Hospital charge variation and Medicare equipment fraud: two forms of gaming the "non-system"

There has been extensive coverage of the recently published report from the Center for Medicare and Medicaid Services (CMS) that revealed dramatic differences in the prices charged for medical services between hospitals, not only between regions but also within the same city. “Hospital Billing Varies Wildly, Government Data Shows”, in the NY Times May 8, 2013, reports that “A hospital in Livingston, N.J., charged $70,712 on average to implant a pacemaker, while a hospital in nearby Rahway, N.J., charged $101,945…In Saint Augustine, Fla., one hospital typically billed nearly $40,000 to remove a gallbladder using minimally invasive surgery, while one in Orange Park, Fla., charged $91,00. …In one hospital in Dallas, the average bill for treating simple pneumonia was $14,610, while another there charged over $38,000.” 

Bloomberg News notes that treatment of psychoses ‘showed the greatest price discrepancies, with the most expensive hospital charging $144,523, more than 52 times its cheapest peer,’ and the ‘most common procedure in the data, treatment of simple pneumonia and lung inflammation with complications, had prices ranging from $5,093 to as much as $124,051.’” The Kansas City Star reports, in “New data reveal puzzling differences in hospital charges”, that “… the hip replacement surgery that one hospital in Ada, Okla., charges at $5,304 cost $223,373 at a hospital in Monterey Park, Calif.,” and giving a local example, “In Kansas City, charges for that surgery range from $24,874 at Truman Medical Center Lakewood to $66,268 at the University of Kansas Hospital.”  Among the many other news sources covering this are Wall Street Journal (“Data shine light on hospital bills”), USA Today, AP,  Los Angeles Times, Washington Post, and others.  The LA Times article notes that the data call “into question medical billing practices just as U.S. officials try to rein in rising costs.”

But, of course, this information should come as no surprise; it confirms something not only well-known by hospitals and physicians for a very long time, but repeated reports by investigative journalists over the last several years. These have included  Atul Gawande’s article, “The Cost Conundrum” in The New Yorker June 1, 2009 (my blog coverage in Medicare Costs: "All Politics are Local", June 11, 2009) and Steven Brill’s February 2013 Time magazine piece “Bitter Pill: Why Medical Bills are Killing Us”, which I discussed in Squeezing the needy: a truly flawed financing system for healthcare, March 2, 2013. Hospitals’ “charge masters” list “list prices” for any number of procedures and equipment which, as noted above, vary wildly. Although Medicare performed the study, in fact Medicare does not pay those prices or anything close to them; it sets its own payment schedule for these procedures which does not vary much between hospitals. However, as Gawande makes clear in “The Cost Conundrum”, there is a second problem arising from the fact that some hospitals seem to do – and bill Medicare for – a far larger number of procedures than are done by other hospitals caring for similar populations.

So why do they have these charges and why do they vary so widely? They vary because different amounts of “fixed costs”, the expenses that hospitals have that are not for the individual patient (staff, building maintenance, equipment, etc.) are loaded into these charges, as are more or less profit. They are high because there are occasional payers (fewer all the time) who do link their payments to charges, such as Worker’s Compensation. While Reuters quotes HHS Secretary Kathleen Sebelius as saying "When consumers easily compare the prices of goods and services, (providers) have strong incentives to keep those prices low. But even basic information about health premiums and hospital charges has long been hidden from consumers. These rates can vary dramatically in ways that can't be easily explained," it is not clear that posting the prices, or having smaller differences, would be of much help to most people. 

Large health insurers, like CMS, do not pay the posted “charges”; although they pay more than Medicare or Medicaid, their payments to hospitals are usually tied to Medicare charges as a multiple (e.g., they might pay 2 times Medicare). Of course, the group that most clearly gets screwed are people with no insurance at all, who are in fact billed for the entire list charge. They are, also of course, very unlikely to be able to pay any significant portion of those charges (minus the rare sheik or hedge fund manager who might show up). Therefore, the difference between owing $24,874 to Truman Medical Center Lakewood or $66,268 to the University of Kansas Hospital for hip replacement surgery may be largely theoretical to them, but in the meantime, it can, and frequently does, absorb their life savings, ruin their credit, and throw them into bankruptcy. And there are “middle class” uninsured families who might be able to pay off $24,874 over a few years, but for whom $66,268 is more than they could pay in a lifetime. (Fortunately, most hospitals, including I know the University of Kansas Hospital, do develop payment plans for patients, which, if they make payments that are agreed on can preserve their credit.)

Meanwhile, in “Medicare anti-fraud effort has Missouri roots” (Kansas City Star May 7, 2013), Lindsey Wise, the paper’s Washington correspondent, describes how the concerns of a St. Louis physician that she was receiving requests from medical device sellers for approval of medical equipment that she hadn’t ordered, and that it turns out her patients hadn’t requested, led her senator, Claire McCaskill, to hold federal hearings. As noted by Sen. McCaskill, “Most Americans have seen ads on TV or received calls or letters promising medical equipment ‘at little or no cost to you,’”  but, as she adds, “there is always a cost to you, because it is paid for by federal tax dollars.”  Both Dr. Kennedy’s patients and others testifying before McCaskill’s committee said they often receive several calls per day from device retailers. Investigations of two companies that had faxed unsolicited requests to Dr. Kennedy discovered, respectively, a 68% and 92% “error rate”, a euphemism for what may well be fraud.

Why mention these two separate issues, Medicare fraud by medical device companies and huge charge disparities among hospitals for the same procedures, in the same blog post? While definitely different – the device sellers, at least those who are guilty of such practices (“Please don’t convict the entire industry,” says the executive director a trade association that represents medical equipment companies), are unscrupulous and perhaps committing fraud, while the hospitals are not – they share they key characteristic of seeking profit by “gaming” the system. Medicare pays for medically necessary equipment (including scooters, oxygen, diabetes monitors, etc.) for patients who need them, and some companies selling them do aggressive direct-to-consumer marketing (as do pharmaceutical companies), to try to increase their sales. Hospitals post exorbitant “prices” for their services that bear little relationship to the cost of providing them (as proven by the wide variation) in hopes that the occasional payer will pay them, or at least pay a percentage of them (unlike Medicare’s fixed reimbursement). What they have in common is the exploitation of a nonsensical non-system of health care in which profit is pursued by taking advantage of its intrinsic disorganization.

For medical supplies, while Sen. McCaskill’s committee discovered many cases where patients did not want the equipment physicians were asked to approve, there are many others cases in which the patient is convinced that it would be good to have, say, a scooter that they don’t have to pay for --  even when the doctor thinks it is not necessary or might even be harmful (for example, when a person who doesn’t exercise because of their weight gets a scooter and does even less activity and thus gains more weight). Fraud is fraud, should be investigated, and it appears that it is being done.

For hospital charges, however, the solution is different. It would be to have a national payment system that, possibly with regional differences based on the cost of labor and other variables, pays a fixed amount for services, as does Medicare – a single payer system. It probably needs fixes (Medicare may currently pay too little, requiring private insurers to subsidize that care; certainly the law should allow the uninsured to be billed at no more than Medicare would pay), but a little rationality would go a long way.

Medicaid Expansion: Do we care for people or not?

A cornerstone of the health coverage reforms in the 2010 Affordable Care Act (ACA) was the expansion of Medicaid to a large population currently ineligible for this benefit. This was intended to cover those who work but have low wage jobs that neither offer health insurance nor sufficient pay to buy health insurance on the private market. (This latter is, in itself, a a very large obstacle; most people in “high-wage” jobs – considered by the Department of Labor to be above about $45,000 a year -- would have great difficulty paying for private health insurance.) In most states, Medicaid covers two populations: children in very poor families and their mothers (in general, if there is a father in the home, the family is not eligible) and poor people in nursing homes (who may well not have been poor until they spent time in a nursing home). Although the first group is much larger, the latter costs much more money because the health care services that they require are so much greater.

The standards for income eligibility vary from state to state, but in many states, including Kansas and Missouri (the states on either side of the Kansas City metropolitan area) it is well below the poverty level. Childless adults, unless they qualify for physical or mental disability, are rarely eligible for Medicaid no matter how poor. Medicaid is a federal/state shared program; depending upon mean state income, the federal government pays 60-80% of the cost. In order to make expansion more acceptable to many states that are already financially strapped, ACA provides for the federal government to pay 100% of the cost of the expansion for the first 3 years, and 90% thereafter. But, nonetheless, this expansion is in jeopardy in many states, because, essentially, the governor, legislative leaders, or both, oppose having the government insure most people. The decision by the Supreme Court that upheld ACA struck down the plan to pull all Medicaid funding from states that did not opt for expansion, thus seriously weakening the leverage that the federal government has to encourage it.

“Paul Nelson works for $10 an hour at a Kansas City car shop, suffers from diabetes and can’t afford the medicine to deal with it,” write Steve Kraske and Jason Hancock in the Kansas City Star, April 27, 2013. In “Nixon’s pleas for Medicaid expansion go unheeded”, they describe how “The working father still earns too much to be eligible for Missouri’s Medicaid program. That’s why he was hoping — praying may be a better word — for an expansion of the program this year so that he could get health coverage.” Nelson is the kind of person who might benefit from Medicaid expansion, but is probably not going to get it because the Republican-controlled Missouri legislature is so opposed to expansion, despite the strong lobbying efforts of Democratic Governor Jay Nixon, who “…displayed more gusto for the cause than any issue since he became governor in 2009…”  is now regarded as “…dead, buried, gone.” Nixon had considered the federally-funded expansion a “no-brainer”, and the fact that “An early February poll by American Viewpoint, which usually surveys for Republicans, found that voters backed expansion by 56-35 percent once they heard ‘a balanced set of arguments for and against the proposal,’” has not swayed the legislature.

In Kansas, Republican governor Sam Brownback has been playing it close to the vest regarding this issue, but Kansas legislative leaders are very strongly opposed to expansion. Brownback engineered the elimination of any opposition to his very conservative policies by running opponents to “moderate” GOP senators (the House was already in the control of the far right) in the 2012 primaries. With major funding from the Koch brothers, abetted by the traditionally low and skewed-to-the-base turnout in primaries, almost all were victorious; even the President of the Senate, Steve Morris, a rancher from far southwestern Kansas, was defeated by a young and inexperienced, but well-financed, challenger. On one issue, funding for higher education, Brownback is currently staking himself out as a relative moderate, compared to legislative leaders, as he is opposing the cuts that they have proposed. If perhaps a bit suspect, since not only did he engineer their victories but his prior budgets have significantly cut higher education, it could potentially signal a willingness to do something similar with Medicaid.

Meanwhile, as the continuation headline for the Star article, “Obama’s switch hurt efforts here”, makes clear, the administration has added its own disincentive to that of the Supreme Court by backing off on cutting Disproportionate Share (DSH) payments to hospitals that take care of a high percentage of Medicaid and uninsured patients. This weakened the commitment of hospitals and their agents, the state hospital associations (and, even more the Chambers of Commerce, which never really support publicly-funded health insurance expansion in any form) to supporting Medicaid expansion. Most still do, though, because they have been counting on expansion of Medicaid to increase their revenue from patients (like, say, Paul Nelson) who were previously uninsured and make up for cuts in Medicare payments, which are already taking place.

But much more important than the financial interests of hospitals or doctors, much more important than the posturing of politicians, is the impact on actual people. Paul Nelson is one person, but there are hundreds of thousands of people in his position in Kansas and Missouri, and many millions in the US. Their numbers are increasing; in an article in the Washington Post about the “Governments may push workers out of employer health care and into health exchange”, cited by Don McCanne’s “Quote of the Day” for April 26, “The owner of Olive Garden and Red Lobster restaurants, for example, began experimenting last year with putting more workers on part-time status.” While the focus of the article is on insurance exchanges, the probability is that low-wage workers who are put on part-time status would be more likely to qualify for Medicaid expansion.

Opponents of Medicaid expansion, in Missouri, Kansas, and elsewhere, often sound concerns about the cost, despite the fact that the federal government will pick up almost all of it. On the finances, they are wrong. But of greater concern they are not really motivated by their flawed understanding of economics, they are motivated by a lack of concern for people who are not like them, and a commitment to policies which expand the wealth of the richest individuals and biggest corporations at the expense of regular people. As the “American Viewpoint” survey points out, it is not the belief of most people, who do care about the health needs of themselves, their friends and neighbors and relatives. And, maybe even, other people who they don’t know.

The ACA, even with Medicaid expansion, even with insurance exchanges, even without changes to DSH or Medicare, does not cover everyone. Glaringly missing are those who, although without papers, are here, working in our community, living by our sides, often paying in through taxes (sales for sure, and frequently income) and sometimes needing health care, as well as others who fall outside the complexities of health insurance coverage. What we really need is an expanded Medicare-for-all, “everyone in, nobody out”. This is the real rational plan. But ACA does cover children up to the age of 26, it will prevent insurance companies from denying coverage to those with pre-existing conditions, and if states proceed with Medicaid expansion, will cover a whole lot more people who desperately need it.

People like Paul Nelson. People like the folks across the street. Maybe people like you. Our people.

Matthew Freeman Lecture and Awards, 2013

On April 1, 2013, Roosevelt University in Chicago presented the 2013 Matthew Freeman Lecture "What Works in Reversing the Cradle-to-prison Pipeline: System Change through Conflict and Collaboration", by Joseph Tulman, Professor of Law and Director of the Took Crowell Institute for At-Risk Youth at the University of the District of Columbia David A. Clarke School of Law. Prof. Tulman focused more on what he calls the "school to prison pipeline", discussing the depressing statistics on the probability of young people in certain communities ending up in prison, and the association of poor school experiences with this result. Most prisoners, he notes, have learning disabilities, not addressed in school, and he spoke about the ways in which he and others have  tried to help. His work is an important addition to a growing movement to address the mass incarceration of largely minority people in the US. 

I just returned from hearing Michelle Alexander, Associate Professor of Law at Ohio State, giving the Cleaver Lecture in Kansas City, on the topic of her book "The New Jim Crow". She points to the massive increase in incarceration over the last 30 years, with the quintupling of the prison population, 80% of whom are in for drug possession. She notes that this is a purposeful strategy pursued after the civil rights movement to create and maintain an "under-caste", where black men are more likely to be in the corrections system than in college; where in some cities and communities 80% of black men have a record. And felony records, often acquired before voting age, may prevent them from ever voting or even getting a job.

During the Jim Crow era, laws in the South institutionalized legal racism. The poor and working class white people, living in states that were often low-wage and non-union, could at least feel that they were superior to blacks. After the successes of the civil rights movement eliminated legal segregation, politicians seeking to mobilize the resentment of those same whites developed a "law and order" program, focused on the "War on Drugs" and targeted at people of color. Crime rates have gone up and down, but incarceration rates have only gone up. Drug use and sales are not significantly higher in minority communities, but arrests are. Felony convictions have decimated communities, and "kept them under control". One of my friends and colleagues notes that "If you're Paris Hilton or Lindsay Lohan, you can get away with virtually anything. If you're black or Latino, you get 5 to 10 years!" Indeed, you don't have to be Paris Hilton or Lindsay Lohan; if you are the right color and live on the right side of town, you can still go to college; if not, you probably will never get a job.

I would also like to congratulate the winners of the 2013 Matthew Freeman Social Justice Award, Nathan Lustig and Bailey Swinney.  Lustig, 22, a psychology major, Chicago resident and native of White Plains, N.Y., was selected for the award based on his commitment and engagement as an activist and organizer both on campus and in the community.

Swinney, 24, a sociology major, resident of Chicago’s Hyde Park neighborhood and native of Euless, Texas, received the award for her work in creating a conducive environment for Roosevelt students to teach reading skills to Cook County juveniles on probation.

It is clear that they are part of the solution.

Thank you, Professor Tulman, Professor Alexander, Nathan, and Bailey.

Nathan Lustig and Bailey Swinney

Payments for surgical complications: With a scalpel or a meat ax?

When you bring your car to a mechanic and there is a complication, when something goes wrong with the procedure they say they are going to do, you don’t expect to pay for it, at least if it is their fault, and if you know it. Say that in repairing one part of the engine, they cut a hose in another part; you wouldn’t expect to be financially responsible for fixing it. You’d think that they should absorb the cost, but of course it might unlikely that you would know whether the complication was their fault (sloppy work) or unpredictable, maybe a pre-existing problem that they hadn’t anticipated. On the other hand, if they fix your brakes or transmission and a few days later they fail, you do expect them to repair it for no cost to you.

The relationship between payment and surgical procedures done on your body in the hospital is more complex. First of all, just as with your car, complications happen. Sometime they are the result of “operator error”, whether mechanic or surgeon, but most of the time they occur with a predictable (but hopefully low) frequency. And, like with your car, some people have higher risk of complications because they are in worse shape. And one of (although certainly not the only) the predictors of being worse shape is, just as with cars, the age of the patient. Therefore, it is important to consider the risk (and potential seriousness) of complications and weigh it against the potential benefit from the surgery.

Secondly, payment for surgery (as for all hospital activities, and to some degree all medical activities) is bewildering and incomprehensible to health economists, not to mention doctors and regular people. With your car, you get a bill for “parts” and for “labor”; if you think you’re overcharged, you go somewhere else next time. In medicine, and particularly in hospitals, “charges” for procedures are a largely mythical but definitely inflated number that bears only a little relationship to the costs the hospital incurs, and is almost never the amount that is paid. Different insurers (private, Medicare, Medicaid, “self-pay”) pay different amounts; big insurance companies can bargain down the rates that they pay, government programs such as Medicare and Medicaid set their rates, and the uninsured are the only ones who get a bill for the whole set of charges (of course, they can rarely pay them, but are often bankrupted or have their credit ruined in the process). (See Bargaining down the medical bills, March 15, 2009, or the experience of health journalist Frank Lalli trying to find out what his medicine would cost, “A health insurance detective story”, NY Times December 2, 2012, and covered in my blog post “Medicare: Consumer choice or choosing your poison? How about coverage for everyone?”, December 15, 2012.)

So, do hospitals make or lose money when there are complications to surgery? The answer is “it depends on who’s paying”. In a recent JAMA, Relationship Between Occurrence of Surgical Complications and Hospital Finances[1], Sunil Eappen and colleagues from the Harvard School of Public Health (including, as last and corresponding author, Atul A. Gawande, the surgeon whose New Yorker essays I have discussed several times) examined this question in a large hospital system in the southeast US whose “inpatient surgical payer mix (Medicare, 45%; private, 40%; Medicaid, 4%; and self-pay, 6%) was comparable to that of an average US hospital in 2010 (Medicare, 40%; private, 41%; Medicaid, 9%; and self-pay, 5%)”. Their study found that “…The financial effects of surgical complications varied considerably by payer type. Complications were associated with more than $30,000 greater contribution margin per privately insured patient ($16,936 vs $55,953) compared with less than $2000 per Medicare patient ($1880 vs $3629). In contrast, for Medicaid and self-pay procedures, those with complications were associated with significantly lower contribution margins than those without complications. As a result, the payer mix will determine the overall economics of surgical complications for a given hospital."

Definitions  of Costs and Margins  (from Eappen, et al.)

Variable costs: Costs that vary with patient  volume (ie, supplies and nurse staffing).

Fixed costs: Costs that do not vary with patient volume (ie, costs for the hospital building, utilities, and maintenance).

Total margin: Revenue minus variable costs and fixed costs.

Contribution margin: Revenue minus variable costs. These are revenues available to offset fixed costs.

This absolutely does not mean that in these hospitals, or any hospital, surgical complications are seen as desirable. It does mean that, when the complications happen, the hospitals make money (their “contribution margin” toward fixed costs goes up – see the box which I have reproduced from the article for explanations of terms) if the patients are privately insured or covered by Medicare and lose money if the patients are covered by Medicaid or self-pay. It provides another example of why hospitals see some patients as “more desirable” based upon their insurance coverage, and illustrates how flawed this system is.

The study by Eappen was done on data from 2010, and there have been some changes since then. Medicare no longer pays for the treatment of complications (surgical or medical) that it has identified as preventable and that did not exist on admission (such as new bed sores or blood clots). It will soon go further and not pay for readmissions to the hospital within a certain period of time, whether or not the readmission is for the same problem. So, to carry on the car analogy, not only will they not pay again if your brakes fail after they’ve been “fixed”, they also won’t pay if you have to bring your car back because it needs transmission work. The latter may be as inappropriate for people as for cars; with time multiple things break down, not always related. With a car, we may sell or junk it; with a person we usually try to treat it. Our high-tech medical system can often get a person from the brink of death to “well enough” to go home or a skilled-care facility, but the same problem or another recurs and requires readmission. And, of course, since this is Medicare, all of our patients over 65 covered by this program now become “less desirable”; it means that, even more than before, hospitals will compete for patients with private insurance coverage.

This is no way to fix the problem. The first step has to be to put everyone in the same boat, to have a universal health insurance system, so that no patient is “more” or “less” desirable from a financial standpoint based upon their insurance coverage. Second, hospitals should not be paid on a “per case” basis or have a charge structure that no one understands. They should not have to seek out “well-insured” patients to cover their actual costs (fixed and variable) or put aside money for purchase of new capital equipment. In Canada, hospitals receive a global yearly payment for operating costs (and capital expenses are considered separately), and can thus make treatment decisions based on best meeting the needs of the patient, rather than “readmissions good” (we make money) or “readmissions bad” (we lose money. It is rather parallel to capitated payments for physicians, which I have discussed (recently, for example, Gaming the system: Integration of healthcare services can just raise costs, not quality, December 1, 2012), allowing physicians to treat patients in person, by phone or email, with long visits or short, depending upon what is most appropriate rather than which has the greatest reimbursement.

Of course, like capitated payments to physicians, hospital global budgets need to be adequate to cover costs and incent efficient but effective performance. A well-designed structure for payment that minimizes “gaming” the system no longer works when it is grossly underfunded. An open and transparent system of funding is most likely to permit cost savings where appropriate and not “across the board” (which is almost always wrong); it encourages the use of a scalpel rather than a meat ax.

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[1] Eappen S, Relationship Between Occurrence of Surgical Complications and Hospital Finances, JAMA 2013;309(15):1599-1606.

Premature babies and informed consent: we need to do it right

The New York Times reported April 10, 2013 that an investigation by the Department of Health and Human Services “has found that a number of prestigious universities failed to tell more than a thousand families in a government-financed study of oxygen levels for extremely premature babies that the risks could include increased chances of blindness or death.”  “Study of Babies Did Not Disclose Risks, U.S. Finds”, by Barbara Tavernise reports that the study of the use of oxygen in 1,300 infants born at 24-27 weeks of gestation during 2004-2009 and published in the  New England Journal of Medicine in 2010, “did have an effect on which infants died and which developed blindness, and that those risks were not properly communicated to the parents, depriving them of information needed to decide whether to participate,” and that these  “…conclusions were listed in great detail in a letter last month to the University of Alabama at Birmingham [UAB], the lead site in the study,” which included 23 academic institutions, including Stanford, Duke and Yale.

The science is complex. Very premature infants such as those studied are at high risk of death and other complications, including blindness. It has long been known that the use of very high concentrations of oxygen, near 100% (room air is 21% oxygen), causes them to have an increased risk of blindness. The Times notes that “Clinical treatment of premature infants has a troubled history. Attempts to treat them with higher oxygen levels that were thought to improve their odds of survival led to many cases of blindness. Premature babies need oxygen because their lungs are underdeveloped and they often need help breathing.” The study under investigation was using lower concentrations, 85-95%, in an effort to find a level that was most beneficial for survival without having an increased risk of serious outcomes, such as blindness. The response letter from the lead investigator at UAB argues that a similar (but not formal control group) of infants had a higher mortality rate than those in the study group; this is criticized by others who note that it is not valid science to retrospectively attempt to create a comparison group because they may be different in important ways. Usually, participants are randomly assigned to either receive the intervention or not, because this means that any differences that may exist, known or not, are likely to be equally present in both groups. In fact, one critic, Michael Carome of Public Citizen’s Group on Health, points to a study published in the journal Pediatrics in 2012 that noted the babies in the other group were sicker and thus more prone to die.

But what is of concern to the HHS investigators, and to me, is that the parents of the babies in the study were apparently not informed of the risk of blindness that is known to accompany high-level oxygen therapy, despite the study (and its consent form) having been approved by the Institutional Review Boards (IRBs) of all 23 participant institutions. This is shocking on the face of it, but is even more surprising given that consent forms have largely become, as the Times article quotes Arthur Caplan, head of the division of medical ethics at New York University Langone Medical Center, “...captured by worries about legal liability, so risks tend to come billowing forward like a huge fog… It’s a truth dump, so they are covered should something go wrong.” He is absolutely correct; consent forms commonly include a list of potential negative outcomes so long as to obfuscate what is important, e.g., “rash, fever, nausea, vomiting, headaches, bleeding, seizures and death”. (NOTE: This is MY rendition of what I think is typical; it is NOT the list contained on the premature infant oxygen study.) What is a patient or parent of a patient to think? How bad are these outcomes? How likely are they to occur? How can I make a decision? And, perhaps most important, how can I give a well-thought-out response, giving or withholding consent, when I am – or my baby is – terribly sick and at high risk. What usually happens, as Dr. Caplan notes, is that “…often in such emergency medical situations, parents often rely more on what doctors say in deciding whether to participate than on the fine print of a consent form.“

Much, if not most, research, even medical research, is done with people who are not at high or immediate risk; much early clinical research, as well as that in the social sciences, specifically looks at “normal volunteers” or at regular people in the community. All require informed consent by participants. There are (at least) 3 different sets of interests in any research. The researcher is interested in finding out the answer to a question, which in clinical research is usually about whether one type of treatment is better than another. The patient (or guardian), whose motivation, according to the urgency of the situation, may be to contribute to expanding medical knowledge, to earn some money (if there is an honorarium involved), to help others in the future who may confront the same problem, or, especially when the situation is very urgent and the patient very sick (as in this study) to hopefully get immediate benefit for themselves or their child. The institution in which the study is conducted (represented by their legal department) is interested in guarding, to the extent possible, against risk of lawsuits.

Interestingly, the allegation in this current study is the failure to mention the potential outcome of blindness, more a typical failing of the “bad old days” when patients were not informed at all of risks (e.g., the Tuskegee syphilis studies) than of the “bad new days” where the risk aversion of universities’ legal departments has created the type of laundry list of bad outcomes noted above. But both are bad. Consent cannot be “informed” if typical, regular, non-lawyer people cannot understand the consent form because the language is so abstruse, or if the list of potential outcomes is a jumble of serious and minor ones. This is particularly true when a patient  is critically ill, and they or their guardian is under incredible stress. This is when, as Dr. Caplan notes, they rely on what the doctors say; unfortunately this puts the doctor in the position of trying to dispassionately provide a recommendation as to whether or not to participate in a study that s/he usually feels passionately about. This is not a setting conducive to true informed consent.

The literature on informed consent is enormous, and it is a major focus of the field of medical ethics. But the key principle must be that participants be adequately informed of the risks that may exist, in language that they can easily understand. The risks must be presented with the most serious ones highlighted, along with the probability that they will occur. They must be presented openly and dispassionately, and study leaders must be available to honestly and completely answer questions. There is, unfortunately, an inverse relationship between the comprehensibility of a consent document and the degree to which it is written in legal language (as anyone who has ever tried to read anything written in legal language can believe).

Consents must be appropriate to the situation. Researchers who wish to, say, interview people outside a local supermarket to find out what they think are health problems in their community, should not have to have those people sign a 3-page consent to participate or no one would do it. Researchers who wish to study clinical interventions in high-risk patients in urgent circumstances need to provide adequate information about risks and benefits in a way that patients can understand, and not use their role as the “doctor” to “sell” a study because they believe the intervention will be beneficial even though the results are not yet in. IRBs need to take their responsibility to protect participants’ interests and be truly informed, while facilitating the conduct of research seriously. It’s not easy. Lawyers need to learn how to write in a way that folks can understand.

Clearly, leaving out a major potential complication like blindness from a consent form is wrong, but there is much more to getting true informed consent than a simple fix. But it has to happen if we are to continue to be able to conduct research in order to have new knowledge.

Research on disparities/inequities, in practices and communities needs much greater funding

This is my first attempt at a blog in several weeks; indeed only one in the last month. I took (and time will tell if I passed) the Family Medicine recertification exam, so I am now able to raise my head above water.

Research is the way we gain new knowledge. It is how we discover if the things that we are doing are the right things to do, or if they are of little or no value, or perhaps even of harm. In the decades after World War II, when the country was optimistic and growing and seeking new frontiers, science was a major area for investment by our government. Things were getting better, returned GIs found a plethora of well-paying jobs, were able to buy houses and cars and plan to send their children to college. American industry did extremely well, if not solely because of great planning and management here, because there was no competition from the rest of the world which had been devastated by the war.

Things were not all good, especially on the political front; there was the cold war, and the associated fanatic fear of Communists epitomized by Senator McCarthy, and there was a legitimate fear of nuclear. But, on the economic front, things were going well for the US. The growth benefited many more people, and the gap between the income of the average worker was large but not unconscionable. Not like today, where as demonstrated by much research, and the title of this HuffPost article, “CEO Pay Grew 127 Times Faster Than Worker Pay Over Last 30 Years”, (“It’s good to be a CEO!”), or in this graphic from Prof. GW Domhoff of UC-SC.

The most dramatic expenditures on science were on space travel; after the Soviet Union launched Sputnik, the first artificial satellite, in 1957 and the space race was on. With the election of John Kennedy in 1960, space exploration moved front and center. All of us who were schoolchildren, in addition to hiding under our desks to protect us from nuclear weapons, were much more productively engaging in a new-found, broad-based physical fitness program encouraged by the President. While Harry Truman was unsuccessful in passing a national health insurance plan, thanks to both the reactionary opposition of the AMA, and the fact that labor unions chose to demonstrate their effectiveness by negotiating health coverage rather than seeking political change as the Labour Party successfully did in Britain, in other areas of science, health moved to the forefront.

The National Institute of Health (NIH) became the major government institution funding medical research and saw enormous growth in the ensuing decades, including a doubling of the budget from about $15B to about $30B in the decade surrounding the last millennium. This fueled the development of an enormous expansion of medical research in laboratories, primarily in universities and medical schools. In addition, corporate support, mainly from pharmaceutical research companies, further enhanced the growth of these laboratories. There were many successes, of which the most famous is the sequencing of the human genome, but our understanding of human biology and how it might contribute to human health and diseases has been remarkably enhanced. Some of this research has led to true medical breakthroughs, with the creation of new drugs and treatment modalities that have sometimes been of great help to large numbers of people with common diseases, and sometimes of enormous help to a few with uncommon ones.

However (and you knew that there was going to be a “however”), the focus on laboratory research and new discoveries at the molecular, protein and genetic levels left unfunded areas of research at least as critical, but not seen as “hard science”, and thus not generally funded by NIH and drug companies. This is a problem. Yes, there are “clinical” research studies, but these are mostly trials of drugs and interventions in populations. The number of studies based in communities, looking at health disparities, and trying to discover how most effectively to have a positive influence on the health of people, populations, rather than occasional individuals, remains small.

 

Certainly, it has grown. As demonstrated in the graph, after the NIH budget doubled, it leveled off, “stagnated” given inflation, until the one-time infusions of American Recovery and Reinvestment Act (ARRA) funds in 2009. Funding for health disparities research has increased, both from NIH and from other federal agencies such as the Centers for Disease Control (CDC) and the Agency for Healthcare Quality and Research (AHRQ), which has but a tiny fraction of the funding that NIH does. NIH created Clinical Translational Science Awards (CTSAs) which funded centers at many medical schools to look at moving research into the community, but much more from the basic science laboratory to first-in-humans trials (or even from one basic science laboratory to another). A major new initiative of the Affordable Care Act (ACA) is the creation of the Patient-Centered Outcomes Research Institute (PCORI), designed to evaluate not just new treatments but how they affect people. However, even the community-based research has focused largely on the recruitment of research subjects to studies designed by academic researchers, rather than on directly studying issues that would improve the health of the people in those communities.

Part of the problem is that it is difficult to get community members to think about what would be in the best interests of their health and that of their communities. They are, after all, not trained in such assessment. In addition, particularly in the communities that are the most vulnerable, that have to greatest health inequities, people are just focused on getting by, paying the rent, buying food, working multiple low-wage jobs. However, another part of the problem is that research at this level is seen as less important and significant, particularly by those who have always focused on new discoveries in the lab and who control most of the agencies such as NIH.

But it is not true. No matter how wonderful the discoveries in the lab, no matter how much they might lead to new understanding, new drugs, new treatments, these are only of value if people benefit from them. So this requires clinical research in the real world, with actual people. But beyond this, if they are to benefit not just a chosen few, the interventions have to be studied among diverse populations, including people facing economic, social, psychological and environmental challenges. In addition, the delivery of these treatments is sporadic. It is clearly demonstrated that administration of aspirin is of benefit to people who have had heart attacks. So it should be used. Why, then, are half the Americans who should be on aspirin not? I don’t know. It probably isn’t cost. It requires research to find out why and to change it. Saying (as is often done) that “new medical knowledge takes 10-20 years to penetrate into practice” is not adequate. Finding out how to get this effective treatment to the people who need it is as important as discovering the treatment. This is known as “fidelity” research.

Finally, effective research on improving people’s health needs to involve medical practices, where the people are being seen. There are many Practice-Based research networks (PBRNs) around the nation, but they are all challenged by how busy the providers are seeing patients; this is at least as true in practices such as Federally-Qualified Health Centers (FQHCs) that care for poorer populations. And yet, without involving them in research, how can we know what is effective in delivering the “best quality” care, and how can practices at the point of care be changed?

This is not to say that we should not fund basic biomedical research or early clinical trials. Nor is it to say that the current programs from NIH and PCORI and others to fund work in health disparities and inequities, and in population and community health are not good. But they are too little. People working in basic laboratory research, early clinical research, practice-based research, and community health should not be competing with each other. There should be more money for all of it, but especially a lot more for fidelity research, community-based participatory research, and practice based research.

Where will the money come from? From policies that are used in every other successful country, and every time the US has been successful, progressive tax policies that take some of our wealth out of the control of private corporations, who use it only to sock away more money, and into the public sector where it can be used to benefit us all.

Can you be "too strong" for family medicine?

Last week medical students and residency training programs received their “match” results, the end product of a complex computerized process. Now (except for the 1100 students at US allopathic schools who did not match and programs that did not fill), students know where they will be training and residency programs know who will be joining them. The number of “un-matched” US students is greater than last year; so is the number of positions. This is the result of recent expansions in both the number of medical schools and the number of students in existing medical schools.


The Association of American Medical Colleges (AAMC) has been lobbying hard for the expansion of residency positions, arguing that expanding medical school class size is not going to translate into more doctors if there are not more residency positions. AAMC is not, however, calling for those increases to be tied to a certain percentage of primary care. Since primary care residents are not big money-makers for the hospitals that are the main sponsors of residency training, and not in great demand by medical students (see more below), it is quite likely that, absent specific stipulations, the opposite will occur – most of the expanded number of residency slots will be in non-primary care specialties. This will, of course, further exacerbate the already unbalanced subspecialty/primary care ratio that currently exists.

Unlike AAMC, many family medicine organizations are calling for expansion of residency slots to be tied to primary care, and I am in agreement with that. However, the concept of “forcing” students to choose primary care residency slots who may not want to makes many people uncomfortable. They would prefer to “make family medicine” more desirable to our students. I would argue that this is going to be an uphill battle given the priorities of many current medical students.

As a family medicine educator, I try to stay on top of the trends in medical education, student preference, and workforce. I also interact with a lot of medical students, so have, I think, some idea of what their priorities are. Sometimes, however, I am surprised by the lack of knowledge about family medicine among students who, I thought, should “know better”. For example, a student recently contacted me about a friend who had applied to family medicine residencies as a “backup” for their preferred, more “selective” specialty, and did not match; the perception was that this student was rejected because they were seen as “too strong” for family medicine. I was surprised. I wrote the following in response:

"I don't think it is possible to have someone be "too strong" for family medicine regardless of how you define strength (grades, board scores, compassion, ability to learn and apply learning, multi-tasking, or how much you can bench press). Family Medicine is truly the most complex and difficult specialty. The breadth is enormous, as I am reminded as I -- for the sixth time in my career -- study for my recertification boards, and study maternity care, sports medicine, caring for people with heart disease, well-child care, ICU care, lung disease, diabetes, fractures, arthritis, acutely-ill children, preventive care, epidemiology, nutrition, diabetes, gynecologic problems, management of psychiatric problems, adolescent issues, and on and on. There is nothing like it. It is also true that the skills, preferences, and experiences that make someone strong for one specialty may not make them "stronger" for another.

"As far as the practice is concerned, family physicians have to see undifferentiated patients and try to come to a conclusion about what they have and how to manage them. This is a lot more conceptually challenging than seeing someone with a ready diagnosis or a narrow scope of diagnoses and applying your in-depth knowledge to figuring out a best method of treatment for it, or doing a procedure on it. Family Physicians (and other primary care/generalist physicians) do not care for one disease or organ system of a person, they care for the person. They manage multiple co-existing chronic diseases -- our adult patients typically have a large number of them such as hypertension, diabetes, heart disease, arthritis, depression, and social stressors in their lives, for example -- and balance the treatments for each so that they do not make the others worse and are best designed for that individual person. And to, while doing so, learn and care for the person. This is harder than doing the same limited set of procedures or treating the same limited set of diagnoses day after day. While a typical subspecialist may have 5 diagnoses that account for 80% of her patient visits, for family medicine the top 20 diagnoses do not cover more than 30%!

"I do not mean in any way to insult or seem to be critical of other specialists; they do important things and we need them to refer to for the procedures that we don't do or the uncommon cases of diseases that are rarer or unresponsive to usual treatment (although I do think that the current balance between subspecialists and primary care doctors is way off). I also do not mean to seem ignorant of the fact that many other specialties, including orthopedics, are much more competitive than family medicine to match in. This is because demand (from students) exceeds supply (of positions) and allows those specialties to set higher (by whatever they mean by this, usually grades and scores) standards. But this should not be confused with the complexity of the specialty. Demand is driven by many things including (but I am sure not limited to), the particular interest of a student in the diseases cared for by a specialty, their interest in performing psychomotor skills (such as procedures), anticipated income, anticipated lifestyle issues, and many others. It is also true that many other specialties require strong medical students. But do not confuse supply/demand issues with the intelligence, hard work, difficulty, decision making ability needed, breadth, and conceptual complexity of a specialty. For these, nothing exceeds family medicine."

I also sent a link to this (I think) wonderful post called "Desperately Seeking Herb Weinman" by Steve Lewis in Pulse, an online journal of narratives about health and medical issues, that gets to other characteristics of primary care doctors that are important to people. The author has a very scary health episode that takes him to the emergency room, and acutely feels the depersonalization of not having a doctor who knew him (like his old, now retired, doctor, Herb Weinman, did): “I know that the overworked ER staff who treated me were good and competent healthcare providers. But I also know that there was not a soul in the ER that day who would have cried if I had died. As Herb Weinman would. And I want that. I want that.”

A colleague, who also has concerns about the motivations of some medical students, reposted a post from a student on “studentdoctor.net”, the largest discussion group for medical students about whether Allergy should replace Anesthesiology on “the ROAD” [Radiology, Ophthalmology, Anesthesiology, Dermatology, which are widely considered by medical students to be the specialties with the highest income-to-work ratio] because it seemed like “…such a cush job.” Then followed a listing of the incomes of different specialists, which I will not replicate, but will note that the low end of all was much higher than the high end of primary care incomes; however, primary care doctors earn a lot more than the average person!

My colleague commented: ”We need a different pool of applicants...We need a different yardstick...We need payment reform. There are plenty of smart people who want to serve. There are a lot of folks who would be thrilled to be the smartest, best paid person in their town.”

I agree. I want many more medical students to want to go into primary care. If it is about money, we are not going to be competitive. It is going to have to be about wanting to care. And that means, to me, using different criteria to accept people to medical school.

More people like Herb Weinman, I guess.

Squeezing the needy: a truly flawed financing system for healthcare

In his always-valuable “Quote of the Day” for February 26, 2013, Don McCanne, MD, cites an article by Robert Pear in the New York Times from February 25, “States Can Cut Back on Medicaid Payments, Administration Says”. He quotes from the article that “In a brief filed with the United States Court of Appeals for the Ninth Circuit, in San Francisco, federal officials defended a decision by California to cut Medicaid payments to many providers by 10 percent…. [it] urged judges to uphold those cuts, which are being challenged by patients, doctors, dentists, hospitals, pharmacists and other health care providers in California…[who] said California’s payment rates were inadequate even before the cuts. They pointed to a federal study that said,’ “California stands out because of its very low Medicaid payment levels.’”

 A similar article that he cites from the Los Angeles Times by Anna Gorman, February 25, 2013, “Healthcare overhaul may threaten California's safety net” states that “An estimated 3 million to 4 million Californians — about 10% of the state's population — could remain uninsured even after the healthcare overhaul law takes full effect,” while at the same time the public hospitals and clinics that would provide care to those additional millions are having their funding streams from the state cut.

And this is in a state with a long history of providing care for its medically indigent by having such hospitals and clinics (unlike, oh, say, Kansas) and with a reasonably progressive Democratic governor, Jerry Brown. But it also has a huge budget deficit. At the most narrow level, the state has no choice but to spend less on the programs over which it has control, and these programs are the ones that benefit those whose low-wage jobs (or no jobs at all) make them dependent on public programs to ensure the health of their families.

The key point here is that the huge transfer of funds from the public sector to private control, as a result of tax cuts on corporations and wealthy individuals, has led to the inability for even states such as California, which arguably want to, to provide the basic health and social safety net for its most needy citizens. This is precisely the result that advocates of these programs want, to “choke” government, and precisely the impact on the poor that would be predicted. Meanwhile, at the local, state and federal level, tax “relief”, in terms of both cuts and direct giveaways to major industries, continue to support the least needy.

At the same time (February 20, 2013), Time magazine has published an amazing exposé by Steven Brill of the ridiculous over-pricing and capricious billing done by US hospitals, “Bitter Pill: Why Medical Bills are Killing Us”. It is a long and through article, citing case after case and example after example, of how the current system of billing and reimbursement in health care, and particularly in hospitals costs a fortune, is sapping the economy overall. And, of course, the burden falls hardest on those who are either uninsured or poorly insured, and are billed “list” prices, which are much higher than those paid by either public (Medicare or Medicaid) or private (eg., Blue Cross, Aetna) insurers. MUCH higher. Often dozens of times higher. A few examples that he cites:

• A troponin (blood test for a heart attack) test billed to an uninsured patient at $199. Medicare pays $14; a CBC (blood count) billed $157 when Medicare pays $11.
• A nuclear heart scan for which Medicare pays $554 billed at $8,000.
• A Medtronic spinal stimulator that lists for $19,000 from the manufacturer (if the hospital paid full list) billed to the patient for $49,000.

The article is good investigative journalism, and goes beyond such simple examples to look at the entire structure of the health system’s payment mechanism, including the incentives to do more and more (even when unnecessary or possible even harmful) expensive – and high profit – tests and procedures. It looks at enormous hospital profit margins and salaries of “C-suite” executives: “…in our largest cities, the system offers lavish paychecks even to midlevel hospital managers, like the 14 administrators at New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $500,000 a year, including six who make over $1 million.” (Of course, salaries in the measly low one-digit millions pale before the incomes of those in the pharmaceutical industry!) It helps us to understand both why costs are so high and why programs that limit payment, like Medicare and Medicaid, are so hated/fear/despised by hospital administrators.

The hospitals may well be taking a loss on Medicaid/Medicare reimbursement, because “Medicare takes seriously the notion that nonprofit hospitals should be paid for all their costs but actually be nonprofit after their calculation.”  But while “Hospital finance people argue vehemently that Medicare doesn’t pay enough and that they lose as much as 10% on an average Medicare patient...even if the Medicare price should be, say, 10% higher, it’s a long way from $11.02 plus 10% to $157.61.”  The thing is that they “need” to make more because, although “non-profit” they make big profits – they just don’t share them with stockholders. “…thousands of nonprofit institutions have morphed into high-profit, high-profile businesses that have the best of both worlds. They have become entities akin to low-risk, must-have public utilities that nonetheless pay their operators as if they were high-risk entrepreneurs.”

What was interesting to me is that most of the patients who received those outrageous bills above were neither unemployed nor uninsured (although the one who was uninsured had the misfortune of being 64 rather than 65, so paid the $199 for her troponin instead of Medicare paying the $14). Rather, they were employed in low wage jobs and had lousy insurance, with very low per-visit, per-year, or lifetime caps and were treated by the hospitals as if they were uninsured (“’We don’t take that kind of discount insurance’ said the woman at MD Anderson [Cancer Center]” when Stephanie Recchi called to make an appointment for Sean; they needed to come up with $48,900 cash up front – and that was just the down payment!). So all estimates about the burden on the uninsured need to be augmented by the impact on the under-insured.
Dr. McCanne’s incisive comment on the two articles notes that while “We have said over and over again that Medicaid, as a welfare program, will never have the political support to fund it adequately. The burden of the additional load of Medicaid patients will surely find the health care resources strained beyond the capacity of willing providers, especially when you consider that California already is not meeting the costs of providing care to this vulnerable population…

"Here's an amazing fact: Low income patients do not have the money to pay for health care. (What an intuitive stroke of genius!) What they need is an affordable system that removes financial barriers to care while ensuring adequate financing of our entire health care delivery system, thereby removing health system disincentives to providing essential care for this vulnerable population. Make that for all of us.”

All of the nonsensical billing and collecting issues that are so horrifyingly reported on by Brill do not need to occur. The simple answer is that there should be a single, posted, price for each item or service and everyone is billed at and pays (or their insurance pays) the same amount. This is the situation in Canada, where fees for physicians are negotiated annually with the provinces and hospitals operate within a global budget. Probably fewer millionaire hospital administrators, but of course creating them should not be the goal of the money we spend on health care.

No poorly-insured, well-insured, uninsured, Medicaid-insured or Medicare insured. Just everyone covered. Simple, clean, elegant, and effective.

Corruption and Scandal in the NHS: What happens when you introduce private incentives to public services

The United Kingdom has a National Health Service which covers everyone (although it allows those with private insurance to access care elsewhere). While not perfect – nothing is – and historically underfunded, it is one very reasonable model for how we could ensure access to health care for everyone. It goes back to the post-WW II period, when the British Labor Party made the decision to expand the existing National Health Insurance program to create the NHS through the political process, while in the US the emphasis among unions was to use collective bargaining to get health insurance as a member benefit.

But the NHS, while profoundly supported by the vast majority of British people, has been a target of attacks by Conservative governments since the Thatcher years. One of the big changes was the creation of several regional “trusts”, quasi-public entities that were invested with NHS funds and made responsible for the provision of care in their regions. This was consistent with the Tory assertion (held even more strongly in the US) that the private sector, or as close as they could get politically to the private sector, would be more efficient and effective than a public “bureaucracy”. Success at meeting "targets" (often high production with inadequate resources) could lead a trust to "foundation" status, where they would have even more control.

Many in Britain had their doubts, certainly among those to the left of the Conservatives. There was concern that the trusts might not be responsive to the health care needs of the people and might be more concerned with enhancing their own salaries, perks, and power. Conservatives (small 'c') tend to believe that government bureaucracies are more inefficient; those on the left see more evidence that privatization is much more likely to serve the self-interest of those in control than the interests of those who are supposed to be served.

I recently read the 1996 mystery novel “Quite Ugly One Morning” by the Scottish writer Christopher Brookmyre. One of the major plot lines involves corruption in the Edinburgh-based regional NHS trust. I don’t want to spoil the plot, and I do recommend the book, but the portrayal of self-serving, stealing, and lack of attention to the actual care of the patients of the NHS was scary. Of course, it was a novel; there were not actual patients being harmed by corruption in the actual regional NHS trusts in the actual United Kingdom. After all, I thought, the British don’t do such things. We do, but that is because so much of our system is private and for-profit. Surely the British value the NHS too much for such things to really happen.

Wrong. It appears, however, that this in fact has been happening. In “English hospital report cites ‘appalling’ suffering”, NY Times February 6, 2013, Sarah Lyall describes conditions cited in a government report on Stafford Hospital, operated by the Mid-Staffordshire Trust: “Shockingly bad care and inhumane treatment at a hospital in the Midlands led to hundreds of unnecessary deaths and stripped countless patients of their dignity and self-respect, according to a scathing report published on Wednesday…. The report, which examined conditions at Stafford Hospital in Staffordshire over a 50-month period between 2005 and 2009, cites example after example of horrific treatment: patients left unbathed and lying in their own urine and excrement; patients left so thirsty that they drank water from vases; patients denied medication, pain relief and food by callous and overworked staff members; patients who contracted infections due to filthy conditions; and patients sent home to die after being given the wrong diagnoses.”

HUNDREDS of people. Maybe as many as 1200 people died unnecessarily. And, in the followup of this scandal, there are investigations into at least 14 other trusts, reported across the British press such as this article in the Telegraph, “Head of NHS ignored warning that patients were in danger, alleges whistleblower”. One of these trusts is United Lincolnshire, whose former chief executive has turned whistleblower, accusing the head of the entire NHS, Sir David Nicholson, of ignoring warnings that substandard care was being provided there. The whistleblower, Gary Walker, was fired from his job and paid off to the tune of about a half-million pounds, to keep quiet.

This would be a great example of “life imitating art” if it weren’t for all the people who died or suffered serious morbidity as a result of “…its efforts to balance its books and save $16 million in 2006 and 2007 in order to achieve so-called foundation-trust status, which made it semi-independent of control by the central government, the hospital laid off too many people and focused relentlessly on external objectives rather than patient care,” (NY Times).  As further documented in the report, this was essentially “speed up”, a condition familiar to assembly-line workers.

“Speaking in the House of Commons,” the NY Times article goes on, “Prime Minister David Cameron apologized for the way the system had allowed ‘horrific abuse to go unchecked and unchallenged’ for so long. So deeply rooted was the trouble, he said, that ‘we cannot say with confidence that failings of care are limited to one hospital.’” Apparently not, given the accusations at Lincolnshire. However, despite these accusations, and perhaps more damningly, the fact that he was the Chief Executive of the Mid-Staffordshire trust during much of the time that the scandalous activities were occurring there, Nicholson is staying put, and so far the government is backing him. (more coverage in the Mail (Feb 13 and 17).

Well, he is staying put so far, but people in Britain far and wide are calling for his resignation, as well they might. Demonstrations in support of the NHS as a system designed to serve the people, not its administrators, have broken out across Britain; an example is this wonderful “Youtube” video of a “flash mob choir” (!) at King’s Cross railroad station in London singing in support of National Health (h/t Alex Scott-Samuel).

It would be possible to pin these atrocities on the National Health Service, as an example of the failing of socialized medicine, but that would be wrong. It would even be wrong to point out that the problem is chronic under-funding of the NHS. The problem, in fact, is a public good being run for private benefit, for the temptation of even great “autonomy” (read: potential for exploitation) by becoming a “foundation” led to deaths far in excess of the scale fictionally portrayed by Brookmyre in the mid-90s. The NHS does not suffer because it is tasked with providing health care to all of the British people; it suffers when a lack of adequate regulation and supervision allow such abuses to go unchecked.

The British people deserve much better. So, for that matter, do Americans. Let’s listen to the “flash mob choir” again!