February 25, 2009

How will the US please stakeholders on both sides of the issue when it comes to health care

Will we get it right while everyone else got it so wrong
Universal Health Care For All

By Melvin J. Howard

As the US is about to experiment with reform to health these are my words of caution. I to believed in a "universal health care system". Who wouldn't support that goal? Doesn't everyone have a "right" to health care? Sounds goods "Affordable Health Care for All". Now for the hard part it takes a lot of research of the topic and understanding economic reasoning and history behind the promises of a single payor system. Having gained my experience of socialized medicine in London and Canada. I realized that government intervention in the market (e.g., Medicare, FDA regulations, physician licensing, insurance regulations etc.) is the reason for artificially high health care prices. It’s not the main reason but it’s up there on the list. What I witness in other countries will have the same effect on the US Health Care System.

Universal Healthcare amplifies all problems:

1) Reduces patient incentives to find the best possible prices for the best possible services/products available.

Patients in the U.S. who receive "free" (taxpayer-funded) health care will have no incentive to conserve their health care dollars. Care is "free" so they visit the doctor's office several times a month or request "free" prescriptions for over-the-counter medication such as Tylenol.

2) Reduces physician incentives to provide competitive care and reduces drug companies' incentives to provide new drugs and treatments.

With no incentive to provide quality care because they will be backed up or can't get efficent O.R. time, physicians and nurses leave the government-monopolized area for better opportunities in a freer country. Shortages will result. Drug companies will be hindered by price controls and regulations and soon cease research and development of new medication. In the U.S., start-up drug companies cannot afford to run the FDA gauntlet, so a few established corporations will dominate the market. Medical technology will be reduced and slow to come to market.

3) It comes from your wallet through higher taxes.

Yes, you do have a right to health care, just as you have a right to food, shelter and property. However, you have no "right" to force others to provide these things for you - All "free" medical care is subsidized through taxes made through compelling means. Believe me some will abuse this right repeatedly.

4) The quality of "free" health care will deteriorate and the average citizen will get sicker.

As the poor and middle-class wait in agony for simple procedures, those with resources can travel to other countries for treatment.

5) Destroys your privacy.

Suddenly your problems are mine and mine are yours. If you eat unhealthy foods or drive a motorcycle without a helmet, I have a direct interest in your business - you are going to see a provider on my tax dollars. Your neighbors might support government bans on smoking, "unsafe" sex or other "risky" behaviors to reduce costs. Politicians will use the federal bureaucracy to force you and your family to comply with programs such as the "New Freedom Commission on Mental Health". The Government will control your medical records therefore Patient doctor confidentiality could be compromised.

6) Destroys your liberty.

When you blindly support a system that bestows power on politicians and bureaucrats, they will receive their orders from those that have strong ties to Government and that won’t be you.

Physician shortages will be the norm:

TORONTO - An association of Canadian doctors is urging the government to provide $1 billion Canadian (U.S. $765 million) to help combat a national shortage of health care workers. By MSNBC

At its annual meeting in Toronto on Tuesday, the Canadian Medical Association said health-reform experts have identified shortfalls among all types of physicians, nurses and technicians as a major obstacle to reducing long waiting lists for procedures that include joint replacement, heart bypass and cancer care.

A report by the association analyzing the shortfall shows Canada has 2.1 physicians per 1,000 residents, ranking it 25th out of 30 countries in the Organization for Economic Co-operation and Development, a forum that assesses economic and social policy.

The medical association wants Canada's government to provide $1 billion Canadian (U.S. $765 million) over five years for a national Health Human Resources Reinvestment Fund to increase the number of openings for medical students and postgraduate training positions, while fast-tracking residencies for medical graduates from other countries and establishing a program to recruit and retain health care professionals.

The fund would also be used to set up an institute to map out the number of doctors, nurses and other care providers that will be needed in the future.

Health Minister Ujjal Dosanjh has said the resource issue will be a key item on the agenda when provincial premiers meet with Prime Minister Paul Martin on Sept. 13 to discuss health care. Health reform is meaningless unless we ensure an adequate supply of doctors and nurses with the infrastructure and tools that they need to attend to their patients," said Dr. Sunil Patel, president of the 58,000-member association. 

Increased waiting times that are inevitable when medical business in monopolized by the government.

Susan Warner swallows addictive painkillers every day to ease the crippling pain she endures waiting for knee-replacement surgery. By Jason Fekete Calgary Herald

One of her knees gave out in October and the Calgary woman has been waiting for the surgery since. However, Warner, 51, is lost in a lineup for the operation at the Rockyview General Hospital that she says could last 18 months.

"It's inhuman. The quality of my life is horrible and there's absolutely nothing I can do about it," she said Tuesday.

Waiting lists are crippling Canada's health-care system and frustrating patients and doctors alike. The Canadian Medical Association released a 10-point prescription on Tuesday that targets waiting lists for surgery and diagnostic procedures like MRIs and CT scans.

It proposes setting benchmark waiting times for surgery, hiring more health professionals, and expanding options for Canadians to get treatment in other jurisdictions.

In Calgary, as the city expands, so does the pressure to get people treated at local hospitals in a reasonable amount of time.

There are about 25,000 Calgarians waiting for surgery or scans at the city's four major hospitals. And the Calgary Health Region estimates waiting times for surgery are growing at an astronomical rate of 12 to 18 per cent every year.

Alberta Health's website says waiting times in Calgary are as follows:

- 62 weeks for a hip replacement at Peter Lougheed Centre;

- 62 weeks for general surgery at Rocky- view General Hospital;

- 30 weeks for MRI scans at Foothills Medical Centre;

- 54 weeks for knee replacement surgery at Rockyview General Hospital;

- 11 weeks for cardiac surgery at Foothills Medical Centre.

For Warner, the wait has come with a heavy price. She says she has become addicted to painkillers that are a daily staple to help her hobble through her workday.

Warner's a photographer, a job that keeps her on her feet most of the day, with or without her cane.

"I know I'm addicted. When I wake up in the morning, I'm shaking and have headaches," she said with a sigh. "I'll have to deal with that after the fact."

In their report, Canada's doctors and nurses are sending a direct message to premiers meeting this week in Niagara-on-the-Lake, Ont., for three days of talks largely on Canada's ailing health-care system.

In its report, titled The Taming of the Queue, the Canadian Medical Association and Canadian Nurses Association argue the Canada Health Act should be revamped to help Canadians get quicker access to better health care.

Waiting for care is part of the "normal functioning of any health system," the report says, but warns excessive waits can have "significant health and economic impacts."

During the June election, Prime Minister Paul Martin identified waiting lists as the top issue facing the medicare system.

He vowed to spend $4 billion over the next five years to reduce waiting times, including focusing on five specific areas: cancer care, joint replacement, heart surgery, diagnostic imaging and sight restoration surgery.

The medical association's report proposes a 10-point plan to fix waiting lists, including:

Establishing reasonable waiting times for different procedures;

Allowing hospital funding to expand or contract depending on pressures, so service delivery isn't constrained by budget caps;

Aggressively recruiting and retaining health-care professionals;

Prioritizing services and ailments through consultation with the public and health-care providers;

Improving the ability of Canadians to seek care in other provinces or out of the country.

The association's president said sustainable reforms -- not just more cash -- should be the premiers' focus if they hope to wean the system off its crutches. Access to health care in a timely manner is job No. 1 and Canadians expect nothing less," said Dr. Sunil Patel. "If (the premiers) focus on dollars alone, then we have lost everything. Canadians will lose confidence in their health-care system."

The report does say the system needs money."There is no doubt that the availability of resources does come to bear on the timeliness and accessibility of health-care services," the report says.The Calgary Health Region has thrown hundreds of millions of dollars into expediting care for residents.

In February, the CHR announced a $450-million plan to open new beds and operating rooms, and expand emergency and intensive care units at the Foothills Medical Centre, Peter Lougheed Centre and Rocky-view General Hospital.

"Our longest waiting lists are in orthopedics and general surgery," said Tracy Wasylak, the CHR's vice-president of surgical services. "We're hoping to put resources into both of those programs this year to drop those waiting lists."

Sick of waiting for her pain to be eased, Warner, meanwhile, said she looked to Montana to expedite the surgery. However, the procedure would cost $25,000 -- leaving her to wait and hope in Canada. It's brutal. I'm in constant pain," Warner said. "I can't work to full capacity. It's difficult to function."

Worldwide Experiments in Socialism

Varying degrees of problems with socialized health care

Great Britain By the Guardian

One in five patients who undergo a heart bypass operation are not receiving the best care while in hospital and some die who might otherwise have survived, according to a new report.

The study, funded by the Department of Health, found the shortcomings were not to do with the actual surgery. The problems lay most often in delays in recognising that a patient was deteriorating after the operation, delays in getting senior clinicians to see a patient and failures to recognise that a patient had other, potentially complicating, problems.

The study showed the importance of teamwork, as well as skill with a scalpel, to a successful outcome. Although the death rates, at less than 2%, are very low and heart surgery in the UK is well regarded internationally, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) says hospitals could do better.

"Two per cent mortality is very impressive," said George Findlay, an intensive care consultant and one of the study's authors. "This is a life-threatening condition, managed well. But for two out of 100 patients, that is a terribly bad outcome. The feeling is we could reduce that if there were attention to more organised teamwork."

One of the most disturbing discoveries for the study team was that half the patients who died had not been not told they were at risk of losing their life, even though the doctors knew it. "That is a big issue," said Findlay. "Even one in 10 did not have any potential complications explained to them. The issue of informed consent is quite a big one."

In two-thirds of the cases studied half of whom were patients who died poor organisation, communication and teamwork adversely affected care. The investigators found nearly half of health trusts do not follow Department of Health national service framework protocols, seven years after they were introduced.

The study was commissioned to look at the overall care of heart bypass patients, following much scrutiny of the death rates of individual surgeons. Cardiothoracic surgeons are the only specialist medical profession to have their individual death rates posted on a website, hosted by the Healthcare Commission. Its launch followed publication of individualised data by the Guardian, obtained under freedom of information legislation.

Sir Bruce Keogh, former president of the Society of Cardiothoracic Surgeons and now medical director of the NHS, asked NCEPOD to carry out the study. "It uncovered some systematic problems where there was room for improvement," he said. "As a speciality we are mature enough now to accept the criticisms and address them."

The spotlight will soon be on other areas of surgery. The Guardian revealed last week that data on death rates in a wide range of operations, taken from routinely collected statistics, will shortly be posted on the NHS Choices website.

Case study

The report cited the following case: "An inpatient waiting for urgent coronary artery bypass grafting had experienced new chest pain in the night prior to surgery. Surgery went ahead the next day as planned and the patient subsequently died. The operating consultant surgeon stated that the patient had clearly deteriorated overnight and that the cardiologists did not inform him of this fact. The [NCEPOD] advisers felt that it was the responsibility of the operating surgeon to ensure that the patient was still in an appropriate condition to undergo surgery and that a surgical review prior to operation would clearly have identified the problem in this case. However, the advisers also felt that this case highlighted a serious lack of communication between cardiology and cardiac surgery."

 Former Union of Soviet Socialist Republics

RZHEV, Russia -- Alexei Serov knew it was time to evacuate the pregnant mothers from his maternity hospital in central Russia when pipes began bursting and plaster started falling off walls. Health regulators closed the clinic, which hadn't been renovated in 40 years, and Dr. Serov moved his patients to a makeshift ward across the street. By Jeanne Whalen Wall street Journal.

Conditions there aren't much better. There is no elevator, so women must be carried upstairs to the operating room if complications arise during birth. A clinic for tuberculosis patients stands next door. And two children died last year because the hospital lacked a simple breathing machine that costs just $15,000.

"We physicians are working on the razor's edge," says Dr. Serov, who earns the equivalent of $130 a month. "All our problems boil down to a lack of financing."

The dire state of Russia's public-health system has helped create what President Vladimir Putin calls a national emergency: Every year nearly a million more Russians die than are born. Even with surging immigration, mostly from former Soviet republics, Russia's population has dropped from 147 million in 1989 to 145 million last year. Life expectancy among men -- who have been hit especially hard by alcoholism and heart disease -- has dropped by five years in that period to 58.5, the lowest level in the developed world. If current trends continue, many demographers predict Russia's population could fall to as low as 100 million by 2050.

These statistics have inescapable economic consequences. Economists say declining health will shrink the nation's labor pool and reduce its productivity, potentially complicating Mr. Putin's stated aim of doubling Russia's gross domestic product over the next 10 years. The cost of treating the nation's looming HIV crisis and the disease's drain on the work force, for example, will shave 10% off the country's GDP by 2010 if it isn't combated properly, according to a World Bank study.

In his first four years in office, Mr. Putin has introduced a number of tax and legal reforms that have helped strengthen state finances and ignite economic growth. But like many of the priorities he has set for the second term he is universally expected to win next month, improving the nation's health will be much harder. Beyond grappling with the widespread unemployment and low living standards that underpin the rise in illness, Mr. Putin must fix a broken-down health-care system largely untouched by the reforms that have swept other areas of society.

For decades before the Soviet Union collapsed in 1991, citizens received free health care, though the quality of service often depended on one's Communist Party connections. Though the system is still state-run, government financing has fallen by more than a third since Soviet times and covers only a fraction of patients' real medical costs -- forcing them to pay the rest out of pocket. Equipment is outdated; doctors and nurses earn barely enough to justify showing up to work. And a Soviet-era focus on in-patient treatment leaves far too many hospital beds and not enough general-practice doctors.

Russian officials are drafting a plan to overhaul the system, but many physicians criticize the Health Ministry in particular for moving slowly. The ministry didn't respond to an interview request, but in a report last year, Health Minister Yuri Shevchenko called health "an indicator of national prestige ... a necessary condition for high labor performance ... [and] the clearest measure of the effectiveness of government leadership."

In what Mr. Putin called a sign of hope, the birth rate began to rise last year for the first time since the fall of the Soviet Union. But being born in Russia is still a dangerous experience. Last month, six premature infants died in a regional hospital of a bacterial infection after nurses failed to sanitize machines that were helping them breathe. A state inquiry blamed the deaths in part on a lack of qualified personnel and equipment, and the chief doctor of the hospital was fired.

Because regional budgets fund the bulk of health-care costs, standards and health statistics vary drastically across Russia's economically diverse regions. Life expectancies can differ by as many as 16 years, according to a World Bank report published in October. And mortality rates in Moscow, home to most of Russia's new wealth, are now 55% lower than rates in some poorer regions, state statistics show.

A short drive out of Moscow reveals the rifts. Rzhev, population 70,000, produces most of the cranes building luxury apartment blocks and shopping malls 300 kilometers away in Moscow. But little of the capital's financial boom has trickled out to Rzhev. Local salaries are about $150 a month, compared with $380 in Moscow. Per-capita spending on health care is about $50 a year, or half what is spent in the capital.

Over the past 13 years, Dr. Serov has watched his maternity ward literally fall apart. He says the hospital has received no government funds for repairs or new equipment for more than a decade, forcing Dr. Serov to beg for grants from local businessmen to buy the occasional incubator. Across town, the chief doctor at Rzhev's main city hospital says he calls the crane factory when he needs an emergency infusion of cash.

Worsening standards of living, meanwhile, have damaged the health of local residents. "Earlier, women who gave birth were healthy, but now every other woman has some sort of pathology," says Galina Zuikova, an obstetrician at the hospital. Stress, unemployment and poor nutrition have helped lead to an increase in hypertension, kidney disease and infections in the women who come to the clinic. Smoking has climbed, too. Because of these problems, "there are more complications at birth than there were 20 or 30 years ago," Dr. Zuikova says.

Russia's constitution guarantees free health care for everyone, but very little is in fact free. Patients often pay the hospital or the doctor extra for better service or medicines. A recent study by the Independent Institute for Social Policy, a Moscow think tank, found that state financing covers only a third of health-care costs, with the rest paid by patients. Some Russians also have private health insurance, but this is still rare.

Where there is money, care can be quite good. Moscow's Center for Endosurgery and Lithotripsy, a private hospital founded 11 years ago by surgeon Alexander Bronshtein, offers Western-standard surgical and clinical care for Moscow's wealthy and upper-middle class residents. Heart surgery runs about $5,000. Top-notch physicians at the clinic earn $3,000 to $5,000 a month. "Patients come here for the high qualifications of our doctors, for the lack of lines -- they get things fast," says Mr. Bronshtein, 65 years old. "Unfortunately, not everyone can afford this clinic," he adds.

Sergei Shishkin, a health-care expert helping the state draft a plan for reform, says the government needs to scale back free care, boost the role of private insurance and drastically increase the number of general-practice doctors. He also advocates closing inefficient hospitals and reallocating funds to the best institutions and workers. Some of these changes will be introduced in draft legislation later this year, he said.

But cutting any of the cherished benefits could be a political minefield for Mr. Putin, who has been very protective of his sky-high approval ratings. One Moscow newspaper Wednesday reported that health-care reform will include the closing of some specialized clinics for children and women. The newspaper quoted Russia's chief pediatrician resurrecting a Soviet-era propaganda cliche in denouncing the move as "machinations of imperialism." The other countries are Cuba, New Zealand, Australia, but some other European countries are going the other way. Much of the pressure to experiment with privatization came from European Union regulations that forced reduced public taxation in Sweden. To function in a lower tax environment, Stockholm turned to the private sector with three goals in mind:

To remove the public monopoly on the delivery of health care services.To control the spiraling costs of public sector services by introducing market forces and competition.

To set new performance benchmarks (i.e., shorter waiting lists) for other Swedish hospitals to emulate. In every category, the experiment has been a success.

Removing the Public Monopoly on Service.

For decades, Stockholm relied on an underperforming civic health service monopoly characterized by long waiting lists, chronic overspending and flagging quality. Since the experiment began, virtually every sector of Stockholm's health system has undergone some form of privatization:Initially, the experiment included 150 private providers who were licensed to compete for health service contracts.

The contractors were originally allowed to compete for contracts in the non-medical services, technical services, ambulatory services, small hospital, home care and nursing home sectors.In 1998 the Council began the gradual privatization of all primary care.

In 1999 St. Göran's, one of Sweden's largest hospitals, was sold to the private company Capio AB.By the end of the experiment's first five years, all but one of the original 150 private contractors had survived and were flourishing. Likewise, by the end of the first year of its privatization, St. Göran's had shown significant improvements over its performance as a public facility. Somthing to think about as America tackles its health care issues learn from the mistakes that other countries have made. A mixture of public and private would be more on the right track than a purely Goverment run health care system.