had concerns about Hervev Bay Hospital.

Nationals health spokesman Stuart Copeland yesterday urged Premier Peter Beattie to stand down Mr Nuttall and Queensland Health DirectorGeneral Steve Buckland. Mr Nuttall yesterday refused to resign. "I am not going to walk away when it gets hard," he said.

The above article appeared in the Brisbane "Sunday Mail" of May 15, 2005 but does not previously appear to have been made available online


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Tuesday, May 17, 2005


In mid December 2004, I stood up in the middle of my primary-care physician's waiting room, and said, "I am carrying a weapon of mass destruction in my breast. I have breast cancer. I came here for treatment, not for cemetery care." At last. The receptionist looked up. After two phone calls in advance and a polite request at the front desk for my medical records and a referral to an oncologist, I had broken the wall of indifference. The office manager, for whom I had written out my requests on a form more than an hour before, came scurrying out with what I needed. I had come to this office from my surgeon's office, several miles away, where I had heard my diagnosis. But he didn't have my complete medical file or the power to write the referral. I felt terrified and confused, but I was following orders from my Health Maintenance Organization (HMO).

The odds of surviving the duel with cancer now are far greater than they were 20 years ago or even 10 years ago, but going through the paces of the medical system is worse than playing a game of Russian roulette. After 17 cancer-free years, my fight with a recurrence is harder because medical insurance for doctors and patients is chaotic with regulations.

As I left my doctor's office, several other patients followed me outside. We agreed: frustration with the system is typical. No, they insisted, I was not out of line or selfish to demand attention. The professionals are so busy with forms, many don't pay attention. Doctors and patients today are caught in a web of bureaucracy that could cost lives. "You have to take care of yourself. You have to fight the bureaucrats to the end," one woman told me.

To begin with, the Framers' intention to "promote the general welfare" in the preamble to the Constitution did not include universal health care. Health is an individual, free-choice matter. The government, whether through Medicare, HMO regulations, or otherwise, should never be in the business of protecting me from myself or of telling a doctor how to practice his healing art.

Too often in the past two years, I've heard, "Don't do this. Don't do that." After a "normal-benign" mammogram report in December 2003, a technician told me, "Don't come back until you've let at least 11 months go by or your medical insurance won't cover your next breast exam." That rule comes directly from the official U.S. government CMS Site (Centers for Medicare & Medicaid Services): "For a woman over the age of 39, Medicare will only pay for a screening mammography after 11 full months have passed following the month in which the last screening mammography was performed."

Do the politicians think my cancer is going to wait for a photograph? Do they think I enjoy going to a radiologist to have my breast pinched and pressed into an X-ray machine? Am I going to overuse a test that exposes me to radiation? On the basis of a British medical journal report in 2001, controversy continues to spin around how useful and accurate the test is. Nonetheless, if I detect an abnormality why can't I go at any time or even bypass a test and go for a biopsy?

One medical-office manager told me the government's intention is to guarantee routine screenings for all women. The American Cancer Society reports that mammograms catch 90 percent of all breast cancers. Therefore, politicians want to equalize the availability to make sure everyone over 39 goes for the test (even though some women under that age develop breast cancer). To hold the medical professionals accountable, Medicare pays for mammograms annually.

Instead of providing encouragement, the rule acts as a deterrent. Many HMOs indirectly compete with Medicare. Both private and public companies, therefore, are heavily regulated. The regulation allows the insurance companies to refuse payment to hold down costs. So, although a radiologist's disclaimer states that any change in breast tissue within the 11-month period should send me back for another test, I believed the narrower interpretation of the rule.

So did my primary-care physician, who exchanged his role as a healing assistant for that of an insurance advisor. During my annual check-up in April 2004, he opined that a new lump, which I had found, lay in almost the exact spot as a benign tumor from two years ago. Therefore, reasonably, it was "scar tissue" from the biopsy.

Seventeen years before, in 1987, I had undergone a lumpectomy to remove a breast tumor. Radiation and five years of taking tomoxifen pills followed. Since then, I had become athletic and vigorous, believing I fell into a 1 percent recidivism category. Rarely did I think of cancer. I didn't have time to be sick, I rationalized. But what finalized my decision in my doctor's office last April was his reminder that my medical insurance would not pay for another mammogram so soon after the "normal" one in 2003. In my opinion, his focus was on the system, not the patient - me. At that moment, I felt too intimidated to ask for another test or even a second opinion. My husband had made a job change. I was worried that our health insurance would refuse to pay for what seemed an unnecessary test. Basically, I didn't want to be labeled a hypochondriac.

Medicare and HMO rules distort our thinking. We are conditioned not only to believe that our health-care providers are gods because they rely on statistics, but also to believe that our health-care insurance will pay for routine needs, not just catastrophic illness. We are conditioned to be passive because we assume medical insurance will cover everything. At the same time, doctors, even in computerized offices, resent filling out a glut of insurance forms to meet the demands of government scrutiny and liability insurance. Doctors in large practices must hire business managers to sort out the mess of paper work. Overhead costs go up. Consequently, doctor/patient rapport suffers, as it did for me.

Eight months later, the "benign scar tissue" had grown more prominent. When I called the primary-care office for the required referral to the radiologist, the receptionist, who didn't know me, suggested I wait for my regular, scheduled mammogram at the end of December. Panicked by the resistance, I broke through my own conditioning and asked for a next-day appointment. There it was, not only in my X-rays but also in the black hole of an ultrasound screen - a suspicious hard mass stared down at me. The following biopsy and lab reports confirmed my worst fears. This marble-sized lump, now grown to 2 centimeters, was a return of the Big C, breast cancer.

Enraged at myself for going along with the rules for eight months, for denying my instincts and not challenging the statistics, I jump-started treatment. Assurances that breast cancer is "slow-growing," that a mastectomy could wait a month until mid January did not impress me. Uncertainty reigns until surgery. In full command, I demanded, "Get the cancer off my chest." Three months later and postmastectomy, I am grateful that aromatase inhibitors have arrived. Research advances have saved me. I am taking a hormone treatment or aromatase inhibitor drug, which reduces the amount of estrogen produced after menopause. (Aromatase inhibitors (AIs) cut the estrogen supply made and distributed in the body.) This new drug promises me survival with possible long-range side effects. I'll take the trade-off - I'm alive.

But, at the same time, I am taking a stand against all assumptions that cancer in any form is slow-growing. We are not wrong to ask for immediate service. Different grades of cancer grow at different rates. Often, in postmenopausal women, invasive breast cancer is slow-growing. But there are exceptions. Some, like inflammatory breast cancer, spread like wildfire, faster than the estrogen receptor-positive cancers. Waiting can be deadly if the cancer is estrogen receptor-negative, a more rapid growing cancer that does not respond to aromatase inhibitors and requires more aggressive chemotherapy with harsher side effects. Some rare cancers have already spread from other sites. Ultimately, cancers have no respect for waiting.

Within the past 20 years, cancer research has made tremendous progress. Also screening and treatment programs are more available for poor women because of private breast-cancer foundations. Breast cancer should not be a death sentence, but women die of a treatable disease. Compared to ovarian or lung cancer, for example, breast cancer is easier to detect. So it is upsetting to hear how a friend's mother died while waiting for insurance payments for treatment. "The insurance companies love to have you pay into the system, but they don't want to pay out," my friend says, describing a system that has grown dysfunctional.

Postmastectomy, I have met other women with breast cancers that have metastasized through the lymph nodes to other parts of their bodies. For eight months I played a game of roulette that could have produced the same result. In 2002, a tumor that was benign landed next to a lymph node. If malignant, that tumor could have spread to my lymph system. I could have been a lot sicker than I was in 2004. I was lucky.

Today beating cancer is still a game of chance. All too often, survival depends on long waits, a swamp of procedures, and unnecessary written referrals for insurance requirements. The perverted public and private systems exhaust the professionals and the patient. We need to break through our conditioning and accept the facts that: (1) The U.S. Constitution does not guarantee the right to health care. Freedom means we take care of ourselves. The government should not be in the business of putting our lives at risk, under the puffed-up pretension of protecting us from ourselves. (2) Government bureaucrats have saddled Medicare and thereby HMOs with top-down health-care insurance regulations that make doctors servants of the system. The rules aren't sacred.

No government body, state or federal legislature, politician or bureaucrat is wise enough or has the omniscient knowledge to strong-arm a decision about an individual person's health care. An insidious trickster like cancer requires the invisible hand of the marketplace that serves the patient first. Medicare/Medicaid should be abolished so that laissez-faire care can optimize individualized monitoring. We must transform the patient's role from passive to active: Let the patient and the doctor take charge. Get the cancer off our chests and the government off our backs.


Foolish FDA meddling: "A year ago, the Food and Drug Administration banned dietary supplements containing the herbal stimulant ephedra. In a decision recently overturned by a federal judge in Utah, the FDA concluded all such products are 'adulterated' because they pose an 'unreasonable risk of illness or injury.' Yet the FDA took no action against such OTC medicines as Primatene and Bronkaid, that contain ephedrine, the most potent stimulant in ephedra. ... To confuse matters even further, the FDA also continued allowing the use of ephedra in traditional Asian medicine because its practitioners 'typically do not use products marketed as dietary supplements.' Hence, loose, dried ephedra prescribed by herbalists remained legal, while exactly the same substance was prohibited when chopped up, placed inside a capsule, and sold in a health food store."


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Monday, May 16, 2005


One in five people who died after surgery received deficient care, and one in 50 died as a direct result of an error or misjudgement, Australia's first audit of surgical deaths shows.

The West Australian analysis, which will now be extended nationwide, found serious problems with the way fluids were administered and monitored after surgery. Fluid problems - typically involving lung failure after excessive hydration - were implicated in 11 per cent of the 179 surgical deaths that occurred in the state in 2004 in which deficient care was considered a factor.

The total number of surgical deaths was 876, but in 80 per cent of cases the care was judged to have been appropriate. The report also identified problems with continuity, when a person came back to hospital for a repeat operation but was admitted under the care of a different doctor who was not fully aware of the patient's medical history.

James Aitken, who runs the audit program, said public hospital employment practices - in which surgeons were paid to work shifts and were not officially on call at other times - contributed to that problem. Many surgeons also worked at private hospitals, which could raise a dilemma if an emergency arose.

But the audit showed some improvements since data collection began in 2002, with fewer operations performed on very sick people where there was no chance of success, and more consistent action to prevent the development of deep vein thrombosis - potentially lethal blood clots that can occur when people are immobilised after surgery. Three-quarters of the doctors said they had made changes in the way they practised after feedback from the program.

Dr Aitken said 95 per cent of West Australian surgeons were now taking part in the voluntary audit, which helped doctors improve their performance by becoming more aware of potential pitfalls. When a patient died under their care, the surgeons forwarded case notes to the audit team, which in turn asked independent experts to comment on whether there had been faults in the person's care, and whether the death might have been prevented.

But patients' families could not gain access to the case reports, protected under freedom-of-information legislation. Russell Stitz, the president of the Royal Australasian College of Surgeons, said surgeons in several states had recently begun contributing to a national audit, but funding negotiations were continuing in NSW.

There were no imminent plans to require surgeons to report deaths under their care, Dr Stitz said. "We'd rather put them in the position where if they don't do it, a cloud falls over their head." And the college would resist public disclosure of individual surgeons' death rates. "If we say we're going to identify the surgeons publicly, they'll run a mile. We will look at someone who's at variance [with normal performance] and remediate them," said Dr Stitz. "We need surgeons. We'd rather get them back up to speed."


Sunday, May 15, 2005


A federal judge took the first formal step Tuesday toward placing the California prison health care system in receivership, saying it has killed "a significant number of prisoners" and is sure to kill more without drastic intervention. Senior U.S. District Judge Thelton Henderson issued an order to show cause why the state should not relinquish control of the system to a court-appointed receiver who could be granted the power to direct policy, staff and spending. Henderson said he'll also consider holding Gov. Arnold Schwarzenegger and members of his corrections team in contempt of court for reneging on reforms promised by the current administration and that of former Gov. Gray Davis. Prompting Henderson to act, he said, were recent admissions made in his San Francisco courtroom by people representing the Department of Corrections that even stop-gap reforms may be impossible, and "unconstitutional conditions will remain until an outside entity is hired to take over."

"The problem of a highly dysfunctional, largely decrepit, overly bureaucratic and politically driven prison system, which these defendants have inherited from past administrations, is too far gone to be corrected by conventional methods," Henderson said. Besides the state's admissions in court, Henderson cited reports by panels of court-appointed experts and a personal visit to San Quentin State Prison in February. The judge said he found "horrifying" conditions, including a main examining room lacking "any means of sanitation - there was no sink and no alcohol gel."

He observed that a dentist "neither washed his hands nor changed his gloves after treating patients into whose mouths he had placed his hands" - a problem that could be fixed, the judge said, without "a budget change proposal, a strategic plan or the hiring of new personnel." Henderson described other conditions related to serious overcrowding at an institution that was designed for 3,317 prisoners but currently houses about 6,000. Some prisoners live in corridors "where they are subjected to having feces and urine flung at them from above, and where water continually seeps from the walls and collects in pools on the floor," the judge said.

Under both Schwarzenegger and Davis the state has signed a series of legal agreements to improve inmate care. But Henderson, who has been meeting monthly with lawyers on both sides of a suit filed in 2001 by the nonprofit Prison Law Office, said the state failed to follow through on the agreements. He said the state submitted a document last month referring to prison medical care as a "broken system" with "fundamental barriers" to improvement, including "budget, personnel, contracts, procurement, information systems, physical plant and space issues."

Henderson set a series of court hearings on the receivership and contempt issues, starting May 31, at which he'll take testimony from court experts and state representatives. He also set a timetable running through July 6 for written arguments. His final orders probably would follow within a few weeks. The Governor's Office referred reporters to the Youth and Adult Correctional Agency, where assistant secretary J.P. Tremblay said, "We do intend to work cooperatively with the court to provide the treatment that's required." Tremblay acknowledged that reforms have been hindered by "some overly bureaucratic systems." ....

Nevertheless, one key lawmaker called Henderson's proposed takeover "an appropriate course of action." "What we have seen is that the Department of Corrections has consistently demonstrated its inability to deliver health care," said Sen. Michael Machado, D-Linden, a member of the Senate budget subcommittee on corrections.....

Henderson said that although the state plans to contract out prison health care management services, that process is expected to take at least 18 months, and there's no estimate on how long it will take to improve the standard of medical care. "In the meantime," he said, "prisoners continue to unnecessarily die, suffer and go unattended." Henderson said the experts advised him that although San Quentin may be in the worst physical condition among the 32 state prisons, "it is paralleled by a number of other prisons in terms of physician and nurse vacancies, incompetent medical staff, lack of supervision and all other aspects of medical care delivery."

The judge said one group of experts attempted to review 193 death records throughout the prison system. Some prisons were unable to locate records. Those records that could be found revealed 34 "highly problematic" deaths, "with multiple instances of incompetence, indifference, neglect and even cruelty by medical staff," Henderson said

More here


Western Australia's senior health bureaucrat has moved to reassure surgical patients of their safety following revelations that 48 patients of one surgeon died during a 30-month period. The deaths came to light upon the release yesterday of an audit of almost 900 hospital deaths in WA between January 2002 and June 2004. Participation in the peer-review audit was voluntary and some surgeons with high death rates declined to take part, including the surgeon found to be involved in the 48 deaths. The audit results come ahead of three separate inquiries in Queensland into the scandal involving Jayant Patel, who has been linked to 20 deaths at Bundaberg Base Hospital. Dr Patel, dubbed 'Dr Death' by colleagues, fled Australia at Easter and is believed to be in India.

Neale Fong, acting director-general of the WA Department of Health, said today processes were in place to protect the safety of surgical patients. Care should be taken in interpreting death rate data because the unnamed surgeon highlighted in the review might handle only extremely ill or high-risk patients, Dr Fong said. "He may well be our best surgeon in WA, who gets all the hard cases and when everyone can't do anything they send (patients) to him and unfortunately there is a high mortality rate," he told ABC radio. "If there was a WA surgeon having that many deaths and it was due to something people were concerned about, we have other mechanisms in place that would identify that surgeon very quickly - much, much before he got to death number 48." Every public and private hospital in WA automatically reviewed deaths, and suspicious cases were referred to the coroner, he said. "There are lots of other ways we can identify rogue surgeons," he said. "I'm quite confident and assured that we have the processes in place - this (audit) just adds another whole dimension to it."

Dr Fong, whose department funded the WA Audit of Surgical Mortality, praised the high rate of participation from surgeons intent on improving work practices and saving lives. He said 96 per cent of doctors had completed at least one or more audit forms, while others working in high-risk cardiothoracic or neurosurgery already participated in separate review processes when deaths occurred. Dr Fong foreshadowed mandatory participation in the audit in the future, with the Royal Australasian College of Surgeons planning to extend it to all other states and into New Zealand.

In Queensland, three inquiries are pending over Dr Patel: one into the state of the health system, another into Dr Patel's appointment and supervision, and a Crime and Misconduct Commission inquiry into Queensland Health's complaints process.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Saturday, May 14, 2005


Another private medicine resource

We know that it is routine for x-rays and many diagnostic tests to be interpreted overnight by medical professionals in India. In a fairly new development, though, it's not just the tests that are headed off to the subcontinent for diagnosis, but the patients themselves -- and they're going in droves.

Medical tourism to India started fairly recently when NRIs (non-resident Indians -- those living and working in the West) began to go "home" to India seeking not just their roots, but root canals. They returned with killer smiles and tales of the staggering savings in costs -- even factoring in airfares -- and excellence of treatment. NRIs, aware from their families of India's state-of-the-art technology and the level of surgical skill, also head off "home" for more critical treatment, like kidney transplants, hip replacements and open heart surgery. Indeed, India's 20 million diaspora returning to the US and Britain after successful treatment are India's best ambassadors.

Britons plagued by their socialist and inefficient National Health Service waiting lists (people diagnosed with cancer or degenerative heart disease can wait for an operation for a year or even more) and Americans who didn't keep up their health insurance after retiring -- or never had any -- are now choosing their hospitals and surgeons on the internet and booking their flights to India. And to make it even easier, there are medical tourism companies in India who will take care of all these details for them.

Now, some enterprising hospitals offer greet-and-treat services with an all-inclusive health-tourist package, including the desired medical procedure, hotel, air travel, bookings and admissions to popular tourist attractions. And India has the overwhelming advantage being Anglophone.

A full cycle of IVF treatment followed by a bracing vacation amid the majesty of the Himalayas! Or get your mouth completely redesigned, your teeth recapped by a dentist employing the latest technology and pop over to the exotic pink city of Jaipur in Rajasthan to practice your new smile … all at a fraction of the cost of the medical procedure alone in the West.

If you need more serious treatment, you can have your kidney transplant or spinal surgery in a hospital that is as hygienic and well-equipped as most hospitals in the West -- and a good deal better than some. Hip replacement recuperation may not include a hike to the base camp of Mount Anapurna, but you'll be well attended by skillful and qualified people and you'll return home with the same results you would have achieved in the West for around a quarter of the cost - or sometimes much less.

Access to open heart surgery in India is immediate, and it will cost, without complications, around $10,000 - against around $50,000 in America or privately in Britain. A biopsy for a brain tumor will cost around $1,000 and surgery around $6,000. Hip replacements using the newest techniques cost in the neighborhood of $6,500, with no waiting lists. There are hospitals specializing in nothing but spinal and joint surgery.

Most British and Americans are accustomed, anyway, to being treated by expatriate Indian doctors.

The implications are mind-boggling. Already, it is being suggested in Britain that the National Health Service send patients to India for cataract and hip-replacement surgeries. Again, it is possible that once this catches on, which is happening at the speed of light, insurance giants in the West will soon funnel patients to India for, say, bypass operations or organ transplants. A sign of both quality and acceptance is the fact that already, Blue Cross and Blue Shield will insure patients treated at some groups of Indian hospitals. The British health insurer BUPA also insures treatment at the same chain.

More here


Two foreign doctors are working in the North-West Queensland town of Mt Isa without proper qualifications or supervision, the state Opposition says. One of the doctors at Mt Isa Hospital had been working as a consultant obstetrician and gynecologist without approved specialist qualifications, and was performing surgery without appropriate supervision, Nationals leader Lawrence Springborg said Medical and nursing staff have also questioned the competence of another overseas-trained doctor working at the hospital, Mr Springborg said. "We have been concerned to learn of these matters in the last 24 hours," he said. "The matter was raised by a senior physician, who was concerned about it.

The Opposition also believes overseas-trained doctors are fleeing the state because of the Medical Board's recent audit of their qualifications and the Beattie Government's commission of inquiry stemming from the scandal over the so-called 'Dr Death'. The inquiry headed by Tony Morris, QC, is investigating the appointment of Indian-trained Jayant Patel, who has been linked with more than 20 deaths at the Bundaberg Base Hospital.

Health Minister Gordon Nuttall said the Opposition should immediately refer the Mt Isa allegations to the Medical Board and the Morris inquiry for investigation. While he was not aware of a mass exodus of overseas-trained doctors from the state, Mr Nuttall said he could understand why some might choose to leave. "The net has been cast and all overseas trained doctors, unfortunately, in my view, are under some cloud of suspicion," he said.

Premier Peter Beattie hit back at the Opposition, saying it was partly responsible for the loss of any foreign doctors from the state's health system. "If they stopped trying to malign the health system and stopped trying to be negative on every occasion, then that won't happen," Mr Beattie said. "If any foreign doctor leaves the system here, it's partly because the opposition seeks to denigrate them at every opportunity with their incessant criticism."

There are about 1670 overseas-trained doctors working in Queensland, mostly in rural and regional areas. The Government has said they are a crucial part of the health system



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Friday, May 13, 2005


Even a flimsy case is stressful

In June 2000, I received a request for Millie's records from a local attorney. I quickly contacted my insurance carrier, and with their approval I sent the records. I didn't hear anything further until March 2002, when I received a "notice of intent" to file a claim. It identified Millie, Harry, and their daughter as plaintiffs. The suit was filed that September, just before the statute of limitations ran out.

It accused me of negligence for failing to properly diagnose Millie's cancer; for not consulting with her other treating physicians; and for enrolling her in a hospice program when her condition wasn't terminal. The plaintiff's expert, a board-certified FP from West Virginia, attested to my alleged negligence. The suit claimed damages for medical expenses; physical and emotional pain and suffering; mental shock, fright, and anguish; humiliation, mortification, and embarrassment. In addition, Harry claimed damages for his loss of Millie's consortium.

Needless to say, I was stunned. Not only that Millie was suing me (I was sure that Harry was really the driving force behind the suit); but also that a local attorney would actually pursue such a weak case. I quickly informed my carrier of the suit, and they assigned an attorney to defend me. After reviewing the records, he announced that my case was definitely worth defending. That pleased me greatly, since I didn't feel like settling. Our experts then reviewed the records and declared this a nuisance suit without merit. Nevertheless, I was told to prepare for a lengthy process, and to plan on adjusting my schedule to accommodate the necessary depositions and hearings.

We scheduled a deposition with Millie and Harry, and my attorney urged me to attend it. Shortly before that date, during a visit to the hospital, I noticed Millie's name on the inpatient list. The following week, my attorney called to tell me the scheduled deposition had been cancelled because of Millie's illness. Soon afterward, she died, at age 75. Millie's death made it difficult for Harry to pursue the case, since their chief complaint had been that she hadn't died. His attorney eventually contacted our attorney and offered to drop the case, which he did, and it was dismissed.

I still have bitter feelings toward that attorney, though. I wonder if he appreciates or cares how such a nuisance suit can disrupt a doctor's life, and cause him significant "pain and suffering." Since this is a small town, I'm sure I'll run into him at some point, and perhaps I'll address the matter directly with him. For me, this case was an exceedingly stressful and time-consuming experience. I'm still upset that despite having helped Millie through her difficulties, and thereby extending her life, I was wrongly accused of negligence. Ironically, if she had passed away sooner, I probably wouldn't have been sued.

More here


Sexual abuse complaint in 1996 and still nothing done. Only the innocent were punished

An inquiry by the Health Rights Commission into serious clinical and systemic complaints at a public mental health unit headed by a struck-off senior psychiatrist took 4½ years and did not result in a final report. The commission's head, David Kerslake, yesterday conceded that the significant inquiry – which began after the referral of a complaint in January 1996 and culminated in a letter in July, 2000, to the Cairns District Health service – "took too long". "From the view of any of the parties involved, I would have expected it to be done more quickly," he said. "We have reviewed our processes since and they do not take that long now. It does not automatically follow when looking into a major complaint that you do a report at the end of it."

The investigations involving the integrated mental health unit and its then head, Keith Muir, began three years after he was struck off in New Jersey for having sex with two vulnerable patients and one year after he had been struck off, in 1995, in New York State. But Mr Kerslake defended the failure of investigators to detect Dr Muir's past, which would have prevented him becoming the most senior public hospital psychiatrist in far north Queensland had it been known. He said his investigators could not be expected to inquire outside their scope or to duplicate the work of the Medical Board of Queensland, which is meant to vet and register doctors from Australia and overseas.

The complaints by psychiatrist Annette Johanssen to the commission a decade ago included her assertions that Dr Muir had engaged in sexual misconduct himself by touching her thigh and the thigh of another woman staffer. The commission is not empowered to act on sexual matters between staff, but a separate Queensland Health investigation, which also failed to detect Dr Muir's past, exonerated him but found against Dr Johanssen. Mental health professionals said she left soon afterwards, largely because she had blown the whistle and subsequently been singled out and punished.

Dr Muir, who was appointed director of psychiatry at Cairns Hospital on July 21, 1992, and transferred in 2003 to Nambour Hospital, has vigorously defended himself against the serious findings and claims made against him.

Mr Kerslake said that at no time in the investigation were there "complaints about sexual misconduct involving patients at Cairns Base Hospital – and if there were, they would have been referred to the medical board". "We conducted a major investigation into clinical and systemic issues," he said. Responding to Queensland Health's statement that the investigation "did not complete", Mr Kerslake said: "We clearly wrote to the hospital and we clearly confirmed that certain changes have been made and we closed off the complaint."

More here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.