Thank You for Joining the Medical/Professional/Business/InfoTech Gatherings on MedicalTuesdays. On the First Tuesday of each quarter, we review HealthCare around the World and the Ideal HealthPlan for the USA, and by extension for all countries, and what prevents its implementation. This week we highlight a new book, Lives At Risk,  that gives the definitive comparison of health plans around the world. Almost every country is looking to the US health-care non-system for ideas on privatizing, while there are still some in our midst that want to adopt a system that has failed for nearly a century.

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In This Issue:
1. MedInfo 2004 - Medical Information Technology Around the World
2. Is the Canada Cure a Pipe Dream?
3. Physician Deception with Third-Party Payers - But It's to Help Their Patients
4. Is There Hospital Deception with First-Party Payers? Anatomy of a Hospital Bill
5. Lives at Risk Around the World  - A Must Read for Everyone Not Ready to Die
6. Health Plan Myths - Helping Patients or Control Doctors, Hospitals & Patients
7. Overheard in the Capital Rotunda - We Can't Let Doctors Control Health Care
8. Quarterly Review of HealthPlanUSA - Patients Regaining Control
 

The dichotomous world health view of the presentations by the various countries was interesting. The speakers from the National Health Service in the UK, Canadian Medicare and Australia began their presentations detailing the size of their bureaucracy, their national health care budget, the number of employees in their department who work on solving health care issues, the number of doctors they employ, and the number of patients that they control. The latter varies from 49 million in the UK, 31 million in Canada, and 21 million in Australia. The bureaucrats spoke with authority on how they were going to control health care for their constituents. Slides depicting the bottom layer of 31 million Canadians with several layers of administrators leading to the chief bureaucrat were chilling. How would anyone with a cardiac catastrophe be able to navigate the maze during that first hour when the highest incidence of cardiac arrhythmias and deaths occur? On one of my visits to the UK, the press was proud to announce that the chief bureaucrat demanded that all urgent cardiac cases not be placed in the standard waiting queue but be moved to the front of the line and be seen by a cardiologist within two weeks! If you survive that, you generally will not need hospitalization at all.

One panel discussed whether clinician involvement in the selection of Clinical Information Systems was necessary. Does finding meaningful ways to engage physicians require creating an organizational climate and culture that respects the heart of medicine? Does the opinion of national clinical bodies matter? As Phil Alper, MD, a medical columnist, noted in one of his articles, some actually felt they knew what it is that we as physicians do and, therefore, do not see the need for us to be involved in health care planning.

Electronic doctor-patient communication was discussed by a scientific panel from UC Davis, Harvard, University of Alabama at Birmingham, and the Dutch Patient and Consumer Federation in The Netherlands. As the use of the Internet has spread, so has the desire of patients wanting to communicate electronically with their physicians. Increasing numbers of private U.S. health insurers and employers pay for electronic clinical consultations and the American College of Physicians has called for the U.S. Government to do the same. Yet provider adoption of such systems has been slow. Barriers to adopt patient-doctor e-communication include fear by doctors of being overwhelmed with messages, concerns about privacy and security, and aversion to change. In the face of these barriers, few provider organizations have deployed patient connectivity systems. Even fewer investigators have systematically studied the impact of the use of such systems on doctors and patients. The members of this panel reported on their pioneering efforts in patient connectivity. The degree of access granted to patients ranged from messaging, making their own appointments, viewing their medical records, to disease management including electronic prescriptions and electronic OnLine medical records. This seemed to satisfy patient desires, boost practice productivity, actually lower the message volume, generate new revenue, and was amenable to any size practice.

The HPUSA working model is still the most complete interface of the insurance and credit providers on the same web interface along with the patient, physician, and the various health care providers with all of the above e-communications. This includes an electronic web-based medical record on a secure site that allows telephone and email consultations in the insurance interface. We have requested participation in the MedInfo 2007 meeting in Brisbane, at which time we will present our HPUSA integrated program. Watch this space quarterly for developments in this area.
 

In American political debates, Canada sounds like paradise for prescription-drug users. Brand-name prescription drugs cost about 60 percent less than in the U.S., according to Canada's price-control board estimates. U.S. politicians, looking for ways to placate prescription-wielding constituents without imposing price controls at home, advocate importing cheaper, price-controlled drugs from Canada.

Step across the border, though, and you hear a loud debate about who should pay Canada's rising prescription-drug tab. The private Canadian Institute for Health Information states that although benefits vary widely by province, government programs of all kinds pay 46.3 percent of Canada's prescription-drug costs, mostly for the poor and the elderly. Employer-provided drug insurance pays 34 percent. Canadian consumers pay the remaining 19.8 percent out of pocket.

Although Prime Minister Paul Martin flirted with what Canadians call "pharmacare" during his recent campaign, he now says the federal government can't afford to pay the whole bill. Besides, he says with substantial evidence, Canadians are more anxious about lengthening waits for health care; he would rather use government money to ease that.

First, when politicians confront rising health-care costs and a growing public appetite for more health care, they find it easier to offer to cover prescription drugs than propose lasting, sometimes politically painful, reforms that would improve the efficiency and quality of health care and make it more affordable in an era of aging populations.

Second, spending on prescription drugs is climbing in all rich countries -- and not only because drug makers are charging more. Canada does spend less per person on prescription drugs than the U.S., partly because it controls prices of brand-name (though not generic) drugs. Yet Canadian spending on prescription drugs is shooting up.

Like Americans, Canadians are using more drugs, take them more frequently and rely on newer, more-costly drugs. It isn't that they're sicker; it's that drug therapy for high blood pressure or high cholesterol has become commonplace. Economist Steven Morgan of the University of British Columbia finds that about 22 percent of the rising cost of providing drugs to that Pacific province's elderly reflects higher prices. About 38 percent reflects more frequent drug use, and 40 percent reflects the type and quantity of drugs used, including the cost of using newer, more-expensive medicines, which may not always be better than older, cheaper ones.

“There is every reason to believe we have only seen the tip of the iceberg when it comes to the potential for new prescription drugs," Mr. Romanow's commission said. "We can expect continued increases in both the supply of, and demand for, drugs, driven by the advent of new genetic technologies and the ability to detect and prevent many genetic diseases." "But," they added, "the benefits will only be fully realized if prescription drugs are integrated into the system in a way that ensures they are appropriately prescribed and utilized.

Read the entire article at: http://online.wsj.com/article/0,,SB109347569851601348,00.html.
 

Last week's issue of the Archives of Internal Medicine (www.archinternmed.com) has an article titled: "Physicians' Interactions With Third-Party Payers - Is Deception Necessary?" The authors list more than a dozen published reports that indicate that physicians sometimes use deceptive tactics with third-party payers. Many physicians appear to be willing to deceive to secure care that they perceive as necessary, particularly when illnesses are severe and appeals procedures for care denials are burdensome. Physicians whose practices include larger numbers of Medicaid or managed-care patients seem more willing to deceive third-party payers than are other physicians.

Dr Sidney Bogardus and coauthors conclude: The probable existence of widespread deception of third-party payers highlights potentially serious problems in the medical profession and the health-care financing system. Although there may be a fundamental problem with individual ethics and integrity, we believe that most physicians have good intentions and a high sense of duty. They try to discern right from wrong, even if doing so imperfectly, and accept some risk to themselves by giving in to deception. The problem seems larger than individual physicians who deceive. Many of the rules and constraints encountered in medical practice may, in fact, be unjust. Deception may be a barometer of those areas in which the dissonance between care and financing rules has become so severe that physicians see lying as the only way to do their jobs. The authors further conclude that it is most urgent for professional organizations and medical educators to take the lead in the struggle to promote a financing system that allows individual physicians to practice with integrity while upholding their primary obligation to the patient.

Read the abstract at the website. To read the entire article go to the Journal: Arch Intern Med 2004;164:1841-1844.
 

A year ago, Mr. Shipman, a 43-year-old former furniture salesman from Herndon, Va., experienced severe chest pains during the night. An ambulance took him first to a community hospital emergency room, and then to Inova Fairfax Hospital, Fairfax, Va. Suspecting a heart attack, doctors first performed a cardiac catheterization to examine and unblock the coronary arteries. Then they inserted a stent, a small metal device that props open a blocked artery so the blood flows better to the heart.
Lacking health insurance, Mr. Shipman says he was worried about the cost. The next morning, too anxious about his bill to stay, Mr. Shipman checked himself out of the hospital against medical advice.

Since then, Mr. Shipman and his wife, Alina, have received hospital bills totaling $29,500 for what they say was a 21-hour hospital stay. In addition, there were other bills: some $1,000 for the ambulance trip, $6,800 from the cardiologist who performed the stent procedure, and several thousand dollars for the local emergency-room visit. In all, the two-day health crisis left the Shipmans saddled with medical bills totaling nearly $40,000.

Indeed, at the time of Mr. Shipman's illness, the Shipmans weren't poor. Mr. Shipman was earning $80,000 a year in salary and commissions selling furniture. They were living in an attractive rented townhouse in suburban Virginia and driving a leased BMW. In March 2002, the Shipmans say, Ms. Shipman left a job with benefits in order to return to college, and the couple decided to go without health insurance. They figured they were healthy and relatively young; health coverage would have cost them several hundred dollars a month, money they figured would be better spent on tuition.

Mr. Shipman recently lost his job at Oak Post furniture showroom, a Virginia operator, and Ms. Shipman has resigned from her university job. The couple was planning to board a flight to visit family in Romania today; Ms. Shipman's mother helped pay for the tickets.

"It has been really, really stressful and I need to get away for a while," Ms. Shipman says. Did she regret not getting health insurance the first time around? "Of course," she says. "Obviously nobody wants to go through this."

To read Lucette Lagnado's entire article, go to http://online.wsj.com/article_print/0,,SB109571706550822844,00.html.

Virtually every country with national health insurance has proclaimed health care to be a basic human right. Yet far from guaranteeing that right, their systems routinely impose health care rationing that delays or denies needed care.
Not only do residents of other countries not have a right to health care, they may have fewer rights than foreigners have. While more than one million British patients waited for care, 10,000 private-pay patients – about half of whom were foreigners – received preferential treatment in Britain’s top government hospitals in 2001.

On the surface, the number of people waiting may seem small relative to the total population –  ranging from 0.5 percent in Canada to 2.5 percent in New Zealand. However, considering that only about 16 percent of the population enters a hospital each year in developed countries, these numbers are quite high. In New Zealand, for example, there is almost one person waiting for every five who receive treatment.

Patients who wait are often waiting in pain. Many are risking their lives. One investigation found that delays in colon cancer treatment are so long in Britain that 20 percent of the cases considered curable at time of diagnosis had become incurable by the time of treatment. Another study found that 121 patients were permanently removed from the waiting list for coronary bypass surgery in Ontario because they had become so sick that they could no longer undergo surgery with a reasonable risk of survival.

One reason people are waiting for care is a conscious decision by the government to limit health care resources. For example, in the United States, almost nine out of every 10 physicians are specialists. In Canada and New Zealand, this number is close to half. In Australia, a mere one-third of all doctors are specialists.

Ironically, Britain was the inventor of the CT scanner and in the 1980s exported about half the scanners used in the world. Yet the British government purchased very few of the devices for the National Health Service (NHS) and even discouraged private gifts of CT scanners to the NHS.

Britain also was the co-developer (with the United States) of kidney dialysis, but it consistently has had one of the lowest dialysis rates in Europe. The use of renal dialysis for kidney failure in the United States is almost double the rate in Canada and more than three times that of Britain. Compared to the United States, patients in other countries also have difficulty obtaining access to advanced diagnostic equipment.

Patients in single-payer systems often lack access to life-saving prescription drugs many Americans take for granted.
According to the World Health Organization (WHO), as many as 25,000 people in Britain die of cancer each year because they cannot obtain the latest cancer treatments. Perhaps as a result of not receiving the care they need, people with curable diseases often do not survive.

Unable to obtain the free health care they have been promised, patients in other countries often turn to the private sector.
Critics of U.S. health care often maintain that the systems of other countries are more efficient. Yet all the evidence points the other way.

Thus almost one-third of the nation’s hospital beds are simply closed off to acute care patients. While countries with national health insurance routinely skimp on services for the seriously ill, they often over-provide to patients with minor ailments.
The British preference for “caring” over “curing” is a direct result of the political nature of national health insurance. In a typical U.S. private health care plan, 41 percent of health care dollars are spent on the sickest 2 percent of the population.

In a political system, politicians cannot afford to spend 40 percent of the budget on 2 percent of the voters, many of whom are probably too sick to vote anyway. The temptation is always to take from the few who are sick and spend instead on the many.

Critics charge that the American health care system discriminates against minorities. They may be surprised to learn that discrimination is rampant where health care systems are run by government.

Despite the promise of equal care for all, inequalities pervade every government-run health care system. In Britain, people from poor urban areas live shorter lives and die more frequently from common, treatable illnesses than their wealthier neighbors.

In Canada, vast inequalities also exist. For example, among the 29 health regions in British Columbia, there is a five-to-one difference in the per capita services of internists and a 31-to-one difference in the services of psychiatrists. Overall, residents of Vancouver receive almost three times more specialist services per person than residents in the Peace River region.

National health care systems have failed not because of minor glitches or easily correctable problems. Rather, the critical problems flow inexorably from the fact that they are government run. Indeed, the problems we identify are the very reason these systems have survived.

In all these countries, the rich and powerful find ways to jump the queues and get to the head of the waiting lines. If it were otherwise -  if the upper crust had no greater access to MRI scans than street sweepers -  these systems would not survive for a minute.

To order a copy, go to http://www.ncpa.org/pub/lives_risk.htm.
 

It also gives them publicity. In an article in the SF Chronicle, “HMOs get an annual checkup,” Pia Sarkar notes that health maintenance organizations are falling behind in persuading smokers to kick their cigarette habit and only reached 49 percent of their patients with flu shots. Doctors are chastised by the Director of the California State Office of Patient Advocate for not reaching these HMO goals.

The incongruity is frequently missed in both criticisms. HMOs have reduced reimbursement for giving flu shots to about $5 less than the cost of the vaccine, syringe, needle and administering it.  When I asked about this discrepancy, I was told I was lacking public health interest. Don’t you think you could just give 400 of your 1000 patients the vaccine? You should be able to afford that. This is a pervasive attitude today brought on by HMOs: Not only can we pay you half of your usual fee, but you should be able to give $2,000 to your patients for a worthy cause. Some years the vaccine has gone preferentially to pharmacies rather than medical offices.

HMOs have also been trying to get doctors to see more patients per hour. In fact, I was asked to book five follow-up appointments per hour instead of four. Even with a 15-minute appointment, one has to rush through human civilities in greeting the patient, obtaining an interim history, doing a physical examination, discussing the diagnostic impressions, writing prescriptions, writing lab or x-ray requisitions, and giving appropriate counsel. Where is the time to proceed into an extended discussion on cigarette smoking, or diet or other health programs?

The chastisement appears to be directed to the wrong culprit.
 

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 Words of Illumination ---

The National Health Service employed 1.4m people in 2003, up from 1.2m when Labour took office in 1997. The health service is the third biggest employer in the world, surpassed only by China's Red Army and the Indian railways. . . . No wonder the NHS doesn’t have money to care for sick people and puts them into waiting queues.

The universal language of children is called gimme. Some of my oldest patients are children. The age of childhood has increased.

Aphorisms ---

A good citizen doesn't rely on government. Government relies on him.

On This Date in History - October 5 ---

Harry S Truman became the first U.S. President to televise a speech from the White House in 1947.
 
 

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