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Thursday, June 25, 2009

Casino Health Care

Roulette wheelEarlier this month, Alabama Sen. Richard Shelby told FOX News' Chris Wallace that President Obama was going to ruin France's health care system. In an interview, Shelby said that Obama's health care reform ideas were the "first step in destroying the best health care system the world has ever known."

While he would seem to be talking about the US health care system, the facts don't really back him up. According to a 2000 World Health Organization (WHO) study (the most recent available), "France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria and Japan." The US "spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance." So Shelby has to be talking about top-ranked France, because the US health care system is a rip-off.

In fact, the US system goes out of its way to deny care. "[Insurance companies] confuse their customers and dump the sick, all so they can satisfy their Wall Street investors," Wendell Potter, a former Cigna senior executive, testified at a hearing of the Senate Committee on Commerce, Science, and Transportation yesterday. "They look carefully to see if a sick policyholder may have omitted a minor illness, a pre-existing condition, when applying for coverage, and then they use that as justification to cancel the policy, even if the enrollee has never missed a premium payment... dumping a small number of enrollees can have a big effect on the bottom line."

So much for our ranking as the "best health care system the world has ever known." For the record, 37th in the world doesn't qualify as "best." That ranking doesn't even make us Miss Congeniality. It just makes us "one of the health care systems the world has known." Not the best, not the worst, just unspectacular and nothing to brag about. It's not gruel, it's not filet mignon, it's just a bologna sandwich. Pretending it's the pinnacle of human endeavor doesn't really help much and no one's really buying it -- even if you throw in chips and a pickle.

According to the WHO, a big problem dragging down the ranking of health care systems is the ability of patients to pay. "The poor are treated with less respect, given less choice of service providers and offered lower-quality amenities," said WHO Director-General Dr Gro Harlem Brundtland. "In trying to buy health from their own pockets, they pay and become poorer."

Sound familiar? It should. Not only are health insurance costs hurting the poor, it's driving people into the poorhouse. According to a American Journal of Medicine report issued earlier this month, medical expenses accounted for 62.1% of all bankruptcies in 2007.

"The US health care financing system is broken, and not only for the poor and uninsured," the study reported. "Middle-class families frequently collapse under the strain of a health care system that treats physical wounds, but often inflicts fiscal ones."

That's not extremely surprising given Potter's testimony that insurance companies try to "confuse their customers and dump the sick." A system that routinely turns patients away isn't going to do all that well. Even people who are insured can find themselves uninsured -- despite a perfect payment history.

It helps to think of the American system of health care funding as gambling. Basically, you bet that your health care costs will be higher than the average person's, then you find an insurer willing to take that wager. Normally, this would be a sucker's bet on your part, since the odds dictate that you're going to be average. But since the costs of being sicker than average are so high, you need to be able to cash out if things take a turn for the worse. In other words, if you can win that bet, you need to win that bet. It's the only way you can pay for your care. And if you have nothing to bet, you can't play.

But health insurance companies aren't really comfortable being in the gambling business, despite being more than willing to take your bet. Probability is a fickle thing and the law of averages is by no mean a constant -- the odds of rolling a six on a die is one in six, but sooner or later someone's going to come along and roll a lot of sixes. This is because each event is a separate event; i.e., if the odds are one in six the first time, they're one in six the second and the third and the fourth, etc. Each time you pick up that die, you're playing a new game. A belief that the odds "owe" you a win or that they absolutely have to apply to a series of events is known as the "gambler's fallacy." The truth is that you could sit there all day and never roll a six or you could roll sixes all day long.

So Shelby's "best health care system the world has ever known" is a casino. And that casino is run by people who don't want to run a casino. They're in the business of risk and they want to be in a riskless business. If you win your bet, they'll try anything they can to welsh on it -- including kicking you out of the casino without your winnings.

Put that way, it doesn't sound like the best way to run a health care system, does it? It's not surprising that the US ranks 37th in the world, behind countries like Colombia, Chile, and Costa Rica -- while barely above Cuba's 39th. Casino capitalism isn't working any better with health care than it has on Wall Street.


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vet said...

"Major countries" - "France, Italy, Spain, Oman, Austria, Japan..."?

One of these things is not like the others.

Proud FA said...


The American Medical System
Is The Leading Cause Of Death And Injury In The United States
By Gary Null PhD, Carolyn Dean MD ND, Martin Feldman MD, Debora Rasio MD, Dorothy Smith PhD

A definitive review and close reading of medical peer-review journals, and government health statistics shows that American medicine frequently causes more harm than good. The number of people having in-hospital, adverse drug reactions (ADR) to prescribed medicine is 2.2 million. (1) Dr. Richard Besser, of the CDC , in 1995, said the number of unnecessary antibiotics prescribed annually for viral infections was 20 million. Dr. Besser, in 2003, now refers to tens of millions of unnecessary antibiotics. (2, 2a)

The number of unnecessary medical and surgical procedures performed annually is 7.5 million. (3) The number of people exposed to unnecessary hospitalization annually is 8.9 million. (4) The total number of iatrogenic [induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures] deaths is 783,936.

The 2001 heart disease annual death rate is 699,697; the annual cancer death rate is 553,251. (5) It is evident that the American medical system is the leading cause of death and injury in the United States.

Never before have the complete statistics on the multiple causes of iatrogenesis been combined in one paper. Medical science amasses tens of thousands of papers annually—each one a tiny fragment of the whole picture. To look at only one piece and try to understand the benefits and risks is to stand one inch away from an elephant and describe everything about it. You have to pull back to reveal the complete picture, such as we have done here. Each specialty, each division of medicine, keeps their own records and data on morbidity and mortality like pieces of a puzzle. But the numbers and statistics were always hiding in plain sight. We have now completed the painstaking work of reviewing thousands and thousands of studies. Finally putting the puzzle together we came up with some disturbing answers.

Proud FA said...

Is American Medicine Working?
At 14% of the Gross National Product, health care spending reached $1.6 trillion in 2003. (15) Considering this enormous expenditure, we should have the best medicine in the world. We should be reversing disease, preventing disease, and doing minimal harm. However, careful and objective review shows the opposite. Because of the extraordinary narrow context of medical technology through which contemporary medicine examines the human condition, we are completely missing the full picture.

Medicine is not taking into consideration the following monumentally important aspects of a healthy human organism:

(a) Stress and how it adversely affects the immune system and life processes
(b) Insufficient exercise
(c) Excessive caloric intake
(d) Highly processed and denatured foods grown in denatured and chemically damaged soil
(e) Exposure to tens of thousands of environmental toxins.

Instead of minimizing these disease-causing factors, we actually cause more illness through medical technology, diagnostic testing, overuse of medical and surgical procedures, and overuse of pharmaceutical drugs. The huge disservice of this therapeutic strategy is the result of little effort or money being appropriated for preventing disease.

Under-reporting of Iatrogenic Events
As few as 5% and only up to 20% of Iatrogenic acts are ever reported. (16, 24, 25, 33,34) This implies that if medical errors were completely and accurately reported, we would have a much higher annual Iatrogenic death rate than 783,936. Dr. Leape, in 1994, said his figure of 180,000 medical mistakes annually was equivalent to three jumbo-jet crashes every two days. (16) Our report shows that six jumbo jets are falling out of the sky each and every day.

Correcting a Compromised System
What we must deduce from this report is that medicine is in need of complete and total reform: from the curriculum in medical schools to protecting patients from excessive medical intervention. It is quite obvious that we can't change anything if we are not honest about what needs to be changed. This report simply shows the degree to which change is required.

Proud FA said...

We are fully aware that what stands in the way of change are powerful pharmaceutical companies, medical technology companies, and special interest groups with enormous vested interests in the business of medicine. They fund medical research, support medical schools and hospitals, and advertise in medical journals. With deep pockets they entice scientists and academics to support their efforts. Such funding can sway the balance of opinion from professional caution to uncritical acceptance of a new therapy or drug.

You only have to look at the number of invested people on hospital, medical, and government health advisory boards to see conflict of interest. The public is mostly unaware of these interlocking interests. For example, a 2003 study found that nearly half of medical school faculty, who serve on Institutional Review Boards (IRB) to advise on clinical trial research, also serve as consultants to the pharmaceutical industry. (17) The authors were concerned that such representation could cause potential conflicts of interest.

A news release by Dr. Erik Campbell, the lead author, said, "Our previous research with faculty has shown us that ties to industry can affect scientific behavior, leading to such things as trade secrecy and delays in publishing research. It's possible that similar relationships with companies could affect IRB members' activities and attitudes." (18)

Medical Ethics and Conflict of Interest in Scientific Medicine
Jonathan Quick, director of Essential Drugs and Medicines Policy for the World Health Organization (WHO) wrote in a recent WHO Bulletin:

"If clinical trials become a commercial venture in which self-interest overrules public interest and desire overrules science, then the social contract which allows research on human subjects in return for medical advances is broken." (19)

Former editor of the New England Journal of Medicine (NEJM), Dr. Marcia Angell, struggled to bring the attention of the world to the problem of commercializing scientific research in her outgoing editorial titled "Is Academic Medicine for Sale?" (20) Angell called for stronger restrictions on pharmaceutical stock ownership and other financial incentives for researchers. She said that growing conflicts of interest are tainting science.

She warned that, "When the boundaries between industry and academic medicine become as blurred as they are now, the business goals of industry influence the mission of medical schools in multiple ways." She did not discount the benefits of research but said a Faustian bargain now existed between medical schools and the pharmaceutical industry.

Angell left the NEMJ in June 2000. Two years later, in June 2002, the NEJM announced that it would now accept biased journalists (those who accept money from drug companies) because it is too difficult to find ones who have no ties. Another former editor of the journal, Dr. Jerome Kassirer, said that was just not the case, that there are plenty of researchers who don't work for drug companies. (21) The ABC report said that one measurable tie between pharmaceutical companies and doctors amounts to over $2 billion a year spent for over 314,000 events that doctors attend.

The ABC report also noted that a survey of clinical trials revealed that when a drug company funds a study, there is a 90% chance that the drug will be perceived as effective whereas a non-drug company-funded study will show favorable results 50% of the time.

It appears that money can't buy you love but it can buy you any "scientific" result you want.

The only safeguard to reporting these studies was if the journal writers remained unbiased. That is no longer the case.

Proud FA said...

Cynthia Crossen, writer for the Wall Street Journal in 1996, published "Tainted Truth: The Manipulation of Fact in America," a book about the widespread practice of lying with statistics. (22) Commenting on the state of scientific research she said that:

"The road to hell was paved with the flood of corporate research dollars that eagerly filled gaps left by slashed government research funding."

Her data on financial involvement showed that in l981 the drug industry "gave" $292 million to colleges and universities for research. In l991 it "gave" $2.1 billion.

The First Iatrogenic Study
Dr. Lucian L. Leape opened medicine's Pandora's box in his 1994 JAMA paper, "Error in Medicine." (16) He began the paper by reminiscing about Florence Nightingale's maxim—"first do no harm." But he found evidence of the opposite happening in medicine. He found that Schimmel reported in 1964 that 20% of hospital patients suffered Iatrogenic injury, with a 20% fatality rate. Steel in 1981 reported that 36% of hospitalized patients experienced iatrogenesis with a 25% fatality rate and adverse drug reactions were involved in 50% of the injuries. Bedell in 1991 reported that 64% of acute heart attacks in one hospital were preventable and were mostly due to adverse drug reactions.

However, Leape focused on his and Brennan's "Harvard Medical Practice Study" published in 1991. (16a) They found that in 1984, in New York State, there was a 4% Iatrogenic injury rate for patients with a 14% fatality rate. From the 98,609 patients injured and the 14% fatality rate, he estimated that in the whole of the United States 180,000 people die each year, partly as a result of Iatrogenic injury. Leape compared these deaths to the equivalent of three jumbo-jet crashes every two days.

Why Leape chose to use the much lower figure of 4% injury for his analysis remains in question. Perhaps he wanted to tread lightly. If Leape had, instead, calculated the average rate among the three studies he cites (36%, 20%, and 4%), he would have come up with a 20% medical error rate. The number of fatalities that he could have presented, using an average rate of injury and his 14% fatality, is an annual 1,189,576 Iatrogenic deaths, or over ten jumbo jets crashing every day.

Leape acknowledged that the literature on medical error is sparse and we are only seeing the tip of the iceberg. He said that when errors are specifically sought out, reported rates are "distressingly high." He cited several autopsy studies with rates as high as 35% to 40% of missed diagnoses causing death. He also commented that an intensive care unit reported an average of 1.7 errors per day per patient, and 29% of those errors were potentially serious or fatal.

We wonder: what is the effect on someone who daily gets the wrong medication, the wrong dose, the wrong procedure; how do we measure the accumulated burden of injury; and when the patient finally succumbs after the tenth error that week, what is entered on the death certificate?

Leape calculated the rate of error in the intensive care unit. First, he found that each patient had an average of 178 "activities" (staff/procedure/medical interactions) a day, of which 1.7 were errors, which means a 1% failure rate. To some this may not seem like much, but putting this into perspective, Leape cited industry standards where in aviation a 0.1% failure rate would mean:

• Two unsafe plane landings per day at O'Hare airport
• In the U.S. mail, 16,000 pieces of lost mail every hour
• In banking, 32,000 bank checks deducted from the wrong bank account every hour