Friday, February 29, 2008

e-Second Opinions: 100 Search Engines and Tools for Medical Self-Diagnosis

Post below lifted from Nursing Online. See the original for links

Although seeing a doctor is best, it's not always easy to get to a doctor right away. Fortunately, there are loads of tools online designed to help you diagnose and treat symptoms right at home. Here we've listed 100 of the best.

Search Engines: Simply type your symptoms or ailment into these search engines, and you'll find helpful information.

eCureMe: To self diagnose with this search engine, you'll just have to search for your most troublesome symptom.
MedlinePlus: MedlinePlus is designed to make finding information on drugs, diseases, and more easy.
Google Health Co-op: Find hand-picked sites for your condition with this search tool from Google.
Amniota: Find all of the information you need with this health search engine.
iSeekHealth: With this handpicked directory, you'll find loads of information.
Healia: This search engine offers high quality information and personalization.
InteliHealth: Powered by Aetna, this site will help you learn about symptoms, conditions, drugs, and more.
NOAH: On this site, you can research health topics by body area or disease.
e-Lynks Health: You'll find lots of information with this portal to health websites.
CureResearch Symptom Center: In this symptom checker, you can search for diseases that match up with what you're feeling.
Healthline Symptom Search: Find possible cures based on your symptoms with this search engine. You can even get a search plug-in for Firefox.
gopubmed: Search for medical publications with this tool.
Yahoo! Health: Use Yahoo! Health to find information about drugs, diseases, and more.
AnswerMed: Simply type in a query to learn about a medical condition or surgery.
OrganizedWisdom: Use this human-powered health search to find the diagnosis information you're looking for.
Afraid to Ask: Use this search tool to find answers to the questions you're afraid to ask your real doctor.
Mayo Clinic: Look up a disease, symptom, and more with the Mayo Clinic's search tools.

Databases: Check out these databases to get answers to some of the most common medical questions.

Conditions and Concerns: This reference provides easy access to information about common ailments and symptoms.
Go Ask Alice!: Check out Go Ask Alice! to find answers to medical questions.
Medical-Articles: Find published medical news with this resource.
Healthwise Self-Care Checklist: On AOL Body, you'll find this checklist that walks you through diagnosis, education, and treatment.
Dr. Koop's Symptoms Reference Index: Go through this extensive list of symptoms to find out what's wrong.
Healthcyclopedia: This site offers an alphabetic index of health conditions.
WrongDiagnosis Symptom Center: Here you can research popular symptoms for more than 10,000 diseases.
Medifocus: Get researched information with Medifocus' guides.
Netwellness: This resource has more than 55,000 pages of information from the faculty of three leading universities.
Home Healthcare Guide: This service from Surgery Door offers lots of information on conditions, emergencies, operations, and more.
Health Library: Check out this library for information that's hand-picked from government agencies, nonprofits, and universities.
Ohio State University Medical Center Patient Education: Find information on conditions, tests, and much more with this resource.
Medinfo: Here you'll find lots of patient-centric information on specific conditions.
eMedTV Health Information: This library of medical information offers data on diseases, procedures, drugs, and more.
Netdoctor Library of Diseases: Find an extensive library of expertly reviewed medical articles here.
All Health: Here you'll find a great medical reference library and symptom finder.
Stop Getting Sick: Use this database to find general information news, and research on diseases and conditions.
SHARing Point Server: This health information system shares data across the world.
Family Doctor: This database has more than 600 articles and guides on medical topics, all reviewed and edited by medical experts.
Diseases Database: Here you can look for information on diseases, symptoms, drugs, and more.

Online Professionals: These sites feature professionals that offer their services online.

Just Answer: With this service, you'll be able to talk to doctors and nurses that are online and ready to answer questions.
eDocAmerica: Whether you're looking for a physician, psychologist, or advice from a nurse, check out this site for help.
BumperBrain: Use this site to locate and get health experts in just about any field.
Netwellness Ask an Expert: Get information from more than 500 world-class experts in this resource.
aarogya: On this wellness site, you can talk to doctors in specific specialties, like cardiology, homeopathy, and oncology.
InteliHealth Ask the Doc: In this resource, you can search for questions and answers related to your ailment, or ask a question of your own.
The ICU Answer Page: Learn all about the ICU in this guide from a critical care nurse.
WrongDiagnosis Ask a Doctor: Choose from 5 fully reviewed doctors for medical advice on this site.
HealthySelf: Ask this expert to do medical research for you.
Allexperts Medical Q&A: Here you'll find past answers to medical questions, plus be able to ask your own.
Kasamba Health & Medicine Experts: Choose from over a hundred health experts online with this site.
Afraid to Ask: Talk to Afraid to Ask's doctors to get answers to the questions you don't want to ask your regular doctor.
Ask the Doctor Online: Contact these doctors for a standard or urgent consultation.
Dr. Sinatra: Check out Dr. Sinatra for information on solutions to health problems.
Consult Doctors: With this service, you can choose to get a standard or stat consultation, and even a full report on a medical question within just a few days.

Tools: Simply plug your medical issues into these tools, and you'll get all sorts of information.

The Analyst: Answer 900 optional multiple-choice questions to get a look at your entire health spectrum with this tool.
Health A to Z: Get a look at what's ailing you with this symptom checker.
PreOp Patient Education: Use this tool to research surgery procedures.
Symptom Checker: Select symptoms, find factors, and get results with this tool.
Descipher: With this tool, you can self-interpret lab test results from your doctor.
MSN Health & Fitness Symptom Checker: Use this visual symptom checker to cure what ails you.
HealthCentral: Use HealthCentral's illustrated guide to find out where it hurts.
EasyDiagnosis: Designed by a team of doctors, EasyDiagnosis takes a look at your main symptoms to determine your illness.
MedicineNet: Use this illustrated guide to pinpoint where it hurts.

Communities: Get support and advocacy from these medical communities.

ThirdAid: Find out how others with your condition are doing, and get independent knowledge from this community.
MSN Health & Fitness Support Groups: Find others with your condition with these support groups.
iMedix: Join this healthcare community to get information on symptoms, diseases, treatments, and more.
WrongDiagnosis Conditions Forum: Check out these forums for information on specific conditions from other sufferers.
Afraid to Ask Forums: Discuss sexuality, body functions, and much more in this community.
Healthcyclopedia Support Groups: Here you'll find support groups for all sorts of conditions and diseases.
MDJunction: Find a support group and learn more about your condition on this site.
Netdoctor Forums: Get information on general health and beyond in these forums.
MedHelp: On MedHelp's Ask a Doctor forums, you can find answers and ask questions of certified doctors.
Case Health: Hear about the medical success stories of others on this site.
MSN Health & Fitness Message Boards: Learn about and discuss conditions like pregnancy, depression, and more on these message boards.
PatientsLikeMe: Share your experience and learn from others on this support site.
DailyStrength: Here you'll find more than 500 support groups for just about every health issue out there.
HelpShare: Here you can ask a medical question and set the value of a good answer.
WrongDiagnosis Symptoms Forum: Learn and share information about symptoms for fertility, allergies, and more here.
HealthWorldWeb: On this site, you'll find loads of communities in which to learn more about your symptoms and conditions.

Assessment: Stay on top of your health and possible risks using these resources.

Heart Attack Risk Calculator: Learn how susceptible you are to a heart attack with this quiz.
Postpartum Depression Assessment: Find out if your intense feelings after pregnancy are normal or discover the sign of a condition that needs to be treated.
Alcohol: Are You Addicted?: Follow this questionnaire to find out if you have a problem with drinking.
How to Review Your Blood Test Results: This guide offers advice on normal ranges for test results.
New Hope Health Clinic: Get this holistic clinic's home testing kit, and you'll learn about your body and what you can do to take care of it.
Online Checkups: Get quick assessments for a variety of conditions with HealthFinder's online checkups.
Stress Trigger Assessment: Assess and identify the stressors in your life with this tool.
Nicotine: Are You Addicted?: Use this questionnaire to assess your addiction to cigarettes.
Fitness Assessment: Find out just how fit you are using this quiz.
Do I Have an Eating Disorder: Answer these questions to find out if you have a problem with food.
Breast Cancer Risk Assessment: Find out if you're at risk for this commonly diagnosed cancer.
Risk Factor Center: Find out your risk factors for diseases and more based on your lifestyle, exposure, and other factors.
The Menopause Assessment Scale: Assess your menopause symptons here.
Type 2 Diabetes Risk Assessment: This quiz will help you determine your risk for Type 2 diabetes.
Lab Tests Online: Get information on lab tests, conditions, and more from this resource.
Urinary Incontinence Test: Follow this questionnaire to determine whether or not you suffer from urinary incontinence.
Interactive Weight Tool: Determine your risk level for weight-related diseases using this tool.
Coronary Artery Disease Assessment: Use this quiz to find out how high your risk is for this common heart disease.
KnowYourRisk Assessment: Revolution health's tool will tell you your risk for diabetes, stroke, and heart disease, and offers information on how you can better prevent these conditions.
WrongDiagnosis Home Diagnostic Testing Center: Get tested right at home for ailments like diabetes, fertility, and more.
Depression Risk Assessment: Follow this questionnaire to see how likely you are to have depression.
Cold or Flu?: Find out if you're sick with the cold, or worse, the flu.
Pitfalls of Online Diagnosis: This article warns against some of the problems that can arise from online diagnosis.

Australia: Over ten years of dodgy doctoring and only now is immigrant doctor stopped

"Your government will look after you", once again

An investigation into a Czech-trained obstetrician and gynaecologist, whose Queensland registration was suspended last night, has found two suspect cases in his work in the state. Dr Roman Hasil worked as a locum at Rockhampton Hospital, in central Queensland, from December 18, 2006, to January 12, 2007. After working for one day at the Redcliffe Hospital, on Brisbane's northern bayside, on March 7, 2007, he disappeared following an inquiry into his performance in New Zealand.

The Medical Board of Queensland last night suspended Dr Hasil's registration after receiving a damning report into his professional conduct from New Zealand authorities. An investigation into Dr Hasil's practices was launched in New Zealand last March after women who underwent sterilisation at Wanganui Hospital later fell pregnant. A NZ Health and Disability Commission report found Dr Hasil had not placed clips correctly on patients' fallopian tubes.

NZ authorities also noted Dr Hasil had a chequered work history in Australia from 1996 to 2005. He had lied about a criminal conviction for domestic violence in Singapore and left Lismore Base Hospital in NSW in 2005 after an allegation against him for "fiddling" timesheets, an accusation he denied. He had been dismissed from a Victorian hospital in 2005 for recording a blood alcohol reading of 0.2 while on call, the New Zealand report said.

Queensland Health acting director-general Andrew Wilson said today a specialist had reviewed Dr Hasil's work in the state and found two cases "indicating an unexpected outcome or deviation from standard practice". The findings of the two cases had been passed on to the medical board, he said. Dr Wilson said Dr Hasil had been involved in 17 obstetric and gynaecological related procedures in Queensland.

Beryl Crosby, who has advocated on behalf of patients of rogue surgeon Dr Jayant Patel, said health authorities needed to improve checks on overseas-trained doctors. Indian-trained Dr Patel, dubbed "Dr Death", is being sought for extradition from the United States on manslaughter charges relating to his work at Bundaberg Base Hospital in southeast Queensland. "They (medical authorities) need to be bloody thorough in their checks and not hire anyone with a record that harmed people," Ms Crosby said. "We don't want this here in Queensland - we've had a gutful. I know we are desperate for doctors, but we are not that desperate that we want to put people in harm's way again. It's just not on."

Dr Hasil remains registered to practice in NSW. The chief executive of the NSW Medical Board, Andrew Dix, said the board was aware of concerns about Dr Hasil, but no complaints had been received in NSW. "We will be taking urgent action to see whether there are grounds for referring him to the medical tribunal," he said on Fairfax radio today. Without a decision from the tribunal, the board did not have the power to deregister, he said.

NZ authorities declined to refer Dr Hasil to prosecutors, but the inquiry report concluded: "Many women of Wanganui have been deeply affected by the substandard care provided by Dr Hasil, and some women have been harmed".


Thursday, February 28, 2008

SCOTUS ruling favors medical device firms

A defeat for the legal piranhas

Patients who are injured by federally approved medical devices can't collect damages if the manufacturers complied with government standards, the Supreme Court ruled Wednesday. The 8-1 decision in a New York case applies to the riskiest devices, like heart valves and pacemakers, which need Food and Drug Administration approval before they can be sold. The court said the 1976 federal law that required FDA clearance for those products would be disrupted by negligence suits under state law, just as it would be impaired by varying state regulations.

Congress' concern for those injured by FDA-approved devices was outweighed by its "solicitude for those who would suffer without new medical devices if juries were allowed to apply the (injury) law of 50 states to all innovations," said Justice Antonin Scalia in the majority opinion.

The court allowed damage claims for injuries caused by products that violate FDA manufacturing specifications or labeling rules, and left intact an earlier decision permitting a broader range of suits over defects in medical devices that don't require FDA review before marketing. But the ruling - on a day in which the justices also limited states' authority to prevent cigarette shipment to minors - was a substantial victory for businesses and a possible foreshadowing of another case, to be argued this fall, about suits by patients claiming harm from FDA-approved drugs.

The medical ruling is "a victory for a national system designed to maximize the benefits to patients" from exhaustive review by government experts, said Theodore Olson, lawyer for Medtronic, manufacturer of the heart catheter involved in the case. While FDA scrutiny is imperfect, he said, it's preferable to product assessment by a jury that "isn't evaluating the needs of patients all over the country and doesn't have expertise."

The plaintiffs' lawyer, Allison Zieve of the Public Citizen Litigation Group, said the decision was "potentially dangerous for patients," because the prospect of damages against manufacturers is an incentive for safety. The suit was filed by Charles Riegel, whose Evergreen Balloon Catheter burst during a 1996 angioplasty. Riegel survived, after emergency bypass surgery, and accused Medtronic of negligence in the design, manufacture and labeling of the device. He died in 2004 of unrelated causes, and his wife, Donna, took over the suit.

In upholding lower-court rulings dismissing the case, the Supreme Court said the catheter, like other devices requiring pre-marketing approval, receives rigorous scrutiny from the FDA, which spends an average of 1,200 hours reviewing each application and grants approval only to those that provide reasonable assurances that the product will be both safe and effective. Scalia cited a provision of the 1976 federal law prohibiting states from enforcing any requirements for medical devices that differed from FDA standards. A jury's finding that the catheter was improperly manufactured or labeled, despite FDA approval, would amount to an additional requirement, he said. "A jury ... sees only the cost of a more dangerous design and is not concerned with its benefits," Scalia said.

Justice Ruth Bader Ginsburg dissented, saying the 1976 law was not intended to thwart negligence suits. She said Congress passed the law to provide uniform regulation after states - led by California - began their own approval process for medical devices in response to lawsuits over infections attributed to the Dalkon Shield intrauterine device. Wednesday's ruling is "at odds with the (law's) central purpose: to protect consumer safety," Ginsburg said.


Australia: Government sorry over 'mutilation doctor'

"Your government will look after you", once again

The NSW Government says it is sorry, but it can't yet explain why a doctor banned from obstetrics was able to continue performing operations which allegedy left many women mutilated. Dr Graeme Steven Reeves is alleged to have mutilated or sexually abused as many as 800 patients. The NSW Medical Board ruled in 1997 that Graeme Stephen Reeves "suffers from personality and relations problems and depression that detrimentally affects his mental capacity to practise medicine". The board ordered him to stop practising obstetrics, but he defied the ban and took up a position in 2001 as a specialist obstetrician and gynaecologist for the Southern Area Health Service, working at Bega and Pambula hospitals. He was struck off the medical register in 2004.

NSW Health Minister Reba Meagher was today asked by reporters how Dr Reeves had continued to practise when hospital and nursing staff must have known about the type of surgery he was performing. "I don't know what was known then by others around Dr Reeves, but I do know this Government radically overhauled the Health Care Complaints Commission to ensure a greater level of protection for patients that have complaints," Ms Meagher said. Since 2005, hospitals had taken greater care in confirming a doctor's references with the NSW medical board, which has increased its transparency in relation to deregistered doctors.

The NSW Government and police have begun investigations following new allegations about Dr Reeves but it will be some time before authorities determine how he was able to continue to practice as an obstetrician and gynaecologist. "I can't explain that," Ms Meagher said. "But what I can assure the women who are coming forward now is that we will support them in every way we possibly can. "I am sorry that they have had such an awful, awful experience at the hands of somebody who was not fit to deliver a medical service."


Wednesday, February 27, 2008

Massachusetts Hospital Association's New Recipe for Fudge

Delusions About Cost & Benefits of Health "Reform" Persist

An amazing story in the usually reliable Boston Globe by Steve LeBlanc made me gulp: might I have to recant my position on the ineffective and expensive Massachusetts health reform? Luckily, no: a report by the Massachusetts Hospital Association on the reform's "success" manages to fudge the numbers just enough to convince the casual reader that the "reform" is achieving its primary objective: reducing hospitals' so-called "uncompensated" care (actually quite well compensated by taxpayers), by enrolling uninsured residents into mandatory health insurance.

Through some kind of magic understandable to politicians, this insurance would transform these folks into responsible patients who would consult with doctors as soon as they felt poorly, instead of waiting until their illnesses turned critical and they crashed the emergency room, only to check out without paying the bill. Sadly,the MHA's exquisite recipe for fudge did rope in Mr. LeBlanc:
It was a key premise of the state's landmark health care law -- the more uninsured people who were enrolled in subsidized health care plans, the fewer uninsured people would show up at hospital emergency rooms for routine care. Now a new study says that's exactly what's happening. The report by the Massachusetts Hospital Association finds that the number of so-called "free care" visits to hospitals have declined by 28 percent over the past three years. That mirrors a 28 percent increase in enrollment in subsidized health care programs, MassHealth and the new Commonwealth Care program, which was created by the law.

It's hard to know where to begin dissecting this outrageous claim. Obviously, the exact mirror-image of savings versus cost increase, 28%, should make any reader suspect that the numbers are being cooked. Here's a list of the ingredients for the fudge recipe:
The 28% decrease in hospital free care visits is from October 2004 to September 2007, versus the same combined increase in MassHealth and Commonwealth Connector enrolment. But MassHealth is just the state's Medicaid program. The "reform" is the Commonwealth Connector, which did not start enrolling people until January 2007. So, the time period, while conveniently resulting in a balanced ledger, is quite irrelevent to the effect of the "reform".

Neither of the 28% figures are dollar costs: they are both head-counts: enrolment in MassHealth and Commonwealth Connector plans, and uncompensated care patient accounts in hospitals. Obviously, comparing the two is meaningless.

A graph on page 3 of the report shows the dollar decline in hospital uncompensated care costs: from just under $700 million (FY2004) to $613.5 million (FY 2007): about 12%, in current dollars. (In order to stretch this figure, the report also notes constant dollars, for which it claims a reduction of 23%, but what difference does this make, as it does not report dollars spent on MassHealth and Commonwealth Care, only heads counted?)

So, what really happened to hospitals' uncompensated care costs during the relevent period? We can't quite tell, but the report does state actual savings from July 1, 2006 to June 30, 2007 of a (sarcasm alert) whopping $10.1 million! Because the Commonwealth Connector launched in January 2007, only the last six months of the fiscal year are relevent. So, let's be generous and guesstimate that savings will have increased to $15 million for the first operating year of the Commonwealth Connector.

Ho, hum.....Is this all that Bay Staters get for a reform for which Governor Patrick is requesting $400 million this year? Uncompensated care savings that barely stretch into the double digits? We have already busted the Commonwealth Connector's boss for cooking up a rotten story about the program's originally budgeted costs. Now, the main beneficiary of the plan's handouts contributes its sugary recipe for fudge to the menu.

Well, if you can't stand the heat, get out of the kitchen - or the state, I suppose. At least that's what many small businesses will do if this "reform" keeps boiling over with new taxes to fund ineffective change - or no real change at all.


Australia: Ambulances wait three hours to hand over patients

No reserve capacity at hospital for surges in demand

This scene outside Cairns Base Hospital's emergency department yesterday is another stark reminder why the region needs a new hospital, now. Ten ambulances were queued outside the choked department by early afternoon, forcing frustrated paramedics to wait for up to three hours before unloading patients.

Officers said they had been putting up with the "bad old days" of no emergency beds for at least a week but yesterday's jam-up had gone from bad to worse as the day went on. "It's beyond a joke," one told The Cairns Post. "Something's got to change." Queensland Ambulance Service area director Warren Martin, who oversees a fleet of 12 vehicles across Cairns, Smithfield and Edmonton, said up to 10 ambulances were effectively out of action for hours. The situation peaked about 2pm when several patients arrived around the same time, causing 10 or 11 ambulances to back up, Mr Martin said.

But he stressed that while the ambulance gridlock outside the emergency department, also known as "ramping", was still happening, new systems to fast-track patients were helping. "It means that when we do ramp, it's not lasting as long," Mr Martin said. "Today was just one of those days." All the patients forced to wait in ambulances yesterday were being closely monitored by emergency doctors, and were in the mid-urgency rather than high-urgency categories, he said. "It's a bit of a cross-section, everything from gastro upset tummies to someone with abdominal pain . I think the hot weather back with a vengeance today has been knocking older people around a bit," Mr Martin said.

Mr Martin said he was "really looking forward" to next year's expected completion of a major expansion to the emergency department, which would double its size and add 12 more beds. A Queensland Health spokesman attributed the delays to a rush of patients at once, with 30 arriving during the most intense period of 12.30pm to 3pm, or about 12 an hour. On a normal day, the department averages five patients per hour. The spokesman said his information was that the maximum number of ambulances waiting at one time had been eight.


Australia: Butcher doctor. Your regulators will protect you (NOT)

THEY call him the Butcher of Bega - a NSW doctor who has committed such monstrous acts that hundreds of terrified victims have remained silent for more than five years. Dr Graeme Stephen Reeves is alleged to have routinely mutilated or sexually abused as many as 500 female patients while he was working as a gynaecologist and obstetrician at various hospitals across Sydney and the NSW south coast.

Despite the NSW Medical Board ruling he had psychiatric problems which "detrimentally affect his mental capacity to practice medicine" more than a decade ago, he managed to continue treating women without detection in a devastating trail of botched operations and negligence.

Hundreds of former patients have come forward with harrowing and graphic evidence about Dr Reeves, who was struck off in 2004 for breaching practice restrictions. As many as 500 emails from women were received by the private watchdog, Medical Error Action Group, last week telling of their humiliation and pain after parts of their genitals were removed or sewn up without their consent.

The outpouring came after a former patient of Dr Reeves, Carolyn Dewaegeneire, broke her five-year silence with two other women to give a public account of her ordeal on Channel 9's Sunday program last weekend.

Despite the shocking revelations on the program, Dr Reeves is still not being investigated by the police, the NSW Medical Board or the Health Care Complaints Commission, over the latest allegations. He is also free to re-apply to return to medical work at any time after serving a three-year ban. Dr Reeves has refused to comment on the allegations. The hospitals where Dr Reeves has practised include Hornsby Ku-ring-gai, Sydney Adventist at Wahroonga, The Hills Private at Baulkham Hills, Royal Hospital for Women and the Bega and Pambula hospitals.

Source. More here and here

Tuesday, February 26, 2008

Authoritarian medicine in Britain -- Health "insurance" with a difference

If they cannot afford to give you a drug or service that you need, you are forbidden to pay for it yourself!

Created 60 years ago as a cornerstone of the British welfare state, the National Health Service is devoted to the principle of free medical care for everyone. But recently it has been wrestling with a problem its founders never anticipated: how to handle patients with complex illnesses who want to pay for parts of their treatment while receiving the rest free from the health service. Although the government is reluctant to discuss the issue, hopscotching back and forth between private and public care has long been standard here for those who can afford it. But a few recent cases have exposed fundamental contradictions between policy and practice in the system, and tested its founding philosophy to its very limits.

One such case was Debbie Hirst's. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologist's support, she decided last year to try to pay the $120,000 cost herself, while continuing with the rest of her publicly financed treatment. By December, she had raised $20,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down.

Mrs. Hirst heard the news from her doctor. "He looked at me and said: `I'm so sorry, Debbie. I've had my wrists slapped from the people upstairs, and I can no longer offer you that service,' " Mrs. Hirst said in an interview. "I said, `Where does that leave me?' He said, `If you pay for Avastin, you'll have to pay for everything' " - in other words, for all her cancer treatment, far more than she could afford.

Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones. Patients "cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs," the health secretary, Alan Johnson, told Parliament. "That way lies the end of the founding principles of the N.H.S.," Mr. Johnson said.

But Mrs. Hirst, 57, whose cancer was diagnosed in 1999, went to the news media, and so did other patients in similar situations. And it became clear that theirs were not isolated cases. In fact, patients, doctors and officials across the health care system widely acknowledge that patients suffering from every imaginable complaint regularly pay for some parts of their treatment while receiving the rest free.

"Of course it's going on in the N.H.S. all the time, but a lot of it is hidden - it's not explicit," said Dr. Paul Charlson, a general practitioner in Yorkshire and a member of Doctors for Reform, a group that is highly critical of the health service. Last year, he was the co-author of a paper laying out examples of how patients with the initiative and the money dip in and out of the system, in effect buying upgrades to their basic free medical care. "People swap from public to private sector all the time, and they're topping up for virtually everything," Dr. Charlson said in an interview. For instance, he said, a patient put on a five-month waiting list to see an orthopedic surgeon may pay $250 for a private consultation, and then switch back to the health service for the actual operation from the same doctor. "Or they'll buy an M.R.I. scan because the wait is so long, and then take the results back to the N.H.S.," Dr. Charlson said.

In his paper, he also wrote about a 46-year-old woman with breast cancer who paid 250 pounds for a second opinion when the health service refused to provide her with one; an elderly man who spent thousands of dollars on a new hearing aid instead of enduring a yearlong wait on the health service; and a 29-year-old woman who, with her doctor's blessing, bought a three-month supply of Tarceva, a drug to treat pancreatic cancer, for more than $6,000 on the Internet because she could not get it through the N.H.S. Asked why these were different from cases like Mrs. Hirst's, a spokeswoman for the health service said no officials were available to comment.

In any case, the rules about private co-payments, as they are called, in cancer care are contradictory and hard to understand, said Nigel Edwards, the director of policy for the N.H.S. Confederation, which represents hospitals and other health-care providers. "I've had conflicting advice from different lawyers," he said, "but it does seem like a violation of natural justice to say that either you don't get the drug you want, or you have to pay for all your treatment."

Karol Sikora, a professor of cancer medicine at the Imperial College School of Medicine and one of Dr. Charlson's co-authors, said that co-payments are particularly prevalent in cancer care. Armed with information from the Internet and patients' networks, cancer patients are increasingly likely to demand, and pay for, cutting-edge drugs that the health service considers too expensive to be cost-effective. "You have a population that is informed and consumerist about how it behaves about health care information, and an N.H.S. that can no longer afford to pay for everything for everybody," he said.

Professor Sikora said that oncologists are adept at circumventing the system by, for example, referring patients to other doctors who can provide the private medication separately. As wrenching as it can be to administer more sophisticated drugs to some patients than to others, he said, "if you're a doctor working in the system, you should let your patients have the treatment they want, if they can afford to pay for it." In any case, he said, the health service is riddled with inequities. Some drugs are available in some parts of the country and not in others. Waiting lists for treatment vary wildly from place to place. Some regions spend $280 per capita on cancer care, Professor Sikora said, while others spend just $90.

In Mrs. Hirst's case, the confusion was compounded by the fact that three other patients at her hospital were already doing what she had been forbidden to do - buying extra drugs to supplement their cancer care. The arrangements had "evolved without anyone questioning whether it was right or wrong," said Laura Mason, a hospital spokeswoman. Because their treatment began before the Health Department explicitly condemned the practice, they have been allowed to continue.

The rules are confusing. "It's quite a fine line," Ms. Mason said. "You can't have a course of N.H.S. and private treatment at the same time on the same appointment - for instance, if a particular drug has to be administered alongside another drug which is N.H.S.-funded." But, she said, the health service rules seem to allow patients to receive the drugs during separate hospital visits - the N.H.S. drugs during an N.H.S. appointment, the extra drugs during a private appointment.

One of Mrs. Hirst's troubles came, it seems, because the Avastin she proposed to pay for would have had to be administered at the same time as the drug Taxol, which she was receiving free on the health service. Because of that, she could not schedule separate appointments. But in a final irony, Mrs. Hirst was told early this month that her cancer had spread and her condition had deteriorated so much she could have the Avastin after all - paid for by the health service. In other words, a system that forbade her to buy the medicine earlier was now saying that she was so sick she could have it at public expense. Mrs. Hirst is pleased, but only up to a point. Avastin is not a cure, but a way to extend her life, perhaps only by several months, and she has missed valuable time. "It may be too bloody late," she said. "I'm a person who left school at 15 and I've worked all my life and I've paid into the system, and I'm not going to live long enough to get my old-age pension from this government," she added.

She also knows that the drug can have grave side effects. "I have campaigned for this drug, and if it goes wrong and kills me, c'est la vie," she said. But, she said, speaking of the government: "If the drug doesn't have a fair chance because the cancer has advanced so much, then they should be raked over the coals for it."


Australia: Public hospital kitchens fail hygiene, safety tests

GRUBBY benchtops, sloppy pest control and off deli meats were found during independent audits of NSW public hospital kitchens that found 94 per cent did not comply with new hygiene and safety laws. The Daily Telegraph can reveal 166 of 171 hospitals checked during voluntary audits "required one or more corrective actions" for them to meet new guidelines set down by the NSW Food Authority. Four public hospitals were deemed so bad they failed completely, scoring an "unacceptable" rating for their operations.

But the hospitals won't be named and shamed as the Food Authority claims it would be a breach of their business affairs - considered more important than patients' right to know of threats to their health. It was also claimed identifying the hospitals would make them unco-operative in complying in future audits.

Overall, documents obtained under Freedom of Information laws show there were 719 areas of corrective action required for the 166 hospitals. Censored audit reports for the failed public hospitals show the detail of how poor some hospitals are on hygiene and safety. One of the reports shows a coolroom was running at an unhealthy warm temperature, a precondition for food poisoning. The same kitchen had frozen meats and milk powder stored beyond use-by dates, with sliced deli meats with a 24-hour life found stored for four days. Another report of a public hospital found unclean can openers, no records on pest control and food handling concerns.

Staff involved in food preparation wearing gloves were observed picking up food off the floor. One staff member was "observed coughing into her glove and not removing it".

The unhealthy kitchens are the latest blow to the NSW health system, already reeling over scandals including mismanagement of Royal North Shore Hospital and the bungled construction of the new Bathurst Hospital. A NSW Health spokeswoman said none of the issues incurred penalty notices and there was no threat to public health. [Really??] "In all cases where there was an issue found at audit, remedial action was undertaken immediately."

Brian Holloway, 56, had nothing but praise for the medical staff at Mona Vale Hospital during his long stay last year - but he had no love for the hospital's menu. He was appalled at being served what he said was quiches served flat like pancakes, rice tough enough to put through a slug gun and mashed potato like "quick-set cement".


Monday, February 25, 2008

The other health care issue: Getting costs down

A few weeks ago a friend of mine received a bill from a hospital in New York where he had had a routine colonoscopy, one of those preventive procedures that people over a certain age are supposed to have every five years or so. The bill, my friend was surprised to see, was for $8,513.36, not including the doctor's fee, which was a few hundred dollars more - this for a procedure involving no anesthesia and taking less than half an hour from start to finish.

What was most surprising about the bill was not even the total, rather high, amount; it was an indication that Medicare - the government insurance program for people 65 and over - had paid the lion's share of the bill, or precisely $8,200.61. Over $8,000 of the taxpayers' money for a routine colonoscopy - a procedure that would normally cost a few hundred dollars, maybe a bit more than a thousand for a high-cost doctor in a high-cost area. What was going on here?

The truth is: I don't know. When I called Medicare to ask about this, a spokesman said Medicare would normally reimburse a hospital about $500 for a colonoscopy performed in New York City - where costs are higher than they would be in, say, Fargo, North Dakota. Why Medicare would have paid 20 times what it is supposed to pay, or if in fact it did pay that amount (maybe the hospital's invoice was incorrect) are questions buried somewhere in the vast federal bureaucracy.

In the meantime, the matter of a friend's medical costs served as a reminder of a large and lively issue in American life, which is why medical costs are so much higher here than in most other advanced industrial countries, and what, if anything, can be done about it. We pay per capita about twice what European countries pay for medical care - roughly $6,000 per person per year - and costs are increasing at three times the rate of inflation.

And beyond that, another question: health care plans to remedy the gaping holes in the American system, most notably the hole represented by the 40 or so million people who have no health insurance, seem to come out almost every day. Both Hillary Clinton and Barack Obama have produced elaborate plans, while one of the claims to fame of the ex-candidate Mitt Romney was that he put the country's first statewide medical plan into effect when he was governor of Massachusetts.

Analysts have pored over both the Clinton plan and the Obama plan and given both of them pretty high marks. The Clinton plan would get more people on the rolls than the Obama plan, but it would have more enforcement in it and would be more expensive. Either plan would probably mark a major step forward from where we are today, and the country does seem in a mood now to make some kind of step.

But while there is a great deal of discussion on how to get more people insured at rates they and the nation can afford, there seems a good deal less talk about ways to get costs down, which is where my friend's colonoscopy and other rather sizable medical bills come in.

Among the other sizable bills was one for hip replacement surgery I underwent at the end of last year, surgery that, as I said in this space at the time, I'm fortunate to have had - and happy, too, that the entire cost was borne by Cigna International, my health insurance company.

Despite the overall worrying picture, there are some things right about American medicine, especially when you are among the lucky ones covered by a good insurance plan, or for that matter among the millions of people 65 and older whose costs are mostly covered by Medicare.

Still, there's that cloying question of cost. My hip replacement was expertly done by my surgeon, Allan Inglis Jr., and his team at New York's St. Luke's/Roosevelt Hospital. But the total cost will end up being around $40,000, or perhaps a few thousand more, once the bills for anesthesia, for four days in the hospital, for medications, pre- and post-operative exams, physical therapy and the prosthesis itself are added in.

Cigna paid $32,000 to Dr. Inglis for the surgery alone, a sum that seemed stratospheric to me and that even the good doctor allowed, in a telephone interview, was "a lot." When I asked him why, if he thought it was a lot, he charged that much, Inglis described a system of billing and payments so complicated and inconsistent that it defies easy understanding. "It's a number out of a hat," he said of the actual amount paid. "We don't have any idea of what we're supposed to be billing because we don't know what the different insurers are going to pay, which is kind of a funny way to do business."

When he submits a bill to an insurer, he said, he doesn't specify an actual amount. He puts in a code for the procedure he's done, and the insurance company pays what it calls its reasonable customary rate. Some insurance companies, like mine, pay a lot, he said, and others, like Medicare, pay less, with the higher payers subsidizing the lower ones.

In the end, the result is higher costs than just about anywhere else. In Germany, for example, the cost of a total hip replacement would be 7,000 to 13,000 euros, or $10,200 to $19,000, depending on the patient's condition and whether there are complications, according to a spokesman at the national health insurer AOK. A private clinic would charge about 20,000 euros.

And if you're willing to go to Thailand or India, you can have the surgery performed for $10,000 to $12,000 all inclusive, in a state-of-the-art hospital with state of the art prosthetics and surgeons. Maybe the answer to the American problem is a bit of medical globalization. If insurance companies would cover the airfares to send willing patients to Thailand, they could save upwards of $30,000 for each hip replacement they cover. They don't reimburse airfares, but maybe they should.


Australia: A farcical public hospital

Even under great public pressure, the bumbling NSW government still manages to do zilch

THE state of the disastrous new $100 million Bathurst Base Hospital has descended into farce after a head doctor bought an air horn from a sports store so he could be summoned in an emergency because he did not trust the alarm system. It was hoped that non-urgent surgery - suspended indefinitely more than a week ago because of safety concerns - would resume yesterday but doctors instead voted to postpone all operations booked for the next week, calling the situation a "crisis".

A representative on the Medical Staff Council, Dr Stavros Prineas, said the alarm system had serious communication problems, putting patients at risk. The emergency alarm could not be heard across the theatre complex - despite sounding in other areas of the hospital - so nurses had resorted to running through corridors looking for doctors during an emergency, he said. He said Telstra was working yesterday to give the hospital mobile phone coverage. Surgery lists would be reviewed weekly but operations would probably be suspended for at least a further three weeks, Dr Prineas said.

The Health Minister, Reba Meagher, has agreed to a potentially multimillion-dollar redesign because the hospital does not meet national health standards. The co-director of the intensive care unit, Brendan Smith, said nothing had improved after Ms Meagher's visit on Thursday. "We still do not have an effective alarm system in the theatres and recovery. Yesterday we did a couple of cases in the theatre and the only way we were able to do it was because I went to the shop and bought an air horn," Dr Smith said.

"We actually gave it to the director-general [of NSW Health], Professor Debora Picone, and said this was what we've been reduced to and she looked shocked and there were a few comments from her minions in the hospital that said, 'I don't know if that's legal', and we said, 'It might not be legal but it's effective', and they got the message loud and clear."

He said doctors were also considering closing maternity because anaesthetists felt they could not provide a safe service. "Everything but the most dire urgent surgery is being cancelled and it's probably that the obstetrics unit will be closed down because we can't give anaesthetic cover," Dr Smith said.

The doctors have issued a list of demands to Ms Meagher including that a purpose-built annex be urgently constructed for services they say were promised but not delivered such as the ambulatory care unit and outpatient clinics.

The State Government yesterday tabled its response to the Nile inquiry into Royal North Shore Hospital and said it would implement all but two of the 45 recommendations. Doctors say the recommendations do not address the basic problems of bed and staff shortages.


Sunday, February 24, 2008

The fantasy pharma of the Left

The left, of course, has its own fantasy solution set: drugs should be both innovative and cheap. But clinical trials for a single successful drug cost $500 million, and not because the labs have outrageous administrative overhead. Even if the government were in charge of running them, they would still be on the hook for that $500 million, which would have to come out of taxes. We can get existing drugs on the cheap by essentially stealing the property of shareholders in drug firms, who risked a lot of money on drugs that they reasonably expected to be profitable under existing laws. But that's a one-trick pony. We cannot get new drugs at bargain basement prices.

Many people are holding out the hope that the government can somehow substitute for the pharmas, bolstered by the ludicrous claim that the government really discovers all the drugs. This is arrant nonsense; government-funded research discovers targets that might someday turn into drugs, if the Big Pharma chemists can: find a molecule synthesis can be economically mass produced; keep the molecule from killing rats, mice, dogs, or humans; get the molecule into a form that does not have to be directly injected into the bloodstream; tweak the molecule so that the liver doesn't immediately chew it into pieces that no longer affect your target; and shepherd the entire thing through years of clinical trials. That's just off the top of my head; research chemists will undoubtedly have more.

There is no evidence of a nationalized industry that consistently does cost effective innovation. Yes, you have a list of things invented by the government--but that number is a small fraction of a fraction of one percent of the number of things in the private sector. If the universe of products were your house, the government would have invented one washer inside the tap of your bathroom sink; the private sector would have developed every other thing you use. Even where the government is given credit for "inventing" something, such as DARPANet's invention of the internet; it turns out that 99% of the process of actually turning it into a product that was useful to end-consumers was handled by private actors, most of them corporations like Netscape, Microsoft, and AOL.

This is why when you start to make a list of all the state-run economies that have produced large numbers of innovative products with a high level of consumer satisfaction, you have to throw your privately manufactured gel pen aside in disgust. For whatever reason, the government is just not good at producing innovation.

Before you say it, I know that you are leaning forward in your chair, your eyes alight, preparing to demand "What about the military?!" and lean back triumphantly in your chair. My friend, have you ever taken a close look at the military procurement process? It costs a fantastic amount of money to generate products that often aren't even wanted by the end users--how many times have you read about some military service being forced to buy some gargantuan piece of equipment they don't want because the thing is being manufactured in a key congressman's district? This is how we spend four percent of our national income on something that most of the American public never sees. Forgive me if I'm not excited about applying the same process to health care.


Australia: Public hospital negligence kills again

A DEVASTATED family has been left angry and searching for answers since their beloved grandmother died after tripping on unfinished roadworks outside the Royal Hobart Hospital. Margaret Wakefield, 77, died in hospital last week after falling near the entrance to the new emergency department. The fit and active grandmother had been going to the hospital to visit a sick relative, and now her family is struggling to comprehend how a simple day out turned to tragedy.

Katie Wakefield, 20, was with her grandmother going to visit a relative in the hospital last Thursday. Miss Wakefield, 20, from Rokeby, was carrying her 18-month-old daughter, Shaelah, while her four-year-old son Justin was holding his great grandma's hand. Then Mrs Wakefield tripped on a section of raised footpath, believed to be the base of an old emergency department sign that had been removed. Miss Wakefield and her children were horrified to see their nan on the ground with blood streaming from her face. "She hit her face on the ground. I thought she'd broken her nose. There was blood everywhere and her glasses were stuck to her face," Miss Wakefield said.

She managed to get her conscious grandmother to the emergency department and waited about two hours for attention. They then spent several hours waiting for scans before being sent home. But soon after leaving the elderly woman's condition worsened. "On the way home she started vomiting so we called an ambulance," Miss Wakefield said. "She just got really confused and couldn't walk, she started deteriorating and they did a scan and found she had a blood clot forming in her brain. "She went into a coma and was on life support, and after that she died."

Miss Wakefield reported the problem pavement to hospital staff and a safety barricade was erected. The pavement has since been repaired. But they can't ignore the irony of having their grandmother die from an accident outside a hospital. "You come to hospital to get better, not to die," Miss Wakefield said. "It's simple: if things hadn't been sticking out of the footpath, she wouldn't have died. "And because of her age they should never have sent her home from hospital in the first place, she should have been kept in for observation."

Hospital community relations director Pene Snashall said condolences had been extended to the family in what was obviously a very sad time for them. She said the RHH was unable to comment further until a coronial inquiry was held.


Saturday, February 23, 2008

Nationalized medicine and the incentives they face

The role of incentives are too easily ignored by individuals who have the idea that the State is somehow, magically, the solution to whatever problem we face. And government-run health care is supposed to be the solution to the scarcity problem in health care. Economists argue that incentives matter and that political-provision of services creates distorted and perverse incentives. And here is a perfect example.

The British National Health Service is notoriously slow in treating patients. Some people deny this is the case and point to various numbers released by the NHS itself to show how efficient it is. And one number the NHS takes seriously is that they require patients admitted to the emergency ward to be seen within 4 hours of admission. Doesn't that sound peachy?

Don't get too excited. Let me point out how well-intentioned interventions can create unintended incentives. A town in a poor country is faced with too many rats. They offer a bounty for each rat that is killed. Proof of a kill required the bounty hunters to hand in a rat's tail. Alas, a bevy of tailess rats were soon seen running about town. To solve that problem the city required the entire carcass of the rat be handed in. And they were inundated with dead rats. But it seemed to have no impact on the number of rats running about. Apparently individuals took to breeding rats.

There was a time when the South African government decided that they would offer an award for every AK-47 that was turned into the police. These weapons were frequently used in major crimes and it was a bit embarrassing to the ANC government that they had been the importers of the weapons in question when they were trying to overthrow the previous government. So they offered a nice hefty bounty on each AK-47 that was turned in. The only problem was that AK-47s could be purchased in neighboring countries for a lower price. One could buy it in Zimbabwe and legally sell it to the South African government at a premium. AK-47s were duly imported in record numbers in order to collect the awards the government was handing out. To say the least they merely increased the number of such weapons in the country.

Governments are very good at establishing perverse incentives without realizing it. And so it was with the NHS. The 4-hour rule is simple. A patient must be seen within 4 fours of admission. If too many patients are not seen in that time the health service could lose funding. Of course the ability to see patients that quickly is not increased by the rule. Instead the local hospitals have incentives to act in very strange ways.

If you know you can't see a patient in emergency care for at least six hours, but you are required to see them within four hours of admission, then the easiest way to solve the problem is to delay admission for an additional two hours. And that is what is happening according to the Left-of-center Guardian. The paper reports, "thousands of seriously ill patients in ambulance `holding patterns'" were being kept outside in the ambulances "to meet a government pledge that all patients are treated within four hours of admission."

The story was originally broken by The Observer. The Guardian notes:
Those affected by 'patient stacking' include people with broken limbs or those suffering fits or breathing problems. An Observer investigation has also found that some wait for up to five hours in ambulances because A&E units have refused to admit them until they can guarantee to treat them within the time limit. Apart from the danger posed to patients, the detaining of ambulances means vehicles and trained crew are not available to answer new 999 calls because they are being kept on hospital sites.

Notice the knock-on effect of this incentive. The hospital can't see the patients within the required 4 hour period. So it refuses to admit the patient until it can see them and meet government edicts. That means the patients is left in the ambulance. That means the ambulance can't treat other patients.

Under normal conditions the government says that it ought to take 15 minutes from the time an ambulance arrives with a patient until they prepared to depart. Ambulance crews say it is usually 5 to 10 minutes. But reports now show that on 14,700 occasions at 35 hospitals in London alone, in the last year, an ambulance mysteriously took over one hour before they could turn around. And on 332 occasions they took more than two hours. The total for the entire country is probably three times that.

For a moment I want you to think about a fast food restaurant -- say McDonalds. Let us say that the manager notices that they aren't serving customers as quickly as they should. So he sets a 4 minutes rule. From the time a customer enters the line, he should not wait more than four minutes to be served his meal. Do you really think that the way they would meet this target is to lock the doors so customers can't get in?

Why is it that clerks at the local grocery store can process your purchase within a few minutes while government departments around the world can keep you waiting for hours at a time? Are clerks at the local Safeway just that much more efficient than those at the DMV? Or do they face entirely different incentives?

Does the DMV fear losing customers? Does Safeway? Does the salary of the checkout clerk at Safeway depend on keeping customers happy? How about the DMV clerks? I don't think the people differ that much. The problem isn't the personnel -- as some Republicans tends to think -- the problem is systemic. Government just hasn't found a way to create the right set of incentives. And people who work for government are responding to the incentives they do face.

Source. See also here on British "patient stacking"

Dying To Save 'The System'

For defenders of Canada's government-monopoly health care system, there is only one goal that truly matters. And, no, despite their earnest insistences to the contrary, that goal is not the health of patients. It is the preservation of the public monopoly at all costs, even patients' lives. This week, the Kawacatoose First Nation, which has an urban reserve on Regina's eastern outskirts, announced it wanted to build a health centre there with its own money. Among other things, the band wants to buy a state-of-the-art MRI machine and perform diagnostic tests on Saskatchewanians -- aboriginal and non-aboriginal-- who currently face some of the longest waits for scans in the country.

This should be a win-win: Aboriginals show entrepreneurial initiative, without any financial obligation on the part of the federal or provincial government, and create well-paying high-tech jobs for natives who desperately need them, while at the same time easing the wait for MRI tests in Saskatchewan that can now run to six or even 12 months. Each year, hundreds or even thousands of Saskatchewan residents -- mostly middle-class -- drive across the border into North Dakota and pay their own money for scans rather than wait for one at home. The Kawacatoose proposal would give them a much closer alternative.

So what was the reaction of the opposition NDP in Saskatchewan? Restrained contempt and veiled fear-mongering. The restraint was a result only of the fact that this proposal was coming from aboriginals. Had a private, non-native company suggested the same thing, Saskatchewan's opposition socialists would have been screaming from the rooftops that greedy insurance companies and health profiteers are lurking under every hospital bed ready to prey on unsuspecting patients the moment they get the green light.

Still, despite their untypical decorum, it was easy to see the NDP's disdain. Health critic Judy Junor said such private facilities threaten the public system, even if they do not offer fee-for-service scans, because they poach staff from public hospitals. "You can buy the machine," she sniffed, "that's the easy part. It's who's going to work it on a day-to-day basis."

The Kawacatoose have said they will not permit queue-jumping by fee-paying patients at their clinic. Instead, they have the money to buy an MRI, and they estimate their band could make some much-needed money by performing scans paid for by the province, so they are seeking permission to go ahead. Still, that is not good enough for Ms. Junor and her colleagues. The NDP sees any service provision not controlled directly by the government as a menace That means health cannot be as high a priority for them as preserving the public monopoly.

During their 16 years in power -- a string that ended just over three months ago -- the Saskatchewan NDP refused to issue licenses for any MRI clinics not owned by government. In 2004, the Muskeg Lake Cree Nation proposed building one on its satellite reserve in Saskatoon. After three frustratingly long years seeking approval, the band gave up and went ahead with plans for an MRI-less clinic. Their members and the public will have to settle for second-best care because of the devotion of medicare's defenders to "the system," first and foremost. By placing "the system" (and the well-paying jobs of NDP-voting union health workers) ahead of providing care for patients, the NDP have shown where their true loyalties lie.

It's the same across the country, and not just among New Democrats. We are short 12,000 to 15,000 doctors in Canada because in the early 1990s, provincial health ministers -- Tory, Liberal and NDP -- desirous of preserving "the system," capped enrolments at medical schools. Doctors, they reasoned, are a major driver of costs with all the tests they order and treatments they perform. The ministers knew that limiting the number of doctors would limit the amount of medical service available to patients. But they were prepared to accept that. They felt they had to limit costs to preserve "the system," so providing care Canadians needed came in second to the system's survival.

The nursing shortage, the sad state of high-tech diagnostic equipment outside our largest cities and the rationing of services via waiting lists are all examples of how medicare's advocates are prepared to sacrifice Canadians' health and comfort -- even their lives -- just so the public monopoly can be maintained.


Friday, February 22, 2008

The laser again

A personal memoir for a change

It is a couple of years since my last visit to the laser but last Monday I had to go again. When my skin cancers get too big for excision or freezing, the laser is the last option before a graft.

So about three weeks ago I rang the best dermatological surgeon in Brisbane -- Russell Hills -- and made an appointment to see him a few days later. He agreed that it was laser time and booked me in for the procedure a couple of weeks later. If I had gone through the public hospital system, I would still be waiting for a consultation and the procedure itself would be a year or more off.

As I have had so much dermatological surgery over the years I am a connoisseur of it so when I say that Russell is the best, I am in a position to know. His excisions and joinups are so fine that they heal with maximum rapidity -- which is the main thing from my viewpoint. That skill does however make him much in demand by ladies for their facelifts etc. You can't see the scars where Russell has been.

Anyway I arrived at Northwest Private Hospital at the appointed time in the late afternoon and went through all the introductory bureaucratic procedures that are mandatory these days. I was however at the end of the day's listings so I was the victim of all the prior medical misadventures of the day. Russell's anaesthetist had been much held up by unforeseen circumstances on his morning list (surgery that was more complicated than foreseen and which therefore went on much longer than planned) so I was two hours late going into theatre. Russell came out personally to apologize and explain to me shortly after I arrived, however, so I kept my cool about that. Being treated with courtesy makes a big difference to my responses.

And in theatre I was given only locals at my request so I was awake and alert there. And I had the odd chat and joke with Russell and the nurses while my lesions were being attended to. It was very civilized.

So Brisbane private medicine is a dream as far as treatment of patients is concerned. I guess not all patients are on first-name terms with their surgeon but it can happen for repeat customers like me.

But there is a but. It costs a lot. Not nearly as much as in America but a lot by Australian standards. Russell charges $140 for a consultation versus $40 for a GP consultation and he charged a $850 co-payment for the laser work. The hospital charges were all covered by my insurance.

So if you get an education, work hard and save your money instead of spending it all on beer and cigarettes, you can get the first-class medical service in your declining years that everyone aspires to. I did and I do.

As I sat down to write this little memoir, I was listening to "Goodbye" (from "The White Horse Inn"). Most pleasant. You can see a small picture of the white horse referred to here

Australia: NSW public hospital agonies continuing

Yet another general manager of the Royal North Shore Hospital has left, increasing pressure on the beleaguered Health Minister, Reba Meagher, who tomorrow travels to Bathurst to face the latest debacle in the state's public hospitals. Mary Bonner, who was appointed two years ago, is the eighth general manager in 11 years to walk out of Royal North Shore, the hospital that has become the symbol of all that is wrong with the state's public health system. It is not clear why Ms Bonner has left but her departure follows the recent resignations of two other health chiefs in the Northern Sydney Central Coast Area Health Service: the project manager for Royal North Shore redevelopment, Andrew Bott, and the general manager of Central Coast Health, Ken Cahill.

Ms Bonner had vowed to do all she could to help turn the hospital around but the Herald understands budget constraints and pressure to meet performance targets despite several years of under-resourcing made her task insurmountable. It is also understood that she felt recommendations from the recent parliamentary inquiry into Royal North Shore were so vague they would not rectify problems, and more funding was needed for real change. Several clinicians told the inquiry of their criticisms of the hospital's redevelopment, including a lack of beds and poor cancer and pathology services.

The latest resignation came as Ms Meagher yesterday dodged questions on how the Department of Health or the builders or project managers of the new $98 million Bathurst Base Hospital got the redevelopment so wrong that it failed to meet national patient safety guidelines. The Department of Health also remained silent on how the Bathurst plans were approved when some areas in such acute services as intensive care and emergency were too small to function adequately. The building company, the John Holland Group, and the project manager, Capital Insight, also refused to comment.

"It's a bloody scandal," a Bathurst doctor, who did not want to be named, said yesterday. "Somebody somewhere has to put their hand up and say they caused this mess ... heads are going to roll." The Herald visited Bathurst Hospital yesterday, where all but the most urgent surgery has been suspended indefinitely due to problems with communications.

One doctor, who did not want to be named, said he was concerned for a patient due to undergo breast cancer surgery tomorrow, and was searching for another hospital. He said patients had been sent to Nepean, Mudgee, Lithgow and Orange hospitals for surgery. "There was no surgery here over the weekend apart from two emergency obstetrics patients - one was an emergency caesar and the other was a miscarriage," he said.

The doctor said he had been told that it could take months before the problems were fixed. The paging system had broken down several times a day, the alarm system and backup were inadequate and the situation was so desperate that inquiries were made about whether the fire alarm system could be connected to the switchboard as a public address system. There is also no mobile phone coverage. Telstra maintained yesterday it had always told the Department of Health that it could not complete the required infrastructure until at least the end of March.

The department has denied rumours that the John Holland Group was given $2.8 million in bonuses for finishing the job early. The department said the project was incomplete because the old hospital had to be demolished and the finishing touches put on the new one. It said no bonuses were paid.

One department, ambulatory care, has been left out altogether from the new hospital, and the Bathurst Medical Staff Council is asking for it to move into the mental health unit. Staff are refusing to occupy that section because they say it is unsafe for patients because there are sheer drops and potential hanging points.

Ms Meagher was due to turn the first sod for the Orange hospital redevelopment tomorrow. Yesterday the Greater Western Area Health Service said it would delay construction after doctors there complained that plans are also flawed. "I won't be turning the sod and I have required the Infrastructure Board to undertake a complete audit of the Orange plans to ensure we are not going to have a repeat of the Bathurst incident," Ms Meagher said.

The Opposition Leader, Barry O'Farrell, said the Health Infrastructure Board, set up last year to oversee big projects, "was just another short-term fix designed to distract from the Iemma Government's ongoing incompetence in delivering health facilities". "Reba Meagher can't even tell the public who is responsible for this latest infrastructure disaster," Mr O'Farrell said. "The public can have no confidence Reba Meagher will not repeat the mistakes at Bathurst at similar hospital upgrades at Orange or Royal North Shore."

Brendan Smith, the co-director of intensive care at Bathurst, said doctors had told the John Holland Group that there was no mobile reception as early as September last year. "In this day and age every doctor and his dog has a mobile phone and that's the standard way we communicate ... none of the areas where we have to run to fairly regularly have mobile reception. We pointed that out at the time."

Dr Smith said there had been "very, very limited consultation". "We were never allowed to see the plans; we were never allowed to have copies of the plans," he said. "With the operating theatres, two of the four were meant to be 50 square metres and that's a national standard ... there's 39 square metres. How the hell did they lose 11 square metres?" A spokeswoman for the Greater Western Area Health Service said it was discussing problems with Telstra. The Bathurst Medical Staff Council said the area health service appeared committed to fixing the problems.


Thursday, February 21, 2008

Over Regulating Health Insurance & The Law of Unintended Consequences

California's Regulators Abolished Legal Underwriting, So Insurers Outsource it to Doctors

I have written quite a few times about California's regulatory adventurism that has made it impossible for health insurers to assess and price health risks in the market for individual health insurance, despite the fact that it is legal to do so. (Although, the recently defeated California Health Care Deforminator, Model ABX1 1 would have outlawed risk-rating, thereby driving premiums up for everybody.)

California regulators recently forbad health plans from rescinding policies wherein applicants have misrepresented their health status or history, unless the plan can prove that an applicant willfully misrepresented himself. Say, for example, you suffered a head injury two months before applying, but did not disclose that on the application, and fooled the health insurer into selling you a policy with premiums set for a person in better health. When the truth comes out, you can just say that you did not realize it was important, or that you forgot about it, and the health plan is stuck with the policy in force. Obviously, this increases everybody's premiums, because health insurers become "gun shy" when they cannot carry out their legal right to underwrite individual health policies.

Because California is a pretty competitive market, one insurer that presumably did not want to jack up premiums has undertaken a different approach, according to an article in the Los Angeles Times. Blue Cross of California has sent a letter to doctors asking them to report any suspected pre-existing conditions to Blue Cross of California when they see a patient covered by an individual policy.

Doctors are appalled that the 3rd party-payer is asking them to "spy" on applicants. I don't blame them. But I find it hard to blame Blue Cross of California, either. After all, California's regulators have eliminated any other way for them to faithfully estimate and price the health risks of individually-written health insurance, despite the law's permitting it.

Many politicians would (mistakenly) abolish risk-writing in individual health insurance, but they have not achieved that yet. Until they do, regulators must allow California's health insurers to underwrite under the protection of current law, not force them to do it through the back door, and jeopardizing the doctor-patient relationship.


New Zealand public hospital mistakes kill 40

For perspective, there's around 4 million people in New Zealand

Mistakes in New Zealand hospitals led to the deaths of 40 patients and left another 142 people seriously ill or injured in the 12 months through June 2007, according to an official report released today. The mistakes included significant overdoses of medicine, surgeons operating on the wrong part of the body or leaving instruments inside after surgery, patients falling and dangerous reactions to blood transfusions, the Health Ministry report said.

It was the first time such figures had been released, and Health Minister David Cunliffe said transparency was the best way for the health sector to improve. The report said that an average of 2.2 of every 10,000 patients treated in New Zealand hospitals were involved in a serious or fatal medical mishap. Cunliffe said that New Zealand hospitals, which admit 834,000 patients a year, were among the safest in the world and compared favourably to those in Australia and the United States, but could do a lot better.

New Zealand Health and Disability Commissioner Ron Paterson told Parliament this month that complaints to him had increased by 20 per cent in the last two years, and he dubbed New Zealand hospitals unsafe. He said that the main problem was an "unduly complicated" health system for a nation of 4.2 million people and lack of collaboration between the 21 district health boards, which had different standards and operations.


Wednesday, February 20, 2008

Massachusetts Health Reform: Rewriting History

On January 31, Shikha Dahlia of the Reason Foundation wrote an op-ed in the Wall Street Journal, "Saying No to Coercive Care". It was great to see someone from Reason Foundation have a swing at the pinata: after all, it was back in November 2004 that Ronald Bailey wrote a feature in Reason Magazine demanding "Mandatory Health Insurance Now!" Anyway, Ms. Dahlia points out that, with costs now anticipated at $400 million, the "reform" is costing 85% more than originally budgeted.

That did not sit well with Jon Kingsdale, the reform's czar (officially, Executive Director of the Commonwealth Health Insurance Connector Authority), who responded in today's WSJ that "the original estimate by the conference committee that wrote the legislation in 2006 pegged it at $725 million" (letter to the editor: "Bay State Insurance is Doing Fine, Thanks"). To be blunt: What is he talking about?

Everyone who has followed the travails of the Massachusetts reform knows that the originally budgeted cost was $125 million from the general fund. Indeed, it's on p. 17 of the health care reform conference committee's report to the House joint caucus, of April 3, 2006, which is at the state's website here - or at least it will be until someone in the Connector bureaucracy reads this blog and makes the report disappear!

The wheels are coming off the Massachusetts health reform - and rewriting its history will not change that.


Australia: Health watchdogs only interested in paperwork

OFFICIALS did not hear the cries of a dying man during a federal investigation into a fatal disease outbreak at a Melbourne nursing home last year because they never left the facility's office, preferring to check paperwork rather than patients.

Minister for Ageing Justine Elliot yesterday accused the former government of sitting on a report by the Aged Care Commissioner into the Broughton Hall nursing home outbreak for nine months. A summary of the report by Aged Care Commissioner Rhonda Parker, filed in May last year and tabled in parliament yesterday, revealed that departmental staff sent to investigate a gastroenteritis outbreak, which eventually killed five people, checked only the nursing home's paperwork and not its residents.

One nursing home resident, Merson Dunstan, who later died, had cried out for help during a departmental visit to Broughton Hall in April last year. But Ms Parker found his calls were not heard because the staff never left the nursing home's office. The departmental staff cited the need to respect infection control protocols for the failure to check on the physical state of residents.

Ms Elliot promised a strengthening of departmental guidelines in order to prevent a repeat of the mistake. "While it does not bring the matter to a close, I hope it is a step forward for the Dunstan family," she said. "It must have been a frustrating and indeed sad nine months for the Dunstan family, and our thoughts are with them as they face the coroner's investigation."

An Aged Care Standards and Accreditation Agency audit on Broughton Hall following the deaths said staff had not known what to do in the event of an outbreak, which delayed reporting and identification of the disease. It found other problems with staff training and in clinical-care management and evacuation procedures at the home.

Then ageing minister Christopher Pyne released the audit results last year, a month before he received the Aged Care Commissioner's report. He said at the time that the audit showed direct links between the breaches and the five deaths at Broughton Hall. Yesterday, Mr Pyne told parliament he had been grievously misrepresented by the new minister's claim that he had done nothing with Ms Parker's report, saying it had fed into later investigations. "Those parts of the report that were germane to the Department of Health and Ageing, which I was a part of, I asked to be implemented," he said.

Ms Elliot hand-delivered a copy of the Aged Care Commissioner's summary report to the Dunstan family earlier this month, but she said the full report could not be released publicly because of Privacy Act considerations. The Dunstan family said through Ms Elliot's office that they were declining comment on the matter. Ms Elliot said guidelines for nurses investigating clinical care in nursing homes were being revised with the help of state, territory and local health authorities. They would provide more specific pointers on how to identify potential problems, she said.


Tuesday, February 19, 2008

1 in 10 patients gets drug errors in Mass. community hospitals

(Community hospitals are usually charitable institutions)

One in every 10 patients admitted to six Massachusetts community hospitals suffered serious and avoidable medication mistakes, according to a report being released today by two nonprofit groups that are urging all hospitals in the state to install a computerized prescription ordering system. The report is the first large-scale study of preventable prescription errors in community hospitals, and its author, Dr. David Bates of Brigham and Women's Hospital in Boston, said he was surprised that these mistakes were so frequent in these community hospitals. Previous studies in large academic hospitals that also lacked computerized systems found such medication errors occurred less than half as often, he said.

Researchers declined to release the names of the six Massachusetts hospitals, which participated in the $5 million study voluntarily on condition that they would remain unnamed. Of 73 hospitals in the state, only 10, almost all of them large teaching hospitals in Boston, have adopted the computerized physician order entry system, which requires doctors to type into a central database every medical order, including prescriptions, diagnostic tests, and blood work. The doctors' orders are matched against the patient's medical history, triggering red flags to prevent problems related to drug allergies, overdoses, and dangerous interactions with other drugs. Bates said that after this system was put in place at Brigham and Women's Hospital in 1995, preventable medication errors declined by 55 percent over the next two years.

The researchers could not explain the higher rate of preventable errors in the community hospitals but cautioned against patients assuming that these hospitals overall are less safe than academic teaching hospitals. They said this is one of only a small number of studies nationwide that have analyzed prescription error rates at hospitals, and comparisons are difficult because each study varied slightly in its scope and definitions.

Donald Thieme, head of the Massachusetts Council of Community Hospitals, said studies show that many community hospitals offer the same, if not better, care for patients with some serious illnesses. He said community hospitals struggle to adopt the computerized prescription systems because of cost, but they are committed to improvements because they want "errors down to zero." Thieme said he could not comment on the specifics of today's study because he had not seen it.

Community hospitals in Massachusetts may not have a choice but to implement such computerized systems, based on increasing pressure from insurers who see the systems enhancing patient safety and saving money. Gerald Greeley, director of information services at Winchester Hospital, said Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care, over the last year, have demanded the gradual introduction of the computerized physician order entry system as a condition of reimbursement contracts with Winchester Hospital.....

The researchers reviewed a total of 4,200 randomly selected patient medical charts at the six community hospitals, covering stays from January 2005 to August 2006. An average of 10.4 percent of patients suffered a preventable "adverse drug event" - defined as a case in which the patient was given a drug even though the medical records noted that the medication could trigger a drug allergy or that the dose given would exacerbate a medical condition. Medication errors were counted only when patients suffered serious reactions, including going into shock or suffering kidney failure. In nearly every instance, the patients remained in the hospital longer to recover from the mistake. Nobody died from any of the mistakes, researchers said.

Everett said the study's findings can be "generalized to all hospitals" without such computerized systems, and indicate that prescription errors are often made in the rushed hospital atmosphere. She recommended that patients inquire about a hospital's patient-safety systems, and ask medical staff to double-check dosages and names of all medications given. "I'd demand it," she said.


Australia: Another disastrous public hospital

New hospital worse than the old one

THE new $98 million Bathurst hospital is so dysfunctional it is dangerous, doctors say, forcing the Health Department to halt demolition of the old one and raising serious concerns about the future of all hospital redevelopments. Surgeons have indefinitely suspended routine elective surgery at the new Bathurst Base Hospital, warning that serious design and construction flaws - such as an inadequate emergency alarm system and a pipe that leaked raw sewage into the maternity ward - are putting patients at risk.

It is the latest in countless public hospital blunders that have forced the Health Minister, Reba Meagher, to call a Special Commission of Inquiry into acute care services in NSW, which began last week. "The minister has sought urgent advice from the area health service about the issues from the redevelopment. This number of issues with a brand new hospital is unacceptable and we are getting to the bottom of that," a spokeswoman for Ms Meagher said yesterday. She said medical staff had been extensively consulted during the planning stage. But the Opposition and doctors say the debacle raises wider concern about the consultation process on all of the state's hospital redevelopments, including the $702 million Royal North Shore facility.

Significant problems with the new Bathurst hospital include possible hanging points and access to sheer drops outside the mental health unit - which has remained empty - and major communication failures with pagers and mobile phones. Medical Staff Council chairman Chris Halloway said areas in intensive care, operating theatres and accident and emergency were also too small. Dr Halloway said the hospital, which opened three weeks ago, was unsafe. "It's mainly accident and emergency and the surgical features that are the problem. The reason that we had to cut off elective surgery is simply . so we could cope with the dysfunction," he said. "We can't deliver a proper standard of patient care . the community in Bathurst don't have the health care facility that they had a couple of months ago."

The inadequate alarm system was "a pivotal safety issue" but also only half of the intensive care beds could be seen from the nurses station due to poor design, he said. "[It] seems to us to be clinically crazy."

Dozens of patients have had their surgery postponed. One Bathurst hospital doctor, who did not want to be named, said developers had decided to "shrink-fit the facility". "They didn't consult us and what consultation there was they didn't pay attention to," he said.

A spokeswoman for the Greater Western Area Health Service did not dispute the safety concerns. A team of technical experts had been at the hospital all weekend attempting to rectify the problems, she said. A fire and safety audit had been ordered as well as an audit on room sizes. "This is a really serious issue for us and we're working extremely hard to try and assess the issues," she said. She said area health service agreed to doctors' demands not to demolish the old hospital yet. "It was down to start tomorrow. It has been deferred until Wednesday," she said.

"It's just another case of the Iemma Government and Reba Meagher failing to listen to frontline health workers," the Opposition Leader, Barry O'Farrell, said. The GWAHS spokeswoman said clinicians were engaged in "extensive consultation".


Monday, February 18, 2008

NHS patient starved to death

A hospital trust will have to pay damages after a patient who had undergone a successful operation for cancer was then inadvertently starved and poisoned to death. Roy Hodgson, 66, a retired pub landlord, underwent a surgical operation to remove a tumour in his throat at the Cumberland Infirmary, in Carlisle, and was given a good chance of making a full recovery. But he suffered weeks of starvation after a nurse failed to insert a feeding tube correctly into his stomach, and senior medical staff failed to spot the mistake.

Mr Hodgson, a father of three grown-up children who ran the Three Tuns pub in Cleator, West Cumbria, for 20 years, suffered such hunger pangs that he attempted to flee the hospital and was discovered near its entrance clutching his stomach.

It emerged at his inquest that several days after his operation on October 16, 2004, the feeding tube came out and the nurse put it back in the wrong place. A radiologist who examined a scan of the area did not spot the error. When nurses fed him through the tube with liquid nourishment, they were effectively poisoning him. He died two weeks later after developing peritonitis.

At the time Karen Hodgson, his daughter, described how her father kept asking for something to eat and drink, and showing them how swollen his stomach was. He would have to write notes to explain his hunger. She said: "A couple of days before he went back into intensive care, the nurses found him in the hospital foyer with his coat on, crouched by the wall and holding his stomach."

The National Health Service Litigation Authority, which handles major claims against NHS hospitals, has written to the family's lawyer confirming that the trust accepts medical negligence. There is yet to be an assessment of the level of damages. Markus Nickson, the family's solicitor, said that the hospital had admitted that staff failed to give Mr Hodgson the care he needed and that he died as a result. He said: "What Mr Hodgson and his family have gone through was appalling."

The hospital, part of the North Cumbria Acute Hospitals NHS Trust, has insisted that it has learnt the lessons of Mr Hodgson's death. The hospital has changed its protocols and any reinsertion of a feeding tube is now only carried out by specialist staff.

Mark Hodgson, 28, the dead man's son, said that the family had not pursued legal action for the money but said that they did not want a similar thing happening to anyone else. He said: "We have been told that they have changed the procedure nationwide. That is the best thing we could have got from this."

Mr Hodgson, an electrical engineer, described his father as a happy, outgoing and caring man who had every hope of a recovery. "What happened was an absolute disgrace," he said. "We wanted justice. We had no idea that he was not being fed properly."

The family's grief was compounded at the time by having to leave the pub that was also their home. They said that the brewery had asked them to leave if they could not open the pub for business. The family, which was running the pub, were forced to raise money through a garage sale of their possessions. Mr Nickson said: "Not only did they lose a loved father because of a ghastly mistake, they were told by the brewery which owned the pub that they would have to get out within a week."

At the inquest last November, John Taylor, the Coroner for West Cumbria, concluded that Mr Hodgson had died as a result of an accident. The coroner was assured by medical staff that procedures at the hospital had been changed in the light of the patient's death. Feeding tubes are no longer put in after surgery, but between diagnosis and the start of any treatment. Nurses would no longer reinsert feeding tubes so soon after an operation when the hole in a patient's stomach was not properly established.


Massachusetts pain

Pretty much as predicted by skeptics

To hold down state costs, officials are considering raising premiums as much as 14 percent and doubling some copayments for the subsidized insurance program that is at the heart of healthcare reform. State officials said they want to ensure that the program, called Commonwealth Care, does not collapse under the weight of soaring costs or under a potential influx of residents whose employers drop coverage because the program offers a better deal for their workers. "If we're not only trying to insure the uninsured, but insure the previously insured, that's going to blow the doors off," said Leslie Kirwan, the state's top budget officer and chairwoman of the Commonwealth Health Insurance Connector Authority board that oversees Commonwealth Care.

But advocates and some members of the authority board that reviewed the proposed increases yesterday said the hikes would price people out of the program. In addition, advocates called them unfair when compared with the 5 percent premium increase the state expects for unsubsidized insurance plans. "We think it undermines the very principle on which the reform stands, to provide access to quality, affordable healthcare and to protect the poor and the most vulnerable," said the Rev. Hurmon Hamilton, president of the Greater Boston Interfaith Organization, a group of congregations that advocates for healthcare access.

The proposed increases might be modified or avoided if insurers lower their prices for covering enrollees in the next fiscal year or if the state finds other sources of revenue. The state is currently negotiating with insurers who are seeking far more than the state wants to pay. Neither side would disclose the size of the gulf.

As proposed, the increases would affect about half of the 170,000 low-income people now enrolled in Commonwealth Care. The premium increases would apply to those whose income is above 150 percent of the federal poverty level and the copayment increases to those above 100 percent of the poverty level. State residents are eligible for the program if their income is at or below 300 percent of the poverty level and they do not have access to work-based insurance. Under the proposal, the lowest premium would rise from $35 to $40 a month, a 14 percent increase.

Jon Kingsdale, executive director of the connector, defended the proposed Commonwealth Care premium increases of $5, $10, or $15 a month as fair, adjusted for income, and far lower than most premium increases in private insurance. Kingsdale said that the subsidized program and the private insurance plans are completely different and that comparing the increases was like comparing apples and oranges.

Connector staff members, who proposed the increases, said they could help prevent the state plan from becoming so attractive that employers drop coverage for their workers and send them to Commonwealth Care. The state is already predicting that enrollment and costs for Commonwealth Care could double over the next three years. "If we're going to preserve political support and keep it economically viable, we've got to maintain some comparability between the benefits and contributions in Commonwealth Care and in the private market," Kingsdale said.

Several connector board members opposed the increases, while others said they seemed reasonable and might be necessary to sustain the program. The board is expected to vote in two weeks on whether to impose any increases, after it reviews insurers' bids. "It's too extreme," said Celia Wcislo, a board member and assistant division director of Local 1199 of the SEIU. She said the state should look to insurers and hospitals instead to foot more of the cost.

In addition to the premium increases, copayments for office visits and prescription drugs could rise by $5 or $10, and some enrollees could see an increase in the total amount of out-of-pocket costs they must cover.

A Brockton mother of five children said those increases could make the plan unaffordable for her family. Mona Divers pays $37 a month in premiums for herself; the rest of her family has other insurance. With a heart condition, high blood pressure, high cholesterol, and a thyroid problem, she needs regular care and racks up copayments for office visits and prescriptions. Her husband's income of about $23,000 doesn't go very far, she said. The family is also paying off about $4,000 in medical bills run up before she enrolled in the state plan. "Back in September, when I signed up, I thought, 'Thank God I have Commonwealth Care to help me,' " she said. If the cost increases, she added, "I don't know if I'm going to be able to keep it up."