Saturday, November 10, 2007
This hypothetical scenario is not much removed from the logic being advanced by President Bush and his supporters to repeatedly torpedo the expansion of SCHIP. They mainly oppose expanding free health coverage from 6 million to 10 million poor kids because it would set us on the slippery slope of better healthcare for all. Of course they've a different name for it - socialized medicine. We already have "socialized medicine" for people above 65. It's called Medicare. Who (including Republicans) wants to do away with Medicare?
I earlier talked about SCHIP in my post of August 3rd. The Bush rhetoric against it hasn't changed, though some new angles have been added. Congress had already addressed initial objections by excluding the expansion to illegal immigrants and adults. Then after Bush's first veto they've lowered the family annual income cap for eligibility to $62,000 from $82,000. But that's apparently not enough.
On the eve of vetoing the second version of the Bill, Bush criticises the Democrats for not sending a Bill "that I can sign." His ability to sign is apparently not about merits but the imperative to keep his friends happy. Chief among these friends is the tobacco lobby since the additional funding for SCHIP is proposed to be covered by extra tobacco taxes. That's okay though there are alternatives to further milking the tobacco cow. I'd prefer SCHIP funding to come from rolling back the enormous giveaways resulting from the 2003 Prescription Drug Act. We can save more on drugs simply by allowing Medicare to negotiate drug prices. But that would widen the issues and give the Bushies additional excuses to resist SCHIP. Not wanting to be sidetracked, the Democrats wisely chose tobacco monies instead.
Also, private insurers worry about children currently insured by them being drawn away to the "free" government coverage. Some of this may happen but it doesn't change the overall benefits from a public policy perspective.
The Bushies' biggest ploy is pushing the requirement that no expansion be allowed till the states certify that 95% of the currently eligible kids have first been covered. This is a near-impossible hurdle as they well know. Moreover, an expansion of SCHIP does not reduce the opportunities for covering the poorer kids. It's like city police saying that they won't investigate any rapes or robberies until they've solved 95% of all past murders. If the Bushies were sincere in their concern about the poorer kids they'd seek simplified aplication procedures that would make it easier to cover such kids. Instead they insist on "safeguards" that make the task harder.
The Republicans' resistance to SCHIP is unpopular. I wonder whether some management gurus are being naive or deceptive in trying to spin this as simply a communications issue. Jack Welch in his BusinessWeek column of October 22, 2007 misses the mark in saying that Bush erred by not getting out in a big way to broadcast his detailed reasons for opposing SCHIP. The real reasons are that Bush wants to protect his cronies and fund contributors - hardly something that he can shout from the rooftop. The fake reasons he might give in campaigning harder against SCHIP are likely to get exposed during news analysis that would accompany such publicity.
There's a good graphic in an Oct. 17, '07 article in the New York Times (created by daughter Rubina, incidentally) that shows income limits and the number children and adults enrolled state by state. It shows one fifth of the states have a substantial number of adults included in the program. The pending SCHIP Bill will not expand adult coverage, but more importantly, note how just one state (New Jersey) has a family income limit above $62,000, at $72,275. So much for Bush publicity on how "rich" kids with family incomes of up to $82,000 will benefit from SCHIP.
As Bush is getting ready to veto a second SCHIP Bill, talks are reportedly proceeding on a third version that will be to Bush's liking. The man hath no shame. The Democrats may have little choice but to accede to this watering down in order to protect kids who are already covered, since the current legislation is about to expire. Still, it'll be a pity if any meaningful changes have to wait till Bush leaves office.
Thursday, October 18, 2007
- US health insurers will start to provide coverage for medical tourism in 2008. Mini-med plans and small employers -not big health plans and blue chip companies-- will lead the way.
- State governments will begin to embrace medical tourism by 2010.
- Opposition to medical tourism by US physicians will be relatively modest.
- Medical tourism won't have a major, direct impact on US health care costs, but the secondary impact will be substantial.
I broadly agree with the paper's expressed opinions, forecasts and predictions. They did a good job crystallizing a lot of the wisdom into those predictions. About the prospects of places attracting US medical tourists here are my views:
Because of pricing I don't think Singapore will ever be a popular destination for Americans, though it may serve a richer clientele from neighboring areas and the Middle East. My bets are on India followed by Malaysia, Thailand, and may be China and Philippines for serious procedures; and Costa Rica / other Latin American countries for the dental / cosmetic procedures, and a few major surgeries for people who don't want to travel too far.
One development is notable in the context of a weakening dollar. A lot of places like in Europe that earlier cost half as much as treatment in the US are no longer financially viable destinations for the cost conscious, so the places like India offering much cheaper treatment will attract proportionately more traffic.
Wednesday, October 17, 2007
The short answer is, France does not look good at least for US medical tourists. Because of its closer proximity it can still serve rich visitors from some other countries, notably the Middle East. From my informal conversations with a lot of the French people I had the same impression that is widely reported in the media - by and large the French are satisfied with their own system even if policy planners are worried about the budgetary gap.
On the last point one thing stood out: almost everyone I talked with said social security paid French healthcare was satisfactory and adequate, but not outstanding. Many said that if cost was no object then they would prefer to go to the American Hospital of Paris. This is a US managed private hospital that does NOT accept the French social security system of payment or reimbursement, and is a favorite among rich Parisians. The reason: it has very attentive staff, ultra clean and somewhat luxurious facilities, and well qualified doctors (many of them working as consultants rather than employees.) I confirmed this in my own tour of the hospital. Rebecca Alliegre who showed me around sounded disappointed when I remarked it was similar to the very good US hospitals I had seen. She said they hope it is better than that. I had actually meant it as a compliment - the top US hospitals are actually great, if hard for patients to get into or afford.
In contrast, I was told the regular French hospitals offer a more pedestrian level of care and attentiveness even if they have the required expertise and equipment. Moreover, none of the hospitals other than the American Hospital has a comprehensive website in English. So online information access to English speaking patients will be a problem, and there may be some spoken language problems for admitted patients as well. For these reasons I'd consider the American Hospital to be the best (perhaps the sole) prospect for US patients.
American Hospital has 180 - 190 beds and is a general surgery hospital. It does all sorts of procedures but none of the "standard" ones popular with medical tourists in very high volume, with the possible exception of angioplasties and corneal transplants.
An aside: I met a very impressive young cardiologist, Dr. Tarragano Francois, who performed 580 out of the 600 angioplasties at American Hospital last year (he does over a thousand in all, the rest being in other facilities.) He mentioned that in France teaching cardiologists (who can train others in angioplasty procedures) need to perform at least 600 angioplasties, and the certification threshold for practising cardiologists is 120 procedures (versus only 75 in the US.) It was also interesting hearing him talk about why he prefers using the latest Xience drug eluting stents manufactured by Abbott Labs, as compared to competing products like Taxus, Cypher and Endeavor. Xience allows better insertion and flows in branch points of arteries, and has a slower and more prolonged delivery of the drug that prevents clots. Very interesting stuff - I wish I had become a doctor.
Back on topic, right since 1956 the American Hospital of Paris is the only JCAHO accredited civilian hospital (not just JCI accredited) outside of the US. It was established way back in 1906 with 19 beds as a way to provide American style and quality care, and originally intended mainly for US expats working in Paris. It has come a way since then, and has upto date equipment, like a 64 slice CT scanner, and a PET scan to be operational next year.
So why is it not suitable for most US medical tourists? The biggest problem is prices. Thanks to a weak dollar, the prices here are about the same as the negotiated prices in US hospitals. My impressions are based on preliminary discussions. Thuy Tien Couty, the Director of Marketing was very cautious about disclosing prices, and she said the list will be available only in mid-November. Other French hospitals are somewhat cheaper, but the differential isn't dramatic, and besides they do not match the service levels of the much cheaper elite hospitals in places like India or Malaysia. Besides, India has super-specialty hospitals with 500+ beds that have deep expertise and quality credentials in almost all the major surgeries sought by medical tourists.
Still, some US patients with private insurance or sufficient means may opt for American Hospital because they would like to enjoy visiting Paris and recuperating here while receiving high quality and attentive care.
Friday, September 21, 2007
Jokes aside though, there are two places where my perspective differs from that of Krugman. One is a minor point - he worries that Hillary took so long to announce her detailed plan and says this may portend her reluctance to deliver on it subsequently. I feel the elections are still so far away that she had every right to take her time and study all the issues carefully. So I do not question her determination based on her timing.
The second difference is more pronounced, and is about the effect of malpractice activity on healthcare costs. Krugman, like Michael Moore in "Sicko," is conspicuously silent on this issue of reining in the trial lawyers through malpractice caps and tort reform. On the contrary I view this as one of the biggest problems and contributors to high US healthcare costs.
The left traditionally stands for civil rights and individual protections that then extends to support of lawyers and litigation. Could his anti-Right leanings constrain Krugman from attacking a leftist viewpoint even when this viewpoint is flawed? I hope this isn't the case because I admire his writing style and crisp logic, and enjoy reading his columns.
Thursday, September 20, 2007
(a) Does it commit to ensure everyone has coverage? Any plan that doesn't is insufficient.
(b) Does it require pooling of risk (i.e., are the healthy forced to get coverage and thus pay into the system?) Without pooling the concept of insurance does not work. This is where Obama falls short.
(c) Is it sensibly funded , i.e., doesn't necessarily lead to breaking the bank of public and private resources? This is the toughest challenge for Edwards and Hillary, but their repeal of tax cuts and forcing large employers to pay into the system or cover employees seems that it can do the trick.
The Republican candidates can only answer positively to "c" above, so their plans are hardly worth talking about - they too seem to realize this and try to avoid the subject or fall back on "Beware HillaryCare" slogans.
Hillary has even left a role for private insurers, saying that they can provide the necessary coverage, even to the currently uninsured. That's quite a contrast from the Michael Moore "Sicko" denunciations. Yet her proposals make sense. Private insurers need to make a profit, which imposes a cost on the system, as Michael Moore and economist Paul Krugman rightly point out. But on the other hand, private insurers can offset these factors and earn their keep if they can discharge the payment and reimbursement function more efficiently, and curb fraudulent billing by providers more efficiently than the government. And the "risk pooling" requirement that insurers cannot turn down or charge more from sick applicants or those with pre-existing conditions removes a big source of inefficiency.
Hillary's plan says nothing about some other big factors behind the high healthcare costs - malpractice and litigation fears; drug pricing and doctor shortages. The first of these is the biggest (and the one that Democrats are least likely to address through tort reform) but it is encouraging to see this Businessweek article of April 30th about the vanishing jury trials.
Mitt Romney has been denouncing Hillary's plan which largely incorporates the features of his own Massachusetts State plan. Romney is the ultimate Chameleon candidate - he seems to have reversed himself on nearly every big issue since his quest for the White House. On healthcare I think he would have been better served even during the primaries by sticking to his earlier stance. After all many Republicans too are worried about healthcare and want meaningful solutions. But this may be a moot point as Romney's so far behind the front-runners.
Friday, August 17, 2007
The best thing about Bumrungrad is its marketing success. The credit goes to its American managers and marketers, who have not only promoted the hospital well in the media, but have also included slick designs and features, streamlined administrative processes and generally made the interface with the foreign patients very user-friendly and reassuring.
Bumrungrad tends to charge well for each of its services, and includes handsome markups for services it arranges through its local service partners. For example their airport "meet and greet" costs $40 and the trip to the hospital costs extra - about twice as much as for a luxury taxi engaged directly at the airport (or six times what an ordinary taxi charges.) But patients may not mind paying all these extras which are complimentary or included in package costs in other international hospitals. Instead, a cause for greater concern are some of their "substance" issues like their quality of treatment.
The Bumrungrad death in Feb. 2006 of the 23 year old American Joshua Goldberg has drawn a lot of attention. This could arguably have happened anywhere, but I too had concerns about the hospital way before that. Joshua's dad has made many allegations against Bumrungrad in his website directed against them, including engaging in a trade for body parts, and sacrificing patients for that purpose. In the absence of any facts to support this I don't set any store by such statements, and attribute them to the rage of a grieving father.
My guess is that Joshua died because of a negative response to one or more of the medications given to him. It's quite possible that negligence was involved and that Bumrungrad management tried to cover up mistakes made, or stonewalled an investigation. On the other hand it may not be the case, but here are the reasons why I am leery of their treatment quality and their practices:
- They don't seem to have outstanding doctors, particularly in areas of major surgery. I've read their policy is to hire primarily Thai nationals, which limits their talent pool. The bios of their doctors on their website is suspect as it mentions "fellowships" at US, etc. hospitals without mention of US residency (the US does not allow board certification or practice of medicine without US residency that spans several years.)
- They don't mention how many procedures they perform, especially major orthopedic or cardiac ones. This number is known to be positively correlated to quality. After Joshua's death and the resulting publicity they have changed their website quite a bit, but even earlier I had noticed that their treatment packages were generally for the minor procedures, e.g., angioplasties, with no mention of heart bypasses.
- They feed the media with claims that are clearly false or ridiculously exaggerated, though they are clever enough not to directly state these on their own literature or website. For example, the NY Times, the Pittsburgh Post-Gazette and other major publications quote them as having treated 58,000 Americans a year, of whom 70% come for major surgeries. A back of the envelope calculation shows they are exaggerating such numbers at least fifty-fold. For instance, see Tom Keesling's blog comments
- They don't put out any quality or outcomes data for major procedures, as some top Indian hospitals often do, and US hospitals are now increasingly required to disclose. Coming to think of it and given their declarations of patient volumes, even if Bumrungrad disclosed outcome statistics I wouldn't believe them unless it is independently verified.
- They don't have a pricelist of the standard procedures, unlike other top-tier hospitals popular with international patients. To get prices from Bumrungrad you have to go back and forth with one of their specialists assigned to your case. Their lack of up front estimates and transparent pricing makes me think, well, almost of used car salesmen. Or Bangkok's PatPong bargaining bazaar.
I've seen Bumrungrad from up close in addition to reading about it. I'd not go, or take a friend or loved one there, except if the outward patient experience (the tourism part of medical tourism) is a high priority. And the procedure is relatively simple, with inherently low risk. When I was visiting Bumrungrad their international lounge was a sea of women in black dresses and head scarves. I was told a large proportion of their foreign patients are women from the Middle East who come for nose jobs or other cosmetic treatments.
I worry because Bumrungrad on being exposed is likely to deeply undermine faith in other hospitals, including those in India, that are truly excellent and a better choice for medical tourists. The best outcome for the medical tourism industry would be for Bumrungrad to clean up its act quickly while acknowledging past mistakes, but I doubt this is going to happen with the current management in place.
Friday, August 3, 2007
The House has passed this Bill 225-204 over vigorous objections by Republicans and threat of veto by President Bush. Their objection is that this would expand "socialized medicine, and Washington-run healthcare." Well, so what? If this form of healthcare works much better than the alternative (and there's every indication that it does) then why should those terms be any grounds for opposition? Two thirds of Americans favor universal coverage, leave alone this more popular issue of covering children.
Interestingly, while 5 Republicans voted for this bill, 10 Democrats opposed it. Those 10 probably caved in to lobbyists or constituent special interests. I'm guessing their opposition arises because of the way this program is financed: by increases in tobacco taxes and cuts in subsidies to the Medicare drug prescription plan.
Paul Krugman wrote a good piece about this today in the New York Times, though it is unfortunately available only to subscribers. Here's the part I particularly liked:
"...The bill is so good that it has Republicans spluttering. “The bill uses children as pawns,” declared Representative Pete Sessions of Texas. Yes, the Democrats are exploiting children — by providing them with health care.
The horror, the horror!
What’s especially encouraging is the way House Democrats were willing to take on the insurance companies. The bill pays for children’s health care in part by cutting subsidies to Medicare Advantage, a privatization scheme that yields big profits for insurers, but that the budget office estimates would cost taxpayers $54 billion in excess payments over the next five years...."
Of course Bush may well veto this, but with all their spin that will probably cost Republicans big in the 2008 elections.
Wednesday, July 25, 2007
Many factors go into deciding whether you are a good candidate for going abroad for a particular procedure and a destination you may have in mind. Reducing these into a single quiz runs the risk of over-simplification. The scores and conclusions from it are not a substitute for common sense and are certainly not medical advice. But they can give some idea about your suitability. There's a reason why some choices are not labeled in continuous alphabetical order.
10 Question Quiz:
1. How much traveling have you done?
a. A lot, including to the region where my intended foreign hospital is located
b. Quite a bit by air, though not to my intended medical travel destination
c. Rarely by air, though some by ground (driving, train, etc.) in the US
d. Never / hardly ever
2. How fit are you to travel?
a. My doctor and I foresee no / hardly any problems
c. I am at very low risk, and can further minimize this with precautions
e. My risk is quite low, but much higher than for an average traveler
f. My doctor has advised against air/extended travel under any circumstances
3. What is the treatment and recovery time for the procedure (before you can fly back)?
a. Less than a week for minor procedures, 2 weeks for major ones
b. 7 - 10 days for minor procedures, or 2 - 4 weeks for major ones
c. 10 - 20 days for minor procedures, or 4 - 8 weeks for major ones
d. Over 20 days for minor procedures, or over 8 weeks for major ones
4. What is you financial situation?
a. Very tight. The savings from foreign treatment will save me from bankruptcy
b. So-so. I can just about afford US care but take a large hit to my savings
c. Comfortable. I can easily afford the US care but will welcome savings
d. Very good. Paying for US care is not a problem at all
5. Approximately how much will your intended treatment cost you in the US?
a. More than $50,000
b. $30,000 - $50,000
c. $10,000 - $30,000
d. $4,000 - $10,000 ($2,000 - $10,000 if you're driving distance away)
f. Below $4,000 (below $2,000 if you're driving distance away)
6. Is the added privacy and anonymity of treatment abroad (e.g., cosmetic surgery) important to you?
a. Very important
b. Somewhat important
d. Not a factor
e. Quite the opposite - I strongly prefer lots of friends and family close at hand
7. How much do you expect to save through treatment abroad?
(Consider your out of pocket costs, factoring in your insurance coverage, if any.)
a. Over 75% of the cost AND this works out to over $10,000
b. 50% - 75% of the cost AND/OR this works out to $5,000 - $10,000
c. 30% - 50% of the cost AND/OR this works out to $5,000 - $10,000
d. 15% - 30% of the cost (0% - 30% if your answer to "6" above is "a")
f. Below 15% of the cost (but choose "d" if your answer to "6" above is "a")
8. How much do you value sight-seeing and the experience of going to a new place?
a. Very important - it's one of the reasons I want to go abroad
b. A good side-benefit but my treatment quality is by far my key priority
c. Hardly matters - but if it helps pass the time while recuperating, that's nice
d. I dislike unfamiliar surroundings, and dread going to a new place
9. Are you familiar with the culture and the language spoken in the country you plan to travel to?
a. Very/quite familiar, and most or all of the people there speak my language
b. Not too familiar, but most or all of the people I'll be with speak my language
c. Not familiar, but many people at the hospital and hotel speak my language
d. The doctor and some of my hospital and hotel staff speak my language
10. How internet savvy are you?
a. Excellent at researching through Google (or equivalent), regular email user
b. Use email; occasionally surf the internet
c. Rarely use email or internet
d. I don't use the internet (someone else is helping with this quiz!)
Give yourself 3 points for an "a"; 2 points for a "b"; 1 point for a "c"; zero points for a "d"; minus 3 points for an "e"; and minus 15 points for an "f".
Add your points and rate yourself for the condition and destination that you have in mind:
25 - 30 points: You are an excellent candidate
20 - 24 points: You are likely still a very good candidate
15 - 19 points: You may gain significantly from this option, but weigh it carefully
6 - 14 points: The pros of your medical travel are probably outweighed by the cons
5 points or below: There's no place like home, including for medical care
Sunday, July 22, 2007
The other notable thing as I mentioned in my earlier post was that contrary to Dr. Sanjay Gupta's and CNN reports it was surprisingly free from any factual errors. I had thought of Michael Moore as a kind of a liberal rabble-rouser who would bend statistics to overstate his case. But he didn't. What he did do of course was to play up that hilarious trip to Guantanamo Bay and Cuba to highlight how Americans without coverage are worse off meeting healthcare needs than the denizens of both those places.
Other countries that he featured certainly have their shortcomings and it is an imperfect world. But they manage to achieve a lot more with their resources, and tellingly, those from Canada or the European countries would never trade their healthcare system for ours.
"Sicko" almost exclusively concentrates on two aspects of US healthcare - the role of private insurers and the pharmaceutical companies. These are responsible for about half the price differential between the US and Europe (where prices are roughly half those in the US.) The other two factors that "Sicko" doesn't mention contribute the same amount to higher US prices. These are malpractice laws and litigation (that leads to defensive medicine and other forms of waste) and artificially induced doctor scarcity that I have talked about earlier.
Still, I can appreciate why Moore stuck to two causes instead of trying to deal with all sources of US healthcare woes. There's only so much you can put into a two hour movie without over-burdening the audience. He did emphasize the high US costs, and didn't want to dilute the basic message of the need for universal coverage.
In short, I highly recommend the movie, whether you watch it in theatres or subsequently on DVD.
Monday, July 16, 2007
Then I saw Dr. Gupta's 4 minute "fact check" report on "Sicko." Some aspects of the report struck me as strange and unbalanced even the first time. But I paid more attention to it after seeing Sicko creator Michael Moore's outburst on Wolf Blitzer's CNN show, followed by Moore's rebuttal on his website. Subsequently, I saw the Moore-Gupta exchange on Larry King Live, then the actual movie "Sicko," and finally Moore's second rebuttal, this time of Gupta's statements made on Larry King Live.
In these situations you normally expect both sides to be at least partly right. But here's the thing - none of Gupta's substantive corrections or criticisms was valid. Worse, when the facts were starkly laid out in Moore's first rebuttal Gupta only acknowledged one mistake and managed to cover himself on Larry King with his debating skills, glibness, and "running out the clock" in the limited air time.
You can follow the successive links to see the whole story, but here are Gupta's key distortions:
- He accuses Moore of cherry-picking numbers from several data sources. I can see that Moore used the most authentic sources and the latest data where available, and going to other sources on a sliding scale when the ones higher up on the list did not have the information.
- Gupta said that Moore "did indeed fudge his numbers." You call it fudging or "cherry-picking" when the numbers you choose are more favorable to the case you're trying to make. In the main example Gupta gave, it was just the opposite. Moore says US healthcare at $7,000 per capita is much more expensive than Cuban healthcare at $251. Gupta says Moore cherry picked and fudged by taking this number of $251 instead of the BBC figure of $229. This is (a) a trivial difference, (b) Moore had picked the more authentic data source, and worst of all (c) the $229 number was making Moore's case even stronger, so he actually gave detractors the benefit of doubt by quoting the higher figure.
- Gupta quibbled with Moore's statement of US per capita healthcare expenses of nearly $7000 , claiming it was "actually $6,098." Well, Gupta's figures are for 2004, while Moore used the more current 2006 estimates from the US Dept. of Health Services. Gupta made the ridiculous point that the 2006 number was a "forecast." If you haven't noticed, 2006 is already gone, so while it's an estimate that may land up, say, a hundred dollars higher or lower than this estimate, the $7,000 figure is a lot more valid than the $6,098 Gupta touted. I want to ask Gupta, if the US authorities said they were really really sure only about numbers of 30 years ago, would he have espoused using those 1977 numbers for comparison, or the current official estimates?
- Gupta pointed out that Canada scored lower than the US in wait times to see the doctor. Talk of focusing on a glass being 20% empty. That same source said that New Zealand, UK, Germany and Australia (all with universal coverage) scored higher than the US in this six-nation study.
- Gupta showed that industry expert Paul Keckley (whose links and Repub affiliations weren't disclosed) dissing the Europeans because 15-20% of people will purchase services outside of the government system. He exaggerates the numbers, but even so this means that 80-85% of the people are happy enough not to look outside the government system, even for any supplemental care.
- Gupta made a big deal of Cuba at 39th place being behind the US in 37th place in WHO rankings. But the film clearly showed this, and irony of the point being made was clear - even a miserable place like Cuba coming anywhere near the US in healthcare comparisons is a shame.
- Gupta also deliberately mis-ascribes the claim to Moore that healthcare in the other countries is "free." Anyone can see Moore means that patients don't get billed so they are not inhibited from going to the hospital/doctor. The film spent several minutes addressing the issue and claim about "drowning in taxes" and Gupta wrongly implied that the film glossed over this aspect.
The list goes on. Did Sicko have any notable omissions? Sure it did, and I'll mention them in a subsequent post. But even here, Moore may have wanted to concentrate on the two issues that most bothered him, without the distraction of the other things that are wrong with US healthcare.
The point is, Gupta's original piece unfairly criticized "Sicko" on nearly all counts, and this does not stem from honest mistakes. He seems to have ended up defending his healthcare industry as a partisan while in the garb of an impartial journalist. CNN deserves credit for at least giving Moore's outburst coverage in their subsequent shows, and some additional time on Larry King Live to make his case. But while the casual watcher may be taken in, the errors in Gupta's initial report and his subsequent stance should be clear to those looking at it in some depth.
Dr. Sanjay Gupta may refuse to retract his story and unconditionally apologize. CNN should then do so on his behalf. That'll be the right thing to do, though I doubt it'll happen.
Tuesday, July 10, 2007
I like Sanjay Gupta and his programs, as well as Wolf Blitzer who I think of as the-man-who-rarely-smiles. But I can see why Moore was angry because at least some (if not all) of Gupta's critique was shoddy and inaccurate.
For example, he needlessly contested Moore's assertion that per capita US healthcare expenditure is $7000 a year saying it is actually $6,098. Even the 2004 figure as reported by OECD is $6,102 and the US Health Department's (HHS) estimates for 2006 exceed $7,000. More seriously, Gupta misquoted the movie as claiming Cuba spent only $25 per capita on healthcare (10% of the actual figure) while Moore fumes that the movie said $251. I just saw Gupta on TV admitting at least to this mistake, while needlessly losing grace by asking why it wasn't $229. (Well, duh, the lower number would just strengthen Moore's claim that Cuban care is much cheaper, so what is Gupta's point?)
As promised by Moore on the CNN program, he posted a strong rebuttal to Gupta's critique on his own website. But even if they've been sloppy, you've got to give CNN credit. They had interviewed Moore live so that his comments and outburst could not be edited, and then have been reporting on the story and the exchange since then on their news channels. Tonight, they've called Moore to Larry King Live for a full interview, with Sanjay Gupta in attendance. This should be interesting.
In a broader context CNN strengthens its centrist credentials with both the left and the right wings complaining that it leans towards the opposite side.
Saturday, July 7, 2007
During our chats Prakash and his wife Shabnam mentioned two health-related incidents, one relating to Shabnam and the other to their son Rishi that I'd like to share.
Some time back Shabnam developed a recurrent redness in one side of the white of her eye that would last for days. A Costco optometrist advised her to get this checked out by a large and flourishing ophthalmic practice that this Costco store worked with. Over the next year till recently Shabnam went to this practice seven times and was seen by three ophthalmologists. Each of them had a different diagnosis and prescribed a different (costly) treatment. Nothing helped.
Then Prakash who is a business professor with no medical background looked up the internet and found the answer - she has occular rosacea, a common condition for people with acne, and that she now manages with simple home treatment. I typed "redness eye" without quotes in the search box of http://www.webmd.com/ and it popped up right away.
The other incident relating to their son Rishi was also ophthalmologist related, and more disturbing. Rishi was a few months old when Prakash and Shabnam noticed in the mornings that he'd have excessive mucus in one inner corner of his eye that they'd clean up. On their pediatrician's recommendation they took him to an ophthalmologist. The ophthalmologist diagnosed 9 month old Rishi with a blocked tear duct and urged them to let him immediately operate on Rishi under general anesthesia. He said the procedure becomes more complicated after 12 months of age.
Prakash wanted to double check, and looked up on the internet as it existed then in 1996. He came across a Canadian website with discussions by doctors that said this blocked tear duct problem is common in infants, and frequently resolves by itself. Moreover, the doctors advised against surgery till at least 18 months of age. Prakash and Shabnam never went to that ophthalmologist again, and sure enough, Rishi's problem permanently cleared of its own by his first birthday. His parents are relieved that they didn't blindly go by the doctor's recommendations.
I've myself always relied on strong word of mouth by patients or doctor friends when choosing our doctors. I almost always end up with great doctors and recommend this practice. And as Prakash's stories show, it can help a lot to look up the internet to check on what your doctor says.
Monday, June 25, 2007
The BusinessWeek story and research by Michael Mandel is titled, "The Real Cost Of Offshoring." The rub is in the subtitle that says "U.S. data show that moving jobs overseas hasn't hurt the economy. Here's why those stats are wrong."
Anyone reading this and the text of the story would naturally think that offshoring (or some part of it) hurts the US economy, and stopping this offshoring will improve the economy. But the reverse still holds true.
All the article says is that the GDP growth is not being properly measured because of a "phantom" factor, so the growth may be half a percent less than calculated. This "would wipe out as much as 40% of the (reported) gains in manufacturing output."
What should have been emphasized is that cutting back on offshoring may protect specific manufacturing or service jobs, but it will make the overall US economy even less competitive and hence further reduce or even reverse GDP growth. UK under the much maligned and under-appreciated Tony Blair serves as a good counter-example. Its much fuller embrace of globalization and unrestricted offshoring of services has contributed significantly to its economic well-being and ten years of uninterrupted positive quarterly growth.
But BusinessWeek insinuates to the contrary. So people will draw the wrong conclusion about the many forms of offshoring, including international medical travel. Here's what I politely wrote to BW:
"Readers may draw the wrong conclusion from your June 18, 2007 cover story, 'The Real Cost of Offshoring.'
"Even if all the calculations and analyses are correct, it does not mean that putting the brakes on offshoring will improve the US economy, or even jobs and worker welfare in the long or medium term. On the contrary, in a globally competitive economy failure to embrace the efficiencies of globalization will make Americans worse off.
"Author Michael Mandel and economist Susan Houseman probably agree with this, but it needs to be stated explicitly."
I doubt they'll publish this.
Thursday, June 14, 2007
The hospitals with the highest costs for procedures like heart bypasses had worse outcomes and mortality rates than those that charged less than half as much. The high priced hospitals argued that their results were skewed by some very expensive procedures but even this doesn't explain most of the discrepancy.
The study hopefully also looked at median costs instead of mean costs. The former, which is what the patient at the 50th percentile or in the middle of the group would pay, removes the distortions of a few extreme payments and addresses the objections of the higher-cost hospitals. Most studies now also make so-called "risk adjustments" so that hospitals handling more complicated or difficult cases are fairly evaluated and compared.
As mentioned in an earlier post hospitals tend to be rewarded rather than penalized for their mistakes resulting in additional or extended treatment. I'm hoping these reports make Americans more savvy healthcare consumers who don't keep buying the "you get what you pay for" line. The same goes for insurers or employers who may be bearing most of the costs for their members or employees. In addition to improving domestic pricing and practices it will be a further impetus to medical tourism.
Wednesday, June 13, 2007
Though he'll release details later this summer, he wants to "free" tens of millions of Americans from employer based insurance and move them to the individual market "to give them more coverage choices." Mirroring GWB's "ownership society" he tells Americans "It is your health, you should own your own insurance."
At present it's the 60% of Americans covered by employer insurance who are the best off, and polls show they like their employers to use their collective purchasing clout to arrange insurance. Instead, Rudy is extending GWB's approach by wanting them to shop for their own care. According to another WSJ report this approach as it applies to the much hyped Health Savings Accounts (HSAs) is already starting to falter.
Of course, more choice to consumers can work well if it is structured properly, as in Edwards' or even Romney's plans where insurers cannot refuse insurance coverage or charge higher rates from sicker patients, and yet the overall pool of members remains viable because everyone including the healthy are forced to buy insurance. But Rudy opposes such compulsory insurance coverage.
Even worse, Rudy doesn't address the biggest problem of how to take care of the 47 million uninsured. Delinking insurance from employers and making it portable does little more than scratch the surface, and Rudy is silent about subsidizing or paying for coverage of those who cannot afford it. The tax breaks he offers for individual coverage have little meaning, especially for those who pay little or no taxes. And as I mentioned in an earlier thread, even for those who do, you get at most a $31 tax break for every $100 you spend on healthcare, so how will you come up with the remaining $69?
His "market forces" argument also is meaningless when you among other things (a) disallow the government from using its purchasing power to negotiate drug prices with companies who have monopoly power in selling them (thanks to their government enforced patents - they find no irony in the strong government role in enforcing these); (b) let providers like physicians restrict their own supply way below free market equilibrium; and (c) let hospitals maintain non-transparent pricing and quality information while gouging payers and patients who come their way and cannot switch in the midst of their treatment.
The way he lauds the "free market" over anything the government does makes me want to ask him why he doesn't urge everyone to buy their own weapons under the 2nd Amendment for self-protection and do away with the police force.
So why has Rudy come up with such a bad plan? He may figure this appeals to the fiscally conservative Right who want to minimize government spending and taxes no matter what, plus those Republicans who blindly (and wrongly) believe unrestricted private activity is always better than governmental involvement. He can also attract a lot of contributions from the healthcare industry players. This can increase his chances of winning the Republican nomination, and he can then change his tune (say to something like the Romney plan with greater government spending) well before the General Elections.
Will such a "bait and switch" strategy work? And will Rudy address some of the glaring deficiencies when he reveals the details of his plan later this summer? I don't know, but as of now I find it to be the worst of those put forth by the Presidential hopefuls.
Friday, June 8, 2007
This helps us understand the state of US healthcare. Okay, so it's not really murder of healthcare. Just a trillion dollars of annual extra spend (or half the US total) compared to say, France or Germany for same or worse care. As my article implies, roughly a third of the trillion dollars go to extra profits or earnings above "free market rates" to providers - drug companies, doctors, hospitals. The remaining two thirds of a trillion dollars is the inefficiency or "lose-lose" costs of keeping the current system in place.
How does this relate to the novel? If the high US healthcare prices were due to one factor unfairly enriching just one player, then that factor would have quickly been singled out and eliminated amidst the full glare of media and political spotlight. Instead we have multiple factors at play that enable each industry player to blame others and thus all can get away with "reasonable doubt."
Then of course with about $300 billion in excess rents at stake it is a no-brainer for the industry players to collectively plunk, say, a mere billion dollars annually to buy off (or "influence") policy makers. This helps to maintain the status quo or even alter it to further benefit the players. It's no accident that the drug benefit for seniors (Medicare Part D) costing about $43 billion annually are largely a giveaway to drug companies and private insurers with far less value to the seniors who are the professed beneficiaries. And Paul Krugman in one of his several articles describes how positive government involvement such as a VA (veteran's) health system built up in the Clinton era is stymied by business interests and their Conservative allies.
Lest all this is too general, let me recap some activities by industry players contributing to high US healthcare prices:
- Trial lawyers and the ABA styming tort law reforms and capping of malpractice damages.
- Drug companies overcharging for drugs by mislabelling government negotiations as "price controls" and taking advantage of a system where patients pays a fixed deductible. So patients don't care about prices, even when drugs have only marginal extra benefit.
- Doctor bodies controlling the physician pipeline to ensure that there's a shortage of doctors, instead of letting free market forces determine the supply.
- Hospitals consolidating to gain monopoly pricing power, and refusing to provide transparent pricing. In the process they often charge outrageously ($10 for an ibuprufen or aspirin pill or $75 for a box of tissues.)
- Private insurers opposing a competing public plan. I'm all for private insurance, but why not allow competition without unfair subsidies by a government institution? (P. 4 of 7 of John Edwards' plan envisages this.)
That's only five activities and players. Apparently you don't need twelve like in the novel to get away with it.
Sunday, May 27, 2007
Healthcare myths are often nurtured by industry players benefiting from them, though some are helped by our predispositions. For example, people comparing items tend to think that the higher priced one is better.
Here are the four biggest myths about US healthcare:
Myth: A major reason for high US hospital prices is cross-subsidy for the uninsured, non-paying patients.
Reality: Only 8% of hospital patients are uninsured and some charges are recovered from even this group. Hospital figures of 12% of un-recovered dues are based on the vastly inflated “list” prices that they bill uninsured patients.
Myth: The extra revenues from the high prices that drug companies charge US patients are ploughed back into research that leads to new, vital and innovative treatments.
Reality: Little of that extra money goes into truly innovative (as opposed to "me too") drugs. And to maximize their returns, drug companies on average spend over 30% of their revenues on marketing (even more so in the US), versus 13% for R&D. (See more in the first post and an incisive article by two Harvard academics.)
Myth: You get what you pay for. Pricey US healthcare is the best in the world.
Reality: Some “five star” foreign hospitals provide better quality in terms of outcomes (lower mortality and complication rates) and patient experience, at a fraction of US prices. Many of them are JCI accredited, with US/UK trained doctors. (See more in an earlier post.)
Myth: US healthcare provides a malpractice safety net / jackpot if things go wrong.
Reality: As many as 95% of US medical negligence cases including 90% of deaths from negligence do not result in a claim, often because the victim and their families don’t know or can’t prove that negligence occurred. Of cases that ARE filed, two thirds fail to secure any compensation. So the malpractice game is like a lottery with less than 3% of the payments going into prize money. And even the lucky winners have to fight an average of five years to collect their proceeds.
Monday, May 21, 2007
GASB 45 would force the state governments to curb wasteful expenses and irresponsible promises, and also have healthcare delivered more cheaply and efficiently to former and current employees. I have personally seen the effect of this newly imposed accountability.
Several state governments faced with budgetary pressures have started exploring innovations like voluntary medical tourism. In this the patients covered by state health insurance who need major surgery are offered incentives to receive treatment abroad in pre-approved hospitals that match or exceed US quality of care. This can dramatically cut costs for the state while being welcomed by patients who receive a portion of the savings. But special interests including local hospitals obviously do not like this, and the states are likely to overcome political opposition only in a budgetary "feet to the fire" situation. GASB 45 exposes a budgetary gap of $50B for Texas alone, and about $1.4 trillion for all 50 states.
But why not simply kill the messenger, GASB 45, so that the looming shortfall doesn't need to be planned for? The Texas Governor and legislators seem set on this course, ably assisted by Texas Controller Susan Combs who is also trying to get other states to join. The New York Times story today quotes how these “Politicians don’t want to deal with the problem ... state lawmakers were betting that by the time rising health care costs became unmanageable, they would no longer be in office and could not be held accountable."
Friday, May 18, 2007
Using this analogy I was initially underwhelmed by the Provencare offering of Geisinger Hospitals Group of Philadelphia that featured in a May 17 story in the New York Times . Geisinger offers a "90 day warranty" on some surgeries that it performs, promising not to bill insurers if extra procedures or care results from any complications.
If negligence on the hospital's part causes complications, the cost of follow-up surgery would pale in comparison to malpractice claims, and in any case I'd expect such care to be offered for free by any hospital to stave off a lawsuit. The 40 point checklist of care that Geisinger introduced is also not a new concept. And they've only introduced the system so far for one type of procedure - heart by-passes.
On more reflection and a little research though, there are good things to be said for the Geisinger initiative. At least they're starting to do what all US hospitals should have been practicing all along - offering a flat rate for standard procedures, and hopefully having a more transparent and simplified pricing system.
I'm amazed how hard it is for patients to get the "real" pricing information - even average or ballpark - out of US hospitals when many good foreign hospitals including those serving medical tourists will readily provide a "tariff list" that details the package and individual costs that patients will need to pay. US hospital bills come piecemeal even for a single procedure. Apart from this being an offshoot of a chaotic and complex billing system I also suspect that hospitals don't want the total charges to be easily known, as they're so high in absolute terms as well as compared to hospitals abroad.
Back to the story in the NYT, from the reported figures it looks that Geisinger would charge a total of about $37,000 for a "warrantied" heart bypass. If true, that's a bargain as the discounted or negotiated insurer rate without any such warranty averages almost twice as high for a typical US hospital. Geisinger's heart surgery outcomes and statistical information also looks very favorable compared to peer US hospitals.
So in the end I'll set aside my initial skepticism of this being just hype, assume the facts are correctly reported, and cautiously applaud the initiative at Geisinger as a precursor for better practices.
Tuesday, May 15, 2007
Except that the tidings here are glum, and elicit groans, not cheers. I'm talking about the "breaking news" from Reuters that the US pays the most (twice as much) for receiving the worst healthcare among the group of peer countries. The study is by the Commonwealth Fund that compares the US with Australia, Britain, Canada and Germany (wonder why they left out France that is rated the best in many studies.)
The Birkhead analogy is that I've been saying and writing about this for over two years, and my last update comparing the US to all the other (OECD) first world countries is here:
Going beyond this Commonwealth study I listed and quantified the contributions of the seven underlying causes for high US costs. Either way the broad insight is that if we can "just" copy the policies and health systems of these countries we can slash our annual healthcare bill by half without compromising quality. Imagine what the resultant trillion dollar savings can be used for. Controlling the deficit, making our businesses more competitive internationally, more resources to support our troops, giving out more no-bid contracts to Halliburton, launching wars against Iran and North Korea... (okay, okay, I'm just kidding about the later ones - sort of.)
Then of course there are the additional implications for my favorite subject - medical tourism. I wonder how long the mainstream Americans will continue buying the line of the US hospitals, "You get what you pay for."
Monday, May 14, 2007
Now distressed carmaker Chrysler is being sold and the prospective new owners hope that UAW concessions on health benefits restore the company's health.
You may have heard that health and other benefits to retirees and current staff place an extra $2000 burden per car for the Detroit Big Three as compared to their Japanese competitors. The WSJ article describes this another way - as a $30 per hour advantage that Toyota has over US makers that may increase to $45 per hour if the present arrangements continue.
Since a large chunk of these costs comes from healthcare, it strengthens the case for reforms like bringing healthcare costs down and also having healthcare for all (including workers) paid through public funds with all employers required to chip in.
But there's also a specific proposal in the current discussions for the UAW to be given a lumpsum of billions of dollars and then be required to manage the health benefits for its own members. Such a step should be welcomed. Direct responsibility will make the unions more supportive of innovative measures that can drastically reduce healthcare costs, especially if they maintain or improve quality.
We can talk about these steps subsequently. The point is, it will be good to see strong consumer groups pushing for healthcare reforms instead of just having key industry players resisting them.
Friday, May 11, 2007
Now relate this to a chain email that I received a couple of days back:
"A recent Physician Census by the Palm Beach County Medical Society confirms that the patient access to care crisis in Florida will worsen as the shortage of physicians reaches dangerous levels. In Florida, like many states across the country, patients can't get the care they need when they need it. Medical lawsuit abuse is forcing good doctors to flee the state, cut back on vital services, or leave medicine altogether. This update to the study shows that the shortage of neurosurgeons is even worse than indicated in the original Physician Census.
Palm Beach County currently has serious shortages of neurosurgeons, general surgeons, and family physicians. The Physician Census confirms that the patient access to care crisis will only get worse and that by 2011:
- Only 70 general surgeons will service an estimated population of over 1.4 million—a number that falls far short of the 208 needed for adequate patient care;
- Just 194 general and family physicians—not even close to the 373 needed—will be active in the county;
- Only seven neurosurgeons will treat emergency patients while 20 will be needed to meet demand;
- Physician shortages of 33% or more will exist among seven essential specialties, including obstetrics and gynecology, thoracic surgery and radiation oncology.
pass this information along to your friends, family, neighbors and colleagues and ask them to stand with us to protect each and every patient’s access to quality medical care and stop medical lawsuit abuse once and for all.
Dr. Jose Arrascue, President of the Palm Beach County Medical Society, cites medical lawsuit abuse as the reason for the bleak outlook for Palm Beach County patients. He says, “too many good doctors view this as a hostile market, with high malpractice premiums [and] no protection from lawsuits.” Most simply decide to practice elsewhere.
With forty-two states now considered to be "in crisis," "verging on crisis," or "experiencing serious problems," Florida patients aren’t alone. And there’s no time to waste. We must work together to fix our nation’s broken medical liability system. Please take a moment to
Thank you for your continued support.
Doctors for Medical Liability Reform317 Massachusetts Ave., N.E.Suite 100Washington, DC 20002
Phone: 1-877-9REFORM dmlr@ProtectPatientsNow.org "
Ironically, this email itself mentions the fact that "Florida is not alone" but "one of the forty two states" that faces doctor shortages. In other words, the root of the problem is a NATIONAL shortage of doctors who therefore have the luxury of picking the place where they want to work. The genesis of this is the artificially constrained pipeline and supply of doctors that I've mentioned in my blog yesterday. Malpractice caps and other tort reforms are certainly necessary but they at most shift the doctor scarcity from one place to another without solving the underlying problem.
Now consider the fact that excellent and highly experienced foreign doctors would swarm into Florida with or without malpractice reforms if only they are allowed to practice here without the bottleneck start-at-the-bottom residency requirement. Fear of importing incompetent or undertrained doctors or those with degrees from dubious institutions? How about allowing in medical graduates only from world class and reputed foreign institutions AND requiring them to pass a rigorous set of Board exams before being licensed?
Such a measure will truly "Protect Patients Now" (the website name of the body behind the email campaign) but expect the physician lobbies to vehemently oppose this. Not surprisingly, they instead push the wrong conclusion, like in the flea joke. Meanwhile, Florida has already enacted some tort reforms. For those still interested at this point here's an article that provides some details in a balanced perspective while questioning the assertions of widespread doctor flight from Florida:
Thursday, May 10, 2007
The only group that benefits from this scarcity are doctors themselves for obvious reasons. But now even some (though few) of the doctors talk of expanding the pipeline. http://www.medscape.com/viewarticle/532152
The case being made out is for Medicare and Medicaid to massively increase the allocations so as to expand the pool of residents. That will of course be money well spent, helping patients and saving money in the long term. But even this may not be necessary.
Most hospitals value their residents. Anyone who has been to a hospital (or even watched shows like Grey's Anatomy or ER) can see how much of the work and care is handled by medical residents. They are after all skilled (particularly past the first year of residency) and cheap labor drawing $40-$50K a year for working 80 hour weeks. Some of those hours may go into classroom-like training or learning by watching, but most of them directly and considerably benefit the hospital.
So why not allow hospitals who want extra residents (outside of caps imposed by the ACGME or RRCs) without subsidies from Medicare to simply take them on? Many experienced foreign doctors also can be brought in this way, who can more than earn their keep as residents from day one. Then there are US medical students who are currently excluded from residency (or residency in their preferred specialization) because of the caps on such residencies. They may be required to pay their way or forgo a part or all of their stipends to the extent that hospitals consider them worth taking in without receiving subsidies. Or they may be required to execute a bond that commits them to work for a certain period at that hospital after graduating, or else to refund their cost of training. Whatever the arrangement I predict there will be no dearth of deserving takers for such offers.
Ignoring any special interests that benefit from the shortage and launching a concerted effort to vastly expand the physician supply should be a top priority for the government.
Wednesday, May 9, 2007
On May 7th, the Senate finally allowed the long overdue cheaper drug imports into the US, but only with a rider that made the whole enactment fruitless.
This rider is the requirement that the Secretary of Health (HHS) certify that the imported drugs are safe, which of course he won't do (at least when he is part of the Bush Administration.) This safety provision is an obvious excuse since many drugs are imported into the US by drug manufacturers under FDA oversight with no such certification requirement. See for example this long-standing refutation: http://democrats.senate.gov/dpc/dpc-new.cfm?doc_name=fs-109-1-73
Disallowing cheaper imports complements the other element that allows higher drug prices in the US - the government neither able nor willing to directly negotiate the prices of drugs that it pays for. The official logic for that policy is even more absurd (i.e., that negotiations are tantamount to price controls) and deserves a separate discussion.
After 2008 a Democratic President and a filibuster-proof Democrat controlled Senate / Congress may finally manage to bring down drug prices. But don't count out the possibility of the drug industry using its largesse to buy enough Democratic support to preserve the status quo. Jack Abramoff (who bought off lawmakers for years) is gone, but not the culture and system that enabled him to thrive.