A Brief History…

This is a pretty good video of an articulate woman telling the CSPAN folks what the rallies are all about.

Sounds right to me

The question of incentives in the House “health reform” bill to pressure the elderly to sign “end of life” agreements has become a lightning rod in the debate. Sarah Palin, mother of a child with Down’s Syndrome, has accused the Obama reform movement of fostering euthanasia.

The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society’ whether they are worthy of health care,” Palin says. “Such a system is downright evil.”

While a bit over the top, there are legitimate reasons for concern. David Brooks on Meet the Press today, called Palin’s statement “crazy.” No, it wasn’t crazy and his reaction shows he still does not have the ear to hear what the public is worried about.

I was not reassured to read in an Aug. 1 Post article that “Democratic strategists” are “hesitant to give extra attention to the issue by refuting the inaccuracies, but they worry that it will further agitate already-skeptical seniors.”

The 1997 ban on assisted-suicide support specifically allowed doctors to honor advance directives. And last year, Congress told doctors to offer a brief chat on end-of-life documents to consenting patients during their initial “Welcome to Medicare” physical exam. That mandate took effect this year.

The “living will” initiative was in hospitals and now we have financial incentives for doctors to “discuss” such topics with elderly or handicapped patents.

Section 1233, however, addresses compassionate goals in disconcerting proximity to fiscal ones. Supporters protest that they’re just trying to facilitate choice — even if patients opt for expensive life-prolonging care. I think they protest too much: If it’s all about obviating suffering, emotional or physical, what’s it doing in a measure to “bend the curve” on health-care costs?

Patients may refuse without penalty, but many will bow to white-coated authority. Once they’re in the meeting, the bill does permit “formulation” of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would “place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign,” I don’t think he’s being realistic.

I remember 1978 when the first attempt at cost control came down from the federal government (Jimmy Carter was president). It was called “PSRO” or “Professional Standards Review Organizations.” We were told it was all about quality but the only measurements anyone was interested in were fiscal, like length of stay.

The enemy of compassionate decision making in these matters is government and legal scrutiny. I have assisted patients with their death. I remember very well one woman who had had a terrible battle with cancer of the anus, the same disease that recently took the life of Farah Fawcett. I had made the diagnosis as stroke of luck. She complained of an anal fissure. At surgery, the treatment at the time was what was called “lateral sphincterotomy.” This meant cutting part-way through the external sphincter, as these patients have a lot of sphincter spasm. The fissure is usually in the midline, anterior as it was in this patient, or posterior. The incision in the sphincter is lateral, away from the fissure. You don’t do anything to the fissure itself. In her case, I felt the fissure and it seemed too thick. Violating the treatment protocol, I biopsied the fissure and it turned out to be cancer. The treatment had become radiation instead of surgery and she had a course of radiation. Because the fissure was anterior, she had the recto-vaginal septum break down and she became incontinent. I had to do a colostomy and then a gynecologist and I spent the next two years trying to repair the recto-vaginal septum. Because it had been radiated, it wouldn’t heal. We finally were able to graft some tissue from her thigh into the septum and get it to heal after two failure and two years.

She never lost her sense of humor or her will to survive and get back to normal. Finally, after a terrible ordeal, we got her there. About a year later, she came in with abdominal swelling and nausea. An ultrasound showed fluid in her abdomen and I feared recurrence of the anal cancer. I did a tap of the abdominal fluid for cytology and it turned out to be an unrelated cancer of the stomach. We had a talk and I told her the cancer, because it was already into the peritoneal fluid, was incurable. What did she want to do ? She had a brother she hadn’t seen in a decade. We sent for him. I kept her on IVs until they had a chance to visit over a few days, then I turned her IV down to a minimal rate and she slowly dehydrated and died. She was always comfortable and was in complete agreement with the plan. We just didn’t talk about it and I didn’t have her sign any sort of consent.

Where would the government have helped in that process ?

I remember well another case. A man who owned the local clock shop. We had done business (I like clocks) and he came in one day with abdominal pain. He turned out to have Burkett’s lymphoma of the small bowel, a rare and rapidly fatal cancer. I resected the primary tumor and turned him over to the oncologist for chemotherapy. Six months later, I was called to see him in the hospital. He was dying and the nurses could not get an IV into him. They wanted me to place a subclavian catheter for IV fluid. I examined him and then went out to talk to the family, about five or six adult children. I asked them why they wanted me to do this. He was obviously dying and comfortable. Why prolong the misery ? Without an IV, he would die by morning. With an IV, he would die by morning. They held a vote and the majority voted to put in the IV. He died before morning. Would the government have helped in that situation ? I’m sure he had a “living will” because, by that time, hospitals required them. However, family can override the provisions of the living will.

In Holland, there is a law against euthanasia that is never enforced. If an ER doctor admits a patient to the hospital with end stage COPD, he loses his job. Those patients get a lethal injection in the ER. No consent; no discussion.

That is the final goal of cost control.

I have advocated the French system as a model for reform of the US health care system. It is the most expensive in Europe and also has the highest satisfaction level of any national program in the world. Now they are having more trouble with cost.

France claims it long ago achieved much of what today’s U.S. health-care overhaul is seeking: It covers everyone, and provides what supporters say is high-quality care. But soaring costs are pushing the system into crisis. The result: As Congress fights over whether America should be more like France, the French government is trying to borrow U.S. tactics.

My impression has been that Canada and not France has been the model for the Obama reformers. France allows private practice, free choice of physician and hospital and the majority of the system is fee-for-service. Maybe things have changed in recent years.

In recent months, France imposed American-style “co-pays” on patients to try to throttle back prescription-drug costs and forced state hospitals to crack down on expenses. “A hospital doesn’t need to be money-losing to provide good-quality treatment,” President Nicolas Sarkozy thundered in a recent speech to doctors.

My information is that the French system always required co-pays and, in fact, required payment in advance with the patient reimbursed by the health plan later. Maybe they have changed the system since 2000, when most of my information was produced, and have suffered from the moral hazard problem created by prepaid care.

My information was that:

The basic principle of French healthcare is avance de frais, or payment directly from patient to doctor. The freedoms of personal payment, freedom to choose a doctor and the doctor’s freedom to practice, are fundamental to the French system. The patient is reimbursed by insurance, 80% by Securite Sociale, and the rest by assurance complementaire but the principle is supported by the French when they are surveyed and they are suspicious of “free care” as wasteful and liable to abuse.

Maybe this has changed in recent years.

And service cuts — such as the closure of a maternity ward near Ms. Cuccarolo’s home — are prompting complaints from patients, doctors and nurses that care is being rationed. That concern echos worries among some Americans that the U.S. changes could lead to rationing.

The French system’s fragile solvency shows how tough it is to provide universal coverage while controlling costs, the professed twin goals of President Barack Obama’s proposed overhaul.

I have favored the French approach because it seemed to be controlling the overuse that is always associated with free care.

French taxpayers fund a state health insurer, Assurance Maladie, proportionally to their income, and patients get treatment even if they can’t pay for it. France spends 11% of national output on health services, compared with 17% in the U.S., and routinely outranks the U.S. in infant mortality and some other health measures.

The problem is that Assurance Maladie has been in the red since 1989. This year the annual shortfall is expected to reach €9.4 billion ($13.5 billion), and €15 billion in 2010, or roughly 10% of its budget.

The system, as it was described in 2000, was chiefly funded by payroll deduction but subsidies may have increased in the past few years. The CMU, the taxpayer supported program for the poor, may have been flooded with applicants just as the “government option” would be flooded with those previously paying for their own care in company health plans.

I suspect that the French economy is capable of paying much less than our own economy could afford. Eleven percent of our economy would far less than we now pay for a system that does not cover 47 million (although that figure is suspect). Maybe the increasing number of illegals in France are stressing the system, just as they are stressing our own system.

The temperature of the health reform debate is rising as August gets under way. There have been some fairly angry protests at Congresspeople’s “town hall meetings.” On the lefty blogs, and even the White House, this is evidence of a right wing conspiracy.

HCAN’s Richard Kirsch said a couple of months ago, “Those attacking reform are really looking to protect their own profits, and [Rick Scott is] a perfect messenger for that. His history of making a fortune by destroying quality in the health-care system and ripping off the government is a great example of what’s really going on…. We cannot have a better first person to attack health care reform than someone who ran a company that ripped off the government of hundreds of millions of dollars.”

Right-wing activists teaming up with a right-wing scam artist to ensure the public can’t have an honest discussion about health care. It’s sad, in a predictable kind of way.

I would also note that left wing Obama supporters can’t have an honest discussion, either. I have previously posted an extensive analysis of what I think a good model for reform might be. I don’t think the command economy model, which was the Clinton Plan and seems to be Obama’s plan if they will take the time to read the bills, will work in the long run. What this approach attempts to do is to control prices by controlling what doctors and hospitals can charge, and then to control utilization by rationing the care that is underpriced. In World War II, there were wage and price controls that survived into the post war years. This was accepted by most citizens, although there was a lot of black market manipulation, because we were at war. Richard Nixon attempted to control the first stirrings of inflation with wage and price controls. Even when he removed them as a bad idea in 1973, he left them on medical services. You cannot write regulations that will take the place of the market. The Soviet Union found this out but we seem doomed to repeat their failures.

The trend in the Democrats’ legislation is to put all adults into Medicare and then control utilization by rationing care, especially for the elderly. What do we know about Medicare as a system so far ? I spent about eight years on the Board of Directors of CMRI, the Medicare peer review organization for California. The last two years, I was chair of the Data Committee. After I retired, I went to Dartmouth for a year to learn how to measure quality in health care by analyzing data from the Medicare claims database. I thought there would be a lot of interest in quality measurement as part of attempts to control costs and reduce waste. I was wrong. The government people were no more interested in this than the insurance companies, maybe less. What they wanted to do was to juggle the reimbursement system to control costs.

In 1989, the government passed a law revising how doctors were paid in an attempt to discourage expensive specialist care and encourage primary care. How did that work out ? It certainly cut payment for highly technical procedures, like those I used to do. What did it do for primary care ?
Not so good. It turns out that paying people less while telling them how important you think they are doesn’t work well.

Over the past 25 years, America’s growing and increasingly diverse population has surpassed its number of trained health personnel.

This debt drives many new graduates into higher-paying specialties or more-affluent communities rather than primary care in rural and urban settings.

What is not mentioned is that payment to primary care physicians is crappy and declining. The nurse shortage has two basic origins. Back in the 1970s, the national nursing organizations decided that RN nurses should all have college degrees. They brought pressure to bear with politicians to close hospital-based diploma nursing schools and to make all prospective nurses go to college. The result was a disaster that nobody talks about. When I was a medical student in the 60s, the LA County Hospital had a nursing school that turned out well prepared nurses who were in tremendous demand. The school close about 1974 and almost all hospital nursing schools were gone soon after. What replaced them were the junior colleges which trained nursing students who got their clinical experience in hospitals but they never got the level of daily practical experience of the old diploma schools. There, they had dormitories and all expenses were paid. Many stayed at the training hospital when they graduated. The only reason that system went away was the egotism of the nursing societies who wanted to require a college degree to become an RN.

Reimbursement of primary care doctors has never been raised as they were promised. Instead, they were tricked into supporting cuts in reimbursement for surgery, an early form of rationing. They bear the burden of the system and their incomes have suffered. Medical students are rational people and have avoided primary care with increasing determination. They now find that their place is being taken by “allied health professionals” including nurse practitioners and physician assistants. I think this is a good idea so long as the role of the physician is kept primary. Many patients are happy to be seen by nurse practitioners. They do need supervisions, though. For a while my ex-wife was working for a local GP as a nurse practitioner. She had a master’s degree and had trained well. Still, she used to call me every day or two about a question that she couldn’t get the GPs to answer for her. Eventually, she was replaced by another MD because the practice administrator told her that MDs were “more versatile.” Of course they are but proper use of NPs is still a good use of resources. There are now small clinics located in drug stores and even Walmart stores, staffed by NPs. Most of these have a list of common conditions that they are equipped to treat. They do not accept patients with other conditions or symptoms, suggesting that they see an MD.

Eventually, we will evolve into a system where people can seek medical care that they can afford and that is convenient without waiting lists and rationing, other than by what we choose to pay. I fear that all these budding innovations will be choked off by premature descent into a command economy system that will freeze all the players in place. This happened in Canada but now after 25 years, private practice is breaking out in Canada.

Accepting money from patients for operations they would otherwise receive free of charge in a public hospital is technically prohibited in this country, even in cases where patients would wait months or even years before receiving treatment.

The country’s publicly financed health insurance system — frequently described as the third rail of its political system and a core value of its national identity — is gradually breaking down. Private clinics are opening around the country by an estimated one a week, and private insurance companies are about to find a gold mine.

Let’s not make a huge mistake and freeze our country into an ill-advised move now when real reform is possible. It may happen regardless of what the government does but it will be harder if we are frozen into a Canadian style socialist system.