Friday, March 31, 2006


What kind of world is it where a fifth of adults expect to continue working long after retirement and the most popular towns are rated by the length of their waiting lists for hip operations? This is not some make-believe, Alice-in-Wonderland world, but Britain in 2006, as experienced by pensioners and revealed by two new surveys. Coming after a report from three NHS watchdogs that concluded that older people were subjected to entrenched ageism and to "patronising and thoughtless" attitudes, the latest research raises the uncomfortable question: is this really all there is?

Ten per cent of retired people work part-time for an average of 14 hours per week to supplement their income. But with an estimated pensions gap of 57 billion pounds, this figure is set to increase dramatically, according to a survey of 500 people, both working and retired, by insurer GE Life. Almost one in five people believe that they will need to continue working part-time once they retire - double the number of those currently retired. With the average pension fund producing an income of just 4,381 pounds a year, many retired people admit that they could have planned better. A third said that they were financially unprepared, while a similar proportion were unsure how they would survive the rest of their retirement. More than half of people nearing retirement said they wished that they had started saving earlier.

It is not all doom and gloom, though, at least not if your idea of fun is a gentle promenade along a pier and easy access to affordable car parking. Southend-on-Sea in Essex is the best place to retire, according to a separate study by Yours magazine. The title, aimed at the over 50s, ranked 60 retirement destinations in Britain, taking into account factors such as house prices, council tax, shopping facilities, crime rates, hospital waiting times, the availability of NHS dentists and the weather. Southend was ranked top because it is relatively flat with a pedestrianised centre, its council tax is almost 100 pounds lower than the average, and it has a low rate of crime. It is also has seven miles of beaches, the world's longest pier, and more than 80 parks and open spaces.

Poole in Dorset came second, thanks to its natural harbour, good shops, farmers' market and affordable parking. The waiting time for a hip replacement in the town is also only 84 days, compared with a national average of 128 days. Whitehaven in Cumbria was third, with below average waiting times for a hip replacement and house prices nearly half the national average


Call to shut hopelessly bureaucratized childrens' hospitals in Queensland, Australia

The Beattie Government is again under fire over its management of the Queensland public hospital system after a damning report called for the closure of two major children's hospitals. A medical panel commissioned by Queensland Health to review pediatric cardiac services has recommended replacing Brisbane's Mater Children's Hospital and the Royal Children's Hospital with a single new hospital. The panel also proposed pediatric services at the Prince Charles Hospital, on Brisbane's north side, be shut down.

Following a series of post-surgery and cardiac deaths, the report found the hospitals were plagued by chronic understaffing, dysfunctional governance and low morale. Its findings were revealed as Premier Peter Beattie ruled out means-testing patients or increasing co-payments for public hospitals, based on the findings of a separate report that explored other possible revenue streams for a system reeling after the "Dr Death" scandal.

Health Minister Stephen Robertson said he would have to consult more widely before shutting any children's hospitals. Admitting he was surprised by the report's findings, Mr Robertson said a single stand-alone hospital could cost the Government about $500 million. The Government yesterday established a taskforce to assess the report's proposals. "This is a big recommendation with big implications for the three hospitals involved and for the public health system's staffing, capital and budget," Mr Robertson said. A proposal to build a single children's hospital in Brisbane was raised under the Goss Labor government in 1994 but rejected.

The latest report found it was "simply impossible" to adequately staff the three existing pediatric units. "It is abundantly clear that systems and arrangements, which had been satisfactory in the past, are no longer able to meet current expectations and standards," the report says. "The service is characterised by chronic understaffing, dysfunctional governance, lack of infrastructure, lack of clinical leadership and unsympathetic line managers regarding specific pediatric needs. "With few exceptions, morale is poor, ranging through frustration and anger to cynicism, hopelessness and despair." The report found no evidence of professional incompetence or negligence among the clinicians.

Opposition Leader Lawrence Springborg said the report was an "a solid vote of no confidence in administration of health in Queensland". "If it wasn't bad enough before now, it's the kids that are suffering under this Government," he said.

Despite the hospital woes, the Government will forgo about $115 million in additional revenue for the health system after an analysis by the Allen Consulting Group found there would be inadequate financial gains from means-testing or increasing patient co-payments. But Mr Robertson refused to rule out the possibility of raising extra revenue by increasing co-payments from people receiving injury compensations payouts.

Mr Springborg said: "Victims who have taken themselves through the court process and have got compensation payments may be subjected to the Government recovering against them."



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 30, 2006


"Prevention is better than cure" must be too hard an idea for socialists

Public health is facing severe staff shortages as fewer doctors enter the specialty. Despite ambitious targets set in a White Paper in 2004, the number of public health specialists is falling. A survey by the Faculty of Public Health published today finds that there are 22 per cent fewer consultants in public health than there were in 2003.

In some areas there is little confidence that there are enough do the job. In England only 36 per cent of primary care trusts (PCTs) believe that they have sufficient capacity to deliver public health effectively - and in the East Midlands, the worst-affected area, the figure falls to only 21 per cent. Northern Ireland, Scotland and Wales are less seriously affected but over the country as a whole only 45 per cent of respondents said their team had adequate or more than adequate capability. The numbers entering the specialty are also falling, with planned recruitment for this year running 40 per cent lower than last year.

In addition, the latest restructuring of the NHS, which envisages merging PCTs and strategic health authorities, could result in the loss of up to 150 more senior positions. Professor Selena Gray, who wrote the report, said: "It demonstrates the urgent need for clear human resources guidance that protects consultants in public health during this next re-organisation and for increased resources for training."

Chris Lovitt, chairman of the Faculty of Public Health's trainee members' committee, says: "The planned massive cuts in recruitment numbers must be reversed if the future of public health is to be secured."

Public health's aim is to improve the health of the whole population by education, monitoring disease, reducing inequalities and controlling hazards, and it has been a neglected area since the Department of Health focused all its efforts on the NHS.

Justin Varney, of the British Medical Association's public health committee, said: "It is recklessly shortsighted to squeeze public health training - the very specialty that must expand to tackle the health gap between the best and worst off. In any outbreak of infectious disease or emergency, public health doctors play a key role."

Babies born in some parts of England are eight times more likely to die before their first birthday than those in other areas, according to the baby charity Bliss. The infant mortality rate in central Birmingham is 12.4 per 1,000 live births, against 1.5 in East Elmbridge and Mid-Surrey. Bliss says that the figures, taken from every primary care trust in England, show that babies in large cities in the North West and Midlands fare worst and suburban areas in the South East do best. The national average for deaths in the first year of life is 5.2 per 1,000.


Patients vs. Paternalism

Sad truth: If a drug has no side effects it will probably have no main effects either

Decisions about drug safety and efficacy are far from easy. Tysabri, a multiple sclerosis (MS) drug that was voluntarily withdrawn from the market last year after the appearance of a previously unknown side effect, illustrates some of the conundrums that exist in drug treatment. In advance of the publication of three critical new studies on Tysabri in the current issue of the New England Journal of Medicine, a major news organization recently asked me, as a physician and former FDA official, whether I knew of examples of prescription drugs that have "efficacy but [also] serious safety issues." That is the rule rather than the exception, I responded.

Obvious examples include the antimetabolites used for traditional chemotherapy. Because these drugs are no more than poisons administered in a way intended to be more toxic to cancer cells than normal ones, it is not surprising that their side effects are often serious and even life-threatening. When I was a medical resident three decades ago, hospital gallows humor included referring to BCNU, an experimental cancer drug, as "Be seein' you." (Approved in 1977, it is still widely used.)

A more recent example is aldesleukin (also known as interleukin-2, or IL-2), a drug that has offered new hope to victims of kidney cancer and malignant melanoma. It is highly effective in a small proportion of patients but exhibits significant toxicity. The patient information booklet warns that those taking the drug "frequently experience serious, life-threatening, or fatal adverse events," including dangerously low blood pressure and reduced organ perfusion, impaired function of infection-fighting white blood cells, disseminated infection, and autoimmune disease.

Antibiotics are another class of wonder drugs that sometimes manifests significant toxicity. Chloramphenicol, a drug that is effective against a wide spectrum of bacterial infections, causes rare cases of fatal aplastic anemia, so it used only sparingly. The potent antibiotic gentamicin is often life-saving but can cause damage to the kidneys, nerves and ears. And significant numbers of patients are allergic to other important antibiotics, including the penicillins and cephalosporins.

But let us return to Tysabri, only the sixth medication approved - and the first in several years - for the treatment of MS, a common and debilitating autoimmune disease that affects the central nervous system. Following impressive results of the drug's testing in clinical trials - the frequency of clinical relapses reduced by more than half - the FDA granted accelerated approval in 2004.

However, by that time several thousand patients were being treated with Tysabri, three had contracted Progressive Multifocal Leukoencephalopathy (PML), a rare neurological disorder caused by a virus. (Because the drug suppresses certain components of the immune response regulators, clinicians and the product's developers had from the beginning been sensitive to the possibility of infections as a side effect.) Precipitously (some would say prematurely) the manufacturers of the drug voluntarily halted production and distribution and withdrew Tysabri from the market. MS patients and many neurologists were bitterly disappointed.

The three clinical studies reported in the New England Journal of Medicine bolster our confidence about both the safety and efficacy of Tysabri. In a study of almost a thousand patients that compared Tysabri to placebo, the drug cut the rate of clinical relapses by 68 percent (from 0.75 to 0.24), reduced by 83 percent the number of new or expanding brain lesions found on MRI, and slowed the clinical progression of disease. (The other currently used drugs for MS lower the occurrence of acute relapses by roughly one third.) Similar results were obtained in a second trial which compared two-drug therapy with Tysabri plus interferon beta-1a to the interferon alone.

Finally, a third study found no additional cases of PML in more than 3,000 patients (exposed to an average of 17.9 monthly doses) who had participated in clinical trials of Tysabri. The investigators concluded that the incidence of this serious side effect is approximately one in a thousand patients treated with the drug. However, it should be noted that all three of the original cases of PML occurred in patients treated with interferon beta or other immunosuppressive agents as well as Tysabri, so the risk might be significantly lower in patients treated with Tysabri alone. Many neurologists who are familiar with Tysabri in MS believe this will prove to be the case.

The "safety" of a drug is a relative thing. Safety and efficacy, the two criteria required for marketing approval of a drug, are inextricably linked. The judgments of regulators (and practicing physicians) require a global and often difficult calculation of risk and benefits, including consideration of what alternative therapies are available. We are willing to tolerate greater uncertainty and more severe side effects for a potential cure for pancreatic cancer or AIDS, for example, than for a new drug that treats heartburn. When FDA grants marketing approval, the drug is deemed to be sufficiently safe and effective to be used for the conditions on the label.

In light of previous studies and the new data published in the New England Journal of Medicine - to which the FDA should have had access months ago - the publicly available evidence certainly supports returning the drug to market, presumably with revised labeling, as quickly as possible. If that happens, physicians and patients will need to decide whether for a given individual the risk of the drug is acceptable in view of the possible benefits.

Even in view of the just-published data, one eminent neurologist who has long and extensive experience with Tysabri remains cautious: "I myself would only use the drug in patients who are 'train wrecks,'" by which he meant patients who were severely symptomatic. He feels that it is only they who "can assume a 1/1000 risk of a fatal complication and for whom such a risk is reasonable. I know many in this category with MS, because of the nature of my practice. But I would not treat that hypothetical 20-year-[old] sophomore on campus with early MS."

I have far less clinical experience than he, but given that Tysabri reduces the number of new or expanding brain lesions as measured by MRI, and that it slows the progression of the disease, it may be that some of the hypothetical 20-year-old college sophomores with MS might opt to take the drug if it makes it possible for them to live more normal lives.

When an FDA advisory committee convenes this week to make recommendations about Tysabri's fate, its members will likely confront a mishmash of testimony from patients, physicians and other experts, perhaps including even some mischief on the part of companies with competing products. As I learned during my own extensive service on advisory committees, there is astonishing variability in an individual's - even an expert individual's - interpretation of the data.

The FDA has the final say. Although society has designated the FDA as a gatekeeper between drug companies and the marketplace, the agency must beware of excessive paternalism and strive to preserve the right of patients, in consultation with their physicians, to make informed individual decisions about the available therapeutic options. Inevitably, different people will have very different comfort levels about risks and benefits.

If our society permits citizens to make risk-benefit decisions about whether or not to have elective surgical facelifts and stomach-stapling operations for weight control. Whether to buy the penis-expanders and weight-loss snake oil nostrums that are intensively advertised on TV, and whether to invest in certificates of deposit, equities or junk bonds. How can we prohibit patients from making life-and-death medical decisions about drugs that have been shown to be effective?

The notion that FDA should "err on the side of safety" sounds like a tautology, but it is an affront to patients with incurable or poorly treatable diseases: for them, there is no safety in the status quo
, and we only damage them further with paternalistic public policy that prevents individuals from exercising their own judgment. If FDA must err, it should be on the side of patients' freedom to choose.



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 29, 2006


Hospital consultants are spurning the National Health Service by paying for medical insurance so they can be treated privately if they become ill. A survey of 500 consultants, commissioned by Bupa, the health insurer, found that 41% of senior hospital doctors have invested in private health cover. Doctors are among the 10 occupations most likely to take out personal medical insurance, according to Bupa. More than 90% of the consultants surveyed have posts within the NHS. All of those surveyed also worked in private hospitals.

Dr Sarah Burnett, a consultant radiologist in London who worked in the NHS for 15 years, said she took out private medical insurance while she was employed in the state service because she was unimpressed with the level of care she witnessed first hand. "NHS treatment is not a pleasant experience in any way - from the standard of the food, to ward cleanliness and the chance of catching MRSA," she said. Last year Burnett was diagnosed with breast cancer, detected during a private medical screening. Within two hours of her annual check she underwent an ultrasound examination that showed multiple small tumours. An hour after that Burnett was seen by a surgeon who arranged a skin-sparing mastectomy. A few days later she was recovering from surgery. "I was lucky enough to have exceptionally prompt treatment because I choose to pay for insurance. Under the NHS I would not have been screened until 50 for breast cancer and would not have been able to catch my cancer at such an early stage," said Burnett. "The type of surgery I had is only rarely available on the NHS, depending on the expertise of your local surgeon."

The British Medical Association (BMA) argues that the consultants' wish to take out private medical cover does not demonstrate a lack of commitment to the NHS. They want speedy treatment so they can get back to looking after their NHS patients as soon as possible. Dr Jonathan Fielden, the deputy chairman of the BMA's consultants' committee, said: "Consultants may also like the anonymity of private care. One of the problems of being treated in the NHS is that consultants might find they are in a bed next to one of their patients."



Elderly people are being neglected and poorly treated by England's health system, inspectors say. The joint report by three public sector watchdogs said the NHS and care services treated older people with a lack of dignity and respect. The Audit Commission, Healthcare Commission and Commission for Social Care Inspection said it was being made worse by a lack of consultation. Campaigners said elderly people had become second-class citizens.

The report, which assesses the government's progress half-way through its 10-year plan to improve services for the over 50s, found while some services had improved, progress had been patchy and slow in other areas. David Behan, chief inspector of the Commission for Social Care Inspection, said: "The evidence from this study is that older people are not involved in the design of services and, consequently, services are not tailored to their needs and aspirations. "It is vital to understand and respond to the specific needs of older people." And Anna Walker, chief executive of the Healthcare Commission, said: "Older people are the biggest users of healthcare, occupying almost two thirds of our hospital beds, yet they continue to be a low priority in both the planning and development of our health service."

None of the 10 communities across England, whose public services were scrutinised, had reached all the government-set milestones to enable them to meet the standards in the national service framework. Two areas of concern were the planning of public transport and the low priority given to foot care services.

One of the worst areas, the report found, was mental health care, where older people found services deteriorating as they passed the age of 65. The vast majority of older people surveyed said they had not been asked their views on the NHS or council services in the last year, and 80% did not think they had influenced the planning of services. The report did find that steps had been taken to address age discrimination in public services and more people were being supported to allow them to live at home.

Gordon Lishman, director-general of Age Concern England, said it was "shocking" that so many social services departments were still failing to meet the needs of older people - the main users of these services. He said: "Sadly, too many older people in need of public services are currently treated as second-class citizens." Liberal Democrat health spokesman Steve Webb said: "The needs of older people are not a priority for this government."

But Care Services Minister Liam Byrne insisted that older people's access to care had been "completely transformed" although neglect was still "too big a part of the story". He said plans would be unveiled next month to improve the situation. And Professor Ian Philp, national director for older people's health, added measures had also been taken to tackle discrimination, but there was more work to do to reverse the lack of respect shown to the elderly.



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 28, 2006

Warning ignored: Babies die

The state government was warned a decade ago that the lives of hole-in-the-heart babies were being endangered by inadequate services at Brisbane's The Prince Charles Hospital. The warning came in a secret report by Booz-Allen Hamilton recommending pediatric cardiology services be removed from Prince Charles to a new "dedicated pediatric institution".

The report's discovery is a blow to the credibility of the troubled state health department which has been accused of hiding problems with pediatric cardiology at Prince Charles. The Booz-Allen Hamilton report, which was withheld from the media, outlines many of the same flaws which are still the subject of controversy today. It warned: "The separation of pediatric cardiac services away from all other pediatric health services . . . results in compromised quality of care for the individual child." It found the "poor integration of multiple specialist services that any one child may require" resulted in "poor communication and potentially compromised care". And it warned the stability of critically ill children was compromised because they had to be ferried between one hospital and another for different specialist treatments.

A new probe was launched recently when doctors at Prince Charles warned fragmented services imperilled critically ill children with heart disease. Head of the hospital's pediatric cardiology unit Dr Nick Haas left for overseas last week after resigning as director. The new investigation team led by three professors of medicine was handed a copy of the Booz-Allen Hamilton report. Despite pledges of transparency and accountability the team's new report remains under wraps. The Booz-Allen Hamilton report recommended that Prince Charles pediatric cardiology services be integrated into a new unit at Royal Children's Hospital.


New Drug Demagoguery

"New Drugs Hit the Market, but Promised Trials Go Undone" and "FDA: Drug Companies Drop Ball on Studies," the headlines blared. Are Americans getting untested drugs? Are drug developers taking short-cuts, or worse? Are regulators incompetent, or impotent? None of the above-although it's hard to tell that from the press coverage.

As a condition of marketing approval of a new drug, the FDA often requires the manufacturer to perform additional studies to confirm efficacy or to look for previously undetected side effects. But according to a recent FDA report, which spurred the headlines, as of the end of last September, of the 1,231 "open post-marketing commitments" to perform clinical studies, only 14 percent had been duly reported to FDA, 65 percent were "pending" (that is, had not yet started), 19 percent were considered "ongoing," and two percent were "delayed."

However, the government's evaluation and approval of new drugs is an exceedingly complex and arcane business, and these statistics can easily be misunderstood or misrepresented.

American pharmaceuticals are the most intensively tested products in history. Moving a drug through laboratory studies and then animal and human testing requires on average 12-15 years and more than $800 million in direct and indirect costs. By the time a drug company applies to the FDA for marketing approval of a new product, on average it has performed more than 70 clinical studies on at least 4,000 patients.

Even after exhaustive clinical testing, questions may remain, particularly if efficacy has been judged by improvement in a "surrogate" endpoint, such as high blood pressure as a marker for heart disease, or shrinkage of a tumor as a stand-in for actual prolonged survival.

These kinds of criteria for measuring efficacy are both common-sensical and based on a scientific rationale-and most often they do correlate with more definitive measures of benefit. Sometimes they're essential to efficient drug testing. I'm reminded of a cartoon in which two pharmaceutical scientists are contemplating a beaker that contains a new medicine. One says to the other, "It looks as though this drug will confer immortality. The trouble is, it will take forever to test it."

The FDA can require manufacturers to perform certain post-marketing follow-up studies, and according to the regulations, "once a post-marketing study commitment has been made, an applicant must report on the progress of the commitment . . . until the post-marketing study commitment is completed or terminated, and FDA determines that the post-marketing study commitment has been fulfilled or that the post-marketing study commitment is either no longer feasible or would no longer provide useful information."

That seems straightforward enough, but in practice widespread prescribing and use of a drug following FDA approval often make the mandated post-marketing studies moot. In other words, the availability of large amounts of data obtained from usage under real-world conditions-sometimes from hundreds of thousands of patients within months of approval-makes additional data from small clinical trials superfluous. In spite of that, the FDA seldom follows through to determine "that the post-marketing study commitment is either no longer feasible or would no longer provide useful information." Hence, the preponderance of post-marketing studies that are "delayed" or "pending."

Another related factor is that in recent years FDA regulators have tended to over-use the requirement for post-marketing studies-mandating them not because they're essential, but merely as a way to inoculate themselves against criticism for too-rapid approvals.

The nuances of this phenomenon have eluded some who should know better. Congressman Maurice D. Hinchey (D-New York) claims mistakenly that the FDA's demands for demonstrations of safety "continue to be blatantly ignored by the pharmaceutical industry," so he and Senators Charles Grassley (R-Iowa) and Christopher Dodd (D-Conn.) have introduced legislation that would give the FDA added authority to require drug companies to carry out post-marketing studies.

Wrong diagnosis, wrong remedy. Instead of bean-counting and indulging in demagoguery, we should be trying to ascertain what fraction of mandated post-approval studies is really necessary, and FDA should clean up its backlog of superfluous post-marketing studies.



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 27, 2006

A total health care monopoly

When a single corporation maintains a 100% market share in its industry, most of us would consider it a monopoly, free of competition and thus detrimental to economic progress, innovation, and human needs. In California, State Senator Sheila Kuehl proposes such a system. The Democratic lawmaker seeks to force all the state's health care sector under the authority of the state government. Doctors' fees and pharmaceutical prices would be set by the state. Health care would be rationed. Private insurance would be illegal. Kuehl's plan, SB840, also known as the California Health Insurance Reliability Act, would be financed by a new 12% payroll tax imposed on workers and their employers.

Proponents of socialized medicine believe that government-controlled health care will cut costs and make medicine more available. But if it would indeed run more smoothly and inexpensively, why is it necessary to forbid-by threat of fines and imprisonment-private insurance? Kuehl and her supporters might realize that the market would provide something that the state-rationed health care system won't. Why else seek to use the violence of the state to crush market competition?

When top executives collude in smoky rooms to set prices, to strong-arm their competitors, to ration their services in concert, it is considered monopolistic. If the government is among the corrupt players in that same smoky room, offering the force and color of law to the collaboration, it is considered "single-payer health care."

Indeed, government is the greatest monopoly of all, the protector of all others. It gives favored companies special benefits and punishes less politically connected firms. It uses regulation to stifle small businesses and innovation and entrenches economic power in the hands of the few.

The most prominent private interests don't go away-they are only further absorbed into the protectionist system. It was Ted Kennedy's HMO Act in 1973 that empowered HMOs, by forcing employers who offered health insurance to their workers to include HMOs as an option. It is the Food and Drug Administration that protects Big Pharma from competition by erecting formidable barriers to entry-a small company cannot afford the hundreds of millions of dollars in bureaucratic expenses to bring a new, potentially life-saving drug to the market. It is no surprise, then, that such regulatory bodies are typically headed by former and future CEOs of the industry that they are legally empowered to police.

The most recent example is President Bush's gargantuan Medicare prescription drug benefit-at once the largest expansion of the welfare state and one of the biggest giveaways to Big Business in recent decades.

A steady move toward corporate socialism has propelled the exorbitant rise of medical costs in America. The proposed solution, even more consolidation of money and power in the hands of the politically connected, cannot solve the problem.

Small businesses, doctors who wish only to help their fellow humans, patients, and alternative medicine practitioners will suffer. Countries with socialized medicine are learning all this the hard way: surgeries are doled out according to crude predictions of how much patients will pay in taxes before they die, patients must wait two years for a routine hip replacement, and desperate refugees flee to buy in foreign nations what is prohibited in their own country. The answer is to deregulate, desocialize, decorporatize health care, to allow consumers to make their own decisions, to strip away the privileged status that the health care establishment enjoys from discriminatory licensing laws and regulatory agencies.

Fifty years ago, America had the best health care system in the world, until the federal government moved in, pushing out the free, voluntary health clinics that had graced nearly every city and major town in the country. Today's politicians recognize the problem that they've created, and yet instead of walking away and allowing the market to achieve the same magic as it does in the other relatively unregulated industries-such as computers, electronics, grocery stores, and the various wonders of the modern economy-they propose more centralized regimentation. Only a free market can liberate the people to serve one another's needs, through the market and charity.

Monopoly is inefficient and inhumane, as liberals recognized throughout the 19th century as they battled against the Big Business-Big Government partnerships in railroads and industry. Nowadays, monopoly is considered the salvation of the common man. Just because ideas change doesn't mean economic laws do. Socialism and monopoly create inefficiency, rationing, shortages, and higher costs. We must reject the total monopoly in California's medicine that Kuehl wishes to impose upon us-for the sake of our health.


The case against mandatory coverage

Writing in the Washington Post on January 18, business columnist Steven Pearlstein argued, "the president must acknowledge that there can be no credible reform without extending health insurance for every American--every employer should be required to pay half the cost of basic health insurance for every employee." The same week, Humana co-founder and retired CEO David Jones told a Naples, Florida audience that government should mandate health coverage because the uninsured "are simply taking a free ride."

Like many other conservatives and Republicans, they call for mandating that every individual have at least "catastrophic" insurance coverage. I know a lot of physicians and insurance brokers who support this policy, and Republican governors in at least Massachusetts and Minnesota have proposed similar ideas. Here's a quick check list of a dozen reasons why mandatory coverage isn't worth the effort:

1. "Free riders" are not really much of a problem. In a June 2003 report for Health Affairs, Jack Hadley and John Holahan reported about 3.5 percent of total health care costs are for uncompensated care. That is a trivial amount of money, far less than most stores lose to shoplifters.

2. Granted that some facilities are hit harder than others, I would venture these tend to be in areas where there are large numbers of illegal immigrants. Mandatory coverage will do absolutely nothing to solve that problem.

3. Health insurance mandates are often compared to mandatory auto insurance coverage, but the comparison falls short for several reasons. Auto mandates don't work very well and certainly don't solve the problem of uninsured motorists. And with an auto mandate you are required to insure against what your two-ton vehicle will do to other people, not to get your own car repaired.

4. In order to have a mandate, we would have to have substantial subsidies and assurances of access (you can't force people to buy what they can't afford or can't find). But once you have those provisions, you probably don't need the mandate. Very few people will absolutely refuse to carry an insurance card no matter what.

5. In order to have a mandate, the government has to decide what it is that is being mandated. Even with "catastrophic" coverage, someone has to decide what expenses go towards meeting the deductible--chiropractors? abortions? sex-change operations? herbal therapy? and on and on and on. Imagine the debates in Congress.

6. Once you've decided what to mandate, you must ensure such coverage will be available to everybody. What happens if no company wants to offer it in Montana? What if a company does offer it in Montana, but provides lousy service? Consumers will have no choice but to buy it, no matter how poor the service.

7. Once you force people to buy a product, you have to make sure the providers of that product aren't ripping them off. That means federal control over premiums. That means federal scrutiny of carrier efficiency. That means examination of administrative expenses to make sure they are "reasonable."

8. As far as I know, nobody has ever looked at the macroeconomic consequences of this idea. Having a mandate means every single individual must be insured (and pay premiums) at all times, regardless of their circumstances. I will be a witness that if I had had to do that in the early 1990s, I would never have been able to leave Blue Cross to start four different businesses, three of which are still in operation and employing 45 people in Northern Virginia. In every case, I had to tighten my belt in a whole lot of ways to get these ventures launched. Going uninsured for a while was just one of them.

9. There are much better ways to address the problem. I would note, for instance, that there were far fewer uninsured 20 years ago, before the states went crazy with mandates and small group "reforms" that dried up the market for coverage and raised costs dramatically.

10. Equalizing the tax treatment for people who buy their own coverage would also help a great deal. That way people wouldn't have to rely on their employer in deciding whether to get coverage.

11. Encouraging innovation in insurance offerings would help, too. We have already seen that HSAs are changing people's minds about the value of coverage. There may also be other approaches that would appeal to other segments of the market. Part of the reason people don't buy coverage is because they don't see much value in what is available. We need to reduce the barriers to entry, to make it easier for new approaches to be tried.

12. I know many physicians (and others) support a mandate (the California Medical Association is on record doing so), but they haven't really thought it through. If carriers are scrutinized as described above, it won't be long until physicians get the same treatment. If people are forced to buy a product and companies are forced to sell it at "reasonable" rates, it isn't much of a leap to start looking at the inputs that drive those rates. Could it be that doctors are price-gouging their patients? My goodness, we can't have that! And it's off to the races.

Mandatory coverage is an idea that won't solve the problems but will create a whole host of new problems and have serious negative consequences throughout the economy.



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 26, 2006


All those bureaucratic salaries have to be paid first

Patients with multiple sclerosis are being told that they cannot have drugs to prevent their disease from getting worse because the NHS cannot afford them.

Ministers have insisted that staff layoffs and hospital deficits have had no effect on patient care. But this is untrue, according to Mike Boggild, consultant neurologist at the Walton Centre in Liverpool. He says that he knows of 50-100 MS patients who have been told they cannot have the drugs, even though under an agreement reached in 2002 ministers promised that they would be provided to all those who qualified.

The MS Society said that some patients had been told they would have to wait a year before being prescribed a drug, while others had had their assessments delayed so they were not on a waiting list. Tom Elkins, of the MS Society, said the problems were greatest in Staffordshire, Sheffield and Wales. He added: "These drugs can prevent disability and there are very clearly defined eligibility criteria. But people are being told they can't have them because the NHS hasn't the money to pay for them. We're back to a postcode lottery. To get the most benefit, patients need these drugs as soon as their illness is diagnosed, not a year later."

Dr Boggild is co-leader of the risk-sharing scheme under which the drugs are provided. This was set up in 2002 after the National Institute for Health and Clinical Excellence ruled that the drugs were not cost-effective. The manufacturers share the risk of providing the drugs. If the drugs do not do what they promise, the NHS pays less for them. Under the scheme, the drugs should be guaranteed for those who are eligible. But Dr Boggild says that many patients are being blocked. "It is nothing like as bad as before the risk-sharing agreement was reached, when thousands were being denied the drugs," he said. "But the promises made by ministers are being flouted in some places. No patient newly diagnosed with MS should be made to wait."

One of the worst areas was Staffordshire, where the University Hospital of North Staffordshire NHS Trust announced last week that it was shedding up to 1,000 jobs. The Department of Health said that the trust planned to reduce costs through improved efficiency, without cutting patient services.

Andrew Colgan, 37, from Newcastle-under-Lyme, is an MS sufferer who has been told that he cannot have the drugs but was assessed in November and told he was suitable. "I saw two MS nurses and two registrars, and they were all very apologetic," he said yesterday. "They said `you are suitable, but the Primary Care Trust has withdrawn funding, so we can't prescribe the drugs'. Maybe I'll get them next year." Mr Colgan qualified as a marine scientist and worked as a teacher but has had to give up work because of his condition. The cuts at North Staffs hospital have also affected him, as he was one of the patients treated there with intravenous steroids. "The ward that caters for this is one of the ones hit by the rendundancies," he said.

However, he is entitled to treatment and was promised it under the risk-sharing agreement. "Sometimes I think they are just waiting for the start of next financial year," he said. "Maybe I'll get it then." The Department of Health said: "We have been assured they are trying to get the drugs to new patients in Staffordshire as soon as they can."


2005: A bad year for health policy

The initial implementation problems of the Medicare drug benefit that went into effect January 1 are being spun by some as reflective of a structural flaw: the inclusion of free-market competition and choice. Plans offering the Medicare drug benefit have multiplied beyond all expectation--2,900 of them nationwide. Opponents argue there is too much choice, saying it is confusing seniors, angering them, and making it difficult for them to choose the "right" plan. Political columnist Harold Meyerson, for example, titled his op-ed piece on the topic, "Bewilder Thy Father and Mother" (Washington Post, November 30, 2005). Choice among many alternatives introduces complexity, says Meyerson, which is both bewildering and economically inefficient. The value of the European style "single payer" alternative, he claims, is its simplicity: It rescues us from complexity (and its resulting inefficiency); it's also said to be cheaper. This is a curious line of reasoning that we normally do not extend to other sectors of the economy. Monopoly is good for you, the argument assumes, as long as it's a government monopoly.

While most seniors clearly do find the unexpected range of choice in drug options confusing, it's worth clearing up a few misconceptions. First, the problem with the drug program is its structure as a weird benefit designed by Congress, with absolutely no analogue in the private market. It is also universal, which means it is crowding out all other coverage. The left is wrong to imply that the drug program, with its much-criticized "donut hole," or coverage gap, is somehow the product of a free-market approach to health care policy.

Second, the critics misunderstand the concept of choice. Real choice implies the personal option to keep what you have and what you like. It is the right to be free of coercion. The reality in this remarkable case is that almost half of the entire pool of eligible Medicare beneficiaries--those who are in employer-based retirement plans and those in Medicaid--will have no personal choice at all in their drug options. If employers decide they no longer wish to offer drug coverage and dump retirees into the government program, they can do that. Retirees have no say in the matter. Why? Because the employer-based system is not a consumer-based system: Employees and retirees get what their employer gives them, whether they like it or not. In this case, most retirees like their existing retirement coverage, but regardless of their wishes, they probably won't be able to keep it.

For persons eligible for Medicaid, their opinion about either Medicaid or the Medicare drug program doesn't make any difference: Congress says they are going into the Medicare drug program. Period.

The anxiety of millions of seniors is understandable. They never liked this legislation, they don't understand it, and the dynamics of a universal entitlement do not let them keep what they want or what they have. It crowds out existing coverage. The result is vast uncertainty among seniors and a political backlash against the White House and the congressional Republicans. None of this was necessary. It all could have been avoided with a targeted drug benefit for seniors who did not have coverage, especially those on low incomes. But the congressional Republican leadership aligned itself with Sen. Edward Kennedy's (D-MA) basic agenda and created a universal drug entitlement.

The carping will go on over the next few months, well into the next congressional election. But the left's agenda will be what it has always been: Impose price controls on drugs, fill up the notorious donut hole with even more federal subsidies, and tighten up the regulations on private plans to drive them out of the program once and for all.

The nation is now committed to plunging, eyes-open, arms up, and screaming, into the greatest entitlement expansion since the Great Society. The nation is committing to paying for trillions of dollars in drug benefits and trillions more that have been promised in total Medicare benefits, which nobody on Capitol Hill or elsewhere has yet figured out how to pay for. Economists at The Heritage Foundation estimate that if we decide to actually make up the $30 trillion Medicare shortfall (that's the size of the long-term unfunded liability of the program) through tax increases, that would amount to an equivalent Medicare payroll tax jump from the current 2.9 percent of payroll to 13.4 percent right away. Taxes would have to rise still higher in subsequent years.

That kind of taxation would sharply reduce disposable income, cut investment spending, retard capital formation, and cost the economy in jobs and productivity. The Heritage numbers crunchers, using the best economic modeling on the market, are working on calculating the economic impact of not paying the taxes and going straight into debt. Not a good alternative.

For health policy, 2005 was a disappointing year overall. The Medicare mess has deepened and Congress has shown no willingness to act responsibly. The federal insurance market reform proposal authored by Rep. John Shadegg (R-AZ), which would have allowed individuals and families to buy health insurance across state lines, was reported out of committee but has not even come to the floor of the House of Representatives for a vote. The Tax Reform Commission proposed capping the tax exclusion on health benefits, but it stopped short of suggesting serious reform. The Medicaid Commission has yet to signal any intention to promote serious structural reform. Nonetheless, there are reasons for optimism. For example:

* On Medicare, Senator John McCain (R-AZ), Congressman Jeff Flake (R-AZ), and 100 members of the House Republican Study Committee introduced legislation last fall to delay implementation of the drug benefit. The bills were still in committee when the drug benefit went into effect on January 1, but the mounting fiscal crisis will soon force some serious action on Medicare; it's unavoidable.

* On Medicaid, the largest health care program, with 53 million enrollees and total costs of approximately $300 million, there are some interesting state initiatives. South Carolina and Florida have introduced new options for Medicaid recipients, including health savings accounts, and are promoting choice and competition among providers to improve access to care among the poorest citizens. The big task is to promote long-term care insurance among the middle class, so that nursing home care doesn't become just another middle-class entitlement. If we do not control middle-class entitlements, we are going to shred the safety net for the poor.

Health savings accounts are also taking off. There are more than a million of these policies now in effect nationwide, and the number is rapidly growing. They are broadly affordable, and about 30 percent of the policy holders are Americans who were previously uninsured. Meanwhile, Gov. Mitt Romney (R) of Massachusetts is trying to enact an innovative insurance reform characterized by reduced regulation, defined contributions for health insurance coverage, and a robust system of private health plan competition. One of every seven dollars in the United States is spent on medical goods and services. In the past few decades, the role of personal spending has declined in health care, except for third-party payment cost-shifting to employees by employers through higher deductibles and copays.

The bigger transition, at least in terms of coverage numbers, seems to be from a highly regulated, employment-based, third-party payment system to a third-party-based government-managed system, as evidenced by the enrollment increases in Medicare and Medicaid. Congress is aiding and abetting this continued expansion of the government's role in health care.



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 25, 2006


One of the largest staff culls in recent NHS history worsened yesterday as more hospitals announced cuts and politicians gave warning of a final total of up to 20,000 job losses. Two trusts, in the North East and Kent, said yesterday that cuts were imminent or likely involving hundreds of members of staff. The announcements took the total job losses this month to more than 3,000, with two thirds occurring in the past week.

The Conservatives yesterday accused the Government of runnning scared of a crisis that would probably result in a cut of between 15,000 and 20,000 employees across the NHS. While Gordon Brown fended off criticism for skirting round the health service’s mounting debts in his Budget statement this week, it also emerged that there would be no specific health funding debate in the wake of his speech.

County Durham and Darlington Acute Hospitals NHS Trust yesterday became the fourth trust in less than 24 hours to give warning of serious service cuts. Up to 700 posts are expected to go over the next three years. The announcement came after news from East Kent Hospitals Trust, one of the largest hospital trusts in the country, of the possibility of job cuts in an attempt to reduce a predicted 35 million pound deficit. On Wednesday night — just hours after the Chancellor addressed the Commons — the Royal Free Hospital in Hampstead, North London, and Queen Mary’s, Sidcup, Southeast London, added their names to the growing list of organisations planning to shed staff.

Andrew Lansley, the Tories’ health spokesman, said that the Government could not be allowed to hide from NHS deficits now running at about 750 million pounds. He predicted total job losses approaching 20,000, and questioned why Patricia Hewitt, the Health Secretary, was not scheduled to take part in post-Budget debates in the Commons. “The Government has mismanaged the service and much of the money it has pumped in has been wasted by bureaucracy or the mismatch of supply and demand,” he said. Although he accepted that some of the bureaucratic job losses could be the result of slack in the system, Mr Lansley said that laying-off doctors, nurses and midwives was absurd. He added that the Conservatives would do the things that Mr Brown had prevented, including allowing foundation hospitals to borrow freely to expand their services.

Mr Brown explained yesterday the absence of detail about health funding during his Budget speech by saying that the extra money for the NHS had already been announced. Health trusts would receive an extra 6 billion pounds in the next financial year and a further 6 billion the year after that, he said. “When we talk about deficits faced by some trusts, most organisations in the NHS are getting more money next year and more money the year after.” The Chancellor added that only a “small number” of trusts were affected by the highly publicised deficits. “They have got to sort their problems out,” Mr Brown said. “There is more money going into the health service. It is our duty to have more value for money.”

Announcing the likelihood of 700 job losses yesterday, hospital chiefs at County Durham and Darlington blamed changes across the NHS nationally — including the use of the private sector to carry out NHS work, and how hospitals are paid for operations. They said the job losses were not about saving money.

More here

Just one episode reported by a doctor on the NHS front-line

Don't read the rest of his reports unless you have a strong stomach. They are too awful. It sounds like the guy is working in a Communist country. But socialism is just slowed-down Communism so it figures

Third patient in is Mary, one of the local speech therapists. She is approaching retirement. I sent her husband into hospital three weeks ago in rip-roaring heart failure. He was on CCU for three days but now is on the far flung corner of Dixon, one of the medical wards. He is partially sighted due to an old stroke, and is hard of hearing. The nursing care is appalling. He has developed pressures sores on his sacrum and heels and, oddly, a suppurating area above both ears which Mary thinks is due to the oxygen mask he uses being too tight. He is losing weight because he cannot really manage to feed himself. Mary was in each day over the weekend. Uneaten food from Saturday was still on his bedside table on Sunday. Mary went to the nursing station at the end of the ward. The nurses were all eating take-away Pizza. Deep Pan pizza from Pizza Hut. Mary remembers that particularly. Mary thinks her husband is dying. She is not sure which consultant he is under, and has not been able to find a doctor to talk to. The nurses over the weekend do not speak English. She tried to tell them that her husband is partially sighted but they do not understand. They show here the nursing assessment. Under “visual problems” it says "none". Mary is in tears and asks what she should do. I suggest she phones the Chief Executive and makes a formal complaint.

I do not suppose that Pizza Hut pizzas carry harmful bacteria, but should they be on an acute medical ward?


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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 24, 2006


Two more hospitals last night joined the list of NHS trusts forced to cut services because of their debts, taking the number of job cuts to more than 2,000 in less than a week. The Royal Free Hospital in Hampstead, North London, and Queen Mary's Hospital in Sidcup, southeast London, became the latest to announce cuts despite six years of unprecedented government funding for the NHS. The Royal Free, which was praised by the Health Secretary last year for its work after the London bombings, said that about 480 posts will be lost under plans to achieve savings of œ25 million in the next year. The trust said it would ensure that redundancies were kept to a minimum. Hospital chiefs at Queen Mary's also gave warning that 190 jobs may be lost in an attempt to reduce a predicted œ13 million deficit.

Andrew Way, chief executive of the Royal Free Hospital NHS Trust, said that the cuts at his hospital would be part of a drive to improve staff efficiency and reconfigure wards. "These measures are not exceptional and are designed to bring the Royal Free into line with other organisations," he said. "We must achieve financial balance if we are to control our own future as the Government has made it very clear that it will not bail out organisations that fail to do so." Mr Way praised staff for their hard work in implementing the trust's "savings plan", which would help to ensure a robust financial future, but Geoff Martin, head of campaigns at London Health Emergency, accused the Royal Free of trying to smuggle the news out on Budget day. He said that the announcement helped to explain why Gordon Brown had "body-swerved the NHS question" in his speech. "Sacking nurses never looks good for the Government," Mr Martin said. "These cuts will have a devastating impact [on] emergency planning in London."

Andrew Lansley, the Tory health spokesman, said: "One year ago ministers were heralding NHS staff as the heroes who were delivering on waiting list targets. Today they are silent as the same NHS staff are threatened with redundancy. Faced with the failure of his billions to deliver corresponding improvements for patients, Gordon Brown and the Treasury have abandoned the NHS."

A Department of Health spokesman said: "We are reassured that these plans reflect the need to treat patients more efficiently and improve the organisation of services."



The doctor who took the Quebec government to the Supreme Court of Canada, causing it to change its policy on wait times and private health insurance, wants to see more privatization. In his Supreme Court case, Dr. Jacques Chaoulli argued "patients will continue to suffer and die" because of waiting lists. Last year, the high court ruled in response that some wait times for medical procedures in the province were unconstitutional.

In February, Quebec Premier Jean Charest announced guaranteed wait times for cataract surgery and hip and knee replacements and changes to make it legal for Quebecers to buy private insurance for those three medical services. On Tuesday, Chaoulli called the move a good first step, while urging the Quebec government to go further with privatization. "I would like that Quebecers have the best value for the public money they spend," Chaoulli said. He said the best way would be to allow more private medicine, including:

* Allowing doctors to work in both the public and private systems, such as at a public hospital and a private clinic, rather than one or the other.
* Privatizing medical schools and hospitals.
* Loosening legal restrictions that limit private insurance.

The ideas were outlined in a 40-page document Chaoulli submitted to a provincial government commission looking into health reforms.



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 23, 2006


More than a third of NHS hospitals and other health trusts are unable to provide their staff with hot water, soap, alcohol rubs and other basic hygiene requirements whenever they need them, according to a national survey. A poll of more than 200,000 employees, conducted by the Healthcare Commission, has revealed alarming shortfalls in NHS hygiene, supposedly a key priority for the Government in its attempt to reduce hospital-acquired infections. The survey found that one in four members of staff felt that the trust they worked for did not do enough to promote the importance of cleaning hands to staff, patients and visitors.

Only 61 per cent of respondents, said that their trusts had hot water, soap, alcohol rubs and paper towels available at all times. A further 28 per cent reported high levels of handcleaning equipment, but one in five NHS workers said that they never had access to such facilities. The commission, the NHS watchdog, described the findings as a worrying neglect of a prerequisite of good healthcare. A total of 51 per cent of staff said that they had received training, learning or development about infection control in the past 12 months - suggesting that half had not.

Hospital-acquired infections, such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile, have been associated with a growing number of deaths in recent years, prompting a government crackdown on poor hygiene. A total of 7,212 cases of MRSA bloodstream infection were detected in English hospitals in 2004-05. Experts suggest that up to 300,000 infections are picked up in healthcare settings every year, causing 5,000 deaths and costing the NHS as much as œ1 billion.

The National Survey of NHS Staff, published today, also highlights other areas where "significant action" is needed, including initiatives to tackle violence and discrimination....

Anna Walker, the chief executive of the commission, said that it was heartening to see the downward trend in reports of violence, harassment and bullying. But she said that work was needed to address hygiene shortcomings. "A high standard of hand hygiene is a prerequisite of safe healthcare and this is undermined if the basic facilities for cleaning hands are not always available," she said.

A spokesman for the Department of Health welcomed the positive findings and said that it was "pleasing to note that "nearly 90 per cent of staff felt that hand hygiene facilities were available either always or most of the time". [One would have expected them to have had 100% availability ever since Florence Nightingale]


Congress Strengthens Long-Term Care

The Deficit Reduction Act (DRA) of 2006, signed into law by President George W. Bush on February 8, curbs Medicaid planning abuse (the sheltering of assets to make a non-eligible person eligible for Medicaid long-term care coverage) and releases the Long-Term Care (LTC) Partnership program for nationwide expansion. The latter consists of private/public partnerships that encourage people to purchase long-term care insurance by allowing them to keep their assets if they ever exhaust their insurance and have to turn to Medicaid. The DRA warns the public that long-term care is a personal responsibility, that its risk and cost should not be ignored, that Medicaid remains a safety net but only for those truly in need, and that everyone who is financially and medically qualified should begin now to save, invest, and insure for long-term care. Properly delivered, that message can prevent a great tragedy that threatens this country: It can save Medicaid for the poor while preparing most Americans to pay privately for top-quality long-term care across the full spectrum of LTC services--from home care to skilled nursing facility care.

The DRA reauthorizes "LTC Insurance Partnerships"; strengthens "undue hardship" protections for Medicaid recipients; extends Medicaid's transfer of assets look-back period from three to five years; starts any applicable eligibility penalty later to prevent "half-a-loaf" giveaways; drops the home equity exemption to $500,000 from unlimited; and closes Medicaid eligibility "loopholes" such as "transfer assets before income," "Medicaid-friendly annuities," "life estates," "partial-month transfers," and "self-canceling installment notes." These minor modifications to Medicaid's hemorrhaging eligibility system are long overdue and critically needed to begin a long process of restoring and preserving the welfare program as the long-term care safety net for the poor and to give prosperous citizens incentives to save, invest, and insure for long-term care so they will be able to pay privately for quality care when they need it.

The American Association of Retired Persons (AARP), big charities, and Medicaid planning attorneys opposed the DRA because it reduces the ability of their affluent members and clients to shelter and divest assets in order to shift the high cost of long-term care from their personal responsibility to taxpayers (who finance Medicaid), long-term care providers (who are paid too little by Medicaid to supply quality care), and the poor (who are unable to obtain the same quantity, quality, and range of services from Medicaid available to the well-to-do because they lack the "key money" to buy their way into the better Medicaid facilities). A statement by AARP CEO Bill Novelli on the House budget reconciliation vote was titled, "Transfer of Assets Provision to Punish the Innocent," and claimed, "The U.S. House of Representatives has ... approved a provision in its budget that will deny long-term care coverage to those who give money to charities, churches, and family members in need. Working with our members, AARP will continue the fight to have this ill-conceived policy reversed."

Without the improvements spelled out in the DRA, however, Medicaid will remain on its slippery fiscal slide toward collapse; LTC insurance, home equity conversion, and other private LTC financing alternatives will continue to languish; the bias in most state Medicaid programs to provide LTC in an institutional setting (i.e., nursing home) will continue, while home and community-based care will suffer; the public will remain anesthetized to the risk of not preparing for long-term care; and ultimately the baby boom generation will have to use its home equity to fund long-term care while the poor will have nowhere to turn when Medicaid disintegrates entirely.

The changes to LTC and Medicaid in the DRA will mean nothing, however, unless the states implement them, the federal government enforces them, the private sector promulgates them, and the public understands them. The states are flush with cash again. A January report on began, "From Massachusetts to Hawaii, signs abound that the immense pressure placed on state budgets by the fiscal crisis early this decade has eased and put tax cuts and new spending in the realm of possibility for the first time in several years." With the fiscal pressure off, states may shy away from enforcing the new Medicaid eligibility rules in DRA '06 just as they dropped the ball on the Omnibus Reconciliation Act of 1993 (OBRA '93), which contained many changes that were never enacted.

Advocacy groups are already mobilizing to fight LTC reform again. What they couldn't stop in the above-board legislative process, they'll try to kill behind the scenes in state legislatures and Medicaid agencies. Elderlaw planners are already offering a fire sale on asset transfers, and they'll soon be mobilizing to impede and repeal the DRA reforms. "Although Congress passed a new law February 1 further restricting the ability of the elderly to transfer assets before qualifying for Medicaid coverage of nursing home care, many people in most states will still have time to plan under the old rules," read an email release from the day after the House vote. "[T]he old rules will likely apply to transfers if the Medicaid application is filed before the state passes the complying legislation. So it may not be too late to plan, and in many cases not too late to transfer assets," the release said.

People won't buy LTC insurance to avoid a Medicaid spend-down liability that does not exist. If the new Medicaid rules are implemented and enforced, the LTC Partnerships established by the DRA will be enormously successful. If not, they won't. The private long-term care insurance industry should actively support efforts to help states implement the new Medicaid rules and LTC Partnerships. Home equity conversion lenders should actively support efforts to educate the American public about the new and likely future Medicaid limits on exempt home equity. LTC providers should actively support efforts to implement the DRA in such a way as to prevent asset transfers that leave people ineligible for Medicaid but unable to pay their own way.



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 22, 2006


The murdering doctor below will almost certainly suffer no penalty. Even Roy Meadow got off the hook eventually. In the USA, the galoot below would be sued to oblivion

A mother died after being given penicillin before a minor operation despite telling doctors that she was allergic to the drug, an inquest was told yesterday. Teresa Innes, 38, was wearing a red allergy band on her wrist and her medical notes stated that she should not be given the antibiotic. However, a doctor at Bradford Royal Infirmary prescribed it as she was about to undergo routine surgery to drain an abscess on her thigh. She suffered anaphylactic shock which stopped her heart for 35 minutes resulting in brain damage and a persistent vegetative state from which she never recovered. The former care worker died two years later, in 2003, after Dame Elizabeth Butler-Sloss, then President of the High Court Family Division, gave the hospital permission to withdraw her artificial feeding.

At her inquest yesterday, Bradford Coroner's Court was told that Ms Innes had been for a week's holiday to Corfu in September 2001 with her son Scott, 17, and noticed an infection on her left thigh when she returned, thought to have come from an insect bite. She developed an abscess on her leg and was prescribed non-penicillin antibiotics by her GP. A week later, when there was no improvement, she returned to her GP who referred her to Bradford Royal Infirmary.

On arrival at the hospital, at least four members of staff were told of her allergy and it was logged in her notes, the inquest was told. However, during a ward round at the hospital that evening, Ms Innes was prescribed penicillin by John Griffith, a doctor, before the minor operation to drain the abscess on her thigh scheduled for that night. Her medical notes, the inquest was told, recorded that she was allergic to the drug and that she was wearing a bright red allergy band on her wrist. The operation was later postponed to the next morning, when she was given a drip containing Magnapen, a form of penicillin.

A statement by Marlene Greaves, a close friend of Ms Innes who accompanied her to hospital, was read to the inquest. Ms Greaves, who has since died, explained how Ms Innes first had an allergic reaction to penicillin in 1997, after giving it to her nephew and then licking the spoon. She took two days to recover. Ms Greaves recalled how Ms Innes was assessed in the accident and emergency department before being transferred to a ward. "Teresa made a point of telling this doctor she was allergic to penicillin but he said he already knew because it was in her notes," Ms Greaves said.

She said that Ms Innes was in pain and that it was "all she could do to lift one leg". Ms Greaves, who had been named as Ms Innes's next of kin, was called early the next morning and told that her friend was seriously ill. Ms Greaves said: "I couldn't believe what they had done and pointed out how many times they had been told about her allergy." She said she was angry at the time and did not realise how serious the situation was. "I feel in many ways Teresa was like a daughter to me. I think and hope if she was alive today she would feel the same about me," she said. "It was just at a time in her life when things were looking up for Teresa. Her life was lost through such a needless mistake."

Post-mortem examinations found that Ms Innes, whose upbringing was described as "something of a struggle", died from brain damage due to a lack of oxygen brought on by anaphylactic shock and leading to an irrecoverable persistent vegetative state. The inquest was told how, in a meeting between Ms Innes's relatives and hospital staff, Dr Griffith admitted to writing the prescription but said he had not seen the wristband. Nicholas Clarke, a doctor, who assessed her condition on arrival at the accident and emergency department, said Ms Innes came with a letter from her GP, Ian Stinson, which noted her allergy. He said he also noted the condition in her notes in "block capital letters" before handing them over to another member of staff.



Experts knew that drugs similar to the one that nearly killed six men at a London hospital last week could have dangerous side effects. Trials last year in the US of a similar "monoclonal antibody" caused severe toxic reactions in patients. But the British study went ahead after the regulatory authority failed to consult outside specialists who would have warned against proceeding.

Angus Dalgleish, a world expert on immunology, said at the weekend he was amazed the trial had been allowed to proceed. "The previous studies which caused similar severe side effects were in patients already suffering from cancer, but (the researchers) should have known they would get a meltdown because this drug was hitting exactly the same immune response pathways," Professor Dalgleish said.

Last week six healthy young male volunteers, who were to be paid pound stg. 2000 ($4800) for the trial, suffered catastrophic side effects within minutes of receiving an experimental drug called TGN1412, which was being tested as a potential treatment for leukemia, rheumatoid arthritis and multiple sclerosis. Two of those given the drug are still in a coma at Northwick Park Hospital, northwest London. The other four have regained consciousness and spoken to relatives.

But doctors said the four men could face months of slow recovery. The monoclonal antibody they were given can linger in the system for months, unlike most conventional drugs that are flushed out in days.

The two others were critically ill in intensive care, and relatives of one of them, Ryan Wilson, said they had been told he could be in a medically induced coma for up to a year. Ganesh Suntharalingam, clinical director of intensive care at Northwick Park Hospital, said an advisory panel was meeting regularly and developing a more detailed understanding of what had happened to the volunteers.

Professor Dalgleish said the Medicines and Healthcare Products Regulatory Agency (MHRA), which approves such drug trials, should have consulted a specialist before approving the study. "I can't understand it. They are normally super-cautious. I would have told the people doing this trial not to do it because the dangers were so great," he said. The data that should have raised the alarm were presented at a meeting of the American Society of Clinical Oncology in May last year. Professor Dalgleish -- a professor of cancer at St George's Hospital medical school, south London -- said an engineered antibody using the same pathway as TGN1412 had produced severe side effects in about half of a group of patients who were dying of cancer.

British experts told The Times last week it had been a mistake to give the drugs to six volunteers at the same time, but MHRA has defended the trial. A spokesman said the MHRA had reviewed the dossier of data that the drug's developer, TeGenero, had produced and confirmed that all was in order. Given the same data, the agency would approve the trial again, he said. "We have (since) given the trial protocol to a new set of assessors and they came to the same conclusions. There was nothing wrong with it."

In Germany, where the drug was developed, prosecutors said they were examining whether to start an investigation into the biotech company TeGenero. And the body responsible for licensing trials, the Paul-Ehrlich-Institut, hinted changes would be needed in the way trials were run. Their spokeswoman told German radio: "We are all going to think about whether to start off with a single person for studies where there is a risk of this kind."



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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, March 21, 2006

The Titanic of health care

Comment from Melanie Phillips in Britain

Has there ever been a more bizarre notion of political responsibility? The NHS is currently engulfed by a deep financial crisis as it careers towards a deficit of between 600 million pounds and a staggering 1 billion. Operations are being cancelled. Hospitals and primary care trusts have frozen staff vacancies. Managers are even threatening to withhold tax and national insurance contributions because they don’t have enough cash to pay them. The service is descending into chaos. As result, the NHS Chief Executive Sir Nigel Crisp has walked the plank. The Government’s insistence that he took early retirement entirely of his own volition is frankly incredible. In fact, he very decently acknowledged responsibility for the service’s problems, as well as for its successes.

So a career beached in ignominy? Hardly. For Sir Nigel has been given a life peerage -- one of only a handful in the Prime Minister’s gift for public servants who have made a particularly distinguished contribution. For this failure to stop the NHS sliding into financial chaos, which has caused him to depart so precipitately from his post, Sir Nigel has therefore been rewarded with a Whitehall plum. Confused? In the surrealist and unending disaster epic that is the NHS, very little makes any sense. Unprecedented amounts of money have been hurled at the service by the Chancellor -- and yet we learn that, some four years on, the NHS appears to be going bust. So how can this have happened?

The immediate reason is that almost all this largesse has been swallowed up by salaries, pensions, drugs, IT systems and other commitments which cost far more than had been expected. As result, virtually no money was left for improving the actual delivery of services to patients, without what are euphemistically called ‘efficiency savings’ – or cuts to you and me. These were so vague as to be next to useless. So almost all the Chancellor’s extra billions disappeared into the mechanics of the system. Meeting the demands by ministers for more, better and faster treatment sent the service shooting into the red.

In a more honourable age, the Health Secretary presiding over such a shambles would have fallen on her scalpel. But here, surely, is the explanation for the ennoblement of Sir Nigel. His peerage was a sop to sweeten the bitter pill of being made the fall-guy for a politician who was determined not to take the rap. Sir Nigel should not have been sacked, because the job he was given was simply impossible. He was being expected to turn round a service which was being driven off the rails by the incoherence, arrogance and incompetence of Government policy.

What has happened has tested to destruction the old excuse that the problems of the NHS were due to lack of money. We now spend more on health care than the European average, but it has vanished into a managerial black hole. An unprecedented level of spending has simply produced an unprecedented level of crisis. This was entirely predictable; indeed, it was in fact predicted by many commentators. The government was warned that this would happen by Nick Bosanquet, the distinguished professor of health policy; it was warned by the influential Reform think tank; it was warned by the OECD, which said that such an enormous amount of money simply could not be processed efficiently in such a short amount of time.

The Government ignored all of them. Instead, it pressed forward with one ill thought-through and incoherent policy innovation after another. The reason Sir Nigel was unable to constrain NHS spending was that its managers were being driven to meet unrealistic ministerial targets -- in particular, the policy of reducing treatment waiting times. It was this policy which meant that more patients had to be processed faster, even though there wasn’t the money to do it. It was this policy which grossly distorted clinical priorities. It was this policy which shunted patients onto ‘ghost’ waiting lists -- which didn’t officially exist -- to artificially massage the figures downwards. And all this to provide the illusion of improvement, so that ministers could make an empty boast that would hoodwink the voters.

Now the Health Secretary Patricia Hewitt claims that only ‘a very small minority'’ of hospitals and NHS bodies have serious financial problems. One shudders to imagine what she thinks a large problem would look like. It should not have been Sir Nigel who resigned but the Health Secretary herself. The notion of ministerial accountability, however, seems to have gone out of the window altogether. Indeed one of the reasons for creating an NHS executive was to enable ministers to do precisely what Ms Hewitt has done -- to wash their hands of the mess that their own policies create. They keep the service under control so tight that it cripples it -- and yet they refuse to accept responsibility when things go wrong.

But although the Government won’t admit this, Ms Hewitt’s own job is also impossible. This is because the NHS is simply unmanageable. Since the mid-seventies, government after government has tried to reform it. Yet every one has made things worse so that the service merely lurches from crisis to crisis. The reason is that it is simply too big. According to some measures, it is the third largest employer in the world. In England and Wales it employs around 1.3 million people, or around one in every 40 people. It is just not possible to manage such a monster from an office in Whitehall.

The bitter irony is that the very premise of the NHS is proving its undoing. Taxpayers’ money is spent on the nation’s health care by ministers -- who thus inevitably tell the service what to do. And what that means is that no government can solve the NHS crisis, because government itself is the problem. Instead of a health service funded by the Treasury, therefore, the solution has to be a different model of funding altogether. The fairest and most efficient alternative is a form of social insurance as practised in Europe, where waiting lists are virtually unknown. Patients purchase healthcare from providers of their choice, with the state guaranteeing levels of provision covering the poorest in society.

Our NHS is a shibboleth because people assume it is the only system that is fair. But this is simply untrue, as anyone who has seen the often shameful way that it treats those who are both poor and elderly can testify. The present system is already a lottery which will become dramatically more unfair as the population ages and new treatments become available. Cancer care alone is forecast to cost an extra 15 billion pounds by 2011. The consequent rationing will become unendurable and unsustainable.

Sir Nigel has gone, but there is no sign that Ms Hewitt has the faintest idea how to address this crisis. She’s still talking about bringing down waiting times to 18 weeks. But as Professor Bosanquet says, this policy – which has not even been properly thought through – should be abandoned before it causes yet more distortions, chaos and patient distress. In the longer term, radical thinking is required. The NHS is the Titanic of health care. Rearranging the deck-chairs yet again will not save it from sinking.


"Patients with some serious conditions could be treated at home rather than in hospital in order to try to cut the number of emergency admissions. The Health Secretray Patricia Hewitt is expected to announce the move as part of Government plans to tackle the NHS cash crisis. Ms Hewitt is said to be preparing plans to encourage people with conditions such as asthma and heart disease to be cared for at home by community nurses. The Department of Health believes the measures could save the cash-strapped NHS up to 400 million pounds a year, according to a BBC report. But the Tories accused her of trying to get "healthcare on the cheap" and said the plans would threaten patient care.

Ms Hewitt said: "If we could cut these unplanned emergency admissions by 30% and patients would have improved lives and hospitals would be able to plan their services better. "The potential savings from those PCTs (Primary Care Trusts) that have many more emergency admissions than the average is almost 2.5 million pounds per PCT."

Shadow health secretary Andrew Lansley said the Government should "let professionals get on with the job of determining how patients are cared for". Dr Beverly Malone, general secretary of the Royal College of Nursing, said: "We are very supportive of care moving from the hospital to the community. "But right now there are not enough nurses in the community to take care of these patients. District nurses are already working flat out."


1,000 staff to go from just one British public hospital

A cash-strapped hospital is to cut up to 1,000 jobs in a desperate attempt to reduce debts of more than 15 million pounds. The University Hospital of North Staffordshire in Stoke warned around three-quarters of the redundancies will be compulsory. Some 370 nursing and midwifery posts are expected to go. Pat Powell, the hospital representative for leading trade union Unison said: "The hospital claims the job cuts will not affect patient care, but we feel they will inevitably affect services."

Hospital chiefs said they were "saddened" by the cuts but the move was essential to address their huge deficit. There are already strict controls in place on recruitment to vacant posts. Managers said they planned to improve efficiency. Antony Sumara, Chief Executive, said: "I am deeply saddened that we now find ourselves in this position. "However, I firmly believe we will be a very strong trust, able to go forward confidently and provide first class services for our patients and good working conditions for our staff."



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. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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.