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Networking to Restore Accountability in HealthCare & Medical Practice
Tuesday, October 15, 2002
Non-surgical Coronary Artery Bypass Grafts (CABG)
Last Thursday, Reginald Lowe, MD, Chief of Cardiology at the University of California at Davis School of Medicine, presented his research at Medical Grand Rounds. In an amazing demonstration of virtual cardiac imaging of coronary arterial and venous circulation with catheters, balloons, rotational jaws, and probes, he demonstrated placing a stent from the coronary artery, through the vein around the obstructed coronary and back into the distal artery, bypassing the blocked artery (Coronary Artery Venous Bypass Stents–CAVBS). All procedures take place in the cath lab rather than a surgical operating suite. He concluded with a photo of a surgical suite and a dinosaur standing side by side. He mentioned that the projected cost of the procedure was $3600. This compares with a $120,000 hospital bill for surgical CABGs, plus the surgeon and cardiologist fees (Sacramento prices). This would suggest that technology, far from being expensive, will in the long run decrease health care costs.
But What Is the Real Value of a CABG Hospitalization?
The father of a colleague of mine from India, who was a high ranking executive, had his CABG at a Sacramento hospital and received a bill from the hospital for $120,000. My colleague told her father that he should go to the hospital business office with his check book and offer to pay $60,000 to see if that would settle the account. He did just that and it was accepted as full payment. This illustrates that when hospital bills are paid by third parties and governments only, the true value of services is never known. The average citizen who is not able to write a check for $60,000 has no bargaining leverage. An actuary told me that he believes the real value of hospital care is probably less than half the price charged, perhaps only a third. To solve the health care financing problems in our country, we need to get hospital charges closer to costs which can only be done if there is competition between hospitals in an open market environment. Of interest was the fact that this executive thought the $6500 cardiac surgeon's fee and the $2500 cardiologist's fees were the best bargain. He said that he was unable to get anyone to manage his properties for less than 10% of the revenue.
A Court Challenge against Canadian Medicare
Last month in the Fraser Forum, Edwin Coffey, MD, a former President of the Quebec Medical Association, a retired Associate Professor at McGill University Faculty of Medicine and Senior Associate Researcher at the Montreal Economic Institute, posed the question, “Why are Canadians denied the freedom to purchase private health services and health insurance so they can safeguard their own health and that of their family members, regardless of what health services or insurance are provided by the state?” This politically incorrect question which is seldom addressed by the expensive commissions that have recently examined Canadian health care, has now been asked in the courtrooms of the Palais de Justice in Montreal. This is a determined constitutional challenge which will invalidate two provisions in Quebec's health legislation that infringe upon freedom and choice and create government monopolies in health care and health insurance. The outcome may be very significant.
The plaintiffs are Jacques Chaoulli, a young family physician who has acquired an extensive knowledge of constitutional law and court procedures, and George Zeliotis, a 70-year old salesman who suffered for nearly a year while on a hospital waiting list. Mr Zeliotis had inquired as to whether he could pay to obtain private surgery to relieve his hip pain, and if he could buy private health insurance in case he needed similar treatment in the future. He was appalled to discover that if his requests for private medical services and health insurance were granted, in the eyes of Canadian health legislation, such action would be illegal and a penal offence for him, the surgeon, and the private insurer.
After six weeks of court proceedings, Judge Ginette Piché dismissed the plaintiff's motion. She did, however, provide a consolation prize to the plaintiffs and to Canadian jurisprudence by declaring that the prohibition of private health insurance and medical services in hospitals by non-participating physicians did constitute an infringement on life and security. She added that the right to purchase a private insurance policy to cover health care, and the right to pay from one's own pocket to receive such health care in a hospital, are incidental economic rights protected by the Canadian Charter of Rights and Freedoms. Judge Piché noted that the revision of health system models is a matter for the legislators and the political order, not the courts.
The Quebec Court of Appeal upheld the lower court's judgment. The Supreme Court must now determine to what extent the state can prevent individuals from using their own resources to purchase health care when it is not available in a suitable manner in the public system. This case is of great political and social importance to all Canadians.
National HealthCare Systems in the English-speaking
World (No 5)
John C Goodman, PhD, president of the National Center for Policy Analysis (www.ncpa.org), in his recent update of the “Twenty Myths about National Health Insurance,” states that the failures of national health insurance are one of the great secrets of modern social science. Not only do ordinary citizens lack an understanding of the defects of national health insurance, all too often they have an idealized view of socialized medicine. For that reason, Goodman and his associates have chosen to present their information in the form of rebuttal to commonly held myths.
Myth Five: Countries with Single-payer Systems
have access to the latest technology.
Goodman states one could argue that the “need” for technology varies from country to country depending on the incidence of various diseases. However, every country needs certain critical, lifesaving technologies to diagnose and treat disease. Whether or not a country’s population has access to these types of technology is a determinant of the effectiveness of that health care system. The ability and willingness of a given country’s health care system to sufficiently invest in the development or purchasing of modern medical technology is an indication of a commitment to health care. By this measure, the United States fares better than its single-payer counterparts.
The Politics of Medical Technology
Goodman gives examples of how the United States has not always been the first country to adopt new technology. We do not always purchase the most technology. And we have not always made cost-effective choices among competing technologies. However, as the role of government expands, health care tends to evolve from a pro-technology phase to an anti-technology phase. In the first state, government tends to spend on items perceived as under-provided by the market or by conventional health insurance. Thus, practically every less-developed country has used government funds to build at least one modern hospital, usually in the largest city, and to stock it with at least one example of each new technology–even though the vast majority of citizens lack basic medical care and public sanitation.
However, as government’s role in medicine expands, more and more interest groups must be accommodated. In this state, government policy tends to become anti-technology because the small number of people who need expensive technology are so heavily outnumbered by the many who desire these amenities. Along the way, these general trends may be violated with respect to any particular technology because of the varied, even random, ways in which special interest pressures are exerted.
Use of Modern Medical Procedures in Britain &
Canada Compared to the United States:
As a result of these political pressures, patients in countries with single-payer health systems usually have less access to critical medical procedures.
* Coronary artery bypass graft (CABG) surgery in the United States is three times as high per capita as Canada, and five times as high as Britain.
* Coronary angioplasty (PTCA) in the United States is five times as high per capita as in Canada, and ten times as high as Britain.
* Renal hemo-dialysis (RHD) in the United States is two times as high per capita as in Canada, and three times as high as Britain.
Even though Britain has been a pioneer in developing important medical technology, it has been slow to make that technology available to its own population. Britain was a co-developer of kidney dialysis along with the United States, yet Britain has had one of the lowest dialysis rates in all of Europe and its equipment can only service five out of six patients in need of dialysis.
Similarly, CT scanners were invented in Britain who exported about half the CT scanners used in the world. Yet the British government purchased very few scanners for the NHS.
One effect of this under-investment is that Britain has the lowest survival rates for victims of lung cancer and heart disease among European countries. Echocardiography, ultrasound imaging of the heart, is low-cost and highly effective. But only about one-third of British heart failure patients receive one. Not only is the survival for heart disease poor in Britain, the country also is not doing much to prevent it.
While critics of the US health care system claim that we have too much technology, all the evidence suggests that Canada has too little–the result of conscious decisions of government officials. In terms of availability of advanced medical technology, Canada now ranks at the bottom of the 29 members of the OECD in spite of the fact that Canadian spending on health care as a percentage of GDP is fifth in the world. On a per capita basis, the US has nine times as many MRI units, four times as many lithotripsy units, and three times as many CT scanners as Canada.
In addition, much of the medical technology that is available in countries with national health insurance is archaic and ineffective. In Canadian hospitals, 63 percent of all x-ray equipment is severely outdated and half of all diagnostic imaging units require replacement. Coronary angioplasty was only available at one regional hospital in British Columbia, but was available in 80 percent of facilities in neighboring Washington and Oregon. Only 20 percent of regional hospitals have MRI units in BC compared to 100 percent of community hospitals in nearby Washington.
Goodman and associates conclude that although the United States pays more for health care, we also get more. And what we get may save our lives. Our experiences in the future may be different. Increasingly, our health care system is acquiring the characteristics of the health care systems of other countries, where access to medical technology is determined by rationing and politics.
Gluttony is epidemic in America. Statistics suggest that 60 percent of the population is overweight (Body Mass Index > 25) and 30 percent are obese (BMI >30), with 5-10 percent morbidly obese (BMI >40). But our extravagant appetite does not stop with excessive food and drink. It also involves excessive and unnecessary health care costs. In this section formerly entitled Exorbitant HealthCare Appetite, we continue to recite examples of patients who increase their health care costs ten to over hundred fold, simply because it does not cost them personally. There is no bureaucratic policing effort that can control these excesses. This is proven by the crises in single-payer and government medicine throughout the world.
Mary, a 60-year-old asthmatic, developed a chest cold on a Tuesday. Although she had experienced increased wheezing on Wednesday, which worsened on Thursday and Friday, she went to the emergency room on Saturday. After four hours of treatment–oral, intravenous, and inhalation therapy–she could not be cleared and was hospitalized for four days at a cost of $5,000. When I saw her for admission, I asked why she did not come in to my office on Wednesday or Friday, when an intravenous injection and modification of her medications could have easily cleared her? She stated that it was not convenient for her family. She traded a $50 office visit for a $5,000 hospital stay, a 100 fold increase in cost, rather than inconvenience her family. I then began my series of questions as to what it would have taken for her to have come in on Wednesday or Friday when I was in the office. “If you had to pay 5 percent of the $1200 a day or $60, would you have come in?” She felt that her family could have afforded that. If she had to pay 10 percent or $120, would she have come in to the office? She said, there was no way she could afford to pay $120. She had no concept of using $5,000 of other people’s money for her convenience since she had to pay neither the $50 office call nor the $5,000 hospital bill. But a 10 percent payment by the patient on a hospital bill would have brought inpatient health care back to the Medical MarketPlace where benefits have to equal or exceed the costs.
While Congress and State Legislatures are debating reduction in Medicare and Medicaid costs by 5 percent, or maybe 10 percent, this lady increased her health care costs by 10,000 percent. There is no system that can afford this extravagance–this gluttony, nor is there any system that can effectively police this gluttonous behavior. No system would dare police or restrict what people feel is a medical emergency. Only the individual can prevent his own medical emergency and do so only if his personal finances are involved. Thus anecdotal evidence suggests that a 10 percent copay without limit for hospital care would come close to restoring the Medical MarketPlace for inpatient health care. This suggests that when individuals curb their own health care appetites, hospital costs may decrease by 30-50 percent.
MedicalTuesday Recommends the Following Efforts in
The Greg Scandlen Health Policy Comments is an important source of market-based medicine. You may log onto NCPA (www.ncpa.org) and register to received Greg’s weekly report, the weekly health policy digest or the full NCPA daily report. We also recommend the market-based reports of Lew Rockwell, president of the Ludwig von Mises institute. Please log on at www.mises.org to obtain the foundation’s reports or log onto Lew’s premier free market site at www.lewrockwell.com. Martin Masse, director of the Montreal Economic Institute, is the publisher of the webzine: Le Québécois Libre. His enlightening articles can be found at www.quebecoislibre.org/apmasse.htm.
MedicalTuesday Recognizes the Following Efforts in Restoring the Doctor & Patient Interface: Dennis Gabos, MD, President of the Society for the Education of Physicians and Patients (SEPP) at www.sepp.net for his efforts in Protecting, Preserving, and Promoting, the Rights, Freedoms, and Responsibilities of Patients and Health Care Professionals, with a special page for our colleagues in nursing, SimpleCare for their success in restoring private practice, www.simplecare.com, HealIndiana as a supporter of market-based medicine, www.HealIndiana.org, the AAPS representing physicians in their struggles against bureaucratic medicine www.AAPSOnline.org.
We continue to receive requests to reproduce the Medical Tuesday e-letter. We grant permission to any non-profit organization to republish this column with attribution to MedicalTuesday and its author as long as a formatted copy of the portion that is republished is sent to Info@MedicalTuesday.net, along with the name of the publication and the date. Be sure that your readership is interested in the Medical MarketPlace rather than bureaucratic medicine. Subscription magazines should contact the author below concerning royalties.
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