Thursday, April 30, 2009

Incompetent DC Emergency Medical Services

And hushing it up is all that Mayor Fenty and the DC administration want to do about it

A man whose brother died of a heart attack hours after being told by a D.C. paramedic that he suffered from acid reflux says his family is outraged to learn that fire officials had prior warning that the paramedic needed retraining. "It's just a slap in the face to my family," said Anthony Givens, 36, the brother of Edward L. Givens of Northeast, who died at his home in December after the call to D.C. Fire and Emergency Medical Services.

The Washington Times reported Friday that scores of the District's paramedics either failed to meet the minimum national standard on written exams that tested their medical knowledge or they mishandled basic lifesaving procedures during videotaped assessments, according to videos, documents and interviews with industry professionals.

The materials also were requested on numerous occasions by the family of slain journalist David E. Rosenbaum. The family repeatedly asked about the testing as part of a settlement in 2008 of a multimillion-dollar lawsuit against the city.

Toby Halliday, Mr. Rosenbaum's son-in-law, said he began late last year asking about the tests conducted at the Maryland Fire and Rescue Institute (MFRI), and the fire department refused to disclose the results, even though the testing was initiated more than a year ago. "The department had initial results on these evaluations late last summer. Despite repeated requests, the department has not released the results to the public, but has characterized the performance of their paramedics on these tests in very positive terms," Mr. Halliday said.

"To the extent that the department feels that the MFRI evaluations demonstrate gaps in performance that require remedial training, we support that effort and are eager to hear what additional training is being provided and when that effort began. We recently met with the mayor to discuss our concerns about these tests and other issues in the EMS program. We are awaiting his response to those concerns," he said.

Mayor Adrian M. Fenty told The Washington Times on Friday that he was unaware of the newspaper report and declined to comment on it until he had a chance to review the matter. Asked about a press release with his name on it that was issued by the fire department on Wednesday addressing questions raised by The Times, Mr. Fenty again said he was unaware of the report and would not comment on it before reviewing the matter. "I think I owe that to the people who elected me," he said. Asked whether he would revisit his decision to leave EMS under the administration of the fire department - after pledging in 2006 as a candidate for mayor to separate the agencies - Mr. Fenty said: "No."

Mr. Givens said he was disappointed with Mr. Fenty's decision. "It's just outright disrespectful for the mayor to say one thing, and then we elect him and he does another," Mr. Givens said. Mr. Givens, whose family has sued the District over the handling of his brother's case, said he was angry that fire officials defended the performances on the videos and the written test scores, the vast majority of which were below 60 percent. "It's almost shameful," he said. "It's like a low blow to my family to say some of the things they're saying."

One professional who viewed the videotapes for The Times expressed concerns specifically about the assessment of the firefighter-paramedic who treated Mr. Givens. "Based upon viewing the videotape, I would have serious concerns about him performing any medical practice," said Graydon Lord, a licensed paramedic and former fire and EMS chief in Cherokee County, Ga. "I would recommend that the medical director make his determination as to whether this provider can safely practice medicine in the pre-hospital-care environment," Mr. Lord said.

Fire Chief Dennis L. Rubin told WRC-TV Channel 4 on Friday that he had not seen any of the tapes until they surfaced in news reports. "Of course it is cause for concern, but the entire idea is that we contracted with the Maryland Fire and Rescue Institute, perhaps the best medical agency in the country, to evaluate our performance in a way that we can change our protocols and train our people."

Mr. Givens said fire officials have not acknowledged any wrongdoing in his brother's case. "I'm so [angry] about this situation. The more I try to uncover things, the [angrier I get]," he said. "I think all too often this happens in Washington."


Shortage of Doctors an Obstacle to Obama Goals

Cutting way back on the time and money that doctors have to spend on red tape would be a great start

Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president. The officials said they were particularly concerned about shortages of primary care providers who are the main source of health care for most Americans. One proposal — to increase Medicare payments to general practitioners, at the expense of high-paid specialists — has touched off a lobbying fight.

Family doctors and internists are pressing Congress for an increase in their Medicare payments. But medical specialists are lobbying against any change that would cut their reimbursements. Congress, the specialists say, should find additional money to pay for primary care and should not redistribute dollars among doctors — a difficult argument at a time of huge budget deficits.

Some of the proposed solutions, while advancing one of President Obama’s goals, could frustrate others. Increasing the supply of doctors, for example, would increase access to care but could make it more difficult to rein in costs.

The need for more doctors comes up at almost every Congressional hearing and White House forum on health care. “We’re not producing enough primary care physicians,” Mr. Obama said at one forum. “The costs of medical education are so high that people feel that they’ve got to specialize.” New doctors typically owe more than $140,000 in loans when they graduate.

Lawmakers from both parties say the shortage of health care professionals is already having serious consequences. “We don’t have enough doctors in primary care or in any specialty,” said Representative Shelley Berkley, Democrat of Nevada. Senator Orrin G. Hatch, Republican of Utah, said, “The work force shortage is reaching crisis proportions.”

Even people with insurance have problems finding doctors. Miriam Harmatz, a lawyer in Miami, said: “My longtime primary care doctor left the practice of medicine five years ago because she could not make ends meet. The same thing happened a year later. Since then, many of the doctors I tried to see would not take my insurance because the payments were so low.”

To cope with the growing shortage, federal officials are considering several proposals. One would increase enrollment in medical schools and residency training programs. Another would encourage greater use of nurse practitioners and physician assistants. A third would expand the National Health Service Corps, which deploys doctors and nurses in rural areas and poor neighborhoods.

Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors — the very ones needed to coordinate the care of older people with chronic conditions like congestive heart failure, diabetes and Alzheimer’s disease. “Primary care physicians are grossly underpaid compared with many specialists,” said Mr. Baucus, who vowed to increase primary care payments as part of legislation to overhaul the health care system.

The Medicare Payment Advisory Commission, an independent federal panel, has recommended an increase of up to 10 percent in the payment for many primary care services, including office visits. To offset the cost, it said, Congress should reduce payments for other services, an idea that riles many specialists. Dr. Peter J. Mandell, a spokesman for the American Association of Orthopaedic Surgeons, said: “We have no problem with financial incentives for primary care. We do have a problem with doing it in a budget-neutral way. “If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.”

The Association of American Medical Colleges is advocating a 30 percent increase in medical school enrollment, which would produce 5,000 additional doctors each year. “If we expand coverage, we need to make sure we have physicians to take care of a population that is growing and becoming older,” said Dr. Atul Grover, the chief lobbyist for the association. “Let’s say we insure everyone. What next? We won’t be able to take care of all those people overnight.”

The experience of Massachusetts is instructive. Under a far-reaching 2006 law, the state succeeded in reducing the number of uninsured. But many who gained coverage have been struggling to find primary care doctors, and the average waiting time for routine office visits has increased. “Some of the newly insured patients still rely on hospital emergency rooms for nonemergency care,” said Erica L. Drazen, a health policy analyst at Computer Sciences Corporation. The ratio of primary care doctors to population is higher in Massachusetts than in other states.

Increasing the supply of doctors could have major implications for health costs. “It’s completely reasonable to say that adding more physicians to the work force is likely to increase health spending,” Dr. Grover said. But he said: “We have to increase spending to save money. If you give people better access to preventive and routine care for chronic illnesses, some acute treatments will be less necessary.”

In many parts of the country, specialists are also in short supply. Linde A. Schuster, 55, of Raton, N.M., said she, her daughter and her mother had all had medical problems that required them to visit doctors in Albuquerque. “It’s a long, exhausting drive, three hours down and three hours back,” Ms. Schuster said.

The situation is even worse in some rural areas. Dr. Richard F. Paris, a family doctor in Hailey, Idaho, said neighboring Custer County had no doctors, even though it is larger than the state of Rhode Island. So he flies in three times a month, over the Sawtooth Mountains, to see patients.

The Obama administration is pouring hundreds of millions of dollars into community health centers. But Mary K. Wakefield, the new administrator of the Health Resources and Services Administration, said many clinics were having difficulty finding doctors and nurses to fill vacancies.

Doctors trained in internal medicine have historically been seen as a major source of frontline primary care. But many of them are now going into subspecialties of internal medicine, like cardiology and oncology.


Wednesday, April 29, 2009

Swine flu worse in Mexico than US, but why?

Could it be that the evil capitalistic medical care in the USA is better than the socialized medicine of Mexico? The drug Relenza cures the illness so let me make a wild guess that Americans who need it get Relenza while very few Mexicans do

Why has the swine flu engulfing Mexico been deadly there, but not in the United States? Nearly all those who died in Mexico were between 20 and 40 years old, and they died of severe pneumonia from a flu-like illness believed caused by a unique swine flu virus. The 11 U.S. victims cover a wider age range, as young as 9 to over 50. All those people either recovered or are recovering; at least two were hospitalized.

"So far we have been quite fortunate," said Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention on Saturday, just hours before three new U.S. cases were confirmed.

Health experts worry about a flu that kills healthy young adults - a hallmark of the worst global flu epidemics. Deaths from most ordinary flu outbreaks occur among the very young and very old.

Why the two countries are experiencing the illness differently is puzzling public health experts, who say they frankly just don't know. [Such a puzzle!]

It may be that the bug only seems more deadly in Mexico. And while experts believe Mexico is the epicenter of the outbreak, they're not certain if new cases are occurring or if the situation is getting worse. They also don't know if another virus might be circulating in Mexico that could be compounding the problem. A big question is, Just how deadly is the virus in Mexico?

The seasonal flu tends to kill just a fraction of 1 percent of those infected. In Mexico, about 70 deaths out of roughly 1,000 cases represents a fatality rate of about 7 percent. The Spanish flu pandemic of 1918-19, which killed an estimated 40 million worldwide, had a fatality rate of about 2.5 percent. The Mexican rate sounds terrifying. But it's possible that far more than 1,000 people have been infected with the virus and that many had few if any symptoms, said Dr. Michael Osterholm, a prominent pandemic expert at the University of Minnesota.

U.S. health officials echoed him. "In Mexico, they were looking for severe diseases and they found some. They may not have been looking as widely for the milder cases," said Schuchat of the CDC. The U.S. health agency sent two investigators to Mexico on Saturday to help, she said.

Currently, even the counted illnesses are problematic. Only a fraction have been lab confirmed. Severe penumonia-like illness happens all the time, so it's challenging to figure out which ones are really tied to the outbreak, U.S. health officials said. "These numbers need to be confirmed," said Dr. Richard Wenzel, the immediate past president of the International Society for Infectious Diseases.

Other ideas about the difference include:

-Genetic analysis of virus samples in the two countries is continuing. The CDC says tests results show the U.S. and Mexican viruses are essentially the same, but some experts have not ruled out the possibility that the virus is changing as it leaks across the border to the north. [A virus as an illegal immigrant!]

-Perhaps nutrition levels are worse in some Mexican communities - poor nutrition can degrade a person's immune defenses, and make them more susceptible to illness.

-Air quality in Mexico City is considered terrible. That too may have affect patients confronted with a novel respiratory disease.

-Access to medical care has been an issue in Asia, where a rare bird flu - which does not spread easily from person-to-person - has killed more than 200 over the last several years. Maybe Mexican patients have also had trouble getting medical care or antiviral drugs, some have speculated - even though the government provides health care.

All that is speculation at this point.

"The question of why the virus appears to be more virulent in Mexico is one that we are looking intensively into," the CDC's Schuchat said. "Rather than speculate, it's important for the science to lead us on this."


Australia: Fatal ambulance bungle a complete bureaucratic disaster

The more we hear the more unbelievable the mess gets. How could anyone be so stupid? It is bordering on evil that such stupdity was left uncorrected

A COMBINATION of bureaucratic bungling and technical glitches meant vital time was lost in the search for a teenager dying in the New South Wales Blue Mountains, an inquest has heard.

Police were made to fill in request forms and wait almost 24 hours before receiving information that they admit may have saved 17-year-old David Iredale, who died after becoming separated from his friends during a trek in the Blue Mountains, west of Sydney. Superintendent Patrick Paroz told Penrith Coroner's Court he made two separate requests to the state emergency services for copies of 000 calls made by the Sydney Grammar student. He did not receive them until almost a day later.

The inquest heard that a "technical difficulty" was to blame for the delay. A disc containing sound files of the calls had to be driven from the city to Katoomba because computer firewalls in the ambulance service system prevented police receiving them by email.

On December 11, 2006, David repeatedly told three New South Wales Ambulance Service operators that he was on the well-known Mt Solitary walking track heading towards the Kedumba River. The inquest heard vital time was wasted time as authorities looked for "Doherty's Pass", which they concluded did not actually exist. "It was time-consuming," said Superintendent Ian Colless, who led initial rescue efforts.

Superintendent Colless said that based on information received from the ambulance service, police treated the calls as a "priority 3", classed as needing action but not urgent. "This is a call we may get every day of the week," he said. Superintendent Colless, who heard the emergency calls for the first time yesterday, agreed that immediate access to them would have given police a more accurate idea of David's location and health. "Not only of the Mt Solitary track but also which portion of the track," he said.

After hearing the calls, Superintendent Colless admitted it was "completely" wrong to assume David was not in distress. The fact David was "yelling" and had fainted meant the situation was "critical", he said.


Tuesday, April 28, 2009

California Waiting for National Health Care

Gov. Arnold Schwarzenegger and the Legislature have abandoned any serious attempt at health care reform in California.

Instead, they're waiting for President Barack Obama to push national reform through Congress ...."
Therefore, it appears that if government-run health care doesn't work at the state level, arguably a pilot project, then it's obviously time to expand the experiment to the national level.

It's slipped my mind while being on the tip of my keyboarding fingers. What's it called when a failed project is repeated with the expectation of different results? Erudite readers will know.

By the way, other states are also waiting. State politicians are tired of being hammered for their unachievable pie-in-the-sky health care promises and want Obama to take up the mantle as the health care charlatan. Meanwhile, America gets screwed.

British grandmother is refused cancer drug

The NHS thinks it has already spent enough money on her

Grandmother Beryl Jarvis, who is battling cancer for the fourth time, has been refused a drug that could save her life – because the NHS says it has already spent enough money on her treatment.

Mrs Jarvis has been told a drug cleared for use last November could help reduce a tumour in her lungs. But the NHS says it is not cost-effective to prescribe the drug. Mrs Jarvis, 66, said: "They are saying that for the sake of £10,000 a year my life is not worth saving. How could they put that price on my life?" Her daughter has described the decision as handing her mother a "death sentence".

Mrs Jarvis first contracted ovarian cancer in the early 1980s. She overcame the disease after she underwent a course of chemotherapy. But in January 2004 she was diagnosed with lung cancer. The former cleaner had a round of chemotherapy, followed by radiotherapy, and was free of the cancer for three years.

Early in 2007 the disease returned and Mrs Jarvis, of Home Close, Southmead, was given another round of chemotherapy. Last spring, her tumour grew again and she underwent more chemotherapy. In November the cancer increased in size and her consultant at Bristol Oncology Centre recommended a drug called Tarceva. He believed it could help reduce the size of the tumour. He applied to NHS Bristol – which is in charge of health spending in the city – to see if they would treat her as an exceptional funding case, but was turned down.

Mrs Jarvis said: "When I heard that Tarceva had been approved I thought I might be entitled to it." But she was turned down because the National Institute of Health and Clinical Excellence (NICE) had not approved it for cases like hers. Other treatments were tried by Mrs Jarvis but she suffered side-effects. She said: "I did not know then that if you had already had two chemotherapy treatments you could not have it. "It seems as though if you have had cancer for so long they don't want to pay money."

Despite this, Mrs Jarvis is determined to continue battling the disease. She desperately wants to attend the wedding of her grandson Lee Brewer in July. It was this determination to see him grow up and get married which got her through her first battle with cancer in the 1980s. Her husband, Nigel, 59, said: "Beryl has been fighting for five and a half years now because she won't give up. The fight is there, why should she be denied this?"

Mrs Jarvis' daughter, Nikki Brewer, said: "When they sent the letter saying they would not pay for the treatment it was a death sentence. They call it exceptional funding, but we are also facing exceptional circumstances."

The drug hit the headlines last year with the case of Carol Rummels, from Stoke Lodge, who was eventually given Tarceva just before the change of guidelines.

Mrs Jarvis, and her husband have been in contact with Mrs Rummels and have also written to their MP, Doug Naysmith. He has passed their concerns on to Bristol South MP Dawn Primarolo in her capacity as a health minister.

A spokesman for NICE said: "The guidance does not recommend erlotinib (Tarceva) for the second-line treatment of locally advanced or metastatic non-small-cell lung cancer in patients who are intolerant of docetaxel, or for third-line treatment after docetaxel therapy because it is not a cost-effective use of NHS resources when used in this way."

NHS Bristol spokeswoman, Julie Hendry, said: "While NHS Bristol has sympathy for Mrs Jarvis, NICE guidelines state that Erlotinib (Tarceva) therapy is not recommended for patients undergoing third- line treatment after docetaxel therapy and our local network of experts have endorsed this guidance. "Every application NHS Bristol receives for this treatment is considered using this guidance in order to ensure fair and equitable treatment for all patients."


Doctors attack embryo screening 'postcode lottery'

The NHS is contributing to needless abortions and the avoidable birth of children with inherited diseases because of a postcode lottery in embryo screening, medical experts said today. Couples who know they are at risk of passing on serious genetic diseases to their children are often refused funding for IVF tests that can detect affected embryos, according to doctors and nurses from Guy’s Hospital in London. This has led to cases in which couples have terminated pregnancies following the results of prenatal tests and incidents where children have been born with a genetic disease that could have been picked up with embryo screening.

When prospective parents know they are at risk of having children with a serious heritable disease, they can use an embryo screening test known as pre-implantation genetic diagnosis (PGD) to ensure they have a healthy baby. Though such couples are generally fertile, they conceive by IVF and a single cell is removed from each embryo for genetic analysis. Only embryos that do not carry the faulty gene carried by the family are then chosen for transfer to the womb.

The service, which costs about £7,000, is available for hundreds of genetic conditions, including cystic fibrosis, Huntington’s disease and muscular dystrophy, and several hundred PGD babies have been born in the UK. The only alternatives are prenatal testing, in which a foetus is tested several months into pregnancy, offering the parents the opportunity to have an abortion if it is affected, or taking no tests at all. All primary care trusts fund prenatal tests during pregnancy when there is a risk but many will not pay for PGD, even though this can prevent abortions.

Alison Lashwood, consultant nurse in genetics and PGD at Guy’s, said: “There are couples we have seen who have not been given funding, who have gone on to have affected children. Others have had to go down the prenatal testing route and some have had terminations.”

Speaking at the launch of Guy’s Hospital’s new Assisted Conception Unit and PGD centre, which opens tomorrow, she described one couple who had been refused PGD on the NHS, who had gone on to have a stillbirth and a baby with a severe inherited disease.

Some PCTs, Ms Lashwood said, apply the same eligibility criteria as they do to IVF for infertility even though it is not a fertility treatment. This means that couples can be refused on grounds of age or because they already have children. The latter is particularly unfair on couples who discover they need the procedure because they have already had a child with a genetic disease. “They cannot get the idea that PGD is an early approach to prenatal diagnosis, not a type of fertility treatment,” Ms Lashwood said. She urged trusts to set up common rules, as are already operated by a consortium of PCTs in south east England.

Yacoub Khalaf, head of the Guy’s unit, said: “More trusts than not understand the need for PGD and that it is not to be mixed up with fertility treatment, but some trusts say they offer prenatal diagnosis, so why don’t you have that? It denies patients a choice.”

Professor Peter Braude, of King’s College, London, said: “Some PCTs regard PGD as a bolt-on to IVF, but it should not be seen that way. Most patients who have PGD are not infertile.”


Monday, April 27, 2009

Appalling: NHS Hospital used wrong sperm to fertilise eggs -- kills embryos

The usual bureaucratic carelessness

WOMEN undergoing fertility treatment have had their eggs fertilised with the wrong sperm in a series of mix-ups at one of Britain’s most famous hospitals. Embryos belonging to three couples had to be destroyed and their cycles of treatment abandoned after the errors were discovered at Guy’s and St Thomas’ hospital in London earlier this year. In a separate blunder, a woman had the wrong embryo implanted at the same hospital in 2007.

Fertility experts say the errors, along with similar mistakes at other hospitals, raise serious concerns about the way IVF clinics are regulated. They believe the Human Fertilisation and Embryology Authority (HFEA), the watchdog, is failing to deal with serious problems. [That's because they are too busy persecuting Dr Taranissi, Britain's most successful IVF practitioner, who is, unforgiveably, a PRIVATE doctor]

The mistakes have raised concerns about a “casual approach” to the 37,000 British couples who seek fertility treatment every year. Critics point out that inspection reports from 2007 and 2008 warned that Guy’s and St Thomas’ was carrying out “risky” procedures in the preparation of sperm samples for fertilisation.

A February 2007 report by the HFEA warned that embryologists at the hospital were running the risk of confusing sperm samples from different men by preparing them in the same container. Yet errors were still being made earlier this year.

One of the recent cases was discovered when the embryologist realised she had used a sample from the wrong man to fertilise a patient’s eggs. Within days of this mistake, scientists carrying out tests designed to ensure that babies are free of hereditary diseases found genes showing that the embryos could not belong to the parents they had believed to be the owners.

In 2007 a patient at Guy’s had been implanted with the wrong embryo. The treatment failed to result in a birth and embryologists later discovered that they had put back a weak embryo – despite the patient having created a stronger one that had a greater chance of developing into a baby.

Documents seen by The Sunday Times show a series of mistakes at other clinics that led to general warnings being issued. In one incident, a surrogate mother was given embryos from a couple who had a similar-sounding surname to the couple who had hired her. The surrogate did not become pregnant. The HFEA warned clinics about the mistake in March 2007, but the incident was not made public.

At another unidentified clinic, a woman became pregnant after she was implanted with embryos belonging to another couple with the same surname. The HFEA told clinics about the mix-up in May 2007 but the public was again not informed. The pregnancy ended in miscarriage. At about the same time, treatment for two other couples had to be abandoned after their embryos were mixed-up.

Josephine Quintavalle of the campaign group Comment on Reproductive Ethics, said: “It is horrifying that this information is not available to the public. I didn’t realise the extent of this. The casualness is just dreadful.”

Sue Avery, consultant embryologist at Birmingham women’s hospital and a former chairwoman of the Association of Clinical Embryologists, said the sperm mix-ups at Guy’s were “very serious”. She said it was disappointing that clinics had not learnt lessons from the mistakes that had led to the birth of black twins to a white couple in Leeds in 2002.

Despite the repeated mistakes at Guy’s and St Thomas’ hospital, the HFEA has not carried out an investigation. Avery said: “We would expect in the case of repetition that the HFEA might want to investigate unless they can be thoroughly satisfied that the centre has taken sufficient action.”

The assisted conception unit at Guy’s and St Thomas’ hospital said a thorough internal investigation had been carried out and the HFEA was informed of the mistakes.

The HFEA said that while IVF was a delicate procedure and it was impossible to eliminate human error, only 0.5% of treatments resulted in problems. It added: “The HFEA takes incidents very seriously. When incidents are reported to us, we will investigate and take action where necessary. The risk of mix-ups is a serious concern for patients, clinics and the HFEA.”


Obama policies must lead to severe health care rationing

Charles Krauthammer

In the service of his ultimate mission -- the leveling of social inequalities -- President Obama offers a tripartite social democratic agenda: nationalized health care, federalized education (ultimately guaranteed through college) and a cash-cow carbon tax (or its equivalent) to subsidize the other two.

Problem is, the math doesn't add up. Not even a carbon tax would pay for Obama's vastly expanded welfare state. Nor will Midwest Democrats stand for a tax that would devastate their already crumbling region. What is obviously required is entitlement reform, meaning Social Security and Medicare/Medicaid. That's where the real money is -- trillions saved that could not only fund hugely expensive health and education programs but also restore budgetary balance. Except that Obama has offered no real entitlement reform. His universal health care proposal would increase costs by perhaps $1 trillion. Medicare/Medicaid reform is supposed to decrease costs.

Obama's own budget projections show staggering budget deficits going out to 2019. If he knows his social agenda is going to drown us in debt, what's he up to? He has an idea. But he dare not speak of it yet. He has only hinted. When asked in his March 24 news conference about the huge debt he's incurring, Obama spoke vaguely of "additional adjustments" that will be unfolding in future budgets.

Rarely have two more anodyne words carried such import. "Additional adjustments" equals major cuts in Social Security and Medicare/Medicaid. Social Security is relatively easy. A bipartisan commission (like the 1983 Alan Greenspan commission) recommends some combination of means testing for richer people, increasing the retirement age, and a technical change in the inflation measure (indexing benefits to prices instead of wages). The proposal is brought to Congress for a no-amendment up-or-down vote. Done.

The hard part is Medicare and Medicaid. In an aging population, how do you keep them from blowing up the budget? There is only one answer: rationing. Why do you think the stimulus package pours $1.1 billion into medical "comparative effectiveness research"? It is the perfect setup for rationing. Once you establish what is "best practice" for expensive operations, medical tests and aggressive therapies, you've laid the premise for funding some and denying others.

It is estimated that a third to a half of one's lifetime health costs are consumed in the last six months of life. Accordingly, Britain's National Health Service can deny treatments it deems not cost-effective -- and if you're old and infirm, the cost-effectiveness of treating you plummets. In Canada, they ration by queuing. You can wait forever for so-called elective procedures like hip replacements.

Rationing is not quite as alien to America as we think. We already ration kidneys and hearts for transplant according to survivability criteria as well as by queuing. A nationalized health insurance system would ration everything from MRIs to intensive care by a myriad of similar criteria.

The more acute thinkers on the left can see rationing coming, provoking Slate blogger Mickey Kaus to warn of the political danger. "Isn't it an epic mistake to try to sell Democratic health care reform on this basis? Possible sales pitch: 'Our plan will deny you unnecessary treatments!' ... Is that really why the middle class will sign on to a revolutionary multitrillion-dollar shift in spending -- so the government can decide their life or health 'is not worth the price'?"

My own preference is for a highly competitive, privatized health insurance system with a government-subsidized transition to portability, breaking the absurd and ruinous link between health insurance and employment. But if you believe that health care is a public good to be guaranteed by the state, then a single-payer system is the next best alternative. Unfortunately, it is fiscally unsustainable without rationing.

Social Security used to be the third rail of American politics. Not anymore. Health care rationing is taking its place -- which is why Obama, the consummate politician, knows to offer the candy (universality) today before serving the spinach (rationing) tomorrow.

Taken as a whole, Obama's social democratic agenda is breathtaking. And the rollout has thus far been brilliant. It follows Kaus' advice to "give pandering a chance" and adheres to the Democratic tradition of being the party that gives things away, while leaving the green-eyeshade stinginess to those heartless Republicans. It will work for a while, but there is no escaping rationing. In the end, the spinach must be served.


Sunday, April 26, 2009

Pregnant mother is refused free NHS maternity dental care after staff said bump, ultrasound and doctor's notes are NOT proof

A woman with most severe dental problems still cannot get treatment in socialized Britain

A mother-to-be has been turned down for free dental treatment - because the surgery will not accept that she is expecting. Sarah Luisis, 27, who is five months pregnant, has been told she needs to provide more proof that she has a baby on the way. That is despite the fact that she has a big bump, a doctor's certificate, antenatal notes and ultrasound pictures of her unborn child.

Miss Luisis, of Hornchurch, Essex, is desperate to see a dentist after enduring weeks of agony with bleeding gums. But the only way she can afford crucial treatment is through maternity cover from the NHS. But the mother of one was turned away from St John's dental practice in Romford because she did not have a Maternity Exemption Certificate. She said: 'I filled in a form to get the certificate when I found out I was pregnant and sent it off. 'But I've discovered that the form was never received in Newcastle where the certificates are issued. 'I now have to fill in another form but that could take up to four weeks to be approved.'

She added: 'I've got a letter from my doctor confirming my pregnancy, my antenatal notes, ultrasound scans and I'm very big for five months anyway. 'You'd think that would be enough.'

Miss Luisis's gums are so bad she wakes up with a mouth full of blood every morning and she fears she has an infection. She has been on the waiting list to see a dentist for the past ten weeks. 'I was recently told that an appointment had finally become available,' she said. 'But it was devastating to be told I'd not be treated because I didn't have the Maternity Exemption Certificate proving that I'm pregnant.'

The part-time admin worker says she cannot afford the £40 fee for the initial appointment, and the cost of further treatment could run into hundreds of pounds. A spokesman for the dental surgery said: 'This is not our policy. It comes from the health authority. 'The PCT have said to us, "We will not pay you if you don't have this information". 'It's not up to us, and we used to take people's word.'


Is Health Care A “Right”? Not According to Governments Who Run Health Care

The advocates of government-run medicine base their claims on the notion that health care is a “right.” They thus attempt to occupy the moral high ground over those who advocate reforms based on the principle of individual choice.

For example, lobbyists in favor of California’s SB-840, a bill that has twice failed to impose a government-monopoly health system, affirm Californians’ “right” to “quality, affordable health insurance.” Many physicians do likewise.

At a recent debate of the Benjamin Rush Society, which comprises physicians and medical students who oppose government control of medicine, Dr. Oliver Fein, represented the Physicians for a National Health Program, (PNHP), which includes the “right” to health care in its mission statement. Fortunately for Dr. Fein, he has not practiced in a country such as Canada, where the government has defined health care as a “right.”

Fortunately for the New York audience, one of the speakers opposing the resolution, that health care should be the responsibility of the federal government, was Dr. Brian Day, a Canadian orthopedic surgeon. He knows all too well the pain caused to both patients and doctors when the government asserts its “right” to control your health care.

Back home in British Columbia, the monopolistic provincial health plan is suing Dr. Day for allegedly receiving direct payment from patients for performing surgeries in his clinic. What makes the case remarkable is that the provincial monopolists have launched their legal attack against Dr. Day based on their new-found conviction that Canadian citizens do not, in fact, have a right to health care.

The state’s claim is remarkable in its arrogance but a necessary legal maneuver if the BC government wants to put Dr. Day out of business. In 2005, the Supreme Court of Canada found that elements of the province of Quebec's monopoly over health care violated citizens' human rights because of the government's failure to deliver care. Since then, other Canadians have launched similar lawsuits in other provinces. It appears they just might win.

By conceding that health care is not a “right,” the provincial monopolists can argue that the 2005 Supreme Court decision is irrelevant. If that is the case, then the government's monopoly obviously cannot violate citizens' rights.

As this episode shows, once the state takes over, the citizen hasn't got a chance. Governments are not competent to provide health care as a “right,” any more than they would be competent to provide shoes as a “right.” Therefore people who define their right to health care differently will have to continue to fight the state to recognize it.

How should it then be defined? When I'm speaking publicly on health reform, people sometimes ask: "Do you think that health care is a human right?" My answer is: "Yes, I believe that you have a right to spend your own money on health care of your choice, free of government interference."

This prompts a moment of reflection in those who understand the difference between a culture in which people take care of each others’ needs as members of a civil society, versus one in which we surrender our liberty to unlimited control of our health-care resources by government agents.

Legislators in Sacramento and Washington need to reflect on those realities, and the plight of Dr. Brian Day. Otherwise governments in the United States may soon be further infringing Americans’ health care choices, and be suing doctors for taking care of patients’ needs.


Saturday, April 25, 2009

Girl, 3, has NHS heart operation cancelled three times because of bed shortage

A three-year-old girl awaiting heart surgery has had her operation cancelled three times this month because of a shortage of beds. Ella Cotterell was due to have aorta-widening surgery on Monday at the Children’s Hospital, Bristol. But 48 hours beforehand, the operation was cancelled for the third time as all 15 beds in the intensive care unit were occupied, her parents said.

A hospital spokesman said that procedures would be reviewed, but the case highlights a growing problem of cancelled operations in the NHS. More than 57,000 surgeries were postponed for non-clinical reasons, including a lack of beds, last year – 10 per cent more than the previous year. Latest figures show that the problem persists. At least 43,000 operations were cancelled in the first nine months of 2008-09, with nearly 1,800 patients not being treated within 28 days of their original scheduled date.

Among the excuses for cancellation the previous year were a hospital running out of shavers to prepare patients for surgery, a surgeon going missing following a fire alarm, and a patient’s translator failing to turn up.

Ella needed open heart surgery when she was nine days old to repair her aorta, the body’s main artery, which had not formed properly in the womb. At 18 months old she suffered a stroke after falling down the stairs at her home and banging her head, temporarily paralysing the left side of her body.

Her parents, Ian Cotterell and Rachel Davis, were told last October that she would need an operation within 12 to 18 months. Doctors carried out two angioplasties, where small balloons are inserted and inflated to clear a blocked blood vessel, but neither was successful. Further surgery was initially planned for April 2 but was cancelled because of emergency cases and rearranged for four days later, the couple said. However, the operation was cancelled again for the same reason.

A third date was arranged for April 20 and last Thursday Ella went to the hospital for tests. On Saturday her parents received another call explaining her operation would have to be cancelled. Ms Davis, who works part-time as an accident and emergency nurse at the Frenchay Hospital in Bristol, said that she was devastated when she was told there were not enough beds. “My husband and I were in tears,” she said. “When our six-year-old son Liam asked what was wrong we told him Ella’s operation had been cancelled again and he said we should tell Gordon Brown.”

The family are waiting for another surgery date. In the meantime, Ella is having to take adult doses of medication to control her blood pressure. “We have asked the doctors if she really needs the surgery as she is so happy at the moment and is running around like a normal little girl, but she could drop down dead at any moment,” Ms Davis said. “Twice I have been told that she may not make it through the night and there have been times when I have gone into her room in the morning and wondered whether she’d still be breathing.

She called on the Government to put more money into the NHS before a child died on the waiting list. “I have worked in the NHS for 22 years so I know what happens in hospitals,” she said. “I cannot fault the doctors and nurses for all they have done for Ella – she would not be alive today without them. “I believe Ella is the tip of the iceberg and that there are many other families out there that have had their operations cancelled many more times but have not spoken out about it. “This is a national problem, there are not enough resources in the NHS and it is about prioritising. “It is a matter of time before a child dies on the waiting list and I don’t want it to be Ella. If that does happen the Government will have blood on their hands.”

Michele Narey, of the University Hospitals Bristol NHS Foundation Trust, said that she could not discuss individual cases. She added: “The decision to cancel any patient for any procedure is taken extremely seriously but is sometimes unavoidable because of the need to effectively manage emergency patients requiring beds on a day-to-day basis. “We know that cancelling procedures can cause additional stress for patients so we will always seek to avoid this wherever possible.”


Australia: The charming NSW government ambulance service again

Culture of sarcasm familiar to another victim

THE sarcasm and insensitivity of ambulance call operators towards dying teenager David Iredale is all too familiar for Gareth Redshaw, who was called a "blatant hoaxer" when he called for help minutes after the Waterfall train disaster. Mr Redshaw, then 19, managed to kick a hole in the glass door of the overturned train carriage and climb up an embankment to call triple-0 from his mobile phone about 7.30am on January 31, 2003.

But the operator who took his first call told a clearly distressed Mr Redshaw that his story was unbelievable and a second, more senior operator also accused him of a hoax. In alarming parallels to evidence given at the inquest into Mr Iredale's death, call operators behaved as if Mr Redshaw was a teenage prankster when he could not provide an exact location of the derailment, which occurred in thick bushland between Waterfall and Helensburgh stations.

The Ambulance Service later apologised for questioning the validity of Mr Redshaw's calls and he was told by divisional management that operators would be given more information to help them distinguish between genuine and hoax calls. But yesterday Mr Redshaw, now 25, said the organisation had clearly failed to implement measures that would ensure the situation did not arise again. "I was promised that the issue of failing to deal with people who couldn't provide a cross-street would be rectified and I am disappointed that management has again failed to act. "The whole culture of the ambulance service needs an overhaul."

Mr Redshaw later told police attending the scene the operators "didn't seem to understand that it was on a railway". "They were saying, 'What suburb, what street' and I was saying there was no suburb, it's on a train line, the train's derailed." But a recording played at the special commission of inquiry into the disaster shows the two operators were sceptical.

Leyla Spinelli admitted she did not take the call seriously as she had found the idea of a whole train overturning "incredible". She had been suspicious after a spate of similar prank calls in the days before the accident and because Mr Redshaw's mobile number did not show up on her screen. "You rang up yesterday and told me … about someone hurting themselves in Queanbeyan, didn't you?" He said: "Queanbeyan? No, I told you I'm serious. F---in' train derailed here."

When Brad Deering took over the call he said: "Gareth, you're not mucking us around, are you mate?" and "Well, if this really happened the railway will know about it."

An Ambulance Service spokesman said procedures for incidents in remote or isolated areas with no street address were changed in 2008.


Friday, April 24, 2009

Girl, 6, dies after NHS GP failed to carry out blood test which would have saved her life

Once again the chronic delays and indifference that characterize socialized medicine were the real killers

A six-year-old girl died from kidney disease after a GP failed to give her a blood test that would have saved her. Bethany Townsend's death was preventable and her illness treatable, an inquest ruled. Her devastated parents are considering legal action against their GP.

Coroner Dr Nigel Chapman, who recorded a verdict of death by natural causes, said: 'The window of opportunity to save Bethany was huge and that length of time was totally unacceptable. 'Sadly Bethany died because a blood test wasn't done. Had one been done, it would have shown the abnormality and she would have gone into hospital and her death would not have occurred.'

Bethany died three weeks after being taken to her local surgery in Newark, Nottinghamshire, just after Christmas. But instead of carrying out a blood test which would have diagnosed her illness, Dr Julie Barker referred her to Newark Hospital for the test. When Bethany arrived a week later nurses found she was too thin for them to find a vein and referred her back to her doctor's surgery. Ten days later Dr Barker tried to draw a blood sample but could not find a vein.

The GP then managed to refer Bethany to a specialist paediatrician but could get an appointment only a month later. But Bethany died from kidney failure on January 22, 2007, weighing just 30lb.

Dr Barker told Nottingham Coroner's Court she had made 'an error of judgment'. The GP said she now referred children immediately for specialist treatment if required. Dr Barker added: 'Obviously I wish I had referred her straight away. 'I felt that she would need specialist treatment and had planned to do that but I wanted to get some test results back.'

Dr Malcolm Lewis, a specialist in kidney disease at the Royal Manchester Children's Hospital, said he believed Dr Barker should have put in an urgent request for Bethany to see a specialist paediatrician. Had she done so a blood sample would have been taken within a week and the youngster would have been immediately sent to a specialist renal unit, he said. 'My expectation would be that had she been sent, Bethany would have lived,' he said.

'From the post-mortem reports I would have been optimistic she would have been able to return to good kidney function for a period of time, but given the damage that would have been done she would have needed a transplant in the future. 'From the description of Bethany's Manclinical state I would expect a phone call that day to refer Bethany. I would expect with her condition that she would have been seen within a week and if I were taking that phone call about a child with a urinary infection I would say come up immediately and have a test.'

A statement from Bethany's parents said: 'This has been an incredibly harrowing period for the family and friends of Bethany, with today's inquest reminding us all of a young life lost and a loving daughter who is sadly missed. 'The question of "would things have been different had Bethany seen a specialist?" is one that will haunt us for ever but we are grateful for some kind of closure now that the circumstances surrounding her death have been made public. 'Hopefully lessons have been learned and nobody else suffers in similar circumstances.'

Dr Doug Black, medical director at NHS Nottinghamshire County, said: 'This girl's death is a tragedy. 'It was avoidable and our deepest sympathies go to her family. 'It's a complex case and we have led a thorough review to ensure we learn lessons from it. 'We have acted firmly to put in place a comprehensive action plan under which the GP involved has undertaken further specialist training.'


Health insurance does not mean medical care

Already, many patients "insured" by Medicare and Medicaid have trouble finding a doctor who will take the pittance that the government will pay for their care

Much as I hate to be the bearer of bad news, I must report the shocking facts: Medical care is medical care. Nothing more and nothing less. This may not seem like a breakthrough on the frontiers of knowledge. But it completely contradicts what is being said by many of those who are urging "universal health care" because so many Americans lack health insurance. Insurance is not medical care. Indeed, health care is not the same as medical care. Countries with universal health care do not have more or better medical care.

The bottom line is medical care. But the rhetoric and the talking points are about insurance. Many people who could afford health insurance do not choose to have it because they know that medical care will be available at the nearest emergency room, whether they have insurance or not.

This is especially true for young people, who do not anticipate long-term medical problems and who can always get a broken leg or an allergy attack taken care of at an emergency room -- and spend their money on a more upscale lifestyle.

This may not be a wise decision but it is their decision, and there is no reason why other people should lose the right to make decisions for themselves because some people make questionable decisions. If you don't think government bureaucrats can make questionable decisions, then you haven't dealt with many government bureaucrats.

It is one thing to deal with bureaucrats when you are at the Department of Motor Vehicles and in good health. It is something else when you have to deal with bureaucrats when you are lying on a gurney and bleeding or are doubled over in pain on a hospital bed.

People who believe in "universal health care" show remarkably little interest -- usually none -- in finding out what that phrase turns out to mean in practice, in those countries where it already exists, such as Britain, Sweden or Canada. For one thing, "universal health care" in these countries means months of waiting for surgery that American get in a matter of weeks or even days. In these and other countries, it means having only a fraction as many MRIs and other high-tech medical devices available per person as in the United States.

In Sweden [and Britain], it means not only having bureaucrats deciding what medicines the government will and will not pay for, but even preventing you from buying the more expensive medicine for yourself with your own money. That would violate the "equality" that is the magic mantra.

Those who think in terms of talking points, instead of trying to understand realities, make much of the fact that some countries with government-controlled medical care have longer life expectancies than that in the United States. That is where the difference between health care and medical care comes in. Medical care is what doctors can do for you. Health care includes what you do for yourself -- such as diet, exercise and lifestyle. If a doctor arrives on the scene to find you wiped out by a drug overdose or shot through the heart by some of your rougher companions, there may not be much that he can do except sign the death certificate.

Even for things that take longer to do you in -- obesity, alcohol, cholesterol, tobacco -- doctors can tell you what to do or not do, but whether you follow their advice or not is what determines the outcome. Americans tend to be more obese, consume more drugs and have more homicides. None of that is going to change with "universal health care" because it isn't health care. It is medical care.

When it comes to things where medical care itself makes the biggest difference -- cancer survival rates, for example -- Americans do much better than people in most other countries.

No one who compares medical care in this country with medical care in other countries is likely to want to switch. But those who cannot be bothered with the facts may help destroy the best medical care in the world by falling for political rhetoric.


Thursday, April 23, 2009

Teenage girl died in agony 'after NHS hospital said she was just a drama queen'

When the girl's appendix was removed, it must not have been intact and the inexperienced foreign doctor did not notice that. Then everybody else was too complacent to notice anything. With cautious medical practice she would have been given antibiotics and would be alive today. But instead of cautious medical practice she got bureaucratic indifference -- and no-one will be penalized for it. That's the socialized medicine system

A teenage girl died in agony in hospital days after medics dismissed her as a 'drama queen' whose pain was 'all psychological', an inquest has heard. Sian Jones, 15, was admitted to hospital with stomach pains, which doctors suspected were caused by appendicitis. When they removed her appendix the next day, her condition continued to worsen.

Doctors said the pain was from the operation and missed a series of tell-tale signs that she was suffering from perienteritis - a serious infection that inflames the lining of the stomach and intestines.

Sian, from Stirchley, Birmingham, died from multiple organ failure, brought on by the infection, a week after being admitted to the city's Heartlands Hospital in August 2007.

Her sister Sarah, 22, said that four days before Sian's death, staff had told their father 'there was nothing physically wrong with her and that it was all psychological, that she was a drama queen'. The family claimed staff also said the pain was brought on by problems at home, as Sian's father, Andrew, was fighting leukaemia. He has since died from the illness.

The inquest at Sutton Coldfield, West Midlands, heard the medic who had most contact with Sian, Dr Nehtab Ahmad, had only started her surgical training at the hospital three days earlier. Dr Ahmad told the hearing the surgical team, including two more senior surgeons, 'thought there was nothing amiss surgically and had been falsely reassured by a CT scan and a review from a paediatric doctor'.

The doctor added: 'With the benefit of hindsight I can see that she was getting worse, but at the time it was not so obvious. In hindsight all the factors were viewed independently and not together. 'The emotional aspect had been raised to me by my seniors and psychological issues were raised in a conversation with her father.'


FDA’s woes will grow under new leadership

The FDA, which regulates products worth more than $1 trillion -- a quarter of every consumer dollar -- has over the past two decades become a dangerous impediment to patients' getting the medicines they need. Drug development costs are up, approvals are down. Reforming a demoralized and chaotic FDA will require leadership that manages competently, is science-driven, is untainted by ideology, and is sufficiently strong to deflect congressional brickbats.

That's why the Obama administration's selections for the leadership at the FDA are especially disappointing. Although Dr. Margaret Hamburg, the nominee for commissioner (as the agency head is called), boasts significant experience in government and is highly thought of in the public health community, her new deputy, Dr. Joshua Sharfstein, is an inconceivably poor choice. The selection of Dr. Sharfstein -- who is acting agency head while Dr. Hamburg awaits Senate confirmation -- is particularly bad, given that he will reportedly be entrusted with oversight of the most important sector of FDA-regulated products, and is apparently being groomed to head the agency.

FDA commissioner has long been one of the most difficult jobs to fill in the federal government. On most high-profile issues, the incumbent is subject to intense criticism from a number of quarters, and the position has never been a stepping stone to fame or fortune. He or she needs to be equal parts scientist, technocrat, and Lord High Executioner (the latter, in order to keep balky bureaucrats in line).

The new leadership will face the added challenge of addressing the legacy of recent incumbents who imposed excessive and expensive burdens on those trying to bring new medicines to consumers, pushed drug development costs into the stratosphere, damaged agency morale, permitted the drug approval process to become politicized, and allowed drug-safety zealots to dominate agency policymaking and decisions.

The new FDA leadership must also confront a trend -- especially among members of Congress and the media -- toward vilifying drug companies, and even alleging that regulators have become too cozy with industry. In response, the FDA has battered the pharmaceutical industry with overly risk-averse, burdensome new policies, as well as erratic and dubious decisions on individual products. As a result, Sharfstein will need to establish credibility and rebuild trust with a variety of stakeholders -- including drug companies and their investors, patient groups, consumer activists, and members of Congress from both parties.

The probability of that happening approaches zero. Sharfstein has a long history of dubious associations and hostility toward the pharmaceutical industry. While a medical student at Harvard, he led a campaign urging classmates to return textbooks donated by a pharmaceutical company (the project failed -- apparently, most of Sharfstein's classmates were less radical than he). Also, while in medical school, he was an intern for FDA Commissioner David Kessler, whom many consider to be the most disliked and disreputable leader of the FDA within memory. (Kessler, who was unceremoniously fired last year as Dean of the medical school at the University of California, San Francisco, has bragged lately about his close ties to the new FDA leadership.)

Of course, it wouldn't be fair to predict an official's future approach to issues based only on his youthful activism, but Sharfstein's early "us versus them" view of the pharmaceutical industry has persisted throughout his career. He went on to work for anti-drug and anti-industry zealot Sidney Wolfe, and as health policy advisor to Rep. Henry Waxman (D-Calif.), who personifies the divisive approach that castigates and persecutes innovative pharmaceutical companies.

These are difficult times for both the drug industry and its regulators. Leadership at the FDA will demand nuance and the ability to weigh benefits and risks -- including the risks of excessive regulation that inhibits innovation and investment in R&D. Federal regulators should not be collaborators with industry, to be sure, but they must cooperate with drug manufacturers in order to get new drugs to patients in a timely and cost-effective way. Sharfstein has shown no willingness to do so, nor does he have any experience with the arcane and high-risk business of developing and regulating prescription drugs.

The aging American population is literally dying for regulatory reform at the FDA -- but not the kind that is in store.


Wednesday, April 22, 2009

Deliberate dumbing down of NHS emergency-room standards 'are putting lives at risk'

Lives are being put at risk by the introduction of medical centres designed to take the pressure off overstretched A& E departments, doctors have warned. Two patients have already been endangered after staff at 'urgent care' centres failed to recognise their symptoms, a survey found. Dozens more of the centres are due to open to prevent patients with minor ailments clogging up emergency departments. In some cases patients must be assessed by GPs or nurses before they are allowed to enter casualty.

The College of Emergency Medicine, which represents A&E doctors, found that a man who had a stroke was sent home from an urgent care centre because staff could not work out what was wrong. He was eventually admitted to hospital and recovered. Urgent care centre staff also failed to spot that a baby had meningitis. Emergency treatment was delayed but the child made a full recovery. The survey, of A&E staff working alongside the centres, did not name which ones were at fault.

John Heyworth, president of the College of Emergency Medicine, said: 'These are worrying examples of things going wrong in urgent care centres. 'In emergency departments we are used to seeing patients who may develop serious complications. 'We want to make sure GPs appreciate the risks and handle things very carefully. 'Speaking to colleagues around the country, our concern is that having a barrier to people actually getting in to A&E is not helpful.' He added: 'Patients tend to know when they are very sick and although around 10 to 20 per cent of patients may use the service inappropriately, the majority will go to their GP if they have a minor problem.'

Discussions to set up urgent care centres, which are particularly used for out-of-hours care, are underway at almost all of the UK's 270 A&E departments. Schemes are already running in Maidstone in Kent, Portsmouth and South-East Hampshire, Huntingdon in Cambridgeshire and Nottingham.

Dr Heyworth said: 'In some cases, where they sit alongside A&E they can work very well, but it is no good imposing them on hospitals and preventing patients from actually getting in. 'Another big worry is that money that should be going into hospital emergency departments is being diverted into these urgent care centres.'

But health bosses say that by preventing 15 'inappropriate' attendances at A&E per day a local primary care trust could save £328,000 a year. If three patients a day were stopped from being admitted to a ward when they would be better off at home, a trust could save £6,000 a day, or £2million a year.

The Department of Health has published a number of strategy documents, including the Direction of Travel for Urgent Care, which make clear that the creation of more urgent care centres is seen as the best way to improve service to patients.

Dr Richard Vautrey, of the British Medical Association's GPs' committee, said: 'We should not assume that GPs are less able to assess risk but we need to recognise that patients themselves are usually able to select the area of the health service they need to access, depending on the severity of their condition.'

A Department of Health spokesman said: ' Urgent care centres play an important role in providing emergency care for non-patients without taking up valuable A&E resources. 'It is for local NHS organisations working with local people to decide whether urgent care centres are a good idea when organising their services. 'We have been clear that any changes to existing services should be based on what is best for patients.'

Doctors from around the country will discuss their concerns about patients being prevented from walking directly into their local A&E at a three-day conference of the College of Emergency Medicine in Brighton from today.


Queue no more

Canada's surprising proposal for fast tracking new drugs to patients

From Canada, the land of long health care queues, comes a genuinely promising idea for speeding new medicines into the hands of patients—a fast track approval process called progressive licensing. Which is exactly what the U.S. needs. In 2007, the Food and Drug Administration (FDA) approved only 19 new drugs, the lowest number since 1983. Last year saw a minor uptick to just 24 new medicines...

Part of the domestic slow down in drug approvals comes from the fact that since the 1980s FDA regulators have more than doubled the number of clinical trials required to get a new drug approved from 30 to about 70. This increase in trials has raised the cost of getting a new drug through the regulatory maze to over $1 billion, thus limiting the number of new drugs that pharmaceutical companies can afford to pursue.

This is where progressive licensing could rescue our creaky pharmaceutical regulatory system. While the final regulations in Canada are still being hammered out, one exciting possibility is that drugmakers could submit some of their new medicines for approval after completing relatively fast and inexpensive Phase 1 and 2 trials. Such trials would provide preliminary information about a drug's safety and efficacy. In exchange for this fast track pre-marketing approval, drugmakers would agree to greater post-marketing surveillance of drug safety. Which means that patients using a new drug would essentially enroll in the equivalent of a Phase 4 trial. This post-marketing information would allow companies and regulators to continually adjust the balance of benefits and risks over the life cycle of new drugs. One important caveat is that such post-marketing scrutiny must not become as costly as the current system of pre-market regulatory review.

Following Canada's preliminary framework, progressive licensing would initially apply just to drugs that address previously unmet medical needs and in those instances where obtaining extensive clinical information is difficult (such as drugs that treat only a small numbers of patients with rare diseases). But why stop there? Canada's free-market Fraser Institute thinks progressive licensing has the potential to fix the current over-regulation of all drugs. Every beneficial drug also has accompanying risks, after all; the question is who gets to weigh the risks and the benefits.

Currently, regulators make the crucial decisions about the risks and benefits of treatment. But this leads to unbalanced benefit-risk evaluations. Remember that from the point of view of pharmaceutical regulators it's far more important to avoid a single highly publicized death from a new drug than it is to worry about the hundreds of unknown patients who die because of delays in approving new life-saving therapies.

In a 2007 report, the Fraser Institute looked at how progressive licensing could be transformed into a more radically open system that allows patients and physicians to evaluate the benefits and risks of new therapies rather than relying on the judgments of timid bureaucrats. In the report, Fraser's Brent Skinner looked at how the risks of new treatments compare to the risks of alternative treatments that the public already accepts.

For example, consider the case of the over-the-counter pain reliever ibuprofen versus the new drug Vioxx. A novel painkiller introduced in 1999, Vioxx was withdrawn from the market because it was found to increase the risk of heart attacks. But further research indicated that many non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, also increase the risk of heart attacks among users.

Both types of medicine effectively relieve pain, but Vioxx had the benefit of reducing the risk of gastrointestinal bleeding, which NSAIDs exacerbate. But who should weight the risk of dying from heart disease versus the risk of dying from bleeding ulcers versus effective pain relief for rheumatoid arthritis? One 1999 study estimated that there are 103,000 hospitalizations and 16,500 deaths in the United States due to complications from NSAID-associated gastric ulcers. As Skinner notes, a patient who is at high risk from gastrointestinal complications might well choose to take the cardiovascular risks associated with Vioxx. Why not let patients and their physicians have this risk information and choose for themselves?

Progressive licensing could modernize the current process from one where bureaucrats grant extensive permission before new drugs hit the market into a system based on initial indications of safety and effectiveness followed by ongoing risk evaluations. This would give patients greater say in their treatment, allowing those who willing to accept a certain amount of risk early access to the latest treatments, while risk-averse patients and physicians could wait until further information became available. It would also increase the scope for private groups—perhaps along the lines of the Underwriters' Laboratories certification process—to evaluate benefits and risks.

Progressive licensing might turn out to be just what the doctors (and patients) ordered for reducing the backlog of new drugs awaiting the nod from overly cautious regulators.


Tuesday, April 21, 2009

Minnesota Virtual Clinic Provides Health Care Online

Soon coming, presumably, to a neighborhood near you will be the virtual clinic, a kind of Internet cafe for people with boo-boos.
Blue Cross and Blue Shield of Minnesota will launch a pilot project in which its 10,000 employees can use a "virtual clinic" to receive a live, 10-minute physician consultation for a flat fee. [...]

Once a doctor and patient have connected, they can communicate via webcam and instant messages.

Roy Schoenberg, who developed the virtual clinic software, said that physicians will have access to patients' electronic health records and that each virtual clinic visit will be added to a patient's EHR.

BCBS is hoping that the "virtual clinic" will play a significant role in transforming health care by making health care more convenient and cost-effective.
A somewhat similar tele-medicine system was launched in the state of Maine a few years ago which included diagnosing and treating patients with psychiatric problems . The intent there was to provide some level of health care to low-density population areas in the remote parts of the state. I haven't seen any reports on the effectiveness of the program in Maine.

Plans are for the Blue Cross and Blue Shield effort in Minnesota to be expanded to the general public.

In any event, I'm far from convinced that doctors can adequately examine patients on the Internet. In addition, I'll probably never feel comfortable about putting patient medical records on the Internet.

Is Government Health Insurance Cheap?

The false comparison between the costs of public and private medical plans.

Congress is currently away on a two-week recess, but weighty work is occurring in its absence. Staff negotiators are trying to come to agreement on a budget framework for 2010 and beyond. Although this is happening behind closed doors, it appears likely that the budget deal will eventually include a government-run health-insurance option, or "public plan," to compete with private health insurance under the comprehensive health-care reform called for by President Barack Obama.

Some lawmakers support or oppose a government-run health-insurance option for purely ideological reasons. Others are open to it because they are pragmatic and -- laudably -- want to be persuaded by data and facts. These moderates have been much influenced by the supposed fact that a public plan such as Medicare is more efficient than commercial insurance. Advocates of the public option routinely ask, "Aren't Medicare's administrative costs a fraction of those of private insurers?"

But the comparison between public and private plans is a false comparison. Private insurance and public benefits are not the same business. For all its warts, private insurance tries to manage care. Medicare is mostly about paying the bills presented to it.

Many who favor a public plan as part of comprehensive health-care reform dismiss the administrative "overhead" of private plans as having little or no value. Ways and Means Health Subcommittee Chairman Pete Stark (D., Calif.), for example, insists that "most private plans are poorly managed." Contrasting them with the supposedly sleek and efficient Medicare program, he labels commercial insurance "the General Motors of medical care."

In fact, the administrative expenses of private insurance plans represent money well spent for their members. Here are four reasons:

First, private insurers must build provider networks. These networks can include high-value providers and exclude low-quality providers. Except for certain circumstances, including criminal acts, Medicare is forbidden from excluding poor quality providers. It lets in everyone who signs up. So one question to ask is, will the public plan have Medicare's indifference to quality -- or invest in the cost of a network?

Second, private insurers must negotiate rates. Medicare just fixes prices using a statutory and regulatory scheme. And anyone who imagines a public plan would be less costly than private plans must keep the following issue front and center: In the many procedure categories where Medicare's statutory price does not cover full provider costs, shortfalls are shifted to private payers who end up subsidizing the public program. So, will a public plan negotiate rates or simply use fiat as a means of gaining subsidies from private insurance?

Third, private insurers must combat fraud -- or go out of business. Indeed, these payers have every incentive to invest in antifraud personnel and strategies down to the point where return and investment are equal. But anyone who thinks that a public plan could serve as a "yardstick" for the private sector needs to consider Medicare's dismal record with regard to fraud, waste and other abuse.

In fact, the total amount of Medicare fraud is unknown. The government does not measure or estimate fraud in its programs; instead, it measures payments made "in error." According to Medicare's own most recent data, payments made in error amount to over $10 billion annually. (Medicaid's payment errors in 2007 equaled a whopping $32.7 billion, according to a report by the Department of Health and Human Services.) Others have claimed Medicare's payments made in error are much higher. Even with the inclusion of the budget of the inspector general for the Department of Health and Human Services, Medicare spends less than one-fifth of 1% on antifraud measures -- a small fraction of what private plans invest in their efforts to build a network of honest providers.

Worse, in four of the past five years Congress has turned back Medicare's pleas for $579 million of additional antifraud funding, on the grounds that these dollars subtract from the budget funds for curing cancer and anti-obesity campaigns. Based on experience, Congress will always underinvest in fraud. Yet according to a House of Representatives Budget Committee hearing in July 2007, return on investment for certain Medicare antifraud measures were estimated to be in excess of 13-1. Will a public plan also hemorrhage from fraud because of chronic Congressional underinvestment?

Fourth, private insurers must incur the administrative cost of marketing. Medicare, of course, does not need to market. A public plan competing with other alternatives would have to market itself to the public, and this means tax dollars used to advertise against private plans. Or the public plan could "compete" by using heavily subsidized marketing channels not available to private insurers, such as Social Security mailings, welfare offices, unemployment check stuffers, and the constellation of government-funded "advocacy organizations."

None of these considerations should be interpreted as a defense of the status quo, or a denial of the fact that major health reform is needed. It is, and now.

There are indeed many places where commercial health insurance is inefficient -- for example, by trying to exclude the sick rather than compete for the business of managing their ailments more effectively. Moreover, the facilitation of a national insurance exchange could lower information and search costs for our increasingly mobile workforce.

But the impulse to "just pass something" -- a refrain heard often in the halls of Congress this spring -- is not good enough. There are more governmental paths to making things worse rather than better. As the case of Medicare's anemic anti-fraud efforts painfully illustrates, less management and lower administrative costs do not necessarily mean the program is really less costly. Fraud losses are just categorized as additional spending rather than as administrative expense.

Ultimately, the desire of many advocates of a government-run health plan to exaggerate Medicare's efficiency derives from the fact that the program does not make a profit. These folks are motivated by the naïve assumption that most of the health sector's ills could be cured if profit-seekers were excluded.

As the Congress continues the health-care debate, today behind closed doors, and soon in the open, there should be an honest discussion of administrative costs and their value. Those who believe that health care should have no profit should be open with their views and not hide behind the false economy of Medicare.


Wrong to expose gross NHS abuses?

Whistleblower nurse who filmed elderly patient neglect found guilty of misconduct over TV exposé. The truth is deadly to socialism

A whistleblower nurse has been found guilty of misconduct for secretly filming the neglect of elderly patients for a BBC documentary. Margaret Haywood, 58, filmed patients suffering in filthy conditions at the Royal Sussex Hospital in Brighton for Panorama. The senior nurse's 20-year career now lies in tatters. A hearing today will decide whether she should be struck off the nursing register. The Nursing and Midwifery Council ruled that Miss Haywood had prioritised filming over her obligations as a nurse and had breached patient confidentiality.

Last night the divorced mother of three from Liverpool told how she risked her career to help patients when working on the Peel and Stewart acute medical ward as an agency nurse between November 2004 and May 2005. She said: 'I did it because of the appalling state patients were in. I knew as soon I went on to the ward there were serious problems. 'There was blood on the curtains which had not been changed. There was faeces on the floor which had not been cleaned. It had obviously been there for days.

'Food was being left on the table when patients obviously needed help to eat. One lady was blind and did not even know the food was in front of her because no one told her. 'There was a lady who used to be a nurse herself who was afraid to ask to go to the toilet because of the nurses' attitude. Another woman who had terminal cancer was left screaming in pain because she was not given pain medication.

'I was absolutely broken-hearted. It's not what you expect when you go into nursing. 'I tried to put things right and get standards improved. I prepared a report, but no one took on board what I was saying. 'It was all being ignored and hushed up; that's why I went to Panorama. I only wanted to help people. I am a very caring and compassionate person.'

The Undercover Nurse programme caused a public uproar when it was screened in July 2005. It later emerged that the hospital, which then had the lowest rating of zero stars and an £8million deficit, had received a number of complaints before filming started. Sussex University Hospitals NHS Trust was forced to a public apology admitting 'serious lapses in the quality of care' after the issue was raised in the House of Commons. Since the programme aired, new care standards have been put into place.

Miss Haywood, a grandmother of seven, now works for a private care home. She admitted breaching confidentiality - even though all patients on the programme gave consent after they were filmed. She said after the hearing: 'I will be devastated if I lose my registration. I've worked so hard. 'Nursing is my life, I'm devoted to it and I'm passionate about what I do. I think it's a case of shooting the messenger. 'I admitted breaching patient confidentiality, but I did not expect them to conclude that my fitness to practise had been impaired.'

Last week a supply teacher who secretly filmed shocking scenes of pupils misbehaving and school cover-ups for a 2005 Channel 4 Dispatches documentary was found guilty of unprofessional conduct and suspended for a year.


Whistleblower nurse considers High Court appeal

The nurse struck off for using a secret camera to expose the neglect of elderly patients at an NHS hospital is considering a High Court appeal against the decision. Margaret Haywood, 58, gathered evidence of "horrendous" conditions at the Royal Sussex County Hospital in Brighton for a BBC Panorama documentary.

Hundreds of nurses have contacted the Nursing and Midwifery Council to protest its decision to to ban her from the profession, amid fears that it will discourage other NHS whistleblowers from coming forward.

Miss Haywood from Liverpool, who worked as a nurse for 20 years, is now taking advice from her professional body about challenging the ruling at the High Court. Chris Cox, director of legal services at the Royal College of Nursing, said: "The RCN has been providing legal representation for Margaret Haywood from the outset and is very surprised at the severity of the punishment dealt out by the NMC panel. "Our legal team are working with Margaret to explore the various legal options available to her in light of the judgment."

The RCN has also set up a Facebook page and a public petition to build support for Miss Haywood, who was said to be devastated by the misconduct hearing's decision on Wednesday. It ruled that she had breached patient confidentiality by agreeing to take undercover footage for the BBC documentary, which was screened in July 2005, even though it conceded that conditions on the ward where she worked were "dreadful".

Yesterday (FRI) the NMC disclosed that it had received 400 emails and 200 telephone calls in support of Miss Haywood, with most of the complaints coming from other nurses.

The Council for Healthcare Regulatory Excellence (CHRE) which reviews all decisions taken by the NMC, said it would not seek to challenge the ruling, as it only intervened when it believed punishments had been too lenient. "She of course has the right to appeal," a spokesman said. Any appeal must be lodged within 28 days.


Monday, April 20, 2009

When Doctors Opt Out

We already know what government-run health care looks like

Here's something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn't automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.

Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.

More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments. I've had several new Medicare patients come to my office in the last few months with multiple diseases and long lists of medications simply because their longtime provider -- who they liked -- abruptly stopped taking Medicare. One of the top mammographers in New York City works in my office building, but she no longer accepts Medicare and charges patients more than $300 cash for each procedure. I continue to send my elderly women patients downstairs for the test because she is so good, but no one is happy about paying.

The problem is even worse with Medicaid. A 2005 Community Tracking Physician survey showed that only 50% of physicians accept this insurance. I am now one of the ones who doesn't take it. I realized a few years ago that it wasn't worth the money to file the paperwork for the $25 or less that I received for an office visit. HMOs are problematic as well. Recent surveys from New York show a 10% yearly dropout rate from the state's largest HMO, the Health Insurance Plan of New York (HIP), and a 14% drop-out rate from Health Net of New York, another big HMO.

The dropout rate is less at major medical centers such as New York University's Langone Medical Center where I work, or Mount Sinai Medical Center, because larger physician networks have more leverage when choosing health plans. Still, I am frequently hamstrung as I try to find a good surgeon or specialist to refer one of my patients to.

Overall, 11% of the doctors at NYU Langone don't participate in at least two insurance plans -- Aetna or Blue Cross, for instance -- so I end up not being able to refer my patients to some of our top specialists. This problem, in addition to the mass of paperwork and diminishing reimbursements, is enough of a reason for me to consider dropping out as well.

Bottom line: None of the current plans, government or private, provide my patients with the care they need. And the care that is provided is increasingly expensive and requires a big battle for approvals. Of course, we're promised by the Obama administration that universal health insurance will avoid all these problems. But how is that possible when you consider that the medical turnstiles will be the same as they are now, only they will be clogged with more and more patients? The doctors that remain in this expanded system will be even more overwhelmed than we are now.

I wouldn't want to be a patient when that happens.


NHS maternity units will still be short-staffed despite surge in number of midwives

NHS maternity units will still be seriously short staffed even after a surge in the number of midwives promised by the Government, critics claimed today.

More than 3,000 extra midwives will be in place by 2012 but new research has found they will still be delivering more babies per year than stipulated by safety guidelines - putting mothers and babies at risk.

The number of births each midwife handles has been rising relentlessly for six years, and is now higher than at any time since Labour took office in 1997.

Ministers' failure to anticipate a rising birth rate by employing enough midwives has led to a doubling in the number of payouts for medical blunders, and for the fact that rising numbers of women are being left alone and terrified during labour.

Experts believe up to 1,000 babies a year die needlessly because doctors and midwives are too overstretched or poorly trained to detect warning signs.

Safety guidelines, laid down by the Royal College of Midwives, say that midwives should deliver an average of 27.5 babies a year - one every 13 days or so - to ensure mother and child have the best quality of care.

In January, the Daily Mail revealed that the average midwife was delivering 34 babies a year, or one ever 10 or 11 days - almost 25 per cent more than they should under the safety standard.

Ministers have promised an extra 3,400 midwives by 2012 to plug the shortage. But new research by the RCM says this means that only four of the country's 10 health regions will meet the safety standards.

Of the six that will fail, four will have more than 32 births per midwife. The East of England region will have a massive 35.2 births per midwife in 2012, followed by the East Midlands (33.9), Yorkshire and the Humber (33.8), and London (33.6).

The Yorkshire figure is actually worse than the current ratio, largely the result of projected birth rate rises, which are largely down to the impact of immigration.

Critics also claim much of the money ministers are earmarking for maternity services is not reaching wards and is being spent on other parts of the NHS.

They say the figures prove the Government has no chance of honouring its pledge that all women should have one-to-one care from a named midwife during the entire pregnancy by the end of this year.

Cathy Warwick, general secretary of the Royal College of Midwives, said: 'Although the situation for most regions will be better, it will still not be good enough to deliver the quality of care women need.

'A step change is needed at regional level to recruit more midwives, and we hope that decision makers will treat it as a priority and put money they have been given for maternity services into maternity services.'

Conservative health spokeswoman Anne Milton said: 'Midwives' morale is currently low and too much of their time is wasted by bureaucracy and red tape. We need to ensure that the workforce spends more time delivering healthy babies from healthy mothers than filling in needless forms.'


Australia. A "caring" Leftist health minister says that the red tape comes first: So you must die

The "caring" one above

A SYDNEY woman who has been told she has six months to live will try to raise more than $2 million for life-saving surgery in the United States after her plea for government funding was rejected. Pauline Talty, 36, from Kellyville, was told on Thursday she would not receive money to have a small bowel transplant in Pittsburgh, under the Federal Government's Medical Treatment Overseas Program, because the operation could be performed at an Australian hospital. Specialists at Melbourne's Austin Hospital, while trained in the procedure, have never performed a bowel transplant because of a lack of donor bowels.

Ms Talty has short bowel syndrome, which developed after her intestines were damaged from radiotherapy she received for treatment of childhood cancer of the kidney.

She said having the operation in Melbourne would put her at "risk of serious complication or even death". "My case is very complex and I don't want to be their first one. I only get one shot at this and if the Austin messes it up, I die. I don't get a second chance."

Due to Ms Talty's stunted bowel growth from radiotherapy, she needs a child's bowel, but Professor Bob Jones, head of the Austin's liver transplant program, told her she may have to wait years for a donor. The average wait for a child's bowel in the US is 240 days. "I don't have years. I was told in October that I have 12 months to live and I have just wasted five months trying to appeal the Government's decision.

"In Pittsburgh, they have been doing this for 20 years and have a 96 per cent success rate, which they have only achieved in the past few years. They have an abundance of bowels so I am not giving up."

The federal Health Minister, Nicola Roxon, said: "I have real admiration for Pauline Talty, for her courage, and determination and I know this must be an incredibly difficult time for her. [But] there are clear, established guidelines for assessing applications under this program … which all applicants must meet."

Ms Talty, who was a business strategist before she became ill, has been in Royal North Shore and Royal Prince Alfred hospitals for 13 months. She is fed through tubes in her chest and groin. Ms Talty has already raised about $200,000 for her living expenses and nursing care while in the US but is now appealing to the public for money to pay for the bowel surgery.