The deinstitutionalizing of the mentally ill in the 1970s followed directly from the ACLU lawsuits against committment of the mentally ill. This followed the movie, “One Flew Over the Cuckoo’s Nest.” That is a damn poor way of making public policy but that is what we have. Now we have one more murder to chalk up to the ACLU. Here is another such example. Mental health professionals worry about the effects. Still, nothing is done.The legal situation is chaotic. But still people, psychotic and their victims, continue to die.
Archive for the ‘medicine’ Category
Another death on the ACLU’s conscience
Saturday, February 16th, 2008Health care reform-Part III
Monday, February 4th, 2008Part I is a post on Evidence Based Medicine.
Part II is here.
The SEIU is planning a big push for universal healthcare in this election cycle. The time seems to be here when we have to think about this.
There is a pretty good post over at Megan McArdles blog with the comments as interesting as the post. She links to Paul Krugman, often a source of misinformation. The topic is the Massachusetts Plan that is seeing cost overruns. Every new health care entitlement, from the National Health Service in England to Medicare here, has seen huge increases in cost that were not predicted. There are a number of reasons. One is the moral hazard problem, in which people will sign up for anything that is free.
One of the comments actually poses a nice outline for a solution:
Response to liberalrob’s question “what’s your solution…”:
Sign up everybody who makes above a certain income threshold for some kind of minimal national health plan that covers ONLY catastrophic health costs. Make the cost based on age, and deduct it automatically from their paycheck like Social Security.
Make it voluntary, but auto-opt-in– that is, you’re signed up unless you fill out a form and say “Thanks, but no thanks.”
If you opt-out, decide not to buy insurance, and get sick– tough cookies.
Everybody who makes below a certain income threshold gets automatically signed up for Medicaid, at no cost.
Oh, and of course either get rid of the employer tax deduction for health insurance or extend it so the employees get the same tax break if they buy their own insurance…
Posted by Gavin Andresen
Let’s take these one at a time:
Sign up everybody who makes above a certain income threshold for some kind of minimal national health plan that covers ONLY catastrophic health costs. Make the cost based on age, and deduct it automatically from their paycheck like Social Security.
I am coming to the reluctant conclusion that a single payer plan of some sort is going to be necessary. The German system has two types of insurance, the state system which is deducted from your paycheck, and private insurance, which is available to those with high incomes who choose to opt out of the state system. The original German system had a number of health plans, some employer based and some community-based, but all had to join one unless your income was quite high, at which point you could opt out. The state system deduction is income determined and is about 14% of gross income. The private system is more like American insurance and is risk-determined, by age and state of health. The Clinton Plan in 1994 was supposed to be based on the German system. This is an attractive option for several reasons.
The present American system has a real problem with “free riders.” These are usually young people who are healthy, could afford insurance but choose to go without because they know that, if disaster strikes, they will be cared for and they can evade the cost of emergency care by bankruptcy if necessary. Some years ago, when I was still in practice, the employee of a colleague, a vascular surgeon who had once been in practice with me, contacted my office because she needed gall bladder surgery. She informed my staff that she had no health insurance even though she was employed full-time. I was very annoyed at my colleague for allowing an employee to be uninsured until I learned that she had opted out because she would rather have the extra money as salary. I don’t know that I would have allowed this but, at least, it wasn’t through any greed of his.
There is the classic free-rider. The famous “47 million uninsured” includes millions of these, as many as a third of the uninsured. Federal laws require that doctors and hospitals care for these people in cases of emergency and emergency is pretty broadly defined. The law is quite onerous and carries severe criminal penalties. Therefore, free riders can be assured of care by specialists and hospitals when emergencies require it.
The consequences for everyone else is the removal from the insurance pool of healthy young adults who would be expected to contribute and would have a low level of utilization. The same factors that make them choose free rider status make them attractive for the general pool of subscribers. This is a classic situation of tragedy of the commons. The sheep herder who grazes his sheep in the communal pasture, depletes the resources of the village without contributing his share. He will profit from this free riding until the system collapses, at which point he may make use of the resources he has taken from the common pool and go on his way leaving others to cope with disaster, or he may suffer the same fate, probably blaming ill luck rather than his own anti-social behavior.
This issue raises the question of mandates. Mandates that everyone buy insurance are part of Hillary Clinton’s plan and not Obama’s plan. Krugman says this will make Obama’s plan fail due to the free rider problem and, for once, I agree with Krugman.
There is another group of uninsured and we will deal with them next.
Point two:
Make it voluntary, but auto-opt-in– that is, you’re signed up unless you fill out a form and say “Thanks, but no thanks.”
If you opt-out, decide not to buy insurance, and get sick– tough cookies.
This is attractive emotionally but is a non-starter because of federal laws that will never be repealed. In the old days of 50 years ago, doctors and hospitals could afford to provide a modest amount of free care to the poor because care was mostly not that expensive for the provider. It was time and not material. Now, much of what is provided to the sick and indigent is expensive and the margin of profit to pay for these cases is far smaller than it once was. There has to be a way to eliminate the majority of the uninsured to prevent bankruptcy of the entire system.
A big share of the problem is illegal immigration. A single payer system without barriers to care would be a further incentive for illegal aliens, especially from Mexico, to seek care in the US. There is already a bus service from Tijuana to Los Angeles County Hospital for Mexican mothers of children who are US citizens to obtain US care for these Medicaid-eligible children. Many suspect pregnant women of entering the country to have “anchor babies” in US hospitals. The 14th Amendment guarantees citizenship for all born in the US. This will never be repealed so provision has to be made for the illegals, another large share of the uninsured.
I spend a day a week at LA County Hospital and about 60% of the patients are Spanish speaking, most of those non-citizens who would not join a single payer plan that required contribution from salary. Just as the federal government has to be the only agency that chooses to enforce the border, they are the only agency to pay for the care of those here illegally. Other community services (like schools) are impacted but we are limiting our comments to health care.
What to do with the poor ?
Everybody who makes below a certain income threshold gets automatically signed up for Medicaid, at no cost.
One problem with Medicaid that few understand is where the money goes.
A huge proportion of Medicaid dollars goes to nursing homes and care of the poor elderly. This will rise as the population ages. The rest goes to pregnant women and children with single men being the least likely to participate. Other conditions like mental health and the disabled from other causes round out the rest of the Medicaid population. Medicaid is not just a program for the poor children. What will we do with the nursing home population ? England does much better with home care than we do. Why ? Much of the population of Britain outside of London lives in villages and small cities that lends themselves to residential care. We have more tendency to warehouse elderly poor, perhaps because our population is more mobile and tends to sever ties with the communities we were born in. We may be more likely to end up alone with no family nearby.
Is the present system, such as it is, less expensive than a government program would be ?
That is a big question and will be Part IV.
A loss of history-updated
Monday, February 4th, 2008ANOTHER UPDATE: No wonder the British teenagers don’t know any history. They are listening to the BBC.
I previously posted a bit about the loss of history in school curricula. I don’t expect much of American public schools anymore but Britain has a much longer history and I have found much more interest in such subjects as medical history in Britain than in the USA. That may be changing as British teenagers increasingly believe that historical figures are fictional and vice versa.
Despite his celebrated military reputation, 47 per cent of respondents dismissed the 12th-century crusading English king Richard the Lionheart as fictional.
More than a quarter (27 per cent) thought Florence Nightingale, the pioneering nurse who coaxed injured soldiers back to health in the Crimean War, was a mythical figure.
In contrast, a series of fictitious characters that have featured in British films and literature over the past few centuries were awarded real-life status.
King Arthur is the mythical figure most commonly mistaken for fact – almost two thirds of teens (65 per cent) believe that he existed and led a round table of knights at Camelot.
Twenty percent of British teens believed that Winston Churchill is a fictional character.
On the medical front, female Muslim medical students are refusing to scrub their forearms because of “modesty rules.”
Minutes of a clinical academics’ meeting at Liverpool University revealed that female Muslim students at Alder Hey children’s hospital had objected to rolling up their sleeves to wear gowns.
Similar concerns have been raised at Leicester University. Minutes from a medical school committee said that “a number of Muslim females had difficulty in complying with the procedures to roll up sleeves to the elbow for appropriate handwashing”.
No doubt Allah will prevent MRSA infections.
Thanks to Eric Blair for the tip to that story.
The best argument for McCain
Monday, February 4th, 2008This writer, a professor at the Naval War College, states the best argument for McCain even though he is not supporting him. I have been disillusioned since 2000.
The immigration bill he sponsored with Ted Kennedy, is the worst blot on his record as a conservative. Libertarians support open borders (although Ron Paul now opposes unlimited immigration) but they usually hedge this with reservations about the welfare state that is so easily accessed by the illegals. I have spent many a long night repairing the damage to these people, usually a consequence of alcohol and ignorance, both well recognized as features of their culture. In 1900, millions came from Europe, were processed through Ellis Island where medical exams and some degree of screening for criminals existed, and allowed to strive for survival and even success in a country that had few safety nets for failure. Today, we see millions arrive with no screening, infected with sometimes exotic variants of infectious disease and who possess a fine sense of their “rights” as enumerated by various political pressure groups.
I do some reviews of Workers Compensation claims in California. I was very nearly terminated by a major Workers Compensation carrier for commenting on a report that the claimant, an illiterate illegal alien with chronic back pain at age 28, was probably not a candidate for vocational rehabilitation. The fact that the observation was true was not a defense. Even the fact that the observation was a justification for more medical treatment was barely adequate to avoid punishment. The rights claimed by illegals are supported by various political groups who hope to profit from their presence. Some, mostly Democrats although I suspect there are some delusional Republicans among them, expect gratitude expressed at the ballot box. Others, like NY City Mayor Mike Bloomberg, simply want cheap labor.
McCain would be better than the Democrat alternatives, although I doubt the topic of illegal immigration is an example of where.
Healthcare reform
Tuesday, January 29th, 2008In my book on the history of medicine I included a chapter on the history that led to the present crisis in health care economics. Basically, there are three general causes of the problem. One is technology. When I was a medical student 40-some years ago, there were no coronary care units, no coronary bypasses, no total hip replacements and life expectancy was about 72 years. When Bismark first established the retirement age at 65 in Germany, that (age 65) was also the average life expectancy. Now it is over 80 years and rising, which leads to the second cause. We have an aging population. Everyone outside of the Muslim world does. Old people need more care and technology has provided the nexus between high technology and age that is breaking the bank.
The third cause is more complex and varies from area to area, depending on the financing of health care. The United States has a mixed system for financing health care. Medicare and Medicaid are government single payer systems for care of the elderly, disabled and the poor (mostly women, children and nursing home residents). In recent years, the mechanism of paying in these systems has changed to the Health Maintenance Organization in many cases. The HMO, as it is abbreviated, is a creature of sociologist and rehabilitation physician, Paul Ellwood.
It would appear that Dr. Paul Ellwood, and his subsequent InterStudy organization, did not expect that the control of their HMOs would be by business executives and corporate shareholders committed only to their own fiduciary motives rather than medical professionals committed to a higher ethic.
The Achilles heel of the HMO system has been the role of perverse incentives. When Paul Ellwood coined the term HMO, he had in mind the fact that fee-for-service medicine creates an incentive for the doctor to do “more” care than the patient really needs in order to increase his own income. John Wennberg, of Dartmouth Medical School, calls this “supplier induced demand.” They did not seem to consider that a powerful HMO has an incentive to do the opposite. In the days before health insurance, the doctor and the patient had a more balanced relationship. Yes, there was a gap in information greater than that between, for example, a car owner and mechanic. Yes, the stakes were higher for the patient than having to buy a new car. Still, the transaction was easier to understand and the incentives were in better balance. Health insurance removed the transaction from the cost-benefit analysis of the patient and doctor to a remote, impersonal third party that, in the early days, had little incentive to interfere. Premiums were often paid by yet another, fourth party, the employer or the government. It is only recently that cost became the driving force it is today.
In his book, “Comeback”, David Frum attributes the distress of the middle class in the US today to the erosion of incomes due to the double whammy of FICA taxes to support programs for the elderly and health insurance premiums deducted by the employer.
In 1992, as President Clinton took office, anticipation was high that a solution was at hand. The Dartmouth people were heavily involved with designing the Clinton Health Plan but the political process went off the rails in an example of how not to do legislative action.
Since the failure of the Clinton attempt at reform, the HMO process has evolved and the only winners appear to be the corporate entities that found how profitable for-profit HMOs could be. They have done this by victimizing both doctors and patients. There has to be a better way.
I’ll post more about this in days to come.
The medical equivalent of global warming
Wednesday, December 26th, 2007This article in the New York Times today, should be required reading for anyone interested in obesity or diabetes. In my history of medicine book, I tell the story of Robert Atkins and his diet. When I was researching the chapter, I looked for references on the subject and found nothing positive about him in the medical literature. In fact, I have seen rather gloating comments on his early death (72), not mentioning that it was a consequence of a slip on ice with a severe head injury. He was described by the coroner as “obese” and this led to gloating in vegetarian circles. In fact, he was not obese when admitted to the hospital following the head injury. Note the intense interest in his health in this report on CNN. And here is an example of the vitriol that followed his death. Unmentioned in that piece, is the source, a radical group called Physicians’ Committee for Responsible Medicine, that opposes all animal research, in addition to advocating a strict vegetarian life.
Do some reading about metabolic syndrome and insulin resistance then think about the anger and even hatred of Atkins. He was an advocate of a science theory that opposed the accepted wisdom on health. For this, he was scolded and vilified in life and there was rejoicing and even lying about his death. Is this what we face 50 years from now when everyone starts to realize that we have crippled the western economies to conform to a science fallacy ?
Is Evidence-Based Medicine Socialized Medicine?
Tuesday, December 18th, 2007Today, Glen Reynolds of Instapundit linked to a rather heated denunciation of Evidence-Based Medicine. The term, vigorously debated in medicine, may not be familiar to those not part of the industry. The definition involves two major issues. One is the medical literature and what is called a randomized trial. This involves a new, or occasionally a standard, form of treatment. The question to be answered is whether the tested form of treatment is better than the control form, which may be no treatment at all. The treating physicians, or institutions, and the patients being treated, ideally, should not know whether the treatment being given is the test version or the control. Obviously, this is easier to do with pills. For ethical reasons, it is difficult to do with surgery although a very few such trials have occurred. Arthroscopy of joints involves very small incisions and a few sham operation trials have been conducted to test the effect of arthroscopic surgery. Those studies are very controversial. Another alternative is the use of randomized trials comparing surgery against non-surgical treatment. The problem here is that it is obvious to everybody concerned, who got the surgery and who didn’t. One such study compared surgery on the medial meniscus of the knee (The rubbery cushion in the knee that is subject to tears) to simple exercise therapy. The results? According to the outcome scores arthroscopic partial medial meniscectomy combined with exercise did not lead to greater improvement than exercise alone.
This brings up the concept of “Outcomes Research.” The difference between outcomes research and the standard clinical research we have done for 100 years is in what is measured. Most journal articles on clinical research list the results as mortality (death) or morbidity (poor health) or cure, if cancer is the topic. In studies of non-fatal conditions, such as low back pain or knee arthritis, results can be misleading. Dartmouth Medical School has studied benign prostatic hypertrophy (known as BPH) for 30 years. The results of surgery, removal of the prostate, cannot be assessed by measuring mortality rate as the mortality of that operation is very low. The cure rate is also misleading because removing the prostate “cures” the condition but often leaves a series of complications, major and minor, in its wake. Outcomes research uses survey methods to determine how the treatment affects the patient’s quality of life. One such is called the “SF 36.” If a man is cured of BPH but dribbles urine all day, the improvement from the pre-treatment condition may be minor or even negative. Similar studies have been done with low back pain. The reader will note that many of these studies come from countries with government funded health care programs. Some of that is because it is easier to follow patients for a long time in such systems because of a uniform record and a single source of data. In a distributed system like the US, there may be difficulty tracking subsequent care, a major consideration for this type of study. We want to know how this patent is doing five years later. In the US people change employer and/or insurance carrier every three years on average. Regrettably, insurance companies usually do not share data.
Take the example of spine fusion for back pain, a common procedure. For many years, the literature on such procedures looked like this. A small number of patients, followed only in retrospect and with no control for possible bias. Surgeons like to operate and they rarely report bad results. A series of 67 patients reported by a malpractice lawyer might look very different.
The Patient Outcomes Research Team approach (or PORT) looks like this. Other studies have shown that spine fusion done for back pain alone has a 95% failure rate when residual pain is the metric. An awful lot of spinal fusion surgery is done in this country every year, billions of dollars worth. Is it all useless ? There are “Guidelines” for what will produce results worth the cost and risk. How are these derived ?
Guidelines are of several types. Some are established by the government. How do they decide what will be included ? The best guidelines are based on randomized trials. Those are few. Many are based on the PORT method where common conditions are studied over years using every system of data collection availabe. Prospective trials, which are randomized, are the best in surgical cases, where it is obvious who got what treatment, but they are difficult to do. Patients may refuse to be included because they, or their doctor, are convinced one type of treatment is best. This is where fear of socialized medicine is most concentrated. They fear that the guidelines are based on cost, not efficacy. I might add that insurance companies often resist outcomes research because they fear that optimal treatment may be more expensive than what is commonly done now. There is always a lot of fear when changes come.
The least useful guidelines, and the most common, are called “Consensus Guidelines.” These are derived from committee meetings in which a group of experts concludes what the best treatment should be. Most of the time, the experts are using a lifetime of experience and a thorough knowledge of the medical literature to come to their conclusions. Bias, however, is not excluded by this process and the guidelines are often muddied with second guessing and reluctance to challenge colleagues who may be out of date. If all doctors kept up to date on medical progress, such guidelines would probably be unnecessary. As it is, they are better than nothing. Evidence Based Medicine, then, consists of trying to use “best practices” when they can be identified. In many instances, the art of medicine still remains the better indicator of what should be done. Doctors need to listen to their patients and they may find that explanation will cure something that surgery would only aggravate. I see this every week when I make hospital rounds with medical students. The students have much less information than the older resident physicans but they have time and interest and patients may respond to that when the science has failed. It is important to know the difference.
God grant me the serenity
to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.