Friday, November 30, 2007

NHS care 'favours middle classes'

ANY healthcare system would -- but the fact that it happens in the NHS deprives the NHS of a major part of its justification

The NHS is a "divisive influence" which favours the assertive middle classes over poorer people, a study says. The report by centre-right think-tank Civitas said the health service was not providing equal treatment to all. It pointed out that people in deprived areas were often more in need of treatment, but less likely to get hip replacements or key x-rays. The report called for more use of the private sector, but other experts said this would just widen inequalities.

Report author Nick Seddon said studies had shown that those on lower incomes made more use of primary care, but were less likely to be referred on for hospital treatment. He highlighted York University research which showed those in deprived areas were more likely to need hip replacements but less likely to get them. And the report also mentioned another study which found angiograhy - x-rays of arteries and veins - rates among the lowest socio-economic groups were 30% lower that in the highest.

Mr Seddon said this was partly attributable to the fact that middle classes were more assertive, articulate and confident in dealing with health professionals. "Much depends on where you live, how much you earn, how old you are and crucially who you know. "It has always been said in defence of the NHS that, although it was not the best in terms of quality, it was at least impressive in term of equity. Now that is no longer true. "The NHS cannot be allowed to continue as it is."

He said part of the problem for the NHS was that it had made little use of the private sector. He suggested the NHS could learn from other European countries with social insurance schemes which encouraged companies to get more involved in health. "In the NHS, private providers have only really got involved in non-emergency operations to date, but why can't they do more? What about heart and cancer care and GPs? "By introducing the private sector, you increase competition and drive up standards."

But Alex Nunns, of the Keep Our NHS Public campaign group, which represents health professionals, the public and academics, said: "The middle classes will always make the best of a system. "In fact, there is evidence to show that when you involve the private sector, it just exacerbates the situation."


Thursday, November 29, 2007

A quarter of women are abandoned by their NHS midwives during childbirth

Midwives are failing to offer proper care and reassurance during childbirth, with one in four women being abandoned during labour or soon after, a watchdog says today. As proposals are being considered for the closure of specialist maternity wards, a shortage of staff and funding is putting mothers and babies at potential risk, experts say. In the largest study of NHS maternity care, the Healthcare Commission found variations across England, with nearly half the women in some trusts reporting that they had been left alone during labour or soon afterwards.

The Government has proposed that all mothers-to-be should be supported by a named midwife throughout their pregnancies by 2009, while official guidelines state that a woman in established labour should not be left on her own, except for short periods or at her own request. Yet in 18 out of the 148 trusts inspected more than one in five women said that they were left alone at a time that worried them while they were in labour. First-time mothers felt particularly unaided.

The Healthcare Commission surveyed 26,000 women who had a baby in January or February. An analysis of the results showed wide variations among trusts. The worst-performing was Milton Keynes General Hospital NHS Trust, where almost half (49 per cent) of women were left alone at a time that worried them. At Lewisham Hospital NHS Trust, 46 per cent were left alone. At Mid Staffordshire General Hospitals NHS Trust, 39 per cent were left alone. At East Cheshire NHS Trust, in contrast, 85 per cent of mothers were never left alone. Many women surveyed also complained about postnatal care, and more than half said that the food on offer was only "fair" or "poor" and one in five said that the bathrooms were "not very clean" or "not at all clean".

Today's report comes before a wider investigation into maternity services that the Healthcare Commission is expected to publish next year. Responses to the quality of care overall were largely positive, with nine out of ten women saying it was excellent, very good or good. But the Royal College of Midwives estimates that at least 5,000 midwives are needed on top of the 24,000 already in England. Louise Silverton, deputy general secretary of the college, said: "Without this, the Government's targets will just be broken promises. We have got to aim for all women to be happy with their care but we will struggle to make this happen unless the worsening shortage of midwives is addressed."

The medical royal colleges advised last month that every woman should receive one-to-one care from a dedicated midwife as she goes through labour. Only one in five women surveyed said that she had a midwife who looked after her during labour and birth, while more than two in five said that three or more staff had cared for them at different times. Other divergences from best practice meant that 43 per cent of women were not given a choice of having their baby at home, and 36 per cent were not offered antenatal classes. The Commission also found that 57 per cent of women gave birth either lying down or with their legs supported in stirrups, despite guidance from the National Institute of Health and Clinical Excellence suggesting that women be discouraged from having their baby in these positions. Overall, two thirds of women said that they "definitely" had confidence and trust in the staff caring for them while a quarter said that they had only "to some extent".

The Government has pledged that, by the end of 2009, women expecting a normal birth will be able to choose whether to have their baby at home, in a midwife-led unit or in hospital. Norman Lamb, the Liberal Democrats' health spokesman, said that the survey had exposed "a huge gap between Government promises and the reality in maternity units across the country". "As well as being denied the option of a home birth as the Government promised, some women also have the confusion of having to deal with a series of different midwives throughout their pregnancy," he said. "There simply aren't enough midwives to deliver on ministers' promises of one-to-one maternity care."

Gwyneth Lewis, national clinical lead for maternity services at the Department of Health, said: "It is encouraging that the vast majority of respondents reported their care as being excellent, very good or good."


Wednesday, November 28, 2007

Medicare as a model? Heaven forfend!

The simplest matters generate vast bureaucracy

The day-job’s at an end – suddenly and abruptly. Suffice to say that the combination of working corporate, and reporting early for extra hours at holiday-times, proved to be my undoing. Back to the drawing-board, but at least there’s a small cushion and no overdue bills outstanding. Perhaps it’s a good time to comment on some more things I learned in that venue, about how the current ethos of “entitlement” will surely be our undoing, unless it is reversed very soon. Full disclosure: The gig I just left, not entirely of my own will, involved processing Medicare forms, and the experience has only strengthened my already-adamant opposition to any ideas being circulated about expanding that benighted program as a model for nationalized health insurance!

As noted in previous columns, the practices of medical professionals and their administrative staff, in complying with the intricacies and absurdities of the Medicare reimbursement system, are apparently driven far more by redundancy and inefficiency than by what would normally be considered good business procedures (were it not for the incentive from the IRS systems to waste resources in printing, mailing and such). Meanwhile, the impetus toward what Arnold Kling at the Cato Institute calls “premium medicine” often leads them to look at a patient’s ailment as a chance to try out all their new expensive diagnostic toys (CAT scans, MRIs, biopsies, etc.), rather than just identifying and treating the illness or malady as simply as possible, and sending the person back into the world.

However, the actions and choices of these practitioner/healers pale in the face of how the Medicare-covered patients themselves (aka, the “beneficiaries”) generally function. (Note: There are exceptions, but from this editor’s experiences, they are rare and notable mostly for their contrast with the norm. We are apparently smack in the midst of several generations of Americans who’ve taken it so for granted that their “retirement years” would be attended by a staff of obsequious underlings that it’s a wonder when any one of them steps up to offer a “refund” of a service granted in error, let alone accepts a ruling against the slightest expense incurred out-of-pocket without multiple levels of appeal first.

The process of getting “flu shots” is only the most obvious example of this; the roughly $25-30 being charged for the shot (and the administrative paperwork accompanying it) is contested by pretty much everyone eligible for Medicare – no matter how much time and paperwork it takes to get the check. The idea that perhaps such a relatively small amount, being shelled out in the name of “prevention” (as they are urged to do at every turn by at least the allopathic wing of the “healing profession”), should automatically be reimbursable … Well, it sure does run counter to the common sense about taking care of yourself that most of these folks grew up believing.

(Meanwhile, according to the latest studies, there may not even be a correlation between getting a flu-shot and avoiding serious illness, as has been claimed so matter-of-factly by those same allopaths and the bureaucrats who backstop them. As the story puts it, “Over the past 25 years, the proportion of those aged 65 years or more who receive flu shots has climbed from 15% to 65% in the US. … Yet current estimates of winter death causes suggest that flu-related mortality has actually risen since 1980.” In other words, what many folks in the “natural healing” world have long suspected ¬– that these widescale inoculations, allegedly a safety-barrier against influenza deaths in the elderly, are not saving any more lives than we do by encouraging healthier immune systems and better care of ourselves in general – may in fact be what is happening here.)

But we digress … Whether or not getting a flu shot improves your chance of survival, in the event that “the crud” makes its usually annual visit among us, is secondary to whether or not you believe it will. If you do, and you choose to get one, expecting it will be paid for by the taxpayers seems a bit presumptuous to these eyes. But that is the paradigm on which the whole Medicare system is founded.

On some levels it might seem to make sense, since after all those who are now receiving these services could in some sense say they have “already paid for them,” as F.I.C.A. payroll-tax deductions over the life of the Medicare program. However, as we all know, this was never a process of “pay as you go” whereby a person’s “FICA-bite” was being set aside to pay for THEIR later care, or even socked away and invested, to create a pool for that person and all of his/her contemporaries to draw from in their declining years. Instead, the money stolen in the 1960s, 70s, 80s and 90s was all being spent as soon as it was expropriated, on that (much smaller in numbers) generation of “seniors.” What’s going out now has no relation to those funds, but is based on what the children and grandchildren of today’s long-living tribal elders are losing from each dollar earned.

Yet the attitude is there, as this editor saw all too close during his stint opening the many letters and forms. If there is a medical situation – a visit to a doctor, nurse, emergency room, clinic or other “covered” healer – it is generally the expectation of the “beneficiary” that all expenses for that malady, along with every test run and diagnosis associated with it, should be paid for by Medicare, either to the healthcare practitioners or their institutions, without question. And in the somewhat rarer case where the healer has stepped out of such a payment process, and simply charged the treated person directly for the procedure, then Medicare should immediately reimburse said “beneficiary” with no questions asked.

The flu shots are only the most obvious example. Weight-loss surgery, new eyeglasses, .. you name it, someone thinks someone else should be paying for it, and they usually have at least a doctor or two, if not a legal beagle, backing up their contentions.

Imagine for just a moment an entire population making such demands on healthcare, for every little thing involved in keeping them “healthy” (By whose definition? Who knows? It should be “covered” anyway!), while taking little or no responsibility for maintaining their wellness themselves. (Imagine further that we are now about to deal with this with a whole generation of “Boomers,” who have spent their entire life expecting the world to treat them as “special people” entitled to the finest of everything – and now they expect someone else to pay for whatever strikes them as necessary … Does anyone wish to challenge the contention that the “Medicare model” is the LAST thing we should be looking at as healthcare “reform” paradigm?


Australia: Cardiology meltdown at major Queensland public hospital

A leading Queensiand cardiologist is on the brink of resigning out of frustration with the state's failing health system. An investigation into problems in cardiac services at Brisbane's Prince Charles Hospital has been launched by the Crime and Misconduct Commission. The specialist cardiologist, who declined to be named, had initially raised concerns with hospital managers but they failed to respond to her complaint. Details of the complaint have not been revealed, but are believed to concern management conflicts stemming from bed and staff shortages.

It is not the first time senior doctors at the Prince Charles cardiac department have been forced to quit. In 2000, heart surgeon Dr Julie Morton resigned, citing workplace environment as the problem, and in 2004 Dr Con Aroney also left the cardiology department. Only last year, renowned heart and lung transplant surgeon Dr John Dunning was so appalled by the state of Queensland Health that he returned to Britain.

Dr Don Kane, president of the Salaried Doctors Queensland union, said Queensland Health had failed to fix on going problems. Managers at the Prince Charles Hospital refused to comment.

The above article by Hannah Davies appeared in the Brisbane "Sunday Mail" on November 25, 2007

Tuesday, November 27, 2007

The NHS has sure got its priorities right

Women are being given controversial "virginity repair" operations on the NHS, it emerged last night. Taxpayers funded 24 hymen replacement operations between 2005 and 2006, official figures revealed.

And increasing numbers of women are paying up to 4,000 pounds in private clinics for the procedure apparently under pressure from future spouses or in-laws who believe they should be virgins on their wedding night. Doctors said most patients are immigrants or British of ethnic origin. The trend has been condemned by critics as a sign of social regression driven by Islamic fundamentalists. Some countries have made hymen reconstruction operations illegal.

Dr Magdy Hend, consultant gynaecologist at the Regency Clinic, Harley Street, London, who started hymen reconstruction more than 18 years ago in the Middle East and the Gulf, said: "In some cultures they like to see that the women will bleed on the wedding night. If the wife or bride is not a virgin, it is a big shame on the family." Dr Hend said he was surprised by the "very good response" to the service and said there is "big competition on the market".


Australia: Medical negligence in regional public hospital ruins a life

Jamie Oxley is only 22 -- but he already feels like a 60-year-old. Three years ago, Mr Oxley went to the Cairns Base Hospital emergency department after experiencing severe abdominal pain and vomiting. About four hours later he was discharged without his twisted bowel being diagnosed, despite X-rays that allegedly showed "classical" evidence of the problem.

He was rushed back to hospital by ambulance nine hours later and doctors had to remove about 3m of his small intestine, resulting in a permanent disability. Mr Oxley, who worked as a seafood processor before his operation, now struggles to work due to fatigue. Mr Oxley, of Yorkeys Knob near Cairns, is suing for $540,000 damages for pain, suffering, loss of amenities of life, economic loss and loss of earning capacity.

His statement of claim against the State of Queensland, filed in the Supreme Court in Brisbane on November 13, alleges Mr Oxley lost a major portion of his small intestine as a result of the failure to diagnose the obstruction early enough to treat it. A filed medical report by Dr John Raftos, a senior Sydney emergency medicine specialist, said X-rays taken when Mr Oxley first went to hospital showed air-fluid levels in the small intestine. "It would be reasonable to expect any ordinary skilled doctor would interpret this X-ray as being diagnostic evidence of small-bowel obstruction," Dr Raftos said.

Before the emergency operation Mr Oxley and his partner Nichola Easton, 21, had bought their own unit and were working hard for their future. Mr Oxley, who had won a regional trainee award, then lost a chance of promotion to a manager's position and later had to give up his job. "I'm only 22 but I'm finding it hard to do a week's work," he said.

Lawyer Damian Scattini, of Quinn and Scattini, said it was another case of a young Queenslander "being left with a life sentence because a Queensland public hospital dropped the ball". "The problem is that it was entirely preventable, but now Jamie is left to live with the consequences of the hospital's neglect," he said.

The above article by Kay Dibben appeared in the Brisbane "Sunday Mail" on November 25, 2007

Monday, November 26, 2007

Stupid NHS pay deal

Reminiscent of how Nye Bevan proposed to shut the doctors up when he introduced the NHS: "I will stuff their mouths with gold"

New NHS contracts that boosted hospital consultants' [senior doctors] pay by more than a quarter have led to a fall in productivity and the number of hours worked, a report by MPs has found. Lauded as a "something for something" deal when it was introduced in 2003, the contract was closer to something for nothing, said Edward Leigh, the chairman of the Public Accounts Committee. Consultants' pay had risen by an average of 27 per cent, but their working hours had fallen and there had been no measurable increases in productivity.

The Department of Health underestimated the cost of the contract by at least 150 million pounds over three years, and rushed its implementation, the committee found. Consultants' work plans, which were supposed to be more tightly controlled, were drafted too quickly and often consisted of no more than what the consultant already did, or planned to do. The contract did improve recruitment and retention, however, and enabled consultants to catch up with the earnings of other similarly qualified professionals.

The growth in the amount of private work undertaken by consultants had been halted, and patients were now more likely to be seen by a consultant than they were a decade ago.

The committee concluded that the increased pay would be justified only if it also led to improvements in productivity. Despite ministers' expectations that the change would result in a 1.5 per cent annual gain in productivity, the department's own figures suggested that productivity fell by 0.5 per cent in 2004, the first full year of the contract, the report concluded. Figures for 2005 and 2006 are not yet available.

Mr Leigh said: "Anyone who is puzzled how large quantities of money can be poured into the NHS to so little effect should examine the example of the new contract for consultants. "The basic aims of the new pay deal were commendable: to make NHS work more attractive to consultants and private practice less so, to give NHS managers more control over the consultants' working week, and to increase the amount of time they spend on directly caring for patients. "In the event, the introduction of the deal was rushed, with NHS managers left in the dark by the Department of Health over what it wanted from the contract. The department pushed to get the contract in place at all costs and many managers agreed hours of work with their consultants which the trusts could not afford." While the numbers of consultants rose by 13 per cent, total consultant activity increased by only 9 per cent and the number of patients treated per consultant fell year on year until 2005-06. There was "little evidence" that hoped-for changes - such as provision of weekend and evening clinics - had materialised, and the average consultant's NHS work fell from 51.6 to 50.2 hours a week.

The new contracts were agreed in 2003 after two years of negotiation between the department and its counterparts in the devolved assemblies, NHS employers and consultants' representatives in the British Medical Association (BMA). The department budgeted an extra 565 million for the first three years of the contract, but in the event it had to pay out 715 million. Much of the additional cost was due to higher-than-expected payments for consultants being on call outside regular hours.

The BMA said that hospital consultants were worth every penny of their new salaries and that criticism of their pay was unjust and unwarranted. Jonathan Fielden, the chairman of the BMA consultants committee, said: "The chairman of the PAC shows a complete lack of understanding about how consultants work. "He ignores the vast efforts that consultants have made to reduce waiting times and improve patient care and fails to appreciate the enormous pressure that hospital trusts have been under to meet government targets."

Norman Lamb, the Liberal Democrat health spokesman, said: "You can't blame consultants for accepting this generous contract, but why did ministers sign off this settlement when it was clearly such a bad deal for taxpayers and patients?"


Sunday, November 25, 2007

Pathetic British emergency medicine

More than half of trauma patients are not receiving good care, experts say. The National Confidential Enquiry into Patient Outcome and Death looked at the care given to 795 patients, many with head injuries from falls and crashes. It found medical staff in 200 hospitals in England, Wales and Northern Ireland often did not appreciate the severity and displayed little urgency. It said care would improve if services were centred at fewer sites - something which is already government policy.

NCEPOD said many of the problems identified in nearly 60% of patients treated across 200 hospitals were associated with staff being too inexperienced. In particular, they found patients were not always given essential tests such as CT scans or assessed by hospital consultants, especially during the night.

Researchers said most hospitals would only deal with one trauma patient a week and this meant staff did not get the necessary experience to keep skills up to date. They also said about 800 trauma patients each year needed to be transferred to other hospitals - often in an "ad hoc" manner - because of a lack of specialist facilities such as neurological services.

Ambulance crews were also criticised for failing to always unblock airways and alert hospitals of incoming cases. But the researchers said in hospitals which dealt with more than 20 cases a week the care was classed as good. The report said this in itself was a good argument for centralising services in regional centres. This is already a government policy, but it is proving controversial because of the aim of a whole host of other services such as maternity and A&E being centralised as well. Campaigners say such a move would lead to many local hospitals being stripped of key services.

Report author Dr George Findlay said: "The number of patients seen has a direct bearing on the experience and ability of clinicians to manage challenging cases. "It is not possible for all hospitals to have a trauma team on call with the necessary experience, organisation and support structures. "We need to look at how we can organise trauma care on a regional basis."

The Royal College of Surgeons said care urgently needed to improve. A spokesman said: "Our mortality rates are among the worst in the developed world, and yet trauma care remains a low priority for the government. "This a national health service and what we need is a national trauma system."

Health Minister Ben Bradshaw said: "We have argued for some time that it is not the proximity of the nearest A&E that matters to most trauma victims but the care they receive from ambulance and paramedic staff and the quality of care they receive once they arrive at hospital. "Concentrating trauma treatment in specialist centres can arouse opposition from some people concerned about 'downgrading' of their local A&E facilities, but what the opponents often fail to recognise is that lives will be saved and the quality of care improved, as this report makes clear."


Crowding in public hospitals kills people

NSW emergency departments are so overcrowded that the situation is contributing to deaths and will continue to do so until more beds are opened, a leading academic has said. New figures, to be released at an emergency medicine conference next week, show that, nationwide, the number of emergency patients waiting to be seen increased by 32 per cent between June and September. Associate Professor Drew Richardson, from the Australian National University medical school, said yesterday the September 3 snapshot of emergency departments also showed a continuing upward trend in patients waiting for a bed since the last snapshot, on June 18, at the same time of 10am.

The new data backs up concerns of emergency staff that chronic overcrowding is affecting patient care, highlighted by Jana Horska's miscarriage in a toilet at Royal North Shore Hospital two months ago. "I believe that mortality is higher in Australian hospitals than it should be because people are being delayed in the emergency department," said Professor Richardson, chairman of road trauma and emergency medicine at Australian National University. "It's about available beds - there's no other way of looking at it . The assumption I make is that hospital overcrowding is contributing to deaths in the Australian community and that until we decide we're going to work our hospitals on the basis of efficiency rather than utilisation, this will continue to happen."

Most of Sydney's major hospitals operate well above 85 per cent capacity - the recognised safe benchmark - to up to 5 per cent over capacity. Professor Richardson will tell the annual scientific meeting of the Australasian College for Emergency Medicine on Tuesday that emergency departments are frequently grinding to a halt - a trend that has been worsening over the past 10 years - because patients are waiting for beds. He said the September survey of 71 hospitals showed a 6 per cent nationwide increase in the number of emergency patients waiting for a ward bed and a 3 per cent increase in those waiting for more than eight hours, known as access block, since the June survey.

NSW had only a 4 per cent increase in patients waiting due to access block but a 20 per cent increase in patients waiting for treatment. However, he said the figures were significantly skewed downwards because the September snapshot was taken in the APEC week in which NSW hospitals cut back services. "NSW deserves a modicum of praise for being better than they used to be, whereas the other states are not, but nationally we have a huge problem," he said.

Professor Richardson said research published in the international journal Critical Care Medicine in June showed that if a patient spent more than six hours in emergency waiting to go to the intensive care unit, their in-hospital mortality rate was 17.4 per cent, compared with 12.9 per cent if there was no delay. He said similar studies in the ACT and Western Australia, published in the Medical Journal of Australia last year, showed emergency department overcrowding was associated with increased mortality.


Saturday, November 24, 2007

NHS negligence kills a little girl

A five-year-old girl died during an operation when a trainee surgeon used an unfamiliar piece of equipment without her parents' knowledge, an inquest heard yesterday. Bethany Bowen died after the morcellator, a coring device with a blade, cut through a major blood vessel during the operation to remove her spleen.

Richard Bowen, her father, told the hearing that the first he and his wife had heard that surgeons were using a new piece of equipment was in the days after Bethany's death. Richard Whittington, the coroner, asked Mr Bowen if he would have given his consent if he knew a different surgical method was to be used during the operation in July 2006 at the John Radcliffe Hospital, Oxford. He replied: "We absolutely and completely trusted the people involved. If they had said they were using new equipment they had never used before, that was a different matter. You would think, `It is a new piece of equipment - why are they using it now?'."

Stephen Gould, a consultant paediatric pathologist who carried out the postmortem examination, told Oxford Coroner's Court that he had never before seen the type of internal injuries he found in Bethany's body. He could not give an accurate cause of death, adding later that the aorta could have been twisted and torn. He said that Kakina Lakhoo, the hospital's consultant paediatric surgeon, told him that the most likely cause of trauma was the morcellator. He added that he had never heard of the device.

Bethany, who lived with her parents and two brothers in Cricklade, Wiltshire, suffered from spherocytosis, a hereditary condition. It involves the body producing the wrong-shaped red blood cells, which are attacked and destroyed by the spleen. The anaemia it causes can be cured only by removing the spleen. Mr Bowen said that despite her condition Bethany was a "happy and lively" little girl who had a "whale of a time" during her first year at school.

The inquest heard that her brother, William, also had the condition and had his spleen operation when he was 2. Mr Bowen said he had assumed that the same surgeon who had carried out William's operation would conduct Bethany's. The inquest heard, however, that William Sherwood, a trainee surgeon, carried out the procedure on July 27 last year, despite having had no substantial training in using the morcellator device.


Australia: House full, overstretched midwives at NSW public hospital warn

SENIOR staff at the state's busiest hospital have threatened to close its doors to women in labour because there are not enough midwives or beds to cope with the baby boom and they fear lives are in danger. Angry midwives at Royal Prince Alfred Hospital in Camperdown wrote to the Herald to complain women were left to labour in chairs because the beds were full, and that they were asked daily to work double shifts to cope with demand. They said the maternity unit was down 29 midwives, and some staff were working three shifts in a 34-hour period.

"Our maternity services are stretched beyond a safe working capacity. We are constantly . asked to care for more mothers and babies than is humanly possible," one midwife, who sought to remain anonymous, said. "Patient safety is continually compromised . bed block is occurring every day. Delivery suite is constantly overcrowded with 14 women in an 11-bed unit and unsafe staffing levels." She said staff had requested that the maternity unit be closed to new patients when full or overcrowded to ensure its safe operation, and that women be transferred to other maternity units in the area.

"Our members have told us it is a complete crisis," said Hannah Dahlen, secretary of the NSW Midwives Association. "They have had vacancies they cannot fill, the staff are burning out and going elsewhere - they are getting desperate." While Ms Dahlen said that many other hospitals were in similar dire straits, she said Royal Prince Alfred was experiencing particular pressures because of a local baby boom. More than 5000 babies were delivered at the hospital last year - almost 1000 more than expected. "That is a 25 per cent increase in the birthrate, and there hasn't been a staff increase, in fact staff have been leaving." Add to that a crisis in the midwife workforce, where up to 600 positions are vacant across the state, and there was an increasing likelihood of mistakes and other problems occurring.

"The gold standard is one midwife to one woman, yet what we currently have is three labouring women to one midwife - it isn't the best care and we do know that the risk of adverse events increases when that happens." It was understandable that the midwives had chosen to make their complaints via a series of unsigned letters to the Herald, given all staff were under threat of disciplinary action if they spoke out against the state's area health services, she said.

However the executive director of Royal Prince Alfred Hospital, Di Gill, disputed the figures, saying there were only 15 vacancies in the unit. Miss Gill also denied that the delivery room was ever overcrowded and insisted "no woman has ever given birth in a corridor". She scoffed at the idea that nurses or midwives might feel that their jobs were under threat if they spoke out about conditions in the unit. "That is rubbish. I am not in the habit of sacking people and certainly not midwives."

Yet the nurses' union backed the midwives' claims. Its general secretary, Brett Holmes, confirmed to the Herald that less than two months ago, there were 29 vacancies in the unit.


Australia: New Victorian public hospital will have everything

Except enough doctors and nurses and beds. That's too hard. One billion dollars just to provide 46 extra beds? Unbelievable. But I guess that it compares with the $702m for just 27 more beds that the NSW government is spending

THE new $1 billion Royal Children's Hospital will have its own aquarium, Scienceworks, cinema -- even visits from zoo animals -- to help take patients' minds off their illness. Plans for the Royal Park hospital were unveiled yesterday, with work to begin within five weeks and finish by 2011. The new buildings will contain 353 beds -- 46 more than the existing hospital -- capable of treating an extra 35,000 patients a year. The original $850 million price tag has grown to an estimated $1 billion to accommodate a 90-room hotel, gym, two childcare centres and a small supermarket.

Premier John Brumby said the $150 million "add-ons" would be paid for by private investors with no cost to taxpayers, under the public-private partnership with the Children's Health Partnership consortium. "It will make it the most state-of-the-art, environmentally and family-friendly children's hospital, not just in Australia, but anywhere in the world," he said. Patients and families will have more privacy, with 85 per cent single bedrooms complete with bedside entertainment systems and pullout double beds for parents. It will be built in parkland immediately west of the present hospital.

A two-storey coral reef aquarium will dominate the hospital entrance, while Melbourne Zoo will bring animals to the hospital for interactive education programs. A Scienceworks display with 20 hands-on experiences and two large exhibit spaces, and a bean-bag cinema, will also help children relax between treatments. McDonald's has the option of keeping a store at the Royal Children's.

Having spent a combined three years in the hospital fighting cystic fibrosis, Leanna Babet, 15, said the comforting surrounds of the new design would put patients at ease. "It is overwhelming when friends come to visit sometimes because this hospital looks so much like a hospital, and with the new designs it just looks funky and cool," she said.

The Royal Children's will be Australia's first five-star green hospital, with a 45 per cent reduction in greenhouse gases and 20 per cent reduction in water demand [What a hot and smelly place that will make it -- if other "Green" buildings are a guide]. But that has not eased the concerns of Melbourne City Council environment committee chair Fraser Brindley, who said the Government missed the opportunity to increase the size of Royal Park by relocating the hospital to Docklands. The Government has promised to demolish much of the old hospital by 2014. It has also said there will be no net loss of parkland.


Friday, November 23, 2007

You may need to go to the High Court to collect on your health insurance in Britain

A dementia sufferer has won a landmark High Court battle to force the NHS to pay her nursing home fees. Hilda Atkinson’s family wanted health chiefs to recognise that she needed 24-hour nursing care, free on the NHS, rather than “social care”, for which local authorities can charge.

Mrs Atkinson, 94, with the backing of her daughter, finally won her case against Plymouth Teaching Primary Care Trust. In a settlement approved by Mr Justice Wilkie, the trust agreed to pay 43,000 pounds to cover nursing care between 2004 and July this year, and to pay future nursing home fees.

Mrs Atkinson – whose other ailments were Parkinson’s disease, angina, osteoporosis and deafness – left her home in 1998 after her husband died. By August 2000 her family, of Downderry, Cornwall, could not care for her any more. She has lived at Consort Village Care Centre in Plymouth since November 2002.

Many people have had to use savings or equity in their homes to finance social care. Nicola Martin, a solicitor with Hugh James, which has 400 similar cases,said: “This case has implications for hundreds of people throughout England and Wales. The issue is to do with whether someone is paying nursing fees because of a health need.”


Shooting the Messenger on Socialized Medicine

Post below lifted from Amy Ridenour. See the original for links

When Rudy Giuliani said the survival rate for prostate cancer is 82 percent in the U.S. but only 44 percent in Britain, which has socialized medicine, you'd think a typical American response would be sympathy for the Britons, and the logical British response, outrage at its government. You'd think wrong. The U.S. press corps devoted considerable energy -- and in some quarters, heated emotion -- to knocking down Giuliani's statistic, even when it had to twist logic like pretzels to do so. Meanwhile, the only outrage detected in Britain was against Giuliani -- for mentioning it. Yet Giuliani's point, which is that socialized medicine systems fare badly compared to our own, remains valid.

Among those springing to the defense of Britain's National Health Service: the Boston Globe, the Washington Post, the Associated Press, the New York Times, the St. Petersburg Times, Reuters, and, predictably, lefty columnists Paul Krugman of the New York Times and Eugene Robinson of the Washington Post. Take the AP story, which sought to take down Giuliani's statistics this way:
The American Cancer Society says that survival rates are actually higher and that it's misleading to compare the two countries. The group cautions that screening for prostate cancer is much more widespread in this country - meaning that in the U.S., higher survival rates include many whose lives probably weren't in danger and whose cancers might have gone unnoticed in the U.K.

Five-year survival rates were 95 percent in the U.S. and 60 percent in the United Kingdom, which includes Britain, in 1993-1995, the most recent time period with data to compare, the group said. Today, rates are higher - 99 percent in the U.S. and an estimated 74 percent in the U.K.

Doctors in the two countries have different approaches. That's because while aggressive prostate cancer can kill, it often grows so slowly, and is found when it's so small, that men die of something else before it ever threatens their lives or even causes symptoms. So there is disagreement - and studies conflict - over whether the chances of survival for men with low-risk tumors really improve with aggressive treatment, or if they can be closely monitored and treated only if their tumors grow, thereby avoiding side effects such as impotence and incontinence.

When you read that carefully you realize the thrust of the argument is that the U.S. system is not better than Britain's at handling prostate cancer because the U.S. system screens more aggressively for this cancer and catches it earlier. But isn't catching cancer early a good thing?

You'd think so, but apparently not when it makes socialized medicine look bad. "Doctors in the two countries," says the AP, "have different approaches. That's because while aggressive prostate cancer can kill, it often grows so slowly, and is found when it's so small, that men die of something else before it ever threatens their lives or even causes symptoms."

So if you are a British man using the National Health Service your taxes pay for, the NHS has decided that you don't need to know if you have prostate cancer early. After all, it "often" grows slowly, so why should you have the option of early treatment that could save your life? The British government will make this intensely personal decision for you. Meanwhile, your brothers in the United States will find out early that they have it, and will decide for themselves if they want to risk side effects by treating it early.

The AP story failed to tell readers that the American Cancer Society is not a neutral party to the debate over the merits of competing health systems. The American Cancer Society is devoting its entire $15 million advertising budget in the coming year to advocating universal health insurance in the United States. It's advocacy arm, the American Cancer Society Cancer Action Network, shills for an expansion of publicly-funded health care in the U.S., as in this statement by its president excoriating President Bush for wanting to expand SCHIP by $5 billion instead of $35 billion over the next five years:
The President today sided with the tobacco industry instead of America's children with his veto of the bipartisan bill to expand the State Children's Health Insurance Program (SCHIP). The President's action strikes a blow against efforts to provide health insurance to low-income children and to save lives through an increase in the federal cigarette tax. The SCHIP bill passed both houses of Congress last week with strong bipartisan majorities. We strongly urge lawmakers to do what's right for public health - not what's most advantageous for the tobacco industry - by overriding this veto.

The American Cancer Society is pushing a petition to all presidential candidates saying, "imagine a world where every man, woman and child has access to the proven screening exams that can detect cancer early and even prevent it," yet when the U.S. does better than Britain at screening for prostate cancer, it calls the early screening a "misleading" factor in comparing the quality of the two countries' systems.

Many of the news stories cited above noted that Giuliani got his statistic from Dr. David Gratzer of the conservative Manhattan Institute, an exceedingly reputable source, but they often went on to deride the reliability of Gratzer's work. None of them fairly represented Gratzer's compelling defense of the accuracy of Giuiliani's remarks. An excerpt:
Let me be very clear about why the Giuliani campaign is correct: the percentage of people diagnosed with prostate cancer who die from it is much higher in Britain than in the United States. The Organisation for Economic Co-operation and Development reports on both the incidence of prostate cancer in member nations and the number of resultant deaths. According to OECD data published in 2000, 49 Britons per 100,000 were diagnosed with prostate cancer, and 28 per 100,000 died of it. This means that 57 percent of Britons diagnosed with prostate cancer died of it; and, consequently, that just 43 percent survived. Economist John Goodman, in Lives at Risk, arrives at precisely the same conclusion: "In the United States, slightly less than one in five people diagnosed with prostate cancer dies of the disease. In the United Kingdom, 57 percent die." None of this is surprising: in the UK, only about 40 percent of cancer patients see an oncologist, and historically, the government has been reluctant to fund new (and often better) cancer drugs.

The press corps is willing to defend socialized medicine, even if it kills them.

Thursday, November 22, 2007

Massachusetts health insurance program going broke already

Surprise! Those marvellous "projections" were too optimistic. But it's a "success", of course

Enrollment in the state's new subsidized health plan is growing so quickly that the state could face a funding gap as large as $147 million by the end of the fiscal year, according to a state projection. An aggressive outreach campaign by the state, hospitals, community groups, and advocates, including an extensive push in the last few weeks, has put enrollment on a path that could reach nearly 180,000 by June 30. Even if signups slow, the program will probably still be over budget - a victim of its own success - because the state has already enrolled nearly as many people as expected for the fiscal year. "It's a good problem to have - people are getting insured and hopefully getting care," said state Senator Richard T. Moore, cochairman of the Legislature's Health Care Financing Committee. "But any shortfall is a big deal."

Budget officials cautioned that the projections could be too high, since there is little history on which to base them. The subsidized program is part of the state's unprecedented initiative requiring nearly all residents to have health insurance. Even if the gap reaches $147 million, there is no indication it would cripple healthcare reform. But the state would have to find ways to pay the insurance bills for so many more people. Options include appropriating more money, using funds allocated to care for those without insurance, or cutting extra payments to certain hospitals that were included in the law mandating insurance.

The state's budget chief, who also oversees the subsidized insurance program, indicated that the state is not considering a cap on enrollment. "It's too early to make any departure from the health reform plan," said Leslie Kirwan, secretary of administration and finance and chairwoman of the Commonwealth Health Insurance Connector. "We will follow the trends and adjust, if needed."

Financial pressures will grow for fiscal 2009, which begins July 1, since insurers who participate in the subsidized program are expected to ask for significantly higher payments from the state. In addition, there is uncertainty about how much the federal government will contribute toward the total cost.

The new enrollment and budget projection, obtained by the Globe last week, was prepared by the connector's chief financial officer, Patrick Holland, to alert board members to a potential problem. The state budgeted $472 million this fiscal year for the subsidized program, based on enrollment estimates made last winter. The program, called Commonwealth Care, provides comprehensive insurance to people without access to work-based coverage who earn less than 300 percent of the federal poverty level, or about $31,000 for an individual. The state money pays the full premium for the lowest-income residents and subsidizes the rest. Members are responsible for small copayments.

The connector began enrolling people in October 2006 and set a goal of 136,000 by June 30, 2008. Outreach has resulted in more than 133,000 people signing up. If enrollment reaches the high estimate of 178,280 by June 30, Holland said, the state cost could hit $619 million. Also driving up the cost was a decision by the connector last winter to eliminate premiums for thousands more people than originally planned, in an effort to make insurance more affordable.

The enrollment boom "is a sign of success, not failure," said John McDonough, executive director of the advocacy group Health Care for All. "The sky is not falling. There's a budget challenge." McDonough also said the higher enrollment suggests that there are more uninsured people in Massachusetts than state surveys showed.

Commonwealth Care is one part of the state's effort to cover the uninsured. Massachusetts has also signed up 55,000 additional adults and children for Medicaid and expanded options for private, unsubsidized insurance. All residents must have insurance by Dec. 31, if the state deems it affordable, or pay a penalty.

Holland noted one positive financial sign for Commonwealth Care: The average monthly medical costs incurred by newly insured members is lower than expected. The state has some flexibility built into its $27 billion budget to help fill the likely gap. Kirwan can shift money from the $448 million Health Care Safety Net Trust Fund, which pays for care at hospitals and health centers for uninsured patients.

Long-term funding of healthcare reform depends, in part, on shifting more and more of those funds to insurance subsidies over the next few years. However, this year's state budget includes significantly less money than last year's for the safety net, and spending in that account last year did not go down as much as some had expected, according to preliminary figures.

Hospital officials are concerned about getting stuck with unpaid bills. "There needs to be adequate funding for the safety net," said Joe Kirkpatrick, vice president of the Massachusetts Hospital Association. Money might also be taken from funds set aside for two hospitals that serve a large number of uninsured patients, according to discussions at a connector board retreat last month.

Boston Medical Center and Cambridge Health Alliance negotiated a special deal in the health reform law that guaranteed them $287 million a year through 2009 in fees and increased Medicaid rates. "That's probably on the table," said Moore.

In addition, he said, the state needs to work harder to reduce healthcare costs. The Legislature could also appropriate more money in a supplemental budget. Kirwan would not discuss possible funding options, saying it was too early in the year to determine if the shortfall would occur. One specialist in healthcare financing said the potential shortfall should not be minimized. "This is one of many warning signs, especially in tandem with the projected state budget deficit and the skyrocketing cost of healthcare in the state," said Alan Sager, professor of health policy and management at the Boston University School of Public Health. "The [healthcare] law is very shaky on the revenue side."


Wednesday, November 21, 2007

Sickening Canadian healthcare

There is a good reason Alberta spends more on health than any other province in the nation -- $3,695 per person -- and yet we wait longer for care. The Fraser Institute notes that if an Albertan sees a family doctor -- if you're lucky enough to have a family doctor, which in Alberta is fast becoming a mythical creature on the same order as a unicorn -- and are referred to a specialist, the average wait before actually getting treated is 19.5 weeks. This is not good.

It is not even up to the sad standard set by other Canadian provinces. Our American cousins look at such numbers and are appalled. Yet there is a very good reason for this. It is because the economic model for our health-care system, in Alberta and across the country, would be instantly recognizable to Josef Stalin and Mao Zedong. Mao and Stalin didn't believe in the rights of individuals to make economic decisions on their own, and neither do those who become hysterical and cry like little girls denied tickets to the new Avril Lavigne tour when it is suggested an absolute government monopoly on health care is killing us, financially and literally.

We have taken the economic model of the Soviet and Maoist collective farm -- the result of which was generally widespread starvation -- and applied it to the delivery of health care. Anyone surprised by the fact it doesn't work is probably also surprised Jack Layton isn't prime minister, the sun rises in the east, sticking a knife into a toaster hurts and that you can sit in a Calgary hospital emergency room suffering a serious gallbladder attack for eight hours before getting a shot of Demerol, which happened to the wife of a friend of mine recently.

Despite our institutionalized disdain in this country for all things American, if a U.S. citizen doesn't have health insurance and goes to a county hospital where medical care, as it is in Canada, is "free," the wait for treatment for a gallbladder attack is .... you guessed it ... about eight hours. The average Canadian, with his much-lauded, universal medical system, is treated like the average American without health-care insurance

Countries that provide a compassionate and intelligent mix of private and public health care simply do better. A recent survey of 28 countries that offer universal health care saw Canada place 26th in terms of medical outcomes for every dollar spent, 18th in access to CAT scans and 22nd in infant mortality. Because of the presence of (gasp of horror!) capitalists in the systems outperforming ours, such as Australia, they have embraced the discipline of the free market, which delivers any product -- from iPods to heart surgeries -- more efficiently and effectively. We place so low because if you're not rewarded for efficiency ... you'll be inefficient.

We used to have a mixed system in this country. Some doctors remained in the public system. Others opted out all the way. Some took publicly insured patients and extra-billed them. That has all been taken away in the name of equality -- the same sort of equality lauded by Mao and Stalin -- and the result has been predictable.

This country saw health care costs rising and decided it would .... restore free market discipline? Naw. We decided to limit the number of doctors graduating and, in a peculiarly Alberta solution, blew up a freaking hospital without having built a new one first. So we now have doctor shortages and hospital bed shortages and the only people surprised are the same ones wondering how come the sun rises in the same place every day. It'd be enough to make you sick if you weren't afraid you wouldn't get timely treatment.


Australia: Regulators finally do something about irresponsible health bureaucrats

QUEENSLAND'S former chief health officer, Gerry FitzGerald, faces disciplinary action for his role in the Dr Death scandal at Bundaberg Base Hospital after a dogged two-year pursuit by a doctor with the Royal Flying Doctor Service on the other side of the country. The Medical Board of Queensland, which had been reluctant to launch proceedings against anyone over the Bundaberg hospital disaster, with the exception of surgeon Jayant Patel, is preparing to start disciplinary action against Dr FitzGerald, one of its former members, for failing to act swiftly.

The decision of the board is sensitive because it was initially dismissive of calls for top administrators to be held accountable. It was pressed into an investigation of Dr FitzGerald by a West Australian-based doctor with the RFDS, Simon Evans. Documents obtained by The Australian yesterday show the board has now agreed that Dr FitzGerald received serious complaints about Dr Patel in early 2005 but "failed to take proper action to ensure that Dr Patel was limited to surgical work that he and the hospital could satisfactorily perform". Dr FitzGerald said yesterday he was "very disappointed" with the board's decision. He said he had tried to do his best under difficult circumstances.

Dr Evans hopes the latest decision will send a powerful message to senior bureaucrats and administrators in charge of health systems that they are not immune from disciplinary action usually reserved for clinicians. Dr Evans urged the board two years ago to start disciplinary action against Dr FitzGerald, who had resigned from Queensland Health after giving evidence at a 2005 judicial inquiry into the problems at Bundaberg Base Hospital, as well as other administrators. "They told me they had absolutely no intention of taking any disciplinary action against any administrators adversely named in the report (of the inquiry)," DrEvans said yesterday from his home in Derby, in Western Australia.

Undeterred by the rebuffs, Dr Evans researched the evidence in greater detail, cited legislation and administrative negligence cases from Britain, and wrote several letters accusing the board of failing in its responsibilities. "From my time at Queensland Health as a clinician I could see where the major problems were - they were with senior medical administrators," Dr Evans said.

The board has concluded that Dr FitzGerald "failed to recommend suspension of Dr Patel when he could and should have done, thus exposing patients to undue risk of harm". The matter is to be heard by the Health Practitioners Tribunal. Medical practitioners found guilty of unprofessional conduct face penalties ranging from fines to being struck off as doctors.

Serious concerns relating to Dr Patel's performance at the Bundaberg hospital were not properly addressed until senior nurse Toni Hoffman put her job on the line by going public in 2005 with evidence of unnecessary deaths and injuries resulting from Dr Patel's surgery.

Dr Patel, who has lived in Portland in the US state of Oregon since fleeing Australia in April 2005, will be arrested by US marshals when the paperwork is completed between Australian and US authorities, possibly as early as next month. The extradition request is understood to relate to 16 charges, including manslaughter and grievous bodily harm, arising from his time at Bundaberg Base Hospital.

Tess Bramich, the widow of a patient who died at the hospital, said she had "forgiven" Dr FitzGerald. Mrs Bramich said since Dr FitzGerald was facing disciplinary proceedings, other administrators also needed to be dealt with. A senior source said the board had always been uncomfortable with the prospect of taking action against a former member. The board permitted Dr Patel to practise in Queensland, overlooking his history of serious disciplinary action for botched surgery in the US.

Retired Supreme Court judge Geoff Davies QC, head of a public inquiry in late 2005, made strong findings against Dr FitzGerald for not acting on a clinical audit that showed Dr Patel's complication rate was at alarming levels. The inquiry ruled that Dr FitzGerald's decision to permit Dr Patel to continue to practise "was a course designed to minimise publicity and in effect conceal the truth. The interests of the patients were ignored." Mr Davies told Dr FitzGerald: "You knew he had 25 times the complication rate for a very normal piece of surgery. "What more do you want to protect the potential patients of Bundaberg Hospital?"

Dr FitzGerald, who won support from patients and Ms Hoffman because of his candour and his apologies on behalf of the health system, has denied he set out to conceal information. He now works at the Queensland University of Technology.


Tuesday, November 20, 2007

Britain: Thousands dying ‘because simple screening system has been delayed’

Delays in introducing a screening programme for a deadly blood condition are costing the lives of thousands of men each year, doctors say. Aortic aneurysms — swellings in the main artery of the stomach — can kill without warning and are the third most common cause of death for older men. But the Government has failed to bring in a national screening programme nearly two years after it was urged to do so.

All four UK health departments are considering whether all men in their mid-sixties should be screened for an abdominal aortic aneurysm (AAA), which is found in up to one in ten men aged 65 to 79. About 7,000 men bleed to death every year because of the condition, even though it can be prevented by a simple operation.

Campaigners say that checking whether men are at risk of a ruptured aneurysm would cost 25 million pounds, half the price of the breast cancer screening programme, and would save as many lives — at least 3,000 a year. The UK National Screening Committee recommended the programme in January last year and sketched out how it would work in May this year.

The abdominal aorta carries blood to the intestines and other organs nearby. Aneurysms, in which the arteries weaken, stretch and bulge, are common in this part of the body. Ruptured aneurysms are catastrophic: more than 85 per cent of men die when an unsuspected aneurysm bursts, compared with only 5 per cent of those who have a planned operation. However, those at risk can be assessed by a simple ultrasound scan.

George Hamilton, president of the Vascular Society of Great Britain and Ireland, accused ministers of unnecessary delays in implementing a full screening programme. “Ruptured aneurysm is a common and painful way to die. The evidence in support of screening is incontrovertible,” he said. The test, which involves measuring the diameter of the aorta, is funded in only a few areas, such as Gloucestershire, where a screening programme has been running since 1990. Yet doctors who offer screening to patients privately have been frustrated by criticisms that they are illegally charging for the service. Brian Heather, a vascular surgeon who pioneered screening for AAA cases at the Gloucestershire Royal Hospital, said that the test could be performed with a briefcase-sized portable ultrasound machine.

Factors that can contribute to the likelihood of developing an aneurysm include family history and risk factors for heart disease such as smoking, obesity and high blood pressure.

Derek Kendall-Smith, 77, a former England rugby international and managing director of a jewellery firm, had surgery for an aneurysm two years ago. He said that a 95 pound voluntary test had saved his life. “If I hadn’t been screened I would have had no idea there was ever a problem,” Mr Kendall-Smith, of Marlow Bottom, Buckinghamshire, said.

A Department of Health spokesman said: “This assessment has to take account of the likely impact on existing healthcare services and the infrastructure and staffing requirements.” [Translation: It would cost too much]


Australia: Public hospital staff warned of prison for media leaks

Health authorities in Western Australia say public hospital staff have been warned they could face two years in prison if they leak confidential reports on adverse incidents. The Health Department is investigating the case of a confidential form, leaked to a Perth newspaper last month, that detailed the case of a man who died from a heart attack in Royal Perth Hospital's emergency department. The man had been admitted for a different health complaint, seen by doctors, stabilised and left on a trolley in the emergency ward awaiting a bed. After 11 hours in emergency, he suffered a massive heart attack and was unable to be resuscitated.

Royal Perth's executive director, Philip Montgomery, said it was the first state breach of a 1973 commonwealth law designed to protect the confidentiality of staff making incident reports under the Advanced Incident Management System, or AIMS. He said the hospital was concerned about the leaking of the AIMS form: "The point of the system is to encourage and facilitate staff to report incidents in such a way that their identity is protected, so clinical care can be improved."

Dr Montgomery said the penalty for releasing incident reports was two years in prison. "The consequence is that we've gone back to all our staff and made them aware you can't breach confidentiality." The matter could be referred to the Corruption and Crime Commission. Dr Montgomery said he accepted the man's 11-hour stay in emergency was too long "but we don't believe there has been any inappropriate clinical care".

An emergency staff doctor told The Weekend Australian the number of AIMS reports had dropped off immediately after the media story, because of staff fears of public disclosure.


Monday, November 19, 2007


Three current stories below:

Barely-disguised corruption from a State government

Labor push to gag hospital inquiry

The NSW Labor Government has moved to shut down a parliamentary inquiry into Royal North Shore Hospital before it hears more damning evidence of malpractice. The Weekend Australian can reveal Labor used its numbers on the inquiry committee to vote down a proposal by Coalition members, at a closed meeting on Wednesday evening, that would have extended the inquiry's reporting deadline past December 14 and also put aside extra days for public hearings.

The cave-in preceded a direct plea to the inquiry yesterday by the couple whose tragedy at RNSH led to the inquiry being established. Mark Dreyer, whose wife Jana Horska miscarried in a toilet adjacent to the hospital's emergency unit on September 25, begged committee chairman Fred Nile to extend the committee's deadline in order to do a thorough job. "There is no deadline that applies to our ongoing grief," Mr Dreyer said.

Asked by Mr Nile what he hoped for from the committee, he replied: "I hope you give this inquiry the necessary time it needs and not be pressured to finish it off by the recommended time of December -- that's what I'd like to say to you personally. "You are a man of high moral standards so I've got some trust in you to carry out what's required." Mr Dreyer added it was important to allow anybody with a story ample time to bring it to the inquiry. "We certainly won't fail you," said Mr Nile, fully aware the committee had already done so.

Informed of the secret committee vote last night, Mr Dreyer said: "This was always my fear, based on the track record of this Government. I put a challenge out to Nile today to show his supposed impartiality. "If this is going to be the case and we don't get the extension we desperately need, we have an inquiry that is doing half the job. Why bother?"

In an emotional 30 minutes of testimony, Mr Dreyer and Ms Horska both wept as, speaking on his wife's behalf, Mr Dreyer described the nursing care she received at RNSH as cold, robotic and mechanical. "There was no comfort, no reassurance to either of us ... in the darkest hour of this ordeal -- there was nothing," he said. He said his pleas and those of Ms Horska, who was in agony, to nursing staff for assistance were "like talking to the wall". "It was urgent to us but not to them," he said.

In further shocking testimony, he said that after her miscarriage Ms Horska was placed on a trolley and left for an hour with her dead baby between her legs. He described as "unbelievable" the insensitivity of NSW Premier Morris Iemma in expecting the couple to provide evidence to a committee of senior doctors during the same week they received pathology results confirming their baby was a boy.

He said that on the morning after the miscarriage, his wife received a visit from a hospital bureaucrat engaged in "damage control" before she was allowed to see a gynaecologist. Earlier, RNSH's director of medical services revealed the hospital relied on charity for basic equipment such as lasers and specialist operating tables. Sharon Miskell told the inquiry that only the skill of the hospital's surgeons had prevented "adverse outcomes" resulting from broken or decaying equipment.


NSW: Fix the hospital or we'll quit, warn doctors

SENIOR surgeons are threatening to resign if the Government does not restore Royal North Shore Hospital to its former glory. Their warning came as the couple who sparked the latest inquiry, Mark Dreyer and Jana Horska, broke down as they relived their ordeal of her miscarrying in the hospital's toilet.

Silence fell over the room as Mr Dreyer detailed the night his wife lost their unborn child on September 25, when Ms Horska was 14weeks pregnant. "There is no deadline to our ongoing grief and suffering," Mr Dreyer said. "It has cost both of us terrible grief and we will always be wondering if the outcome would have been different if we had been treated as a priority."

Christian Democrats' leader Fred Nile, the parliamentary inquiry committee's chairman, promised the couple "the inquiry won't fail you". Mr Dreyer said he had no faith in the Government for implementing change. "I think people would have had a lot more respect for (Premier) Morris Iemma to come out and take the politics out of it, take away the political spin which has been very hurtful for us," he said. "The insensitivity has just been unbelievable, they don't understand the pain they cause with this rubbish they peddle."

There is only one more day of public hearings, on Monday, before the committee retires to consider its recommendations. But it has been swamped with damning complaints which doctors from the hospital have said are an embarrassment. The inquiry was told equipment was so inadequate that only the competence of surgeons had prevented harm coming to patients. Director of medical services Dr Sharon Miskell said there had been instances where equipment was broken, inadequate or non-existent. "We are unable to perform surgery, we are delaying surgery," she said.

Three of the hospital's senior surgeons spoke of their embarrassment at the gradual decay of the once marquee hospital. Area director of intensive and critical care Professor Malcolm Fisher warned he was on the brink of quitting. "The findings of this committee and the response of the health department are crucial," he said. "They will determine if we give this a go or walk." Other doctors described the health department's "inept system" as failing patients as well as being the cause of the hospital's loss of staff. Intensive care director Dr Ray Raper said he was embarrassed this week at a patient's recount of a hospital stay. "My colleagues have been telling me for a long time they are embarrassed of the conditions of the hospital," he said.


Oppressive health bureaucracy defeated in court

Angry obstetricians have demanded an apology from a regional health service after a judge last week threw out its attempt to sue one of its own doctors to claw back part of a $7.5 million negligence payout. Birth specialists condemned the case brought by the Greater Southern Area Health Service in southern NSW as a waste of taxpayers' money and "a disgraceful attack" on Wagga Wagga obstetrician George Angus. The GSAHS had claimed Angus should be jointly liable to pay $7.5 million awarded in respect of a birth at the Wagga Wagga Base Hospital in 1995 -- even though he was merely the senior obstetrician on-call and denied ever being consulted about the case.

During the birth the baby's shoulders became stuck and the baby's brain was deprived of oxygen for several minutes. The child has cerebral palsy, epilepsy and moderate intellectual disabilities. The health service admitted liability in the negligence claim brought on behalf of the family, and it was settled in May 2003. The GSAHS's subsequent move to sue Angus sparked alarm among obstetricians throughout NSW.

Justice Michael Adams in the NSW Supreme Court rejected the health service's case, ruling that a more junior doctor did not consult Angus on whether a drug to increase contractions should be given to the mother during labour. The judge also ruled there was nothing to suggest Angus acted in a way that was medically inapppropriate on the basis of the knowledge he had at the time. Adams ordered the health service to pay Angus's costs. Megan Keaney, head of claims in NSW for Angus's insurer, Avant, said she was "confident" total costs for both sides would exceed $500,000.

"The fundamental reason that he (Angus) won was that the court confirmed that he had not seen the patient," Keaney told Weekend Health. "It was the hospital's case that he had. It was always our view that the evidence to support that assertion was very slim. "There's no doubt that this has created a lot of ill-will between obstetricians in rural south-western NSW and NSW Health. That's quite understandable, given their (GSAHS's) approach to this claim."

Christine Tippett, president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said had the case gone the other way the "implications for doctors on call would have been very serious". "What it would have meant was that any doctor on-call for a public hospital could have been called as a co-defendant on a claim, even if they had not been called (for advice) or provided any service for the patient," Tippett said. "That's quite untenable. We consider that Angus should receive an apology for the distress that this case has caused him."

Albury-Wodonga obstetrician Pieter Mourik, who was previously the representative for the Wagga region on the RANZCOG council, said the case was a "tragedy" and the GSAHS should "hang its head in shame" for bringing the action. While he welcomed the outcome, he said the "damage has already been done" as Wagga's three obstetricians were no longer working at the Base hospital, now served by locums and overseas-trained doctors.

"The NSW Department of Health is also responsible for this disgraceful attack on a capable, rural obstetrician," Mourik said. Angus told Weekend Health the outcome was anticlimactic "because I didn't think they had a case in the first place".

"To be dragged through the court for 10 days, for something I know nothing about, and didn't know anything about -- and then to be told you're not guilty of something that I was not guilty of in the first place -- it was a bit of a hollow victory," Angus said. "The sad thing about this is the fact that all this public money on a court case that had no merit. (Other doctors) are very suspicious of the health service now -- the GSAHS has done itself a disservice."

After the case GSAHS chief executive Heather Gray declined to say if an apology would be forthcoming. A GSAHS spokesman this week declined to add to her comments. "The Greater Southern Area Health Service and NSW Health is still to review in detail the judgment handed down," Gray said in a statement. "The costs are yet to be determined. GSAHS is making no further comment on the matter at this time."


Sunday, November 18, 2007

Australia: Long wait imposed by public hospital permanently damages baby

No recognition of what the failure to provide prompt treatment could lead to

Another mother has told of her harrowing experience at the Rockhampton Base Hospital, furious over a bungle that caused her four-month-old daughter to lose an ovary. Nicole Simpson yesterday revealed how she waited two months for contact [an appointment] from the hospital after her daughter Jade was referred there with a hernia by their family doctor.

The details of how Jade was treated will stoke the anger that has reverberated around the state after The Courier-Mail reported this week that two-year-old Ryan Saunders from Emerald had waited 30 hours in September before his twisted bowel was diagnosed in Rockhampton Hospital. Ryan died just as he was about to fly to Brisbane for an emergency operation.

Jade Simpson's ordeal came to light as Queensland Health chief health officer Jeannette Young insisted the Rockhampton Hospital was doing a good job. Dr Young spent yesterday at the hospital to hear directly from staff, many of whom are upset over the attention Ryan's case has received. "They have got a very good paediatric service, there is nothing wrong with it at all," she said.

Jade's hernia burst before the hospital made any contact and she spent three days in pain at the hospital waiting to be transferred to Brisbane by the Royal Flying Doctor Service. Mrs Simpson and her daughter were eventually forced to catch a commercial flight, and Jade was operated on 30 minutes after arriving at the Royal Children's Hospital. The operation in March 2006 came too late to save one of Jade's ovaries. "She has only got a 50 per cent chance of having children when she is older and it is all their fault," an angry Mrs Simpson said. "If she had been seen to earlier should would still have two."

Queensland Health is undertaking its own probe, known as a "root cause analysis". However, Mrs Simpson said her daughter's ordeal was also the subject of a "root cause analysis" which she condemned as little better than a cover-up. "All it basically said was 'we did our best, too bad, so sad'," she said. Mrs Simpson said she warned politicians, from local MP Robert Schwarten through to former premier Peter Beattie, of the hospital's shambolic efforts in a bid to prevent further children from suffering. "The main reason for writing to them was so it didn't happen again but it did and this time someone died," she said.

Dr Young yesterday said she was unaware of Jade's case but insisted the hospital was performing well. She met Ryan's parents Donna and Terry on Monday to discuss their son's treatment and hear their concerns. However, she dismissed criticism of Ryan's 20-hour wait for an ultrasound scan after he had been sent from Emerald with a suspected twisted bowel. "It is not a lack of equipment, it is not a lack of staff, it is not a lack of resources," Dr Young said.


Saturday, November 17, 2007

Australia: More public hospital craziness

This is utterly insane. $702m for just 27 more beds -- or $26 million per bed. And that's just the building cost

Plans to redevelop Royal North Shore Hospital will only mean an extra 27 new beds, which would fall short of meeting future demand, doctors have told a NSW parliamentary inquiry into the hospital. NSW Health Minister, Reba Meagher said this week that a $702 million redevelopment would result in the hospital having 626 beds, including 46 critical care beds and 40 mental health beds.

At the inquiry today, the hospital's director of trauma Tony Joseph said the minister's comments was the first time that number had been revealed. "Thus the new hospital will provide a total of 27 more beds than the current total of 599, which is a concern, given the projected population growth for the northern part of Sydney," Dr Joseph said. He said he had done a recent snapshot survey of the hospital and found that 10 out of 24 wards at the hospital's main clinical services block had been closed or converted to "other non-inpatient services".

The inquiry was set up after Jana Horska, 32, miscarried in the toilets of the hospital's emergency department in September. Ms Horska is to appear before the inquiry this afternoon.


Friday, November 16, 2007

Australia: Toddler dies in agony after public hospital negligence

The Queensland government has ordered a review into the death of a three-year-old boy who was allegedly left untreated for 30 hours at a regional hospital. Nationals MP Vaughan Johnson told state parliament today Ryan Saunders was rushed by helicopter from Emerald hospital to Rockhampton hospital "where he lay screaming in agony for over 24 hours with his distraught, traumatised and helpless parents by his side".

Mr Johnson said Ryan was suffering stomach pains and was taken to Emerald hospital by his parents on October 25. He was later transferred to Rockhampton following fears he may have a twisted bowel. Mr Johnson said Ryan was ignored by doctors for more than 24 hours at Rockhampton hospital and died the next day. "They virtually did nothing with him for about 30 hours ... This is just totally unacceptable," Mr Johnson said. The MP called for an investigation into the incident.

Queensland Health Minister Stephen Robertson said the case had been forwarded to the coroner and an independent review would also be carried out. "Central Queensland Health Service District will also be commissioning a root cause analysis to look at the care provided and identify if there are any issues that need to be addressed to improve the care that was provided," Mr Robertson told state parliament. "This analysis will be provided by an expert team external to Central Queensland Health Service District." Mr Robertson said it would be inappropriate to discuss the details of the case but acknowledged "the tragedy that did befall that family".

He said health officials had already met with Ryan's parents and would meet with them again on Friday. "At these meetings, the family will be provided with all available information in relation to the care provided," he said. The minister said the findings and recommendations of the independent review would be made available to the family.


Thursday, November 15, 2007

Australia: More revelations about NSW public hospital

Amazing that this was ever tolerated

Cockroaches crawled over patients undergoing surgery and theatre staff were forced to catch a falling patient after an operating table collapsed in the middle of a procedure at the Royal North Shore Hospital. The incidents were part of a litany of horror stories about the hospital that were revealed as a NSW parliamentary inquiry into the RNSH began yesterday. In a written submission to the inquiry, Jeffery Sleye Hughes, who was senior orthopaedic consultant at the hospital for 12 years until this year, detailed:

* patients with infected joints and compound fractures being "left to rot" in wards for 18 hours or more because of "inappropriate theatre management";

* patients being lied to about the reason their surgery was delayed, by units in the hospital trying to cover their backs;

* live cockroaches running over operating theatre tables during surgery;

* high-pressure hoses exploding in theatre during operations and injuring staff; and

* operating tables collapsing during surgery, with surgeons forced to catch falling patients.

The inquiry, which is due to report next month, was called following the publicity surrounding the case of Sydney woman Jana Horska, who miscarried in a toilet adjacent to the hospital's emergency unit in September, after waiting hours for treatment.

In another submission, Sydney woman Maureen Cain told how her husband lost both legs after contracting a staph infection at the hospital in 1998. "The family and I were horrified at the filthy conditions but, as we were so occupied with supporting our husband and father, (we) did not do anything at the time," Mrs Cain wrote. "Wards were dirty, bed frame had congealed matter on it, there was no ventilation in the bathroom, syringe left under the bed for three days before I picked it up - I could go on and on."

NSW Health Minister Reba Meagher insisted conditions would improve under new management and stressed the need for better financial management to end budget overruns. "There will be no cuts to nurses, no cuts to doctors and no cuts to beds," Ms Meagher said. "Our investment in frontline services will continue to increase in those important areas, but it is important that the hospital's financial management is improved and there have been a number of ideas floated."

Acting nursing director Linda Davidson told the inquiry nurses at RNSH had been spat at and abused in the street following coverage of problems at the hospital. "I have had it reported to me that some nursing staff in the community are actually undergoing similar situations that their colleagues at Camden and Campbelltown experienced, which was abuse in the streets and actual spitting episodes," she said. "So when that comes back within that environment, the morale does tend to wane accordingly." Nurses at Campbelltown and Camden Hospitals were abused in the streets when the hospitals were at the centre of maltreatment allegations in 2004.


Wednesday, November 14, 2007

Head-in-the-sand health bureaucrats in Australia

Queensland ambulance bosses were warned months ago about chronic understaffing and overworked paramedics suffering severe fatigue on the job. Confidential workplace health and safety documents obtained bt The Sunday Mail reveal that stressed frontline troops raised concerns as long ago as 2005. They warned that driving ambulances while fatigued threatened paramedics, patients and the public.

One said it was not uncommon for paramedics to have micro-sleeps at the wheel. A supervisor submitted a report to the Qeensland Ambulance Service workplace health and safety officer in May, outlining specific problems in Southeast Queensland. He recommended a review of fatigue policies: using other staff to drive fatigued officers back to the station and then home; and communications officers being more vigilant about overtime. He also called for an investigation by an independent agency.

Sources said yesterday that the report was ignored by QAS management. Stanthorpe ambulance Officer Julie Clark last week gave The Sunday Mail details of a nightmare shift of 36 hours. Ms Clark, 43, a trainee paramedic, said there were major safety concerns for all people involved and that someone could have been "in- jured or worse, killed" if she had fallen asleep. Ambulance Commissioner Jim Higgins said long shifts were "rare" but conceded the Clark situation "could have been managed better".

Paramedics were critical of Mr Higgins' claims and said marathon shifts were common. Several recently complained to their supervisor, who filed a report with the QAS workplace health and safety officer. "As the immmediate supervisor of staff who are regularly driving while fatigued, I have great concern about the safety of these officers and the members of the communitv that are exposed to these fiatigued officers." he wrote. "The QAS itself has identified that fatigue as an issue ... (but) this has not translated ... because we are quite regularly working 16 hours plus.

The supervisor said officers strongly believe that the community deserved better than being treated by a fatigued officer who couid possibly make an incorrect decision about the emergency health treatment given, which could lead to long-term ill-health or even death. Emergency Medical Service Protection Association president Prebs Sathiaseelan said it was just the "tip of the iceberg". "QAS management has known about the problem for a longtime. They received documentation through the normal channels of communication, but it was ignored," he said. Emergency Services Minister Neil Roberts said he had asked Mr Higgins to send a notice to all ambulance officers tomorrow reminding them of measures in place to alleviate fatigue.

The above article by Darrell Giles appeared in the Brisbane "Sunday Mail" on November 11, 2007

Australia: Public hospital neglect 'killed mother'

"DON'T leave your loved ones alone at Royal North Shore Hospital." That is Lindy Batterham's advice as, one year after the agonising and preventable death of her mother, Joyce, she struggles to come to terms with the negligent care the 90-year-old received at RNSH, and the cover-up that followed. Left at the hospital overnight, simply so that her heart medication could be assessed in the morning, Joyce was dropped on the floor by a nurse, broke her hip, suffered a stroke during surgery and died six days later. "I'll be traumatised by my mother's last six days for the rest of my life, having flashbacks of witnessing her dying in a nightmare of pain," Ms Batterham, 52, said.

Her account of her mother's last days, revealed to The Australian yesterday, is one more RNSH horror story embattled NSW Health Minister Reba Meagher doesn't need as she prepares to front a parliamentary inquiry into the hospital this morning. The inquiry has been forced on the NSW Labor Government following the case of Jana Horska, who was left to miscarry in a toilet adjacent to the hospital's emergency unit in September. Ms Horska's case provoked an avalanche of complaints against the hospital.

When Ms Batterham left her mother at RNSH around midnight on November 10 last year, Joyce, who lived with Ms Batterham, was alert and in sound health. After arriving by ambulance at RNSH emergency at about 6pm with breathing difficulties that had been successfully treated before, Joyce did not see a doctor until 3am the following morning. Those nine hours were spent in great discomfort.

As the result of a pressure sore and poor circulation causing pain in her good leg, Joyce spent much of the time sitting on the edge of her ambulance stretcher, dangling her leg over the side. The doctor said there was nothing much wrong with Joyce and that she could stay overnight in the hospital's aged-care ward and see a specialist about her medication the following morning. Exhausted, Ms Batterham went home, little imagining she would never speak to her mum again.

"She could still be with us now, but because one nurse tried to move my mum, who was a large woman with only one leg, from her wheelchair to a hospital bed without a rail or anything for my mother to hold on to, she was dropped to the ground, resulting in a broken hip," she said. "When I arrived about an hour after Joyce had been dropped, I found they had put her back in the wheelchair and given her painkillers to address the extreme pain she complained of, then left her, with no access to a buzzer. "It was only after I intervened and insisted she be seen by a doctor and X-rayed for a possible fracture, and laid down on the bed instead of with her leg dangling, that these things finally happened." Three hours after being dropped, Joyce was finally seen by an orthopedic surgeon.

But there were more bungles ahead. Joyce's surgery the next day, Sunday, was postponed - without her or Ms Batterham being told. And when Ms Batterham phoned on the Monday morning to ask when the surgery would happen, she was astounded to hear it had already begun. She was unable to comfort her mother before surgery and was denied the opportunity to speak with her again, since Joyce was unable to communicate following a stroke on the operating table.

But what really angers Ms Batterham, as she prepares to lodge a submission with the parliamentary inquiry, is the hospital's lack of accountability and the way key details were airbrushed out of the written report she finally received on Joyce's death, which is being investigated by the Coroner. There was no mention of the fact Ms Batterham had to beg for her mother's hip to be examined by a doctor. No mention of the fact her pain was misdiagnosed by nurses as being the result of poor circulation. Above all, there was no admission that the attempt by a nurse to lift Joyce by herself, with no handrail, was a dangerous practice.


Tuesday, November 13, 2007

It looks like Britain does not have a monopoly on filthy public hospitals

Cockroaches crawled on operating tables during procedures, the inquiry into Sydney's Royal North Shore Hospital [Australia] has been told. Health Minister Reba Meagher is the first witness to face the inquiry this morning, being held at NSW Parliament. The hospital's doctors and former management are giving evidence into the hopital, which has been the centre of many complaints over the past two months. One doctor, who has since resigned, complained of the filthy conditions in operating theatres.

Nationals state MP Jenny Gardiner told the inquiry the allegations were made in a submission from the doctor who worked at the hospital for 16 years. "He refers to the killing of live cockroaches on operating theatre tables during operations and `no response when I forward a written complaint and response is requested'."

Ms Meagher said that was unacceptable. "That is why the new management has responded to concerns of staff at the hospital and ordered a complete clean of the hospital," Ms Meagher said. Contract cleaners were sent to the hospital on the eve of a tour of the facility by the parliamentary committee. Ms Meagher has denied the clean-up was an attempted cover-up, saying it was done after a request by staff and had been arranged before the committee indicated it would visit.


Monday, November 12, 2007

Medicare whistleblowers under attack

A day after legislation was introduced in the House calling for a moratorium on a controversial Medicare auditing program, the Atlanta-based company at the center of the California fight came out swinging. PRG-Schultz International officials, breaking their silence Friday for the first time since the controversy erupted this summer, disputed charges that it is mishandling the audits. They said that millions of dollars in overcharges they have identified at rehabilitation hospitals are returning money to the Medicare program just as Congress intended – and that only a fraction of its determinations are being overturned on appeal. Even so, they said the company has voluntarily agreed to forgo commissions that it is entitled to under its contract on decisions that are later overturned on appeal.

"They believe we are bounty hunters," N. Lee White, who heads U.S operations for PRG-Shultz International, said of California lawmakers and the California Hospital Association. "I don't appreciate the characterization."

California House members, prodded on the hospital association, have complained about the targeting of rehabilitation hospitals treating elderly patients recovering from knee and hip replacement surgery. More than 90 percent of those claims have been rejected by the auditors on grounds that they are not medically necessary. Auditor decisions have led to millions of dollars being withdrawn from the hospitals, putting some of them in financial jeopardy and altering treatment decisions for future patients.

On Thursday, Reps. Lois Capps, D-Santa Barbara, and Devin Nunes, R-Visalia, introduced a bill that would halt the program for a year while it is studied more deeply by CMS – the Centers for Medicare and Medicaid Services – which oversees it, and by the Government Accountability Office, the auditing arm of Congress. The two lawmakers charged that CMS has failed to answer questions about the program. The agency ordered a "pause" in PRG-Schultz's review of rehabilitation hospitals because of the concerns, but the lawmakers were unable this week to find out if the auditing has resumed.

White said the pause is still in effect, meaning that it has been extended longer than the month that was initially envisioned. The fact that the rejection rate has been so high, he said, is a reflection of how patients are being unnecessarily directed into the high-cost rehabilitation hospitals, taking money out of the Medicare program that otherwise would be going to serve other patients. But White noted that many of the 85 or so rehabilitation hospitals whose claims have been reviewed have had no rejections. "This implies that there are others who are doing it disproportionately wrong," he said. "Our charge is to find the people who have overcharged for whatever reason and recoup the money."

White also disputed critics' charges that it is the only for-profit company doing the audits. PRG-Schultz advertises itself as the largest recovery auditing company in the world, and White said it has many other government agencies and large companies among its client list. "We are a serious company, and we take this seriously," he said. The auditing program is part of a pilot project authorized by Congress that began in 2005 in California, Florida and New York. PRG-Schultz is the contractor selected for California, and it hopes to expand its work to other states when the program begins to expand nationally next year. The program was intended to help control skyrocketing Medicare costs by adding another tool to check for claims errors.

"To date, more than $230 million in overpayments to health care providers have been found in California alone," according to a recent handout the company said was distributed to California lawmakers. One criticism of the program is that it uses "recovery auditors" who are paid commissions. The hospital association said PRG-Schultz receives 25 to 30 cents on every dollar it recoups. In a two-hour meeting with McClatchy Newspapers on Friday, White declined to confirm that rate but didn't dispute it, either.

White acknowledged that auditors have focused heavily on rehabilitation hospitals' work with knee and hip replacement patients. He said that it is examining these claims because the GAO had identified the area as one likely to involve overcharges. "Although some joint replacement patients may need admissions to an inpatient rehabilitation facility, our analysis showed that few of these patients had comorbidities that suggested a possible need for the intensity of services offered by an IRF," the GAO said in an April 2005 report. Comorbidities are medical conditions in addition to the surgery that could complicate a patient's recovery. Because rehabilitation hospitals are prepared to handle the most needy of patients, their rates are much higher than alternative facilities such as nursing homes.

"The issue is not whether a joint replacement patient needs rehabilitation," White said. "It's the level of care needed. The issue is what is medically necessary for that patient."

Capps said in a statement Friday that she and Nunes introduced their bill because the auditing program was hurting health care for the elderly and the Centers for Medicare and Medicaid Services was refusing to answer questions about it. "I'm as concerned about ending Medicare fraud as anyone, but I'm also concerned when a poorly managed government program is running quality providers like the Santa Barbara Rehabilitation Institute out of business for no good reason," she said. Jan Emerson, spokeswoman for the hospital association, said, "We stand by our previously expressed concerns."