Dorothy Guellec

Certain

things should be "off limits to commerce" Healthcare in my view can be

compared to Education which, so far, has not been totally privatized. If

shareholders must be satisfied, then patients’ interests will be compromised.

The way managed care works is by rewarding investors, HMO CEO’s, and even

doctors, while simultaneously holding down services to patients.

Six

months ago Healthcare was not a hot topic, today it is. Hardly a week goes by

without a major story, either on TV or in print. Recently 60 minutes did a story

on Seniors going to Montreal with Mike Wallace to purchase prescriptions. I was

truly surprised as the Industry Standard on 7/10/99 reported "CBS acquired

35% of Internet health company Medscape in exchange for $157 million in

advertising and promotion – a potentially profitable investment if Meds cape’s

pending IPO soars". So is everything up for grabs? I guess so.

The

New England Journal of Medicine in their August editorial concluded that

"some aspects of life are off-limits to commerce. We prohibit the selling

of children and the buying of wives, juries and kidneys." Parenthetically

we do allow the sale of female eggs on the web and body parts for

transplantation are routinely sold. "Tainted blood is an inevitable

consequence of paying blood donors; even sophisticated laboratory tests can’t

supplant the gift-giving relationship as a safeguard of the purity of blood.

Like blood healthcare is too precious, intimate, and corruptible to entrust to

the market."

Dr.

Steven Katz President of the Conn. State Medical Society wrote on 10/13/99 that

"HMO’s have not been paying doctors at all in many cases (latest estimate

that docs in Fairfield County Ct. are owed 40 million dollars by 7 managed care

organizations)"

Dick

Huber, CEO of Aetna still owns $60 million of Aetna stock after having the value

fall $61 million.

Let’s

consider the case of Joe Plocica who signed up with an HMO in Texas that

advertised " as many hospital days as your doctor will authorize." The

patient later was hospitalized following a suicide attempt but was discharged

too early. That very night he proceeded to drink antifreeze and lapsed into a

coma and died. Mr.Plocica’s family sued the managed care company. The lawyer in

his brief states (1) that Mr. Plocica was "encouraged to enroll via

deceptive TV advertising" (2) The HMO failed to use ordinary care in

influencing, controlling, participating in or providing health care treatment.

(3) The managed care companies involved in Mr.Plocica’s care used

"aggressive cost controls and incentive compensation arrangements"

thereby influencing the practice of medicine. (4) The HMO’s involved created

unreasonable risk by increasing the likelihood there would be a failure to

properly diagnose, test and refer patients for specialty medical care. (5) The

administrators of the managed care companies were also paid incentive

compensation as were the physicians, based on holding down costs. There was no

reward for quality care. Joe Plocica was the "victim of a knowing,

calculated scheme whereby the Defendants (The HMO’s in question) increased their

profit by adversely affecting medically necessary, but costly, psychiatric

medical care. There will be many more suits in the future, class action and

individual.

This

trend can hardly bode well for a system that is supposed to represent healing,

caring and pain control.

 

WHAT

HAPPENED TO COMPASSION AND HEALING?

The

US Congress can’t seem to understand the difference between palliative care

(pain control, not killing the patient) and physician assisted suicide. This

week (October 24) the infamous Henry Hyde and his fellow Senator from Oklahoma

Don Rickles intend to overturn Oregon’s law on physician assisted suicide

BECAUSE they want to give the DEA (Drug Enforcement Administration) the power to

determine whether a controlled substance has been prescribed for a

"legitimate medical purpose". Now we have another administrative

bureaucratic tier to go through before the doctor can prescribe appropriate

treatment. Eleven states have said that the bill would do"significant

harm" to doctor’s ability to manage their patients’ pain. It doesn’t take a

genius to understand this:

1)

cancer patients do not become drug addicts and, if by some remote chance they

were to develop some tolerance, so what? They are getting pain relief. I hope

Henry Hyde is never caught screaming out in pain in a hospital just to be told

that the DEA did not approve the request for morphine.

2)

We are too paranoid about drugs and can’t see their legitimate use in medicine

3)

Doctors are poorly trained in Palliative Care although there are several new

programs starting up in Medical Schools.

Most

doctors took the Hippocratic oath on completion of Medical School but few really

live by its words. There was a time in this country when patients trusted their

doctors completely…trusted them with their very lives and listened to them.

You used to be able to talk to your doctor in privacy behind closed doors and

you felt entirely confident that what he or she recommended was 100% in your

best interest. Because of the complicated nature of managed care your physician

may be preoccupied with many different issues that do not have to do with health

care. The Managed Care and Emergency Medical Ethics Policy Statement of the

American College of Emergency Physicians is inherently contradictory. The

American College endorses the following:

• The

  ethical obligations of emergency physicians do not change when practicing in

  a managed care or any other environment. The physician’s primary

  responsibility remains with the patient.

• When

  the economic interests of physicians, hospitals, purchasers of health

  services or managed care organizations are in conflict with patient welfare,

  the highest priority is patient welfare.

• Because

  the financial resources of our society are finite, emergency physicians have

  a responsibility to practice medicine in a cost-conscious manner. Regardless

  of the payment structure, the emergency physician should not provide care

  without reasonable expectation of patient benefit.

There

is a conflict in the above because "patient benefit" really means

Medical Futility.

"Futile

Care Theory" allows doctors and health-insurance executives to deny not

merely high-tech interventions but treatments as CPR and antibiotics to the

disabled and people at the end of life. These caretakers and healers can, and

do, routinely override the patient and family’s wishes by assessing the quality

of life. Little noticed by the mainstream Futile Care Theory is already being

implemented in hospitals, nursing homes, hospices and clinics. Again money is

speaking, and even in the pristine halls of Palliative Care this message crossed

my desk. "You ask how to get physician buy-in to your palliative program?

The best way to accomplish this goal is to make it a service that looks

Like

any other consult service. For example, your consults should be staffed by a

physician with recognized expertise in palliative medicine. The actual consult

note needs to look like other consultant notes, like the cardiologist or

oncologist, or any other medical sub-specialty. If you want credibility avoid

alternative therapies initially. Focus on the medical problems and how they are

affected by the patients’ social situation that will be the bread and butter for

your service. Help a few docs out of a jam, without coming across as too

"touchy-feely" or as co-dependent crusaders, and you will get

referrals. Once you have established your legitimacy, you can begin to change

the standard of practice at your institution. It is important to have visibility

in the hospital, the specialized units, and have a doc that is active in medical

staff activities."

 

SPREADING

OUR METHODS ABROAD

According

to the Bangkok Post 7/8/99 Hospitals were left with massive stocks (up to 19

years) of overpriced goods. Many community hospitals bought drugs and medical

kits at exorbitant prices on the orders of officials found involved in this

medical supplies scam. The medicine had 3-year expiration dates. In Nakhon

Pathom, officials testified before the Counter Corruption Commission that a

surgical mask, usually priced at 15 baht, was bought at 120 baht. A surgical cap

was priced at 150 baht instead of the usual 15 baht.

Wockhardt

Health Institute has become India’s first hospital to tie up with a health

insurance company, US-based Blue Cross and Blue Shield Ass’n. The alliance will

be of special help to the frequent US business travelers in India, non-resident

Indians who travel to India on holidays and people covered under the plan while

in the US and who have now returned to India. However, Indians staying in India

will be able to access the facility only after a clear policy emerges on the

participation of foreign companies in the insurance sector.

An

excerpt on a website follows: "How about corporatising hospitals to attract

foreign patients? We can make a ‘killing’ with cheaper rates in India. We could

allow world’s best doctors in India so that patients from all over the world are

attracted to India for treatment. We should also ask the WTO to have a clause

that Western governments should not subsidize healthcare, as it would affect out

business interests. For starters, we could have tax concessions for hospitals

getting their money from abroad. To protect our citizens, we could have a clause

that no more than x% of patients can be foreigners. Or else, Indians will be

neglected". All humor aside The Hindu reported on December 28,1998 that

"The Centre has recommended to the World Bank a proposal for implementing a

Rs.850-crore ‘health scheme’ in Tamil Nadu, aimed at upgrading the health care

system in the State.

Is

it just a coincidence then that on March 20,1999 the Calcutta Stock Exchange set

up the first Indian Stock Exchange for derivatives? The new exchange will also

be used for futures trading in commodities. The system will include adequate

risk management measures and be on a par with other international systems. You

may draw your own conclusions.

A

little over a year ago in Mumbai, India Sheela D’Souza’s 62 year old father was

admitted late at night with severe breathing problems to a neighborhood nursing

home. He was wheeled into the Intensive Care Unit and hooked up to an oxygen

cylinder.

"But

he continued gasping. I asked the nurse to check the tubes, check the cylinder.

She shrugged me off," recalls Ms. D’Souza (name changed), a Kurla resident.

"Finally, my persistent questioning forced her to take another look. The

cylinder was empty."

In

many of the city’s mushrooming private ICUs such specialized critical care is

more a myth than a reality. These ICUs are often housed in cramped nursing homes

which are understaffed and inadequately equipped.

The

bottom line is profit not patients. Stay tuned.