Saturday, May 31, 2008


Two current articles below

19th century medicine in a 21st century public hospital: Four days to diagnose a broken bone!

X-rays? Who cares about x-rays? That's all too hard!

Wide Bay mother Sharon Eggmolesse says it's not good enough that Bundaberg Hospital took four days to diagnose a painful break in her son's foot. Ms Eggmolesse told The Courier-Mail she had taken Jaeden, 9, to hospital on May 12. "His foot had swollen up and he couldn't walk on it at all," she said. After X-rays were taken, Ms Eggmolesse was told Jaeden could have jarred ligaments. He was sent home bandaged and on crutches with a direction to see his general practitioner in three days.

Ms Eggmolesse said that while they were at their GP, with Jaeden "in considerable pain", the hospital advised her husband it had now received an X-ray report from a radiologist saying a bone in Jaeden's foot was broken. She said she was told by her GP, who sought a second opinion, that Jaeden should have had his foot plastered straight away.

When she queried the delay with the hospital, she was told there was no radiologist on site and that Jaeden's X-rays, like those of all patients, had been sent off site. A radiologist in Victoria had detected the broken bone.

Queensland Health said the delay was not a symptom of the worldwide shortage of radiologists, which has prompted a private imaging clinic in Townsville to offer a salary package just shy of $1million in an effort to attract a radiologist. Rather, a Queensland Health spokesperson said only nine Queensland Health sites were staffed with radiologists. Nine other hospitals, including Bundaberg, used private providers; in Bundaberg's case, Medical Imaging Australia.

Ms Eggmolesse said her son had follow-up X-rays at a local private hospital, where the results were available the same day.


Your regulators will protect you -- in their usual bored way

Complaints about a mad doctor since 1986 but he was not deregistered until 2004. And he hurt lots of people in those 18 years of official sleep

The NSW Health Minister, Reba Meagher, has twice told Parliament no background checks were done on the rogue doctor at the centre of the Butcher of Bega scandal, despite a Government report confirming a month ago the Health Department knew of an issue with his obstetric practice when it hired him. Ms Meagher - who had refused to make the report public until yesterday - repeated in Parliament two weeks ago that no background checks were done on Graeme Reeves before he was employed as an obstetrician at two South Coast hospitals in 2002 despite being banned from the specialty in 1997. Police are investigating hundreds of serious allegations against Mr Reeves of sexual assault and botched procedures, including genital mutilation.

On May 15, Ms Meagher insisted no checks were done by the Greater Southern Area Health Service after the Herald revealed documents that showed a senior health executive hired Mr Reeves despite making a diary note of a referee telling him Mr Reeves was "not meant to do obstetrics". A report by the judge Deirdre O'Connor, dated May 2, stated that the Health Department should have directly contacted the NSW Medical Board to check his registration after the referee's warning and that its failure to do so was "the main oversight". The department had conducted a criminal record check.

The Opposition health spokeswoman, Jillian Skinner, called for Ms Meagher, who is overseas on holidays, to apologise for misleading Parliament. "Health Minister Reba Meagher has twice misled Parliament . where she said there's been no checks done . this report from Deirdre O'Connor clearly shows that there was a document among the papers that showed there'd been a reference check where it was pointed out that Dr Reeves was not supposed to do obstetrics," Mrs Skinner said.

The Health Department yesterday refused to discuss the diary note, as did a spokeswoman for Ms Meagher. "I'm just not going to have this conversation . she has not misled Parliament. She said from the beginning that no appropriate background checks have been carried out and the matter is now being investigated so we'll leave it there," the spokeswoman said. Both shunted blame for the delay in releasing the report onto the Garling health inquiry.

The O'Connor report confirmed executives at GSAHS knew Mr Reeves had been illegally practising obstetrics at Bega and Pambula hospitals as early as November 2002, and again twice in January 2003, but allowed him to continue in gynaecology until July 2003. The report shows the full extent of complaints made against Mr Reeves by medical staff and patients dating back to 1986 at Hornsby Hospital, and demonstrates a spectacular failure by NSW Health organisations to communicate. Mr Reeves was not deregistered until 2004.

Ms O'Connor's report recommended a review of information sharing and giving the Medical Board and HCCC greater powers to pursue and monitor doctors.


Friday, May 30, 2008

We Need Free Trade in Health Care

Health-care reform is a major election issue. Yet while Democrats Hillary Clinton and Barack Obama offer comprehensive plans, important gaps remain. Neither plan addresses the need for more doctors, a problem that Gov. Mitt Romney ran into when he introduced comprehensive medical coverage in Massachusetts in 2006. The other problem is the cost, an issue that earlier this year killed Gov. Arnold Schwarzenegger's ambitious attempt at reform in California.

No presidential candidate can afford to ignore the potential of international trade in medical services to address these issues. Consider the four modes of service transactions distinguished by the WTO's 1995 General Agreement on Trade in Services.

Mode 1 refers to "arm's length" services that are typically found online: The provider and the user of services do not have to be in physical proximity. Mode 2 relates to patients going to doctors elsewhere. Mode 3 refers mainly to creating and staffing hospitals in other countries. Mode 4 encompasses doctors and other medical personnel going to where the patients are. All modes promise varying, and substantial, cost savings. Arm's-length transactions can save a significant fraction of administrative expenditures (estimated by experts at $500 billion annually) by shifting claims processing and customer service offshore. Nearly half of such savings are already in hand. Foreign doctors providing telemedicine offer yet unrealized savings. We estimate that the savings in health-care costs could easily reach $70 billion-$75 billion.

Mode 2, where U.S. patients go to foreign medical facilities, was considered an exotic idea 15 years ago. Now this is a reality known as "medical tourism." Today, many foreign hospitals and physicians are offering world-class services at a fraction of the U.S. prices. Costly procedures with short convalescence periods, which today include heart and joint replacement surgeries, are candidates for such treatment abroad. By our estimates, 30 such procedures, costing about $220 billion in 2005, could have been "exported."

Mode 3, with hospitals established abroad, will primarily offer our doctors and hospitals considerable opportunity to earn abroad. Of course, the establishment of foreign-owned medical facilities in the U.S. is also possible, and could lead to price reductions by offering competition to the U.S. medical industry.

Mode 4 concerns doctors and other medical providers going where the patients are. It offers substantial cost savings, since the earnings of foreign doctors are typically lower than those of comparable suppliers in the U.S. But the importation of doctors is even more critical in meeting supply needs than in providing lower costs. According to the 2005 Census, the U.S. had an estimated availability of 2.4 doctors per 1,000 population (the number was 3.3 in leading developed countries tracked by the OECD).

Comprehensive coverage of the over 45 million uninsured today will require that they can access doctors and related medical personnel. An IOU that cannot be cashed in is worthless. Massachusetts ran into this problem: Few doctors wanted (or were able, given widespread shortages in many specialties) to treat many of the patients qualifying under the program. The solution lies in allowing imports of medical personnel tied into tending to the newly insured. This is what the Great Society program did in the 1960s, with imports of doctors whose visas tied them, for specific periods, to serving remote, rural areas. U.S.-trained physicians practicing for a specified period in an "underserved" area were not required to return home.

It is time to expand such programs – for instance, by making physicians trained at accredited foreign institutions eligible for such entry into the U.S. But in order to do this, both Democratic candidates will first need to abandon their party's antipathy to foreign trade.


Australia: Cancer patients kept waiting for life-saving treatment

CANCER patients are waiting up to almost three times longer for life-saving treatment than they should be at some of the state's biggest hospitals. A leaked Queensland Health memo shows patients are being put at risk from radiation oncology unit delays at the Royal Brisbane and Women's, Princess Alexandra, Mater and Townsville hospitals. The patients are expected to wait an average of 27 days despite the "maximum acceptable limit" of 10 days. "Patients for whom delay in starting will have a significant adverse affect on outcome," the QH Radiation Therapy Services memo warns radiation oncologists.

Health Minister Stephen Robertson was unavailable Monday, May 26, but his department admitted treatment facilities were under pressure. The figures have prompted the Opposition to refer Mr Robertson for allegedly misleading State Parliament after he claimed last month there was no centrally collected data for waiting times.

Liberal health spokesman John-Paul Langbroek said the memo was further evidence the Minister was failing to contain waiting list blow-outs. "It is simply not good enough because this is important treatment for very sick people and lives are being put at risk," Mr Langbroek said. "People are dying in our system because of these poor services."

Townsville Hospital was expecting the worst delays with next appointments 28 days away for category two patients, followed by RBWH and the PAH on 25 days. Category three patients were waiting as long as 55 days in Townsville despite a maximum recommended wait of 20 days. The department said all category one patients were cleared immediately.

Queensland Health cancer control chair Euan Walpole said the memo was used to help clinicians plan appointments, adding some patients may be treated sooner. "The Government has provided an extra linear accelerator both at Townsville Hospital and the PA Hospital, and staffing has been increased to extend the operating hours of the available machines, providing additional treatment shifts," Dr Walpole said.

The Courier-Mail has recently highlighted problems with waiting lists for other treatments such as breast cancer due to a shortage of radiographers. Australian Medical Association Queensland president Ross Cartmill said the figures again illustrated the poor planning and chronic underfunding of health. "If these people are being treated for malignancies with radiation, they are suffering very serious problems and must be treated quicker," Dr Cartmill said.


Thursday, May 29, 2008

NHS hospitals lose 32,000 beds in a decade

More than 30,000 hospital beds have been lost since Labour came to power, with record cuts in NHS wards last year

The cutbacks mean increasing numbers of hospitals are going on "black alert" - which involves closing their doors to new patients because they are full. Patients' groups described the loss of the beds, at a time when overcrowded wards have seen soaring rates of killer infections, as "a national scandal". The reduction contradicts a pledge from Tony Blair at the turn of the century that there would be 7,000 more NHS beds by 2010. New figures, seen by The Telegraph, show that the number of health service beds fell more than 8,000 last year, as the NHS began a reorganisation process which will mean the closure of dozens of hospitals.

More than 40 per cent of maternity units turned away women in labour last year because they had no room. Meanwhile, ambulances have been forced to queue outside overstretched hospitals, treating patients in car parks just yards from accident and emergency departments. The new statistics, revealed in response to a parliamentary question by Ed Vaizey, the Conservative MP, show that almost 32,000 NHS hospital beds went between 1997, when Labour took office, and 2007.

More than 8,400 beds were cut in the year ending March 2007, the largest fall in 14 years. One in six beds has been closed over the decade. There are now 167,019 beds in NHS wards, compared with 198,848 in 1997. The figures emerged as health authorities are drawing up plans which will see the likely closure of dozens of district general hospitals. The East of England health authority has admitted that two accident and emergency departments and a maternity unit could close.

Andrew Lansley, the shadow health secretary, said the Government's financial mismanagement had forced hospitals to make cuts which could risk lives. "These bed cuts were financially driven: the sharp rise in the numbers closed happened at a time when the health service was under desperate pressure to clear a massive deficit."

Katherine Murphy, from the Patients' Association, said: "This is a national scandal. More than 30,000 beds have been lost at a time when demand is increasing."

In the same decade that the beds were cut, death rates from the infections MRSA and Clostridium difficile rose five-fold. Investigations into the biggest C. diff outbreak in Britain, which killed 90 patients at hospitals run by Maidstone and Tunbridge Wells trust in 2005 and 2006, found that overcrowding amid pressure to meet hospital waiting targets was a factor behind the infection's spread.

More than 2,000 maternity beds have been lost since 1997. Research by the Conservatives found that last year, 42 per cent of maternity units had refused to accept women in labour on at least one occasion. Sue MacDonald, from the Royal College of Midwives, said: "We feel the cuts have gone too far." Norman Lamb, the Liberal Democrat health spokesman, met officials recently after pressures on his local hospital, the Norfolk and Norwich, forced it to declare an emergency "black alert," closing to new admissions, with 10 ambulances "stacked" outside, treating patients.

The Department of Health said bed numbers had fallen because hospitals were more efficient, with patients staying for shorter periods, while services were treating more people with chronic conditions in their own homes.


Toddler's surgery cancelled three times in a row by Australian public hospital

A two-year-old girl with cerebral palsy who requires surgery to stop vomiting six times a day has had her surgery cancelled three times, her father has said. The last cancellation, yesterday, happened after the girl and her parents were forced to wait at Sydney Children's Hospital, Randwick, from 10am until 3.45pm, said the girl's father, Nick Thomas.

The toddler, Zara , was told last year she needed corrective surgery to fix a reflux problem, Mr Thomas said. "We were told last year that she needed it because she's been in hospital twice with pneumonia," he told Radio 2UE. "When she vomits ... she can't move [her] head around [and it] ends up back in her lungs, [causing] pneumonia."

After meeting with doctors in January this year, Mr Thomas was told there was a three-month waiting list for the surgery, which was booked for April 22. But the hospital cancelled the surgery because the doctor was away, Mr Thomas said. "They rescheduled and rung us two days before she was meant to go in and cancelled again," he said. Yesterday was the third time the surgery was cancelled, but only after Zara had to wait at the hospital most of the day, Mr Thomas said.

"We got there at 10am, we had to stop her feeding at 7am, and we didn't take any milk with us thinking she was going to have the operation. "They came in at 3.45pm yesterday afternoon and they said they didn't have enough time to do the surgery. "They want us to come back on Thursday and they can't promise it."

Mr Thomas said the hospital staff told him they had complained to the Health Minister Reba Meagher that they needed more theatre time. The minister's office has been contacted for comment. "We're a first world country, this shouldn't happen," Mr Thomas said. "You go there and see all the kids and it's not fair [that] they have to wait."

A doctor at the hospital said Zara's surgery was postponed because more critical cases had arisen. "The hospital sincerely regrets the distress caused by the rescheduling of her previous surgeries," Michael Brydon, director of clinical operations Sydney Children's Hospital, Randwick, said. "The surgeon was required to operate on more seriously ill patients that he deemed to have a higher clinical need than Zara. As is always urgent critical or emergency care must take priority,'' Dr Brydon said. Surgery for Zara had now been scheduled for tomorrow, he said.

Mr Thomas said he did not have private health insurance. But the head of one of Australia's biggest health insurance funds contacted 2UE after hearing Mr Thomas's call, and pledged to cover the full cost of Zara's treatment, the radio station said. The fund did not wish to be named. "I don't know what to say ... that's great, that's awesome," Mr Thomas said, after 2UE called him to inform him of the fund's promise.


Wednesday, May 28, 2008

NHS ordered to end care bias against men

The equality watchdog has ordered the National Health Service (NHS) to take urgent action to end anti-male discrimination in healthcare. The Equality and Human Rights Commission (EHRC), headed by Trevor Phillips, has written to strategic health authorities warning them to ensure that doctors and hospitals in their areas give equal priority to men and women. The commission has legal powers to issue compliance orders to NHS trusts that persistently fail to provide equal care for men.

While the commission does not cite specific examples of discrimination, it details evidence of poorer male health. Other groups have pointed to male-unfriendly surgery opening hours. Men are twice as likely as women to die from the 10 most common cancers that affect both sexes and, typically, develop heart disease 10 years earlier than women. Men under the age of 45 visit their GP only half as often as women and are less likely to have dental check-ups.

On average, men die five years younger than women and 16% of men die while still of working age compared with 6% of women. Men are also three times more likely to commit suicide than women.

A new law, the gender equality duty, which came into force in April 2007, obliges all public services to ensure they care for both sexes equally. In March, Phil McCarvill, head of public service duties at the EHRC, sent warning letters to strategic health authorities, the bodies which manage local NHS trusts. cCarvill said: "We are writing to you specifically regarding the gender equality duty in response to particular concerns raised with us by the Men's Health Forum and the action we want you to take in response to this. We will view the failure to take any action as a result of this letter as a breach of your legal responsibilities in this area."

Research carried out by the forum found that men were unhappy with the service provided by their local GP surgeries. The forum points out that since men are twice as likely as women to work full-time and three times as likely to work overtime, it is more difficult for them to see doctors during conventional opening hours.

Other experts have pointed to the fact that, while there is a national screening programme for breast cancer, there is no equivalent yet for men for prostate cancer, although it claims a similar number of lives. Women are also screened for cervical cancer.

Peter Baker, chief executive of the Men's Health Forum, said: "The GP model doesn't work particularly well for men, particularly young men aged between 16 and 45 who GPs tend not to see unless there is something very seriously wrong with them. There is discrimination because these services are being underused by the group with the greatest need." The forum also suggests trusts offer health checks in venues frequented by men, such as work-places or sports clubs.

The Commons health select committee inquiry into health inequality will next month hear evidence that men are being discriminated against in the NHS.


Crazy NHS financial management

They have denied services to so many people that they now have a huge surplus

Hospitals and NHS managers were pressured into spending hundreds of millions of pounds before the start of the financial year to "hide" a 1 billion pound surplus. Opposition parties have accused the Government of encouraging NHS financial mismanagement after it emerged that some trusts had been ordering millions of pounds of equipment "as long as they could be invoiced before the end of March" - the end of the financial year.

Primary care trusts also advanced up to 400 million for future services to foundation trusts, which, as free-standing businesses, can keep the money. Some local councils have also been paid in advance for services. The NHS had forecast a surplus of 1.8 billion in March, but managers now suggest that the true figure was closer to 3 billion, with up to 1 billion being "hidden" by preordering. Some chief executives have been told that their bonuses could be jeopardised if they exceeded their "control totals" target, so have been using various accounting methods to reduce it.

Two years ago the NHS returned a deficit of 547 million, which was turned into a 515 million surplus in 2006-07. The steps taken to turn the service round have proved to be so effective that the surplus has risen to unprecedented levels in 2007-08. However, such a large surplus presents its own problems as patient representatives have criticised NHS managers for underspending while patients were still being denied vital treatments. Unions have also used the surpluses to argue for better pay for NHS workers, claiming that they have been generated by greater efficiency from staff.

Doris-Ann Williams, director-general of the British In Vitro Diagnostics Association, whose members supply equipment to the NHS, told the Financial Times that members had received "a flurry of unexpected cash orders for capital equipment purchases as long as they could be invoiced before the end of March".

The Department of Health has said that all the surpluses would remain within the NHS. This has been possible since 1999, when Gordon Brown, then Chancellor of the Exchequer, relaxed the rules on carrying forward surpluses from one year to the next. But last year the Treasury quietly clawed back unspent money from the Department of Health and there are fears that it may do so again if the surplus significantly exceeds its 1.8 billion target.

Stephen O'Brien, the Conservative Shadow Health Minister, said: "Labour's financial incompetence under Gordon Brown is making it boom or bust in the NHS - and this uncertainty does nothing to help patients and the hard working medical staff. If money allocated to the NHS is not going on patients then it should not be hoarded."

Norman Lamb, the Liberal Democrat health spokesman, said: "We do have a crazy situation of substantial surpluses in many acute trusts. "One of the casualties is mental health services, which benefit from neither targets nor the PreBudget Report and have to negotiate block contracts with primary care trusts. They have suffered as acute trusts cash in. This creates a distortion in priorities."

A spokesman for the Department of Health said: "Thanks to the efforts of NHS staff over the past year and half we are now in a strong and sustainable financial position, but also - importantly - we remain on course to deliver against our key pledges. The NHS and its staff have managed to achieve all of this at the same time as cutting waiting lists to their lowest ever. "NHS organisations are bound by strict accounting practices and are subject to a full audit at the end of each financial year."


Tuesday, May 27, 2008

Cancer victim told to pay for his own drugs by NHS

Government health insurance can be very hard to claim on

A cancer patient who was sent home to die by hospital doctors but then discovered a cocktail of drugs that stabilised his illness has now been told that the NHS will not pay for his medicine. Jack Hose, 71, a retired engineer, was receiving a chemotherapy drug called irinotecan on the NHS, but it was failing to halt his bowel cancer. NHS doctors told Hose, from Bournemouth, that they could do no more for him and that he should go home and make the most of the rest of his life while taking painkillers.

Hose was not prepared to die and sought a second opinion from a private doctor who recommended trying another drug, called cetuximab, in combination with irinotecan. The mix of drugs appears to have stabilised Hose’s cancer. However, cetuximab is not funded by the NHS.

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, which is treating Hose, has told him that, if he takes the drug, he will need to pay for all his care, including the cost of the medicine he initially received on the NHS. Hose is the latest victim of the government’s policy of denying NHS treatment to patients who pay for an additional private drug. Alan Johnson, the health secretary, says such an arrangement, known as “co-payments”, would lead to a two-tiered NHS.

“It seems outrageous that, having paid National Insurance contributions for 50 years, they are now asking me to pay for my care,” said Hose.


Why do American doctors stick with the health care system?

In response to yesterday's post on John McCain's sort-of, not-quite rejection of a government-designed health-care system, a reader writes to ask me:
If they are so dissatisfied with the current state of medical insurance, why aren't more doctors operating outside of the insurance industry by providing good care for a reasonable cost and completely boycotting medical insurance?

That's a good question, since the current system is a disaster and proposals put forward by the leading presidential candidates promise to enhance the worst aspects of what's already in place. To quote a Forbes column by Yaron Brook recommended to me by the same reader:
But by the time Medicare and Medicaid were enacted in 1965, this view of health care as an economic product--for which each individual must assume responsibility--had given way to a view of health care as a "right," an unearned "entitlement," to be provided at others' expense.

This entitlement mentality fueled the rise of our current third-party-payer system, a blend of government programs, such as Medicare and Medicaid, together with government-controlled employer-based health insurance (itself spawned by perverse tax incentives during the wage and price controls of World War II).

Today, what we have is not a system grounded in American individualism, but a collectivist system that aims to relieve the individual of the "burden" of paying for his own health care by coercively imposing its costs on his neighbors. For every dollar's worth of hospital care a patient consumes, that patient pays only about 3 cents out-of-pocket; the rest is paid by third-party coverage. And for the health care system as a whole, patients pay only about 14%.

The result of shifting the responsibility for health care costs away from the individuals who accrue them was an explosion in spending.

This is exactly right. The dominant means of paying for health care in the United States has little to do with the discipline and consumer feedback of the free market. Prices for procedures and visits are set not according to supply and demand in the local market, but according to insurance company compensation and the mysteries of medical coding. Each procedure must be coded at the highest justifiable level -- too low and you're giving services away, too high and you're flirting with fraud. The charges for each code are then set at a level above expected insurance company (including Medicare and Medicaid) compensation. To maximize compensation, medical practices charge at a level well above what the companies are actually willing to compensate. If a practice is being compensated equivalent to its charges, the assumption is that the office is charging too little.

Smart cash-paying patients who know to ask at well-run practices will often find an entirely separate and unadvertised price list that bears little resemblance to what insurance companies are charged. That is, it's a lot lower. These separate price lists for cash-paying customers have been adopted at a very few medical practices as the only price lists. Practices that use SimpleCare charge patients directly and don't deal with insurance companies or government programs at all, although patients are free to submit their bills to insurers for reimbursement.

How much lower are these cash prices? SimpleCare providers are reported to charge 30% to 50% less than competitors who work through the traditional insurance schemes. And that's with much less effort and expense in collecting payments.

All right. So the system of codes and insurers as it now exists is arcane, difficult to navigate and drives up costs. So, as my reader asks, "why aren't more doctors operating outside of the insurance industry by providing good care for a reasonable cost and completely boycotting medical insurance?"

The fact is, doctors are some of the least business savvy people I've ever met. Most will admit that, too. Medical school teaches them how to save lives, but not how to run an office. Unfamiliar with alternatives, physicians go with what they know, which is the system in place. Successful practices almost always rely on practice managers who are trained in the arcane art of extracting money from insurance companies and the government. They have conferences, newsletters and mailing lists devoted to proper coding and price-setting. Practice managers are highly skilled at running medical practices under the current system and only under the current system.

And once physicians who've opened their own practices find themselves bringing in more money than they put out in expenses, they have little incentive to start jiggering with the business model. Shifting gears would involve putting profitability on the line for the hope of reestablishing profitability under a different (if more sensible) business model -- all the while swimming upstream against the prevailing assumption, so well described by Yaron Brook, that health care is a "right" that should be free. Switching to a pay-as-you-go model requires getting patients who balk at coughing up $20 for a co-pay to pay the full (but discounted off of current prices) cost of their health care.

That's one of the maddening things about medicine. People who drive to the office in a new truck with a carton of cigarettes in the back and who just spent a couple of hundred bucks to get their dogs de-wormed will bitch about handing over $20 for a co-pay. People don't mind paying the veterinarian, but that greedy doctor ...

The prevailing entitlement attitude toward medicine is another big barrier toward changing to a more market-oriented model that would lower costs.

And, of course, since most health care consumers pay little or none of the actual cost of the services they consume, there's a strong incentive among an expensive subset of patients to demand ever-more tests, more medication, more visits and more specialized treatments that drive up costs overall for the whole system.

There are health-care providers who do use a market model, though. If you're a fan of alternative medicine, chances are that your homeopath or naturopath, right after a monologue about the evils of profit-driven mainstream medicine, will guide you to the counter where you're expected to pay, in full, for all services rendered that day.


Monday, May 26, 2008

NHS hospital kills the elderly

When Edna Purnell was referred for “gentle rehabilitation” at a local healthcare unit after a hip replacement operation, her family thought she would be given exercises to get her back on her feet and sent home after a fortnight. Instead she was put to bed in a darkened room and put on a regime of morphine within a day of her arrival. Less than a month later she was dead.

This weekend the full story has emerged of Purnell’s death and her family’s subsequent campaign, which led to a series of investigations of the deaths of 92 elderly people at Gosport War Memorial hospital in Hampshire between 1996 and 2000. An inquest into 10 of the deaths was ordered earlier this month by Jack Straw, the justice secretary, as revealed by The Sunday Times last week.

The families allege that their relatives’ deaths were hastened by a regime of heavy morphine use and little or no food, drink or exercise. The inquest will be heard this autumn and is expected to raise serious questions about treatment of the elderly in Britain’s hospitals and care homes and the value attached to their lives.

Purnell, a twice-married extravert, had enjoyed an expatriate lifestyle across the world from Cuba to Hong Kong. She became frail only as she entered her nineties and moved into an old people’s home, where she had a fall in the late autumn of 1998. Despite her age she was considered fit enough for hip replacement surgery at the Haslar hospital, Portsmouth, and within three days of the operation she was out of bed and moving around.

Mike Wilson, Purnell’s 71-year-old son, says that she was well on the mend before she was moved to Gosport. Hospital records show she had not required even the mildest of painkillers in the five days preceding her transfer. “She was a fighter; she was out of bed, bright-eyed and bushy-tailed and moving around with a [walking] frame after the operation,” he said. “Two days after she got [to Gosport] she was like a zombie, in a completely trance-like state.”

Wilson said nurses told him the elderly could deteriorate quickly when moved but he became convinced that it was the sedation, not her underlying condition, that was the problem. “When I complained about the morphine, they said it was to help her sleep at night, but in fact they were giving it to her all day long as well,” he said. “She became extremely dehydrated.” By the hospital’s own admission Purnell was given little or nothing to drink.

Despite her son’s complaints, not only high doses of morphine were administered to Purnell, but also mida-zolam, a sedative three to four times more powerful. It is meant to be used only under close supervision because of its dangerous nature and the extreme variability of individual responses to it. As he became more concerned, Wilson began a diary chronicling his mother’s treatment. The diary and notes he has obtained from the hospital include a threat to have him arrested for trying to feed his mother. “If he tries to do this again the police should be called and he should be arrested on the technicality of assaulting his mother,” the notes read.

Purnell died in December 1998, three weeks after her transfer to Gosport. “It is my belief that, intentionally or otherwise, she was being deprived of the basics to sustain life,” Wilson said.

After his mother’s death Wilson delivered leaflets to local surgeries and health centres asking for other families with similar experiences to come forward. Complaints flooded in with stories of recovering patients referred for rehabilitation but given large doses of painkillers. Most relatives had been urged to go home or even to go on holiday in the final days of their loved ones’ lives. A series of police and other investigations petered out, although some experts continued to believe there were reasons for suspicion at Gosport.

Richard Baker, professor of clinical governance at Leicester University, studied the deaths six years ago. Baker, whose statistical analysis of mortality among patients of Harold Shipman helped to convict the Manchester GP of mass murder, believes there is a need for further investigation. “I hope this [investigation] does eventually get somewhere,” he said last week.

A spokesman for Hampshire primary care trust, which runs the hospital, declined to comment on specific cases but said: “Since a 2002 investigation and the introduction of new clinical procedures, the level of clinical incidents has been entirely normal for a hospital of this size.”


Australia: Health bureaucrat gets the boot!

Sort of. Bureaucrats are almost totally protected from accountability, for some reason

THE senior health executive who employed the "Butcher of Bega" Graeme Reeves, despite being warned he was banned from obstetrics, has become the first head to roll over the scandal. The Greater Southern Area Health Service has suspended Dr Jon Mortimer from duty on full pay "pending the outcome of further inquiries" into the appointment of Mr Reeves, who is accused of mutilating hundreds of women while working as a gynaecologist and obstetrician.

A handwritten diary note by Dr Mortimer, who at the time was deputy director of medical services for Southern Area Health Service, shows an unnamed referee warned him that Mr Reeves "was not meant to do obstetrics". The discovery, tabled in the NSW Parliament, contradicted statements from Health Minister Reba Meagher that the health service failed to perform background checks, when it in fact did. "The [documents] show that background checks were carried out, but were then ignored or dismissed," Opposition health spokeswoman Jillian Skinner said.

Dr Mortimer is the first executive to be publicly reprimanded by NSW Health following the scandal which has rocked the health system since it was exposed by Channel Nine's Sunday program in February. Hundreds of patients have since come forward with claims of sexual assault, mutilations and botched procedures, including at several South Coast hospitals in 2002-03. Director-general of population health and chief health officer Denise Robinson, who was chief executive of SAHS at the time of Reeves's appointment, resigned this month, citing career opportunities elsewhere. Dr Mortimer's boss, Dr Robert Arthurson, remains in his position.

Mr Reeves was appointed as a visiting specialist obstetrician and gynaecologist at Bega and Pambula district hospitals after meeting Dr Mortimer and his colleague Kym Durance in January 2002. Dr Mortimer then chaired the five-member committee which recommended he be hired in March 2002. A handwritten note made by Dr Mortimer on the minutes of that meeting said "rego check" with a large tick over it. Yet Mr Reeves's registration with the NSW Medical Board was conditional and he was banned from practising obstetrics in 1997 following the death of a woman and a baby under his care.

It is unclear if his false assertion about holding current Visiting Medical Officer (VMO) appointments at Hornsby Ku-Ring-Gai and Sydney Adventist hospitals were checked at the time. The Medical Error Action Group has received 575 complaints about Mr Reeves, and its founder Lorraine Long welcomed Dr Mortimer's suspension. "It's absurd the people in public service are not doing their jobs," she said. Dr Mortimer did not return calls last week. His voicemail message said he was on leave.


Australian public hospital 'a fire risk'

An audit of Mareeba Hospital and its nurses' quarters has exposed a litany of fire safety breaches that could force it to close. The Cairns Post reveals Queensland Health has been given until June 20 to make urgent repairs on Mareeba Hospital buildings described as fire hazards. Safety problems identified by the Queensland Fire and Rescue Service include faulty smoke doors in the hospital and inadequate fire safety signs, problems with locks and the lack of a fire safety management plan at the nurses quarters.

Of most concern is the nurses' quarters, with a source telling Cairns Post maintenance problems in the 60-year-old building breached the Building and Other Legislation Amendment Act, which was brought in as a result of the Childers Backpackers fire in 2000. Fifteen backpackers were killed in a horrific arson attack after they were unable to exit the burning building. "The accommodation for the nurses was not up to regulation," the source said. "It's a fire hazard."


Sunday, May 25, 2008

NHS Hospitals still not getting clean bill of health from patients

Patients experience wide variations in cleanliness and "striking" differences in some areas of patient care while in hospital, a national survey by the country's health watchdog shows. The Healthcare Commission found that patients treated in NHS hospitals are generally satisfied with their care, and a growing proportion rate it as excellent. But there are increasing concerns about cleanliness, and fewer patients than in previous surveys believed that doctors and nurses always washed their hands between patients.

The biggest variations came in how long patients were kept waiting for admission to hospital, their experience of mixed-sex wards, the quality of food and the help they were given in eating it. The survey, which has been carried out annually since 2002, questioned 75,000 adult patients at 165 trusts. In general, the results show that patient satisfaction is inching up.

Those rating their overall care as "excellent", for example, went up from 41 per cent in 2006 to 42 per cent in 2007. In 2002, the first year of the survey, it was 38 per cent. The Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust in Shropshire ranked top last year with 77 per cent reporting excellent care, and Ealing Hospital NHS Trust in London bottom, with 24 per cent.

Patients also reported slight improvements in how long they waited in accident and emergency before being admitted to a ward. In 2007 73 per cent said that they waited up to four hours, compared with 72 per cent in 2006 and 67 per cent in 2002. The number of patients reporting that their hospital was "very clean" fell from 56 per cent in 2002 to 53 per cent in 2006, and the same figure in 2007. Among the best performing trusts, around 80 per cent said their room or ward was "very clean". But fewer than half of patients reported that lavatories and bathrooms were very clean. In the best trusts this figure was as high as 81 per cent but in the worst was as low as 22 per cent.

The survey found that 68 per cent of patients said that, as far as they knew, doctors "always" washed their hands between patients, down 1 per cent on last year. At the worst-performing trust, Maidstone and Tunbridge Wells, only 45 per cent said yes. At the best, Queen Victoria Hospital NHS Foundation Trust in East Grinstead, 88 per cent said yes.

About a quarter of people reported being in a mixed-sex ward when first admitted to hospital, and a fifth when they moved wards, both figures showing slight improvements compared with last year. More than a fifth of patients (22 per cent) complained that nurses "often or sometimes" talked over their heads as if they weren'tthere, and that a similar proportion of doctors did the same.

Food was rated as good or very good by 55 per cent of respondents, up 1 per cent since 2006. In the highest-scoring trust for food, Robert Jones and Agnes Hunt Orthopaedic and District Hospital, 62 per cent of patients rated it "very good" while in the worst, Royal Liverpool and Broadgreen University Hospitals NHS Trust, only 8 per cent said it was very good.

Ann Keen, the Health Minister, said: "This survey gives a real insight into what patients think about their care, with many reporting high levels of trust in NHS staff, high standards of care and high rates of cleanliness during their stay in hospital. "But we are not complacent. We will continue to listen to patients and work on those areas where improvements need to continue."

Anna Walker, chief executive of the Healthcare Commission, said: "This survey gives the most comprehensive picture available of how patients feel about NHS hospitals. And, importantly, it allows comparisons between trusts across the country. "Overall, it's encouraging that a steadily increasing percentage of patients say care is `excellent'. But the survey also shows that in some hospitals the NHS is struggling to deliver on some of the basics of hospital care. There are striking variations in performance in key areas such as providing single-sex accommodation and giving people help when they need it. Those performing poorly must learn from those who perform well. "It's crucial that trusts take this information on board. The patient voice must be heard loudly on the boards of trusts across the country."


Australia: A nasty health bureaucracy

A paramedic cleared of sexually assaulting a drug-affected patient is shattered that Melbourne's ambulance service won't reinstate him. Simon Howe, 32, was found not guilty of digital rape and indecent assault by the County Court this week and now wants his job back. But the Metropolitan Ambulance Service yesterday claimed he was sacked for breaching his employment contract by not filling out an incident report. They said working for the MAS again was not an option.

Mr Howe yesterday said he had proved his innocence in court and was now being put through the added trauma of an unfair dismissal case. "I'm devastated, shattered, my life has been turned upside down," Mr Howe said yesterday. "As far as MAS is concerned I was guilty. I have had to pay for the right to prove my innocence and I still have to pay today."

Mr Howe said stricter security measures such as cameras were needed in ambulances to protect paramedics against false allegations or violence. He said he had held his head high since the complaint, cleared his name and now wanted to get back to work helping people. "Unfortunately there are more and more reasons for paramedics not to stay on the job," he said. "Ambulance paramedics are already cautious about which patients they take and have refused to take patients."

The Ambulance Employees union yesterday condemned the MAS for their refusal to reinstate Mr Howe and said he was being victimised and unfairly treated. They said a second paramedic in the ambulance at the time had not filled out an incident report either but was never disciplined or sacked. "It's appalling -- the court has found him to be innocent, yet MAS are still treating him like he is a criminal," Ambulance Employees Australia state secretary Steve McGhie said. "They should accept the jury's decision and reinstate him immediately."

Mr Howe was sacked by the MAS in February last year after a 22-year-old drug-affected patient claimed she was assaulted as she was being rushed to hospital at 6.19am on November 5, 2006. The MAS decided that Mr Howe failed to provide an adequate explanation of the allegations, failed to inform them what had occurred with the patient and did not lodge a report. A court heard that traces of the drugs ice and GHB were found in the woman's system. It was told Mr Howe was restraining the female patient because she was behaving erratically. It also heard her memory was scrambled by the drugs.

A MAS spokesman yesterday said they could not comment on the matter further as it was before the courts.


Saturday, May 24, 2008

Australia: You may be dead before you get a public hospital appointment in Queensland

QUEENSLAND Health made two specialist appointments for a man who had been dead six years and sent the notification to an address where he had never lived. The letter "shattered" the man's widow, Diane Baldwin, when she found it on Tuesday among mail addressed to her and her new partner. "You can imagine how devastated I was when I got it," Ms Baldwin said. "I was shaking."

Astoundingly, Leonard Baldwin had been scheduled for two specialist urology appointments at the Queen Elizabeth II Hospital on May 27 despite never seeking such treatment while he was alive, she said. Mr Baldwin died of a heart attack on the side of a road in NSW six years ago.

Ms Baldwin said she had farewelled her husband just before Christmas, expecting him to be gone a week. But she next saw him in a funeral home where she had to identify his body. "I'm trying to get on with my life and this completely devastated me," she said."It brought it all back and yesterday I was a mess."

Queensland Health blamed a "typing error" and apologised for any distress the letter caused Ms Baldwin. But a department spokeswoman was unable to explain why the letter was addressed to a house at which Mr Baldwin had never lived. The couple had been living at Beenleigh at the time of his death and had "never lived over this way, ever, when he was alive", Ms Baldwin said. She said she rang a phone number on the letter to advise them Mr Baldwin had been dead six years.

"It would be good if they could do something about the people who are alive rather than the dead getting appointments," she said. "They talk about waiting lists and people can't get in but someone dead can." Last year, a man who had been dead for almost a year was scheduled for surgery at the Royal Brisbane and Women's Hospital . The blunder stunned grieving mother Ann Heath, 66, who said her son Michael Trindall, 45, should never have been on a public waiting list.

That disclosure came just weeks after then premier Peter Beattie announced the Government would tender for a broker to manage its public hospital elective surgery waiting lists. Mr Trindall also had been scheduled for a urology appointment, which his mother said he would not have needed even if he were alive.


Elderly patients in Australian public hospitals are 'malnourished or at risk'

Partly due to "healthy" food! The myth that there is such a thing as healthy food is normally just a time and money waster but sometimes the consequences can be more severe

NEARLY one-third of elderly hospital patients are malnourished, and a further 61 per cent are at risk of malnutrition. A study of 100 Australian hospital patients aged 70 or more also suggests doctors and nurses do a poor job of spotting the problem. Even when they do, few of the patients affected are referred to a dietitian for help. The study, carried out at Melbourne's St Vincent's Hospital, found doctors and nurses recorded a patient's recent weight loss in only 19 per cent of cases. Poor appetite, another risk factor for malnutrition, was recorded in medical notes barely half the time, or in 53 per cent of cases. Just 7 per cent who had recently lost weight, and 9 per cent of patients with poor appetites, were referred to a dietitian.

The authors of the paper, published in the journal Nutrition & Dietetics, wrote that malnutrition in elderly hospitalised patients "remains a significant problem with low rates of recognition and referral by medical and nursing staff". They called for better education for doctors and nurses to encourage better identification of the problem. "No one's really taking any notice of the fact that people are coming into hospital undernourished," said study co-author Alison Bowie.

The palatability of hospital meals was another issue. Ms Bowie said the tendency to make hospital food healthy, with low-fat and low-salt meals, did not help to make them more appealing. "We are working on making hospital meals more energy-dense," she said. "Being on a low-fat diet isn't the No1 priority when you are sick in hospital."

Nutrition status of the study's participants was assessed using a "mini nutritional assessment" tool, which consisted of 18 questions resulting in a score. Patients who scored less than 17 were classified as malnourished, while scores between 17 and 23.5 indicated risk of malnutrition.

The study's authors wrote that the understanding of malnutrition risk factors among doctors and nurses was poor, and "considerable scope" existed to improve training programs. Last month, a public inquiry into NSW hospitals was told that hospital food was "atrocious" and malnutrition was "rife".

Dietitians' Association of Australia executive director Claire Hewat said the latest study showed that malnutrition was a problem "even in a wealthy, Western country like Australia". "There's been research saying this for as long as I can remember as a professional, but it keeps being swept under the carpet. "People who are malnourished heal more slowly, their wounds break down, they are at greater risk from pressure sores, they are weak so they can't get up and do their physio so easily, and they are more prone to falling. "All elderly people should be screened (for malnutrition) so we can pick people up more quickly. "If they (governments) don't do something about it, it's going to blow their costs out of the water," Ms Hewat said.


Friday, May 23, 2008

A huge failure in Massachusetts

Mitt Romney's presidential run is history, but it looks as if the taxpayers of Massachusetts will be paying for it for years to come. The former Governor had hoped to ride his grand state "universal" health-care reform of 2006 to the White House, but his state's residents are now having to live with what he and the state's Democratic Legislature passed. As the Boston press likes to say, it's "the new Big Dig."

The showpiece of RomneyCare was its individual mandate, a requirement that all Massachusetts residents obtain health insurance by July of last year or else pay penalties. The idea was that getting everyone into the insurance system would eliminate the "free-rider" problem of those who refuse to buy insurance but then go to emergency rooms when they're sick; thus costs would fall. "Will it work? I'm optimistic, but time will tell," Mr. Romney wrote in these pages in 2006.

Well, the returns are rolling in, and the critics look prescient. First, the plan isn't "universal" at all: About 350,000 more people are now insured in Massachusetts since the reform passed. Federal estimates put the prior number of uninsured at more than 657,000, so there was a reduction. But it was not secured through the market reforms that Governor Romney promised. Instead, Massachusetts also created a new state entitlement that is already trembling on the verge of bankruptcy inside of a year.

Some two-thirds of the growth in coverage owes to a low- or no-cost public insurance option. Called Commonwealth Care, it uses a sliding income scale to subsidize coverage for everyone under 300% of the federal poverty level, or about $63,000 for a family of four. Commonwealth Care also accounts for 60% of statewide growth in individual insurance over the last year, and the trend is expected to accelerate, perhaps double.

One lesson here is that while pledging "universal" coverage is easy, the harder problem is paying for it. This year's appropriation for Commonwealth Care was $472 million, but officials have asked for an add-on that will bring it to $625 million. For 2009, Governor Deval Patrick requested $869 million but has already conceded that even that huge figure is too low. Over the coming decade, the expected overruns float in as much as $4 billion over budget. It's too early to tell how much is new coverage or if state programs are displacing private insurance.

The "new Big Dig" moniker refers to the legendary cost overruns when Boston rebuilt its traffic system. Now state legislators are pushing new schemes to offset RomneyCare's runaway expenses, including reductions in state payments to doctors and hospitals, enlarged business penalties, an increase in the state tobacco tax, and more restrictions on drug companies and insurers.

Mr. Romney's fundamental mistake was focusing on making health insurance "universal" without first reforming the private insurance market. The "connector" that was supposed to link individuals to private insurance options has barely been used, as lower-income workers flood to the public option. Meanwhile, low-cost private insurers continue to avoid the state because it imposes multiple and costly mandates on all policies.

Hailed at first as a new national model, the Massachusetts nonmiracle ought to be a warning to Washington. Barack Obama and Hillary Clinton are both proposing versions of RomneyCare on a national scale, with similar promises that covering everyone under a government plan will reduce costs. Mr. Obama at least argues that more people would be covered were insurance more affordable. But his solution is Massachusetts on steroids - make insurance less expensive for policyholders by transferring the extra costs onto the government. Mrs. Clinton likes that but also wants the individual mandate, despite the mediocre results so far.

The real problem in health care is the way the tax code and third-party payment system distort incentives. That's where John McCain has been focusing his reform efforts - because that really does have the potential to reduce costs while covering more of the uninsured - and Republicans ought to follow his lead. In this respect paradoxically, we can be thankful that Massachusetts ignored the cost problems that doomed other recent liberal health insurance overhauls in California, Pennsylvania, Wisconsin and Illinois. The Bay State is showing everyone how not to reform health care.


Australian public hospital tries to dodge blame for incompetent surgeon

The Alfred Hospital has absolved itself of legal responsibility for the botched surgery of disgraced surgeon Thomas Kossmann, despite a review finding that his work as the Melbourne hospital's head of trauma put lives at risk. Although patients were subjected to unnecessary and bungled operations, Bayside Health chief Jennifer Williams said yesterday she did not expect to pay compensation. "From the information I have about the nature of the complaints, I would not envisage an insurance claim, but that would be a matter for future consideration," she said.

About 20 patients have contacted the hospital expressing concerns about operations Dr Kossmann performed on them, and the hospital has written to about another dozen. Slater & Gordon lawyer Paula Shelton said the hospital appeared to have breached its duty of care to the patients, and she encouraged them to come forward to discuss potential claims. "There's very good authority to say the hospital is responsible for the behaviour of Dr Kossmann," she said.

But Ms Williams refused to accept any responsibility for the hospital employing Dr Kossmann or for his bungled surgery, although she admitted the Alfred did not check the exaggerated claims in his CV and relied on the Royal Australasian College of Surgeons' assurances about his competence.

Orthopedic surgeon Bob Dickens yesterday released the findings of a damning peer review into Dr Kossmann, which were first revealed in The Australian last month. Mr Dickens, who headed the review panel, found Dr Kossmann had exaggerated his experience on his CV, conducted risky and unnecessary surgery and rorted government insurance agencies, including the Transport Accident Commission. He called for a sweeping audit of the Alfred's audit procedures, as well as the billing of Dr Kossmann and all other Alfred trauma surgeons.

The review has sparked a row between the college of surgeons, which blamed the hospital for not detecting the professor's surgical failings, and the hospital, which accused the college.

Mr Dickens's panel investigated 24 cases involving Dr Kossmann and found problems with 13, including grave errors. "Lives were put at risk. There were examples of catastrophic bleeding where there was difficulty getting control of the bleeding," he said. He cited other examples where a poorly placed screw in a heart had to be removed in a second operation, and how Dr Kossmann caused a hemorrhage in one of the main arteries supplying the brain during another procedure.

He said no one died as a result of the bungles, but patients were exposed to unnecessary risks, including infections. He questioned the college's decision to allow Dr Kossmann to practise without sitting the examination for foreign doctors. But college vice-president Ian Dickinson said the college had not erred in exempting Dr Kossmann from the exam. He blamed the hospital for failing to detect the failings through its audit and peer-review processes, and accused Dr Kossmann's previous employers of providing "glowing assessments" of his work.

Dr Kossmann, who resigned from the Alfred last month but denies wrongdoing, branded the review a "witchhunt" and said the press conference was a "show trial".


Thursday, May 22, 2008

The Republican Health-Care Surrender


Hillary Clinton's presidential aspirations may have died in North Carolina last week, but her most famous bad idea is alive and well in Washington, D.C. With likely increases in Democrat ranks in the House and Senate, and a Democrat (possibly) in the White House, plan on a big fight in 2009 over who - you or the federal government - will control your family's health-care decisions.

We won this fight last time around. One of the GOP's shining moments was our principled opposition to HillaryCare in 1994. The first lady's overreach helped lay the groundwork for the Republican takeover of Congress that November. We may not be so lucky next time. While the Democratic Party appears unified under the banner of big-government health care, the GOP seems conflicted and running scared. This is a classic case of Republicans being afraid that the public will not understand good policy reforms. Rather than promoting the principles of consumer choice, individual responsibility and provider competition that would transform our broken health-care system, key Republicans are bowing to political pressure and signing on with the government-run health-care Democrats.

Emblematic of this phenomenon is Iowa Sen. Chuck Grassley, who, as the Finance Committee's ranking Republican, will play an influential - perhaps crucial - role in next year's debate. Mr. Grassley has quite correctly complained that the current budget "does nothing about entitlements," and that Democrats see entitlement reform as "a matter for another day." But he has actively grown the most broken entitlement, Medicare, by driving the prescription drug benefit expansion in 2003. In just five short years, the unfunded liability for that single program has ballooned by more than the entire unfunded liability for Social Security. Since then Mr. Grassley has tried several times, unsuccessfully, to add further costs to the broken Medicare system. In 2006, for instance, he championed the elimination of the program's late-enrollment penalty, a rule change that would've cost $1.7 billion.

Medicare is not the only government health-care program which the senator has fought to expand. In the wake of Hurricane Katrina, Mr. Grassley joined with Democratic Sen. Max Baucus to sponsor the 2005 "Emergency Health Care Relief Act," which would have funneled an additional $9 billion into Medicaid. Ostensibly, the bill was intended to provide relief to disaster victims. But the effect would have simply been to expand the number of Americans who depend on taxpayer-funded health insurance.

A better predictor of Mr. Grassley's future behavior in next year's health-care fight may be who he sided with in last year's battle to dramatically expand government-run heath care. He opposed President Bush and supported Sen. Hillary Clinton's politically motivated, multibillion dollar expansion of the State Children's Health Insurance Program, which would have pushed more than two million children into the government health-care system. The plan, which failed thanks to a presidential veto and the resistance of a brave minority in the House, was to have been financed by a cigarette tax, thus tying the health of American children to the purchase of cigarettes. Indeed, Mr. Grassley's approach to health-care policy often seems to follow Mrs. Clinton's lead. Like the former first lady, the ranking Republican on the Senate committee with primary jurisdiction over health policy has endorsed a health-care plan with an individual mandate to purchase health insurance.

This endorsement comes in spite of clear evidence that individual mandates, besides violating an individual's right to choose, actually drive up health-care costs. In Massachusetts, which recently adopted a mandate of its own, skyrocketing cost overruns are currently projected at around $2 billion. The average price of a premium in the Bay State is nearly double what was predicted. And developing minimum benefit requirements - as mandates must do - merely creates a giant giveaway to health-care lobbyists, all while limiting the health-care choices of those covered. In practice, mandates force individuals to purchase coverage they may not need and drive up costs.

The plan Mr. Grassley advocates, S. 334 (legislation originally proposed by Oregon Democratic Sen. Ron Wyden), would create even greater chaos and upheaval in America's health-care system than Mrs. Clinton's current proposal. It would force the majority of Americans who are already covered to give up their current, employer-provided plans. Unfortunately, Mr. Grassley is not alone. Six other Republican senators - Mike Enzi (Wyoming), Bob Bennett (Utah), Judd Gregg (New Hampshire), Norm Coleman (Minnesota), Lamar Alexander (Tennessee) and Mike Crapo (Idaho) - have either introduced or co-sponsored bills that require mandates. These Republican plans feature even more stringent insurance demands for individuals than the one proposed by Barack Obama, who (at least for now) would only mandate insurance for children.

I believe the American people will reward innovative, principled leadership on health care. A rational, conservative solution to rising health-care costs gets the government and other third parties out of our health-care business. Both our families and the GOP can win by expanding Health Savings Accounts, by allowing people to buy insurance across state lines, by doing away with tax policies that encourage third-party payment systems, and by embracing health-care price disclosure.

I have always argued that when we act like us, we win. We proved that in 1994. And when we act like them, we lose. Republicans proved that in 2006. Which GOP will show up on health-care reform is yet to be seen.


Australia: Young doctors misused in public hospitals

JUNIOR doctors say they are being forced to work in high-stress senior positions, claiming it is putting patients' lives in danger in South Australia. They say they are being left in charge of life-threatening cases like heart attacks because senior doctors are leaving the state for better pay and conditions. Young doctors have entered the fray over the industrial dispute with the State Government, warning patients will be at "immediate risk" if conditions are not improved. A letter signed by more than 300 trainee doctors was sent to the Government this week calling for the urgent resolution of issues, including:

REMUNERATION that reflects their responsibilities, and increased base pay for junior doctors to address issues of attraction and retention.

BETTER professional development allowances to reflect increased training costs.

MINIMUM staffing levels sufficient to allow attendance at conferences and professional development courses.

FAMILY friendly provisions.

The letter said the exodus of doctors due to "poor pay and lack of professional development support" was compromising patient safety. "South Australia is presently unable to provide suitable levels of consultant supervision to junior staff," said the letter to Premier Mike Rann, Industrial Relations Minister Michael Wright and Health Minister John Hill. "This has compromised both our training as junior doctors and the care of public hospital patients."

SA Trainee Doctor spokeswoman Dr Jemma Anderson said existing pay structures did not reflect the increasing demands on junior doctors. "For too long, it has become the norm that trainee doctors work horrendous hours with increasingly limited supervision and teaching," she said. "In SA public hospitals right now, there are doctors only a few months out of their internship working in very senior roles. "If you had a heart attack in one of these hospitals, that junior doctor could be the one leading the resuscitation team to revive you. "This is dangerous for patients and puts trainee doctors under huge stress. "You don't get 300 doctors signing a letter like this unless something is very, very wrong with the system - it's a system on the edge of collapse."

Mr Hill, who is overseas, said in a statement the Government's $260 million offer would make SA junior doctors among the highest paid in the nation. "Junior doctors will receive an up to 17 per cent increase over the life of the agreement," he said. "For medical practitioners in training, their base salary will be the second highest in the nation, after Queensland." He released figures showing a step four medical practitioner in training would go from $68,964 a year base salary to $80,977 by the end of the proposed agreement, plus $10,000 annually for professional development.

Mr Hill acknowledged junior doctors needed supervision and the Health Department's chief medical officer was mentoring them. "The State Government is committed to training and retaining young doctors in the SA health system," he said. "They are the future of our system and we want to keep them in SA."

But Dr Anderson said while the increase was welcome, doctors were not being paid for the level of the work they were actually performing. The South Australian Salaried Medical Officers Association and the Government will meet in the Industrial Relations Commission again on Friday. SASMOA senior industrial officer Andrew Murray said it was waiting on a response from the Government to questions about its new pay offer.


Wednesday, May 21, 2008

Medicaid Money Laundering

Every politician moans that entitlement spending is out of control, so it ought to be easy at least to stop blatant fraud and abuse. Evidently not: Congress is currently resisting an attempt to rein in even a Big Con that everyone acknowledges.

The scene of this crime is Medicaid, the open-ended program that provides health coverage for about 59 million low-income people, with the rolls expanding every year. States determine eligibility and what services to cover, and the feds pick up at least half the tab, though the effective "matching rate" is as high as 83%. Now it turns out that states have been goosing their financing arrangements to maximize their federal payouts and dump more of their costs onto taxpayers nationwide.

The swindle works like this: A state overpays state-run health-care providers, such as county hospitals or nursing homes, for Medicaid benefits far in excess of its typical rates. Then the federal government reimburses the state for "half" of the inflated bills. Once the state bags the extra matching funds, the hospital is required to rebate the extra money it received at the scam's outset. Cash thus makes a round trip from states to providers and back to the states – all to dupe Washington.

The Government Accountability Office and other federal inspectors have copiously documented these "creative financing schemes" going back to the Clinton Administration. New York deposited its proceeds in a Medicaid account, recycling federal dollars to decrease its overall contribution. So did Michigan. States like Wisconsin and Pennsylvania fattened their political priorities. Oregon funded K-12 education during a budget shortfall.

The right word for this is fraud. A corporation caught in this kind of self-dealing – faking payments to extract billions, then laundering the money – would be indicted. In fact, a new industry of contingency-fee consultants has sprung up to help states find and exploit the "ambiguities" in Medicaid's regulatory wasteland. All the feds can do is notice loopholes when they get too expensive and close them, whereupon the cycle starts over.

The Bush Administration did just that. In 2003, it began audits that resulted in 29 states dialing back the practice. In 2007, officials tried to make the reforms permanent through formal rules changes, saying federal Medicaid dollars would only pay for Medicaid services received by Medicaid beneficiaries. Naturally, the states were furious. All 50 Governors were (and are) opposed, while pressure groups like AARP and their media collaborators chime in with horror stories about "cuts" to the social safety net. Congress promptly forbade enforcement of the new regulations. That moratorium, which was slipped into last year's Iraq war funding bill, expires at the end of this month.

Now Congress wants to extend it until President Bush leaves office. The House passed a bill – 349-62 – but Harry Reid was unable to whisk it through the Senate unnoticed. Wavering GOP Senators are trying to strike a deal with the Bush Administration, which is threatening a veto, mostly with offers to beef up the $25 million allocated to "combat" Medicaid fraud and abuse. Of course, these antifraud troops only fight after state schemes have paid out. And should the moratorium stick around, states will merely revert to their con artistry, knowing they are no longer being watched.

A reform alternative would be for the government to distribute block grants, rather than a set fee for every Medicaid service. That would amputate Washington from state accounting and insulate taxpayers from these shakedowns. States would have an incentive to spend more responsibly, and also craft innovative policies without Beltway micromanagement. But we can dream.

In the short term, Congress could – but probably won't – allow the Administration to close this case. No one really knows how much the state grifters have already grabbed, though the Congressional Budget Office estimates that the Administration remedies would save $17.8 billion over five years and $42.2 billion over 10.

We realize this is considered a mere gratuity in Washington, but Medicaid's money laundering is further evidence that Congress isn't serious about spending discipline.


Australia: Farce as NSW firefighters act as ambulance officers

Ambulance/paramedic services are provided by State governments in Australia. There are big problems with such services in all States. Current reports from two States below

FIREFIGHTERS say they are acting as ambulance officers and treating the sick at crash scenes and other emergencies in a growing trend aimed at plugging holes in the health system. The Daily Telegraph can reveal NSW Fire Brigades crews last year responded to 5583 medical emergencies. And the number of firefighter call-outs is climbing, up by 1200 since 2005, documents obtained under Freedom of Information show.

But the NSW Fire Brigade has rejected claims firefighters are propping up the health system. The brigade's assistant public affairs director Kate Dennis said there were a very small number of first-aid interventions. Firefighters provided CPR, oxygen and other medical assistance in hundreds of non-fire related cases last year.

The Ambulance Service last night admitted it does rely on firefighters to respond if its crews are unavailable. Documents show many of the medical emergencies involved people trapped in car accidents, which are mandatory for the fire brigade to attend. But on 528 occasions last year firefighters performed first aid at non-fire emergencies.

Ambulance officers said they were concerned about the increasing reliance on firefighters responding to medical call-outs. "There are times when we are tied up at another job and the fireys are the first to get there, so they have to start treating the patient," a 30-year ambulance veteran said. "We aren't knocking our comrades but we are concerned that the Government will use fireys to respond to jobs. All three emergency services are covering each other's tail."

Maianbar artist Julie Mellae didn't care who turned up to help her 70-year-old father during a heart attack last year - as long as someone responded to her call. A fire crew was dispatched to her home to offer medical assistance to her father Albert Cosgrove. "Probably in the suburbs it would sound a bit quirky to have fire brigade people help out with a medical problem," she said. "But out here when there is a tragedy everybody helps out where they can."

In the latest example of the overstretched system, ambulance officers in the Hunter have also taken industrial action over one-person crews attending emergencies. They have rejected a plan to man the ambulances with a volunteer firefighter or SES worker.

Fire Brigade Employees Union state secretary Simon Flynn said there was a growing "overflow system" where fireys were propping up the health system. The union is taking its concerns to the Industrial Relations Court next week. Under changes within the brigade in 2003, fire engines were equipped with defibrillator and trauma kits while getting the equivalent to graduate ambulance officer training.

However, an Ambulance Service spokesman said firefighters would never replace paramedics. "First-aid skills are important for any emergency service operative and we support firefighters being trained in life-saving interventions to assist paramedics," he said.


Serious ambulance problems in Tasmania too

COUNTRY ambulance stations are closed up to nine hours a day - sometimes three times a week - because paramedics are seriously fatigued. Some paramedics are on duty for 96 hours straight, Australian College of Ambulance Professionals Tasmanian branch chairman Tim Rider said. When paramedics took nine-hour fatigue breaks, there was no one to cover for them and stations were unmanned. As a result, Mr Rider said people near Huonville, New Norfolk and Sorell were at risk in an emergency.

"Fatigue is a significant issue for paramedics when they're on the road driving and it can affect their clear, cool judgment," he said. "It also places the community at risk because they have to put up with a longer response time if we can't back-fill (the fatigue break), which is usually the norm."

The Health and Community Services Union put a staffing plan for Huonville, New Norfolk and Sorell to the Government three years ago. But HCSU assistant secretary Tim Jacobson said the plan was not acted on. "People are sick of working overtime," Mr Jacobson said. "Outer-urban stations operate on a model that doesn't have a full complement of full-time staffing. "It's becoming more problematic because of urban sprawl and increasing case loads. There is no fat in the system to provide cover when there are absences or vacancies."

Fatigue was a serious issue for paramedics at outer-urban stations, where a four-day-on, four-day-off work roster meant they were on call overnight after working more than 11 hours. Paramedics were increasingly taking nine-hour fatigue breaks.

Mr Rider said outer-urban services required more resources, including full-time staff, and a new work model. "The four-on, four-off roster is very well liked by paramedics in town. But the fact is the days of the single branch officer is way outdated in today's environment, given the workload and the OHS issues," he said. "They're basically on duty for 96 hours straight, and their clinical judgment can be impaired." Mr Rider said the Tasmanian Ambulance Service was aware of the problem and would advertise for more qualified paramedics this year.


Tuesday, May 20, 2008

Why Doctors Are Heading for Texas

When Sam Houston was still hanging his hat in Tennessee in the 1830s, it wasn't uncommon for fellow Tennesseans who were packing up and moving south and west to hang a sign on their cabins that read "GTT" – Gone to Texas. Today obstetricians, surgeons and other doctors might consider reviving the practice. Over the past three years, some 7,000 M.D.s have flooded into Texas, many from Tennessee. Why? Two words: Tort reform.

In 2003 and in 2005, Texas enacted a series of reforms to the state's civil justice system. They are stunning in their success. Texas Medical Liability Trust, one of the largest malpractice insurance companies in the state, has slashed its premiums by 35%, saving doctors some $217 million over four years. There is also a competitive malpractice insurance industry in Texas, with over 30 companies competing for business. This is driving rates down.

The result is an influx of doctors so great that recently the State Board of Medical Examiners couldn't process all the new medical-license applications quickly enough. The board faced a backlog of 3,000 applications. To handle the extra workload, the legislature rushed through an emergency appropriation last year.

Now many of the newly arriving doctors are heading to rural or underserved parts of the state. Four new anesthesiologists have headed to Beaumont, for example. Meanwhile, San Antonio has experienced a 52% growth in the number of new doctors.

But if tort reform has been a boon – and it is likely one of the reasons the state's economy has thrived in recent years – it was not easy to enact. In one particularly grueling fight in the legislature in 2003, an important piece of a reform bill went down to a narrow defeat in the state Senate after a single Republican switched his support to vote against it. Republican Gov. Rick Perry was so incensed that he bolted out of his office in the Capitol, sprinted into the Senate chamber, and vaulted a railing to come face to face with the defecting senator.

That confrontation fizzled, however, and before long Texas succeeded at enacting two simple but effective reforms. One capped medical malpractice awards for noneconomic damages at $250,000, changed the burden of proof for claiming injury for emergency room care from simple negligence to "willful and wanton neglect," and required that an independent medical expert file a report in support of the claimant.

This has allowed doctors and hospitals to cut costs and even increase the resources devoted to charity care. Take Christus Health, a nonprofit Catholic health system across the state. Thanks to tort reform, over the past four years Christus saved $100 million that it otherwise would have spent fending off bogus lawsuits or paying higher insurance premiums. Every dollar saved was reinvested in helping poor patients.

The second 2003 reform cleaned up much of the mess surrounding asbestos litigation by creating something called multidistrict litigation (MDL). This took every case in the state involving a common injury or complaint, like silicosis or asbestosis, and consolidated it for pretrial discovery in one court. One judge now makes all pretrial discovery and evidence rulings, including the validity of expert doctor reports, for all cases. This creates legal consistency and virtually eliminates "venue shopping" – a process by which trial lawyers file briefs in districts that they know will be friendly to frivolous suits. Trials still occur in plaintiffs' home counties.

More change sailed through the legislature in 2005; tort reform had become popular with voters and lobbying against it was ineffectual. The 2005 reform created minimum medical standards to prove an injury in asbestos and silica cases. Now plaintiffs must show diminished lung capacity in addition to an X-ray indicating disease.

In sum, these reforms have worked wonders. There are about 85,000 asbestos plaintiffs in Texas. Under the old system, each would be advancing in the courts. But in the four years since the creation of MDLs, only 300 plaintiffs' cases have been certified ready for trial. And in each case the plaintiff is almost certainly sick with mesothelioma or cancer. No one else claiming "asbestosis" has yet filed a pulmonology report showing diminished lung capacity. This means that only one-third of 1% of all those people who have filed suit claiming they were sick with asbestosis have actually had a qualified and impartial doctor agree that they have an asbestos-caused illness.

In the silica MDL, there are somewhere between 4,000 and 6,000 plaintiff cases. In the four years since the cases were consolidated under the MDL, 47 plaintiffs have filed a motion to proceed to trial based on a medical report indicating diminished pulmonary capacity. Of those 47, the court has certified 29 people as having diminished lung capacity. This, too, is less than 1% of all the "silicosis" claims made in Texas. No one has proven the real cause of his illness to be silica, as no case yet has been certified for trial.

Before the asbestos and silica MDLs were created, nonmalignancy plaintiffs settled with defendants for anywhere between $30,000 to $150,000 per case. No one knows how many bogus cases were settled in the state with large cash payments. Lawyers who specialized in defending those cases say there were tens of thousands.

The full costs of large settlements and runaway malpractice suits may never be known. But it is clear that the costs were paid for by consumers through the increased price of goods, by pensioners through diminished stock prices, and by workers through lost jobs. Another group often overlooked is those who are priced out of health care, or who didn't receive charity care because doctors were squeezed by tort lawyers. Frivolous lawsuits hit the uninsured the hardest.

Texas recently became home to more Fortune 500 companies than New York and California. Things are trending well for the Lone Star State. Anecdotally, we can see that while doctors are moving in, trial lawyers are packing up and heading west. They're GTC -- Gone to California.


Australia: Waiting lists up as public hospital surgeons sent on compulsory leave

More "administrator" madness

QUEENSLAND'S top surgeons are being forced to down scalpels for up to six months to take leave - leaving their patients having to wait even longer for operations. Queensland Health has allowed doctors to rack up months of leave but now demands they take it all, despite the impact on blown-out surgery wait lists. Elective surgery lists have blown out by 15 per cent and consultations by 50 per cent in the past three years.

The revelation came after another horror day for Health Minister Stephen Robertson yesterday, with the release of a damning audit revealing hundreds of Queensland Health staff were living in unsafe accommodation. The embattled department was also forced to apologise to a Gold Coast woman who spent three hours in labour on the floor of a hospital storeroom because there was no bed for her.

One senior consulting surgeon who treats hundreds of patients a month called the forced leave irresponsible and life-threatening. "This is just going to balloon the waiting lists for operations and consultations," he said. "They could just give us a payment, or just get off our backs. We have a job to do."

Salaried Doctors Queensland president Don Kane said Queensland Health was more concerned about clearing leave than cutting wait lists. The union, which represents 2000 doctors, blamed health managers for failing to provide backup so doctors could take leave at appropriate times. "It should never have been allowed to get to this stage," he said. "This is pretty typical."

Queensland Health said the payout or partial payout of leave for all public servants was banned. Queensland Health acting director-general Andrew Wilson said it was important doctors took leave for their wellbeing and that of patients. Dr Wilson said it was better to have doctors take heavy leave as a "large block" so a replacement doctor could be employed for a longer period. He failed to explain why managers had allowed huge amounts of leave to mount.

The surgeon said his supervisor had badgered him and other surgeons to take large blocks of leave. The discussions had been conducted verbally because doctors were never supposed to accumulate that much leave and the bureaucrats wanted nothing in writing, he said. "For any of us to take that length of time off, it's going to delay the work and de-skill the surgeons," he said.

Queensland Health said it was able to fill the leave gaps without disruption to the waiting list, but the surgeon disagreed. "There are plenty of patients who will fall through the cracks,' the surgeon said.


Monday, May 19, 2008

Socialist haters at work in Britain

The National Health Service has refused to pay for an operation to prevent a pensioner’s agonising migraines because the woman paid privately for earlier treatment. Maureen Alden, 74, from Bristol, spent her life savings on a £13,000 operation two years ago to implant wires into her brain which prevent migraines by stimulating the nerves. The operation was successful and cut her attacks by 80%. The battery which powers the medical device is about to run out, however, and the retired typist cannot obtain funding for a replacement.

Alden’s case will reignite the debate over the ban on NHS patients supplementing their care by paying for treatments that are not funded by the health service. Breast cancer sufferers have been told they will be denied NHS treatment if they pay privately for “top-up” drugs. Patients are taking legal action to fight the ban.

Alden is backed by her GP, Dr Sarah Vaughan, who said: “This seems appalling to me. Funding decisions should be made on medical grounds such as how badly the patient needs the treatment, not whether they have previously paid privately.”

Alden had the device, an occipital nerve stimulator, implanted in March 2006. The battery is expected to run out in the next six months. A permanent battery has since been developed, so if the NHS pays 8,500 pounds for a replacement then Alden should not require any further treatment.

Vaughan warns that if Alden is denied the treatment the NHS will end up spending as much on expensive medication. South Gloucestershire Primary Care Trust said: “If someone elects to privately fund a treatment that is not funded by the PCT and no exceptional grounds have been agreed in advance, the individual will remain responsible for funding any ongoing costs.”

A British Medical Association (BMA) spokeswoman said: "Ethically the BMA does not believe that if someone has treatment privately they should be prevented from accessing any NHS care related to this initial procedure."


Congress Messing with Your HSA

Never mind the presidential race. The battle over who will control your health care is already taking place, under the radar, in Congress. In April, House Democrats passed legislation that would impose onerous and unnecessary reporting requirements on people with tax-free health savings accounts. As of January, more than 6 million Americans have HSA coverage. That includes nearly 640,000 Californians, or about 3 percent of all Californians under age 65. In some states, HSA plans cover nearly one in 10 people under 65.

Current law requires HSA holders to document their withdrawals in the event of an IRS audit. The new legislation would require every HSA holder to document every HSA withdrawal, every time they file their taxes. That's right: Congressional Democrats have found a way to make Americans' medical bills and tax returns even more complicated. Led by Health Subcommittee Chairman Pete Stark, D-Fremont, supporters claim the legislation seeks only to prevent people from claiming a tax break for nonqualified expenses. Stark cites reports that "HSA funds appear to have been spent on escort services, at casinos and bowling facilities."

Yet Congress' own Government Accountability Office found that 90 percent of HSA withdrawals are applied directly to qualified medical expenses. Even if the remaining 10 percent were spent at brothels and bowling alleys, federal law does not require funds contributed to an HSA to be used only for medical care. It requires only that withdrawals not exceed qualified medical expenses, or that the account holder pay taxes and a penalty on any excess withdrawals. In either case, random audits police compliance. More importantly, HSA critics haven't produced any actual evidence of unlawful withdrawals.

The real reason for the anti-HSA legislation lies elsewhere. The federal government has traditionally offered workers a large tax break for job-based health benefits. In practice, however, that tax break effectively robs you of control over a large chunk of your earnings: the money your employer puts toward your health insurance. For the average insured family, that's about $9,000 per year. The law also robs you of control over your coverage decisions.

In 2004, Congress extended that tax break to employee-owned HSAs, enabling workers to reclaim ownership of a portion of those earnings. If a family obtains a high-deductible health plan, he or his employer can contribute as much as $5,800 to an HSA, tax-free. The family owns the account, which stays with them from job to job. So long as they spend that money on medical care, HSA funds are never taxed. Otherwise, HSA rules are identical to those for traditional IRAs.

Some politicians just don't want workers to control their own earnings and have launched an all-out assault on HSAs. Last week, Stark complained, "The total value of all Health Savings Accounts contributions reported to IRS in 2005 was about twice that of withdrawals … suggesting an interest in it more as a shelter than vehicle to obtain needed health care or supplement inadequate coverage."

Stark is shocked — shocked! — that workers are using their health savings accounts as … a savings vehicle. Stark further alleges that HSAs "are an effective tax shelter for people whose average incomes are nearly triple that of average tax filers." True, HSAs provide a tax break that gets more valuable as earnings rise. (That's because income tax rates rise with income.) Yet the tax break for employer-controlled coverage provides identical tax breaks to millions more high-income earners. Where is the outrage over that tax loophole?

HSA opponents offer no evidence that unlawful HSA withdrawals are a serious problem, and they can't say why random audits aren't enough to deter them. They are highly suspicious when Americans take money out of their HSAs — but equally suspicious when they leave it in. And tax breaks for the wealthy appear to be kosher, unless they let workers control their earnings. All of which leaves Stark and his fellow travelers open to the charge that what really bothers them is the fact that HSAs let workers control their own money.