Health Care Shouldn't Be Commercial
Certain things should be "off limits to commerce" Healthcare in my view can be compared to Education which, so far, has not been totally privatized. If shareholders must be satisfied, then patients' interests will be compromised. The way managed care works is by rewarding investors, HMO CEO's, and even doctors, while simultaneously holding down services to patients.
Six months ago Healthcare was not a hot topic, today it is. Hardly a week goes by without a major story, either on TV or in print. Recently 60 minutes did a story on Seniors going to Montreal with Mike Wallace to purchase prescriptions. I was truly surprised as the Industry Standard on 7/10/99 reported "CBS acquired 35% of Internet health company Medscape in exchange for $157 million in advertising and promotion - a potentially profitable investment if Meds cape's pending IPO soars". So is everything up for grabs? I guess so.
The New England Journal of Medicine in their August editorial concluded that "some aspects of life are off-limits to commerce. We prohibit the selling of children and the buying of wives, juries and kidneys." Parenthetically we do allow the sale of female eggs on the web and body parts for transplantation are routinely sold. "Tainted blood is an inevitable consequence of paying blood donors; even sophisticated laboratory tests can't supplant the gift-giving relationship as a safeguard of the purity of blood. Like blood healthcare is too precious, intimate, and corruptible to entrust to the market."
Dr. Steven Katz President of the Conn. State Medical Society wrote on 10/13/99 that "HMO's have not been paying doctors at all in many cases (latest estimate that docs in Fairfield County Ct. are owed 40 million dollars by 7 managed care organizations)"
Dick Huber, CEO of Aetna still owns $60 million of Aetna stock after having the value fall $61 million.
Let's consider the case of Joe Plocica who signed up with an HMO in Texas that advertised " as many hospital days as your doctor will authorize." The patient later was hospitalized following a suicide attempt but was discharged too early. That very night he proceeded to drink antifreeze and lapsed into a coma and died. Mr.Plocica's family sued the managed care company. The lawyer in his brief states (1) that Mr. Plocica was "encouraged to enroll via deceptive TV advertising" (2) The HMO failed to use ordinary care in influencing, controlling, participating in or providing health care treatment. (3) The managed care companies involved in Mr.Plocica's care used "aggressive cost controls and incentive compensation arrangements" thereby influencing the practice of medicine. (4) The HMO's involved created unreasonable risk by increasing the likelihood there would be a failure to properly diagnose, test and refer patients for specialty medical care. (5) The administrators of the managed care companies were also paid incentive compensation as were the physicians, based on holding down costs. There was no reward for quality care. Joe Plocica was the "victim of a knowing, calculated scheme whereby the Defendants (The HMO's in question) increased their profit by adversely affecting medically necessary, but costly, psychiatric medical care. There will be many more suits in the future, class action and individual.
This trend can hardly bode well for a system that is supposed to represent healing, caring and pain control.
WHAT HAPPENED TO COMPASSION AND HEALING?
The US Congress can't seem to understand the difference between palliative care (pain control, not killing the patient) and physician assisted suicide. This week (October 24) the infamous Henry Hyde and his fellow Senator from Oklahoma Don Rickles intend to overturn Oregon's law on physician assisted suicide BECAUSE they want to give the DEA (Drug Enforcement Administration) the power to determine whether a controlled substance has been prescribed for a "legitimate medical purpose". Now we have another administrative bureaucratic tier to go through before the doctor can prescribe appropriate treatment. Eleven states have said that the bill would do"significant harm" to doctor's ability to manage their patients' pain. It doesn't take a genius to understand this:
1) cancer patients do not become drug addicts and, if by some remote chance they were to develop some tolerance, so what? They are getting pain relief. I hope Henry Hyde is never caught screaming out in pain in a hospital just to be told that the DEA did not approve the request for morphine.
2) We are too paranoid about drugs and can't see their legitimate use in medicine
3) Doctors are poorly trained in Palliative Care although there are several new programs starting up in Medical Schools.
Most doctors took the Hippocratic oath on completion of Medical School but few really live by its words. There was a time in this country when patients trusted their doctors completely trusted them with their very lives and listened to them. You used to be able to talk to your doctor in privacy behind closed doors and you felt entirely confident that what he or she recommended was 100% in your best interest. Because of the complicated nature of managed care your physician may be preoccupied with many different issues that do not have to do with health care. The Managed Care and Emergency Medical Ethics Policy Statement of the American College of Emergency Physicians is inherently contradictory. The American College endorses the following:
- The ethical obligations of emergency physicians do not change when practicing in a managed care or any other environment. The physician's primary responsibility remains with the patient.
- When the economic interests of physicians, hospitals, purchasers of health services or managed care organizations are in conflict with patient welfare, the highest priority is patient welfare.
- Because the financial resources of our society are finite, emergency physicians have a responsibility to practice medicine in a cost-conscious manner. Regardless of the payment structure, the emergency physician should not provide care without reasonable expectation of patient benefit.
There is a conflict in the above because "patient benefit" really means Medical Futility.
"Futile Care Theory" allows doctors and health-insurance executives to deny not merely high-tech interventions but treatments as CPR and antibiotics to the disabled and people at the end of life. These caretakers and healers can, and do, routinely override the patient and family's wishes by assessing the quality of life. Little noticed by the mainstream Futile Care Theory is already being implemented in hospitals, nursing homes, hospices and clinics. Again money is speaking, and even in the pristine halls of Palliative Care this message crossed my desk. "You ask how to get physician buy-in to your palliative program? The best way to accomplish this goal is to make it a service that looks
Like any other consult service. For example, your consults should be staffed by a physician with recognized expertise in palliative medicine. The actual consult note needs to look like other consultant notes, like the cardiologist or oncologist, or any other medical sub-specialty. If you want credibility avoid alternative therapies initially. Focus on the medical problems and how they are affected by the patients' social situation that will be the bread and butter for your service. Help a few docs out of a jam, without coming across as too "touchy-feely" or as co-dependent crusaders, and you will get referrals. Once you have established your legitimacy, you can begin to change the standard of practice at your institution. It is important to have visibility in the hospital, the specialized units, and have a doc that is active in medical staff activities."
SPREADING OUR METHODS ABROAD
According to the Bangkok Post 7/8/99 Hospitals were left with massive stocks (up to 19 years) of overpriced goods. Many community hospitals bought drugs and medical kits at exorbitant prices on the orders of officials found involved in this medical supplies scam. The medicine had 3-year expiration dates. In Nakhon Pathom, officials testified before the Counter Corruption Commission that a surgical mask, usually priced at 15 baht, was bought at 120 baht. A surgical cap was priced at 150 baht instead of the usual 15 baht.
Wockhardt Health Institute has become India's first hospital to tie up with a health insurance company, US-based Blue Cross and Blue Shield Ass'n. The alliance will be of special help to the frequent US business travelers in India, non-resident Indians who travel to India on holidays and people covered under the plan while in the US and who have now returned to India. However, Indians staying in India will be able to access the facility only after a clear policy emerges on the participation of foreign companies in the insurance sector.
An excerpt on a website follows: "How about corporatising hospitals to attract foreign patients? We can make a 'killing' with cheaper rates in India. We could allow world's best doctors in India so that patients from all over the world are attracted to India for treatment. We should also ask the WTO to have a clause that Western governments should not subsidize healthcare, as it would affect out business interests. For starters, we could have tax concessions for hospitals getting their money from abroad. To protect our citizens, we could have a clause that no more than x% of patients can be foreigners. Or else, Indians will be neglected". All humor aside The Hindu reported on December 28,1998 that "The Centre has recommended to the World Bank a proposal for implementing a Rs.850-crore 'health scheme' in Tamil Nadu, aimed at upgrading the health care system in the State.
Is it just a coincidence then that on March 20,1999 the Calcutta Stock Exchange set up the first Indian Stock Exchange for derivatives? The new exchange will also be used for futures trading in commodities. The system will include adequate risk management measures and be on a par with other international systems. You may draw your own conclusions.
A little over a year ago in Mumbai, India Sheela D'Souza's 62 year old father was admitted late at night with severe breathing problems to a neighborhood nursing home. He was wheeled into the Intensive Care Unit and hooked up to an oxygen cylinder.
"But he continued gasping. I asked the nurse to check the tubes, check the cylinder. She shrugged me off," recalls Ms. D'Souza (name changed), a Kurla resident. "Finally, my persistent questioning forced her to take another look. The cylinder was empty."
In many of the city's mushrooming private ICUs such specialized critical care is more a myth than a reality. These ICUs are often housed in cramped nursing homes which are understaffed and inadequately equipped.
The bottom line is profit not patients. Stay tuned.