Easy Domestic Fixes For Doctor Shortages

Doctor shortages typically occur in poor countries that lack the resources to train physicians, or to sustain enough of them to provide proper care.  Only in the US is there a wholly different reason - their supply is tightly controlled in several ways by private doctor dominated bodies with cross-memberships.

The medical schools numbers and overall capacity is controlled by the AAMC (Association of American Medical Colleges) and the LCME (Liaison Committee on Medical Education).  LCME members are appointed in equal parts by the AAMC and the AMA.  In the 1980s and 1990s they allowed only one medical school to be added, though now they've belatedly allowed an 18% increase over the current 131 schools.  It still isn't enough.

They discourage applicants another way.  In all other countries students typically enter medical school straight after high school.  But the US medical schools require a college degree, even if it's in something as unrelated to future medical practice as art history or Slavic languages.  This needlessly adds a crushing expense and burden of four extra years of college, thus taking at least 11 years post high school in the US to become a doctor, as opposed to seven elsewhere.  It also means four less years in these doctors' medical career.

Still, a lack of medical school graduates can be made up by foreign medical graduates who comprise over a fourth of US doctors (Table 108 of NCHS (CDC/HHS) Health publication, 2009).  A much worse restriction on supply is the national cap on medical residencies imposed by the ACGME and the RRCs (again, private doctor bodies). You can't practice in the US without such residency.

Then there was an amazing coup in freezing doctor supply through the passage by a Republican / Gingrich controlled Congress of the Balanced Budget Act of 1997.  Sneaked into this 537 page long Act are sections 4621 and 4623 that froze the future number of medical residents to 1996 levels, for whom Medicare had long paid almost the entire cost of training and salaries. The Medicare direct and indirect payment to hospitals for each of the roughly 100,000 residents, amount to $10 billion a year.  The freeze "saved" incremental payments of $1 billion or so, but resultant scarcities of doctors in subsequent years enabled excess fees hundreds of times greater.  This is like "saving" by denying a patient cheap medicines now, leading to hospitalization costing a hundredfold more.

As a result of these freezes on residents in the Act the doctor trade associations could now sit back and escape adverse notice.  Henceforth this restrictive legislation under the guise of savings would do the job for them by blocking the much needed doctor expansion.  Notably, the provisions capped the number of residents, rather than the total sum of money for payments, which remained very high per resident, averaging over $100K per year.  Why does this matter?

Because it prevents the HHS from obvious solutions like spreading the same pot of money over more residents, thereby increasing doctor supply at no extra cost.  For example, reducing Medicare payment from $100K annually per resident to $75K would allow a 33% increase of funded residencies with the same resources.  There will be plenty of takers.  Residents are eagerly sought by hospitals since they form a vital part of the operations. At an annual salary of $50K, they are remarkably cheap and underpaid.

Hospitals pay nothing for them presently, and will readily pay them $25K if the other $75K ($25K towards salaries and $50K for training and tuition) comes from Medicare.  Reducing Medicare payments per resident may also encourage privately funded or self-funded residencies, which will then face a less steep differential than the current $100K.  But as I said HHS hasn't been allowed this option even though it can dramatically expand doctor supply at no extra cost.

All this has created long standing shortages, with the US having only two thirds of the average doctor density in other developed countries.  This strikingly impacts the price and availability of services.  US doctors earn well over twice as much as their first world counterparts, both in absolute terms and relative to the average incomes in their respective countries.  It is one of the top three contributors to the inflated price of US health care, right up there with hospitals and providers saddled by inefficiencies, over-regulation and legal exposure, and a dysfunctional, complex private insurance system.

Not surprisingly, doctor groups and their experts dispute such nexus between doctor scarcities and inflated provider costs and earnings.  Their counter-arguments are flawed as described in my June 27 post.  There I also stressed the need to import doctors to address shortages, for at least the next ten years.  This is the lead time for any policy changes on domestic supply to have an impact.

But over the longer term these coveted and high paying physician positions can and should be filled by Americans.  The good news is that the solutions need little or no funding, are administratively straightforward and easy to put in place.  The biggest obstacle may be the opposition and fierce lobbying by doctors' bodies.  However, an enlightened administration and lawmakers should be able to do the right thing.  Especially if they are prodded by the increased (and overdue) public awareness of the issues involved, and the potential to add good American jobs.  Besides, if we have new laws that let in foreign doctors to ease shortages, doctor groups may no longer see any benefit from restricting domestic supply, and drop their opposition to such changes.

Here are the fixes that will make it easier and cheaper for talented Americans to pursue medical careers without compromising quality, and eventually internally meet all our doctor requirements:

1)  Medical schools should drop the college graduation requirement and like in all other countries, allow in high school graduates.  The core subject requirements can be met through prescribed AP courses in high schools, with the MCAT typically taken around the same time as the SAT.  The four years of time and resources for college education that is saved can instead be applied to residency training and the actual practice of medicine.

2) The expansion of medical schools and setting up of new ones should not be constrained by the AAMC and LCME with an eye to future demand for doctors.  They should only concern themselves with determining whether such institutions meet the appropriate academic and quality standards.  If the AAMC and LCME refuse to go along the government can replace them with other bodies that it sets up for control over establishing, expanding and accrediting medical schools.

3)  All residency caps imposed by the ACGME and the RRCs should be eliminated.  These bodies should only set professional standards and test procedures, and assess candidates, not determine the quantity of intake.  Like in other professions and disciplines, let the free market prevail. Teaching hospitals can determine how many residencies they want to offer keeping in mind their needs as well as the demand by candidates looking to their own future career prospects.  Of course, almost all residencies presently are wholly supported through public funding, although this shouldn't necessarily continue to be the case.  So residencies will still be constrained by the availability of such funds.  But the decisions on such funding (and consequent availability of residencies) will be made by committees of public representatives looking to ensure adequate future supply.  Not by private doctor bodies whose members benefit from scarcities.

4) The government should be prepared to counter resistance to (3) above, since the ACGME and the RRCs as private bodies may insist on capping residencies as they've been doing so far.  But they derive their power from the government recognizing them as the authority for assigning and filling residency positions.  If they do not cooperate, the government can set up other bodies to implement these functions, either in place of, or in parallel to, the ACGME and the RRCs.

5)  The ill-advised provisions of the Balanced Budget Act of 1997 that restrict the number of residencies should be repealed.  The funding for residencies by Congress will still be needed as it was before 1997, through normal appropriations.  The HHS can seek such funding based on projections of future need for doctors, estimated by an appropriate body of unbiased experts, while erring on the side of oversupply.

6) Doctor fears of future unemployment can be assuaged by guaranteeing their employment by public agencies, so long as they are qualified and competent.  Their minimum salary can be set at a decent, say, $150,000 - $200,000 annually depending on experience and specialty, and they can be employed in public clinics and the like.  Such salaried doctors patterned on UK's NHS will be cheap by US standards and save Medicare and Medicaid money if patients go to them instead of other doctors.  At the same time these salaried doctors will not be spending time chasing insurance payments or running a practice and consequently enjoy a better work-life balance.  Under such a public employment guarantee scheme, doctors will likely be less opposed to the other changes proposed here.

7) Finally, Americans can be quite naive and vulnerable to propaganda by special interests, as shown by public opinion against the March 2010 health reforms and even more so, the failed 1993 reforms.  So the government will need to stay on top and ahead on the message.

Costly Nelson Eye On Free Trade

In 1801 Horatio Nelson put a telescope to his blind eye to disregard signals to retreat from a naval battle.  His valor resulted in a crucial victory over the French fleet.  But the US turning a Nelson eye on solutions through free trade in health services is an act of cowardice and cynicism.

The "W" Bushies are also guilty of such neglect after the benefits of trade grew with the proliferation of world class medical facilities abroad, and the advent of the internet and better communications.  But the failure of Obama's team is more poignant when new laws covering the uninsured add to overall costs, as well as to the scarcity (and resultant leverage) of domestic providers.   

On trade in health services, Prof. Bhagwati and I in mid-2008 highlighted promising approaches and reiterated these in my December 2009 post. Four subsequent posts have elaborated on each category (or mode) and quantified potential savings.  The overall picture is compelling.

Highly qualified foreign doctors who have cleared the required US medical board exams can remotely consult through video-conference with a nurse at hand to assist with the patient, if necessary.  Diagnostic radiology does not even need direct patient contact.  This type of telemedicine can easily replace a fourth of primary care visits and diagnostic radiology readings, as well as a tenth of specialist visits, and all at a fifth of the cost.  This will not only help meet the crisis of additional demand due to health reforms and an aging populace, but also save $16B in 2006 terms.  This translates to $267B of savings over the next 10 years, $133B in public funds.  Even the states can authorize telemedicine within their areas, if the federal government doesn't act.

 In medical travel, US patients go to reputed hospitals abroad for major surgeries and medical procedures, often performed by US or UK trained doctors, at a fraction of the cost.  The movement can receive a huge fillip if lawmakers and the leadership reduce legal exposure through legislation, create protocols and procedures to select and qualify foreign hospitals, and identify procedures to be covered.  They should also send publicly funded patients and lay down the incentives for such patients to volunteer, so that private insurers can follow suit and get legal cover.  There are some 30 major procedures costing $300B in 2007 terms that are suitable for medical travel.  Assuming a fourth of these are off-shored the savings are $57B annually in 2007, which comes to $950B over the next 10 years, half of this in public funds.

The third way of trading in health services is to allow and encourage foreign entities to set up hospitals here.  This will allow under-served areas to be covered and introduce greater competition in MSAs, 90% of which face highly concentrated markets for hospitals.  But most importantly, this will bring badly needed reverse innovation to the egregiously expensive and inefficient US hospital system.  Policy changes needed include easing the process and shortening the time line for approval, creating standard guidelines and norms for facilitating this, and doing away with state regulations holding up such hospital creation.  The resultant savings due to competitive pressures and forced changes bringing US costs halfway down to European levels (or "just" 1.5 times instead of being twice as high) are $175B in 2007.  This comes to $2.73 trillion over the next 10 years, with $1.36 trillion of this in public funds.

The final piece is allowing highly qualified foreign doctors trained in one of the pre-approved list of accredited foreign institutions to practice in the US, without going through a US residency.  Other conditions can be imposed on them, like requiring them to clear the required US board exams, or tying their visas to practicing in designated under-served areas.  This will immediately boost doctor supply and should be undertaken in parallel with expanding the domestic pipeline that will start having an impact in 10 years. The US has 2.4 doctors per 1000 people compared to the OECD average of 3.4.  Boosting this US ratio from 2.4 to 3.0 will require 200,000 additional doctors, but this increased number will ensure better access by patients, as well as reduce the scarcity related prices for doctor services.  If these prices go down by 23.5% to the Medicare rates dictated by the (never implemented) SGR formula that are still generous by European standards, then the savings are $79B in 2007.  That is $1.26 trillion over the next 10 years, with $630B of this in public funds.

Therefore apart from the vital increase in access to badly needed services by US patients, the total savings from all four modes of trade are estimated at $5.2 trillion over the next 10 years.  Nearly half of this or $2.6 trillion will be in public funds.  To get some perspective, compare this with the $1 trillion projected added cost of the health reforms bill that created such a firestorm among Republicans.  Had they faced the trade option squarely (requiring them to face down their health industry lobbies which is why they didn't, of course) we'd have saved substantially even after the passage of health reforms.

There is hope yet.  Dr. Donald Berwick's appointment as Director of CMS (during Congressional recess, over Republican objections) is a positive development.  He has studied and talked extensively about the merits of foreign health systems, including Britain's.  If he can look not just at these systems, but to them for solutions (and carry the political will of the Obama team with him) then a lot of these desirable measures can become reality.

Trade of course is not the only answer.  Several unrelated domestic policy initiatives can make a huge difference (more on these later.)  But its potential and benefits are so large that Obama and the lawmakers should urgently look at it - with their good eye for a change - and act accordingly.

CDC Can Do More on Swine Flu

Looking up the CDC website on swine flu guidance reminded me of an old joke about a balloonist who was swept away by the winds and got lost.

He lowered himself next to a tall office building. He wrote "Where Am I?" on a placard and held it up for the people inside the building windows to see. Those people responded with their own placard that said "You Are in a Balloon 100 Feet Up in the Air." That answer was however enough for the balloonist to know that he was at the Microsoft headquarters in the Seattle suburb of Redmond. For going by its help feature in its products only Microsoft could provide an answer that was completely correct and yet so irrelevant and useless.

How's this related to swine flu? About two weeks ago I briefly came down with the sniffles and a mild fever that lasted less than a day. Then over this Labor Day weekend we drove to Pittsburgh where Anita's nephew had similar symptoms. We isolated the affected person (me and our nephew) and considered the obvious question of whether to seek testing, and if yes, where.

Testing would help the authorities to compile statistics and monitor the spread of the disease. Patients testing positive would know what to watch out for and be extra careful about exposing others. Recovered patients presumably acquire immunity, and needn't worry about subsequent exposure, or getting inoculated when the swine flu vaccine becomes available.

On the other hand, patients arriving in large numbers in medical facilities could put providers and other patients at risk, and strain scarce resources. Also, uninfected patients can acquire the H1N1 virus from others in the very clinic that they visit.

Weighing these pros and cons we looked at the CDC and other official websites for guidance. Despite all the other information crammed in there, we found nothing addressing these obvious questions. Countless other patients and American families may be similarly confused and frustrated.

The closest answer I got after clicking through links and menus was an indirect one, under "Home Care Guidance: Physician Directions to Patient / Parent." It said that you should see a doctor or seek medical help if you develop certain serious symptoms, presumably meaning that you shouldn't if these don't occur. It needs to be a lot more explicit and easy to find.

The new health care and CDC leadership under the Obama administration has been in place for quite some time, with Director Thomas Friedan confirmed in May 2009. They should have personally scrutinized their agency's website and confirmed there are no glaring omissions. They don't seem to have adequately done so, but this is fixable. Having worked in government these are the obvious added steps I would take in regard to swine flu were I directing CDC or the HHS in regard to the flu:

1) Prominently feature in the Frequently Questions (FAQs) and other parts of their website, as well as in briefs to the media

• Advice to persons with typical symptoms and parents on whether and when to get tested for swine flu, and when not to
• Similar advice on when to seek medical help or visit a doctor, and when to hold off out of concerns of spreading or contracting infection
• Some information about the cost of testing, the best places to go to (doctor's office, clinic or hospital emergency room?) and the reliability of the tests. Add more "layman" information about the benefits - and the downside or risks - of anti-viral treatments like Tamiflu and Relenza.

2) Have an interactive feature on the website where users can enter their address or zip code. They then get a listing with addresses and contact information of nearby medical facilities that have special swine flu treatment arrangements and / or accept patient samples for testing. To keep pricing transparent and competitive, such facilities should disclose their prices for standard testing and treatment, and this information should also be displayed. If an interactive feature is beyond CDC's scope they can at least provide links to state and local government resources that provide this information. It will specially help the uninsured, and many insured patients as well.

3) Engage and coordinate efforts with large providers and test labs to expand capabilities to handle swine flu patients. The CDC can also issue standard guidelines and practices (e.g., separate windows and rapid turnover waiting areas for flu patients in emergency rooms with proper signage, to limit cross-infections) that help providers and patients alike. The CDC can even use its power to disseminate information to have "suggested prices" for testing and treatment. Coupled with inviting providers to include their prices in the links on the CDC website as at (2) above, this will encourage lower prices.

4) Orchestrate a system to enable healthy family members to get sterile vials or containers from labs, collect patients' samples like nasal swabs, and submit these for testing. This way patients being tested get to stay at home and again limits inconvenience and the spread of infection.

5) Encourage or help set up a system of home visits to patients by health workers. Such workers should have either already contracted and recovered from H1N1 infections, or have been vaccinated after this treatment becomes available, so that they are immune.

Similar steps can be taken to disseminate detailed information about the swine flu vaccine which is expected to be widely available very soon. The CDC and the HHS are large organization with multiple responsibilities. So ideas like these may not have been considered. I hope they are responsive once they see them. Since H1N1 flu has now spread worldwide, other countries can also adopt similar practices.

A Common Doctor Blind Spot

Patient alert: Many doctors seem to have a blindspot while treating infections. This can subject patients to needless agony or worse. I have personally observed this at least half a dozen times in India and the US, and some cases ended very badly. In all of these the patients were intensively treated with all kinds of strong antibiotics, to no avail. Here they are in chronological order:

1. Over forty years ago my father's uncle suffered a slow and agonizing death from virtual starvation after being hospitalized and then released. He refused to eat anything, and by the time they figured out why, it was too late.
2. My brother Kaku as an infant was afflicted with this infection and suffered for weeks after a hernia operation. It even transferred to my mother who was breast-feeding him. Finally, a very good and experienced doctor diagnosed the problem and it disappeared quickly.
3. Vivek from my college and subsequently my IAS batchmate in HP had a severe illness in the late 70's that landed him in one hospital in India and then another for several weeks. He had high fever, loss of appetite, yellow eyes and other symptoms of hepatitis that had doctors stumped since he did not respond to conventional treatments. Starting from a healthy body weight he lost about forty pounds in that time before doctors in India's famed AIIMS hospital correctly identified the infection. They then quickly (and easily) treated him, bringing him back from the brink.
4. In the late 80's my friend Raj was hospitalised in LA for several days with high fever and other symptoms that defied any treatment. Finally, a doctor of Indian origin happened upon his case, asked him one very relevant question, then ordered a test that confirmed that doctor's suspicions and prescribed medication that rapidly cured Raj.
5. About 10 years ago my young cousin Pavan in the US who was a medical student had a tonsillectomy. A few days later the pain in his throat was so acute despite all the medicines he received that he couldn't eat. Based on her experience (and high intelligence) my mother who has no medical background guessed at the problem and asked Pavan's family to bring it up with his doctor. The doctor after needless delay finally listened and Pavan was treated, but his prolonged suffering caused him to miss his medical board exams that year.
6. Just last month my father-in-law (Daddy) was recovering from two major surgeries at Inlaks hospital in Pune, including complications of pneumonia and hospital acquired infections. His lungs cleared and surgical wounds healed after a strong regimen of antibiotics, but he continued suffer from cough and persistent throat irritation. He couldn't sleep, asked to gargle every 15 - 30 minutes even at night. The Inlaks doctors ordered more antibiotics and tests and thought the irritation was due to residual infection in the breathing passages, as well as the feeding tube that was subsequently inserted because Daddy wouldn't eat or drink. But the problems was as bad or worse for several days after the feeding tube was removed and he was taken back home. Then I had Dr. I examine Daddy at home. Dr. I is very intelligent and sought after though he doesn't have quite the fancy qualifications of the Inlaks doctors. He had Daddy open his mouth wide, depressed his tongue and peered at the back of his throat with a flashlight. That was enough to provide the answer and clearing the condition in two days, though this was after two weeks of avoidable suffering and debilitation.

There is a common thread in all these cases. The doctors did not consider anything beyond bacteria and viruses as the cause of the infections, or simply ascribed the problem to "weakness" or irritation.

But in four of these cases at 1, 2, 5 and 6 above involving my great-uncle, brother Kaku, cousin Pavan and Daddy respectively the culprit was oral fungus, commonly known as thrush. The "good" bacteria in the oral cavity normally keeps this fungus in check, but antibiotics can kill this good bacteria. Then this very painful fungus infects the delicate lining of the oral cavity and typically shows up as white spots (though these may not be visible in the esophagus.) Once diagnosed, thrush is easily and rapidly treated. But if doctors who don't catch on and simply give more antibiotics can make the problem worse instead of better.

In case 3 involving my colleague Vivek, the culprit was amoebiasis where it was the amoeba that had invaded the liver. Again, while antibiotics don't work at all, anti-amoebic medications rapidly clear the condition - provided the doctors make the correct call.

Wanna guess what Raj had come down with in case 4? Well, it was malaria. The American doctors did not have this on their radar as it rarely occurs in the US. But the Indian doctor asked Raj if he had been abroad recently, and when Raj mentioned his recent trip to India, the doctor asked for his blood to be tested for the malarial parasite, and viola!

The takeaway: it seems to be a fairly common doctors' blind spot. If conventional treatment isn't working ask your doctor early on if he / she has considered and ruled out non-bacterial and non-viral infections like those caused by fungi, amoeba and parasites.

Exercise Don'ts And Dos

I know, I know. Diet and exercise is the nauseatingly repetitive advice for best warding off many health problems. And unlike claims by some enthusiasts about the "high" you enjoy while exercising, the best part of my workout by far is when it is all over for that day.

Exercise for me has been purely an obligatory part of physical maintenance, and I used to follow a home regimen some days a week. So if you've been having problems overcoming inertia or a hectic schedule I'll encourage you to be more active. But trust me, I feel your pain.

Fifteen years ago my (then future) sister-in-law Deanne first helped overcome my reluctance to enter a gym. She introduced me to some exercise equipment and I've been a fairly regular gym goer since then. I'm glad it's paid off, but I've had sporadic problems because of wrong exercises or poor form that I learned about and corrected only subsequently.

But today I happened upon this excellent article with illustrations on WebMD.com about nine bad or least effective exercises, and better ones in their place. I'm guilty of at least three of those nine lapses, and wish I had seen this article earlier. It's certainly worth a look.

For those who don't like the concept of gyms or using exercise equipment there's also this useful article about seven "most effective" exercises that can be done at home. Five of these require no equipment at all and in the other two dumbbells or simple home objects can substitute for the barbells shown. Of course there are several lists of "best exercises" featured in magazines and other publications, and this is just one of them.

Finally, here's the Wikipedia description of the classic 5BX / 10BX system for men and women (with a link to download it) that takes just 10 - 15 minutes a day. I used this for many years after it was taught early in my service career, and still like to go back to it from time to time.

Right To Death

A Feb. 5th article by Jane Brody in the New York Times articulates a lot of my feelings about exiting life gracefully. I admire people with a strong will to live and am all for giving them the opportunity and means to prolong their lives as much as possible.

At the same time there are many people who haved lived full lives and don't want to end up with a miserable, lingering existence when they're too old, sick and incapacitated. Add to this group those who are terminally ill, know for certain that drastic and highly painful treatments will only get them a few months, and would rather pass away on their own terms. If or when I'm in such a situation I'd solidly prefer this option.

I'd go further in case I developed a condition that gives me only a few more months to live. I'd then prefer an immediate exit if it can save multiple other lives, e.g., through donation of organs that are still usable, instead of waiting till these are also ravaged by time and further treatment. Laws should be enacted that would allow me to do this.

I thought well of Dr. Kevorkian for pushing for legalization of assisted suicide under the right circumstances. Oregon and countries like The Netherlands, Belgium and Switzerland have taken welcome steps in this direction and I hope the rest of the world follows suit. While economics should not be a key factor in this debate a study I saw found that 28% of all US healthcare spending is on people in their last year of life.

Any laws allowing assisted suicide or euthanasia should have strong safeguards of course. What we would certainly not want is any person feeling pressured (even through silent cues and non verbal behavior) to end their lives to avoid being a burden on their family or others. I believe Oregon addressed this, and any further improvements can be carefully considered.

There's a related issue of the dilemma faced by the families of people who can no longer make their own decisions, and haven't made living wills covering their circumstances. A relative of mine faced this very difficult decision and felt torn before and after making it. I say to that person that you did the right thing, and this took a lot more bravery and fortitude than shirking responsibility.

Finally, getting to the brighter issue of continued living when it needs long term and/or assisted care, it's worth considering care overseas. It's a variant of medical tourism that is just beginning to be looked at. It can greatly ease the financial and physical burden of caring for Americans unable to look after themselves. Further, it can improve their quality of life thanks to an abundance of good, inexpensive help available in the right places. I just finished a little study for one such facility in India. I'm merely mentioning this idea here as it merits detailed discussion separately.

Choosing The Right Medical Tourism Company

I won't go here into whether US medical tourists should deal directly with foreign doctors / hospitals or use one of the several medical tourism companies that offer to help facilitate the process. That can be the subject of a separate post. The latter option certainly makes things easier for most people.

I'll proceed from the point where you or your loved one are (a) exploring medical tourism as an option for your condition and circumstances, and (b) planning to use one of the "free" medical tourism operators in case you go abroad.

Since US insurers have been tardy about offering medical tourism solutions with the right incentives, I'll also assume you're individuals who are planning this on your own, and paying mainly or entirely out of pocket.

You'll likely know about these operators either through medical tourism accounts in the media, or typing something like "medical tourism" in a search engine like Google and seeing the sponsored and unsponsored links leading up to these operators' websites. You'll probably see about half a dozen to about a dozen options. You may like to study all the websites, and perhaps also Google the names of the medical tourism companies to see if any relevant stories or references about them come up.

I know some "good" medical tourism companies but none of them is anywhere near ideal in my view. So I won't name any companies, and leave you to choose one based on your own judgement. But listed below are some of the key factors that should help your decision:

• Credentials of the management team: Does the company list its management and their bios? What is their background and experience, and how relevant is it to healthcare and the services they are offering? Do they have certified doctors and/or nurses to help or advise you?
• Who are the foreign partner doctors and hospitals? The choice of the doctor for your specific procedure, followed by choice of the hospital are the two most important decisions, and it's a huge plus to have a company that allows you to see and evaluate both. Some people wonder how important is JCI accreditation for a hospital. This accreditation at least establishes a certain standard and demonstrates the hospital's interest in serving quality conscious medical tourists. It does not guarantee that the hospital is world class, or that there aren't better hospitals around. Still, given that over 100 hospitals worldwide are now JCI accredited and the list is growing, you are likely better off limiting yourself to JCI accredited hospitals, particularly for major surgeries
• Access to live operators and relevant help: Most companies will have a phone contact number (often toll free) in addition to web-based query forms or email. You should call such numbers and have your questions answered. This will also give you a feel for the company. If you are kicked into voicemail or fail to reach someone live, that's not a good sign for two reasons: (a) It is indicative of a small operation that is not sufficiently or professionally staffed and (b) You may have similar problems contacting the company in real time if you need their help once you are abroad
• How much information is out there? In general, having a lot of good, up to date and relevant information on the website (while avoiding clutter) is indicative of professionalism, aside from being useful to the patient.
• How "open" is the site? Some sites have stopped showing their partner doctors and hospitals, because of cases where medical tourists have used the information to bypass the company and go directly to these providers. For the same reason, some sites require prior registration before allowing greater access, so that they can collect their marketing fee from the attending hospital even if the patient subsequently bypasses them. These developments are understandable though unfortunate. A free flow of information allows for comparisons and sounder choices by patients of medical tour operators
• Information on medical procedures and pricing: In general, it is a good sign if the company posts some typical procedure prices and descriptions on its website. Beware of bait pricing, though some operators have been forced to adopt this practice because they'll be otherwise disadvantaged by their unscrupulous competitors
• Services offered, the infrastructure and arrangements in the foreign location: You should compare the services being offered and whether/what you're being charged for them. Services include arranging for visas, transmitting medical records, getting appointments with the foreign doctor, travel arrangements, cell phone in the foreign country, meet and greet at the airport, having a companion or local contact in the foreign location, local transportation, etc.
• Word of mouth: This is admittedly a tough one, but great if you can manage it. Talking to former customers/patients who used the company can be very useful so long as the company is not cherry-picking only those who they know are very satisfied or served well. If the company can somehow let you draw upon a "random sample" that can be a lot better. By random sample I mean that they describe and list the patients in general terms (to protect privacy) that they sent in an interval of time that you specify and let you pick the patient you'd like to talk to (if the patients are willing to do so, of course)
• Testimonials: These can suffer from the selection bias I talk about above. That is, the company lists opinions of only the most satisfied customers and you've no idea about any horror stories. Still, some companies carry a very large number of detailed testimonials and video discussions that can be educative
• News reports and media stories: This may not be a huge factor because the media can also be fooled by hype as in Bumrungrad's case (this is a hospital, not a medical tourism company.) But a lot of favorable media coverage of a company and the company's history can be reassuring. Plus, such a company will have a reputation to protect. Don't confine yourself to the stories listed on the companies' own websites - they will obviously exclude negative material. You should use search engines like Google and look through the "unsponsored" links to get more information. This is likely to be helpful even though companies can maneuver some high listings through SOE (search optimization engine) techniques

Most of these companies are paid a fixed percent of the package cost by the hospitals as marketing fees or commission. So they stand to earn more if you go to a more expensive hospital. This is just something you should be aware of, though they may advocate a more expensive option for bona fide health reasons and for your own well being.

In closing a little research and comparison shopping can very worthwhile. Good luck!

Bumrungrad: Go Elsewhere For Medical Tourism

My colleague David Williams had asked for my comments on his MedTripInfo website posting about the world's best known medical tourism destination - the Bumrungrad Hospital in Bangkok. Alas, "best known" is certainly not "best choice" as far as I'm concerned. Here are my views that I also posted on David's website:

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.

No Kidding About Coverage

When logic cannot work, try mouthing inane phrases to discredit a sound measure. That's the tactic of choice for our Republican lawmakers and our President once again. The issue at hand is extending and expanding the Children's Health Insurance Program so that it covers children of lower middle class families in addition to poorer children.

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.

Are You A Good Candidate For Medical Tourism?

Here's a quiz I wrote at the request of my colleague and fellow BCG alum, David Williams who runs medtripinfo.com. This is a site dedicated to international medical travel (also called medical tourism) for Americans.

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!)

---------------------------------------
Scoring:

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

Sicko's Critique By Dr. Sanjay Gupta, CNN Is Entirely Misplaced

Funny how a little conflict of interest can show up a person who's so well thought of for years. I've avidly watched Dr. Sanjay Gupta on CNN and affiliated stations, and found him to be very informative, articulate, engaging and interesting. He is all that, but I also ascribed honesty and sincerity to his earnest doctor's persona.

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.

Moore Bites CNN Back

I'll talk more about "Sicko" after seeing it, but here was an interesting explosion on Wolf Blitzer's CNN program by Michael Moore yesterday. Moore reacted angrily to Dr. Sanjay Gupta's four minute long fact-check segment on "Sicko" that preceded Moore's interview.

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.

Two Doctor Stories, And Takeaways

Some doctors are very good and others are not. It pays to pick your doctors carefully, and also to do your own research. This was reinforced when we spent time with Anita's brother Prakash and his family this past July 4th holiday.

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.

You Don't Get What You Pay For (QED)

This is somewhat new. Past studies have repeatedly shown US Healthcare to cost much more and yet deliver lower overall quality than in other developed countries. But now this Pennsylvania government survey as reported in the New York Times shows the same disparities among US hospitals themselves.

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.

If They Don't Have Bread, Let Them Eat Hay

When a woman is dumping her boyfriend she may break it like good news, saying she'll always cherish him, and loves him enough to set him free. That's my reaction on seeing a WSJ report on Rudy Giuliani's healthcare proposals.

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.

Murder On The Healthcare Express

In Agatha Christie's classic "Murder On The Orient Express" the famous detective Hercule Poirot is unable to solve a murder because the clues point to twelve people on the train. So he cannot identify the killer among them. Turns out that all twelve were involved.

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.

Four Myths About US Healthcare

Nazi propagandist Joseph Goebbels (1897-1945) famously said that a lie repeated often enough becomes the truth.

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.

Texas: Party Now, P(r)ay Later

In a first for any state, Texas is about to scuttle rules drawn up by the Governmental Accounting Standards Board. These rules (GASB 45) require governments to disclose the cost of healthcare they have promised to their employees, so that their future expenses are kept in line with expected revenues. Texan politicians want to continue spending now, without worrying about a financial crunch after their time. Their colleagues in other states may also like this easy way out.

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."

Surgical Warranty Or Gimmicry?

Remember the Firestone tire defects of the late 1990s and 2000 that caused Ford Explorer SUVs to be involved in several accidents and deaths? How much would it matter if compensation for any accident and injury also included the free replacement of the defective tires?

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.

To Your Poor (And Costly) Health

I see myself like Larry Birkhead emerging from that Bermuda courtroom after DNA test results on Anna Nicole Smith's daughter are confirmed and saying, "I hate to say I told you so, but..."

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.)

http://www.reuters.com/article/domesticNews/idUSN1430711120070515?pageNumber=1

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:
http://www.globalhealthnet.com/WasteDoublesUSHealthCosts.html

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."