By Maggie Mahar
Health Beat Blog, January 06, 2010

“Aker University Hospital is a dingy place to heal. The floors are streaked and scratched. A light layer of dust coats the blood pressure monitors. A faint stench of urine and bleach wafts from a pile of soiled bedsheets dropped in a corner.”

This is how an Associated Press story, published in the New York Times last week, begins. The next sentence comes as a surprise:

“Look closer, however, at a microscopic level, and this place is pristine. There is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated hospital of Europe, North America and Asia this year, soaring virtually unchecked.

By Sara Mansfield Taber
The Washington Post
Sunday, January 10, 2010; B01

In the final months before her death in May, my mother kept her shoes on all day, even when napping. She had to — at her assisted-living facility in Mitchellville, Md., three certified nursing assistants looked after 39 residents. My mom couldn’t depend on one of them to have the time to put her shoes on when she needed to get out of bed. Only in the mornings and evenings, when one of her private aides was with her for about 30 minutes, did she have personalized care.

Disabled by heart disease, two hip replacements and depression, my mother was often groggy when I visited. She needed me to take her hand and pull her up so she could grab the bed rail and maneuver into a sitting position. Though she brightened when I told her stories about her grandchildren over lunch in the facility’s dining room, her joy vanished as soon as we returned to her unit. A blank look on her face, she would lay back on her bed, prone and helpless.

Like many American women of my generation, I struggled to figure out how to best care for my aging mother. As the end neared, I compared notes with my friends Fiona and Juliette. Fiona lives in Canada, but her mother lives in their native England, while Juliette lives with her mother in their family home in France. How could we establish safe and comfortable environments for our ailing mothers? How could we find high-quality medical care within reach of their incomes, and our own? And how could we preserve their mental health and sense of well-being while limiting our stress?

My mother’s plight made my stress considerable. Each month, Lois Taber paid $4,069 to reside in her assisted-living community, $1,400 for private aides and an average of $140 for medications. Just before she died at age 82, she liquidated assets from her 401(k) to pay for a $5,800 hearing aid. At $169.50 per ride, the retirement home’s fee for transporting her to medical appointments was prohibitive. Other than Medicare, my mom had no government-subsidized elder-care services. Already, the lack of affordable in-home support had forced my parents to leave their beloved house in Chevy Chase, Md., to receive the basic care they needed.

Overseas, things are different — that is, better. In England, which has a national health system similar in structure to our Veterans Affairs system, Fiona’s mum, Pat Reid, suffers from disabling arthritis and diabetes, and cannot move without great pain. But a government-supplied home health aide visits Pat at breakfast, lunch and dinner every day. This costs the family 120 pounds a week (approximately $785 per month), a little more than half of what my mom paid for private aides. Lower-income patients receive this service free. The National Health Service provides general practitioners, nursing care, ambulance services, diabetic clinic visits, medications and hospitalizations for no charge. Doctors and nurses make home visits.

In addition, Pat’s son Simon, who has no work at the moment and lives in his mother’s converted garage, receives 50 pounds a week (about $325 per month) from the government to help him look after her. With this government support, Pat is able to stay in the home where she lived with her husband for more than 35 years. The cost of her care is well within her monthly income of 2,000 pounds.

In France, Juliette’s maman, Madeleine Fournot, has Alzheimer’s disease. She receives assistance via a national health reimbursement system similar to Medicare as well as through a special program for the elderly and disabled called l’Allocation Personalisée à l’Autonomie (“Personal Autonomy Allocation”). Since the government refunds 560 of every 1,200 euros Juliette spends on her mother’s medical expenses, she is able to hire a caregiver who looks after her mother around the clock 3 1/2 days per week. This allows Madeleine to stay in her suburban Paris home, where her family has lived for three generations, and provides Juliette a regular respite from elder care.

Madeleine receives one free doctor’s visit per month, and the doctor makes house calls when needed. Four days a week, a physical therapist visits her, charging a one euro co-pay per visit — less than the cost of a cup of coffee on the Champs-Élysées. Because Madeleine is on blood thinners, a hematology technician comes each week to check her blood levels. If she is in bed when he arrives, she can stay snug under her covers while he takes the sample. All medications related to Madeleine’s Alzheimer’s are free, as is transportation to her neurologist in Paris. Her doctor simply fills out a form stating that she cannot stand without assistance, and she is reimbursed for the 30-minute taxi ride into the city.

Other services available to Madeleine include daily medication-administration house calls by a trained nurse, daily meal service (a three-course lunch and soup for dinner) and a specially designed activity program for Alzheimer’s patients. The total monthly cost of Madeleine’s care is 1,500 Euros, or $2,205.

I am struck by all that Fiona’s mum and Juliette’s maman can take for granted. They enjoy access to services far beyond free and full medical and prescription drug coverage. In England, my mother’s $5,800 hearing aid would have been free. While Mum and Maman get house calls from their doctors and cash compensation for family members who care for them, I often had to take time off from work — an expensive proposition for a self-employed psychologist and writer — to help Mom. Taking her back and forth to her medical appointments ate up entire days and, with her disabilities, she could barely get in and out of my car. This was hard work, not quality time with an aging parent.

Mom, Mum and Maman were not very different people. All three married civil servants, led middle-class lives and retired on government pensions. Pat and her husband, a BBC editor and translator who escaped five Italian prison camps during World War II, sought to create a peaceful life for their children. After her husband died, Pat took a job on the local council for village planning. Madeleine spent most of her middle years in Afghanistan, where her husband was posted with the United Nations. My mother worked in orphanages and schools in Asia, Europe and the United States as she followed my father, a CIA officer, across three continents. All three women eventually became widows and developed significant medical problems. Illness and enfeeblement limited their lives, and they came to require help with their daily activities.

There, the similarity ends. As seniors, each woman’s quality of life was shaped by her government’s health-care policies. The services offered to older people in Britain and France seem, to this American observer, straightforward, logical and humane. These countries provide the basic help their elders need to remain in their homes and in their communities, close to family and friends. It upsets me to think how much more peacefully my mother’s life might have ended had she had the support available to older people in Britain and France. Why should Mum and Maman be able to grow old at home, but not Mom?

Many Americans protest that Europeans pay high taxes for medical care. It is true that people in other countries pay more in taxes, but, between out-of-pocket expenses and private health insurance premiums, many Americans spend much of their tax savings staying alive. Of course, high-quality health care costs money. Treating Mom like Mum and Maman is expensive. But Pat and Madeleine both have much lower living and medical expenses than my mother had, and, unlike Americans, they never had to pay for health insurance in their prime.

If our taxes were somewhat higher but we received dependable services that enabled us to spend less out of pocket on doctors’ visits, medications and nursing care — services that helped us remain independent, at home, and that reli
eved our families of financial and emotional burdens — wouldn’t peace of mind outweigh the additional cost?

My mother, a physical therapist and teacher with a blow of cumulus hair, was a hard-working person whose motto was: “If, at the end of the day, I can say I’ve helped someone’s life to be better, then I’ve had a good day.” It would have been nice if, at the end of her days, she could have taken her shoes off.

Sara Mansfield Taber, a psychologist and writer, is the author of “Bread of Three Rivers: The Story of a French Loaf.”

http://www.washingtonpost.com/wp-dyn/content/article/2010/01/08/AR2010010803586.html

By Claudia Chaufan
The Social Medicine Portal, Jan. 7, 2010

I must confess that I was disappointed to see Dr. Atul Gawande’s mantra that more or more expensive care is not necessarily better care go unchallenged even by the otherwise outstanding Amy Goodman’s “Democracy Now.” Unchallenged, that is, when this rather obvious (or at least very reasonable) observation was presented as the critical explanation for why the United States spends more in health care, per person, than any other country in the world, even as it leaves millions uninsured or underinsured, leads thousands to bankruptcy, and allows 45,000 people — 15 times the number murdered in 9/11 — to die for lack of health insurance. Nor was he challenged when he presented his views of Massachusetts as a sound model for health care reform, even as he granted that the program had “failed to control costs.” In fairness to the interviewers, Dr. Steffie Woolhandler’s statement that the center of the Massachusetts program did not hold were shown briefly. Yet to the already confused listener or viewer, the showcase of “opposing expert views” must have felt like the usual “he said, she said” — not awfully enlightening and at best leading to skepticism about both positions.

So back to Dr. Gawande, it appears that he is smart enough to realize that certain forms of payments, like fee for service, lead practitioners to provide more care (which sometimes, but by no means always, may be unnecessary), whereas salaried doctors do not have that incentive (incidentally, salaried doctors are the norm in “socialized medicine”-type systems). And yet, Gawande is not perspicacious enough to ask himself why is it that Canada, Taiwan, France, or Japan, where fee for service reigns supreme, still spend a fraction of even what our cheapest and best run hospitals do. While I am not arguing in favor of fee for service — quite the contrary, I, like many, agree that it at least a very inefficient and administratively burdensome form of payment — I am just pointing out that given this rather banal observation, it is clear that fee for service cannot be the whole story of our high health care costs.

At any rate, had Gawande (or his interviewers) asked this critical question, rather than continuing in the all-too-American exercise of navel-gazing by comparing one (low-cost) American hospital with another (high-cost) American hospital, he might have studied a well-run, or even the best run, American hospital’s costs against the costs of some hospitals in other countries. And he surely would not have failed to see, as it appears he has, that even Switzerland, that comes second after the United States in health care costs (even if Swiss costs are substantially lower, by around 40 percent, than the U.S.’s), and has “private insurers,” bans profit making from the financing of medically necessary care. Right! It’s the financing, stupid!

The same is the case with the health care of all other industrialized economies. So even when Europeans, or the Japanese, talk about “private” insurers in health care they rarely, if ever, mean “for-profit” insurers. Private insurers are essentially tightly regulated subsidiaries of government, and if they are ever caught “cherry-picking” they are forced to transfer some of their money to another insurer that covered sicker patients or, as the Swiss do, lower their premiums during subsequent months, unimaginable in the America private health insurance scenario.

Admittedly, some readers might puzzle: “Why would insurers even be in business if not to become filthy rich?” Well, at least one reason is that if they do a good job and attract many members, then they can sell for-profit insurance for the “over and above” services (private hospital rooms, cosmetic surgery, etc.). And note, when Swiss insurers, who prior to 1994 were pretty much like American insurers, failed to meet their part of the social contract (i.e. were becoming filthy rich at the expense of everybody else’s suffering), they got their lesson: price controls and mandated benefits that they had to provide at no profit if they wanted to remain in business.

And had Gawande delved into the politics of health care (and not merely the Pollyannaish version of its history), he surely would not have failed to discover that the coming into being of the National Health Services (NHS) was anything but a “historical accident” (and if it was, then anything can be, and the expression is meaningless). It is surely true that the physical structures, the public hospitals, were “already there” after World War II, a war during which hospitals had been built that provided publicly funded medical care for servicemen. Yet it is equally true, and arguably much more important, that around 1948 there was a confluence of critical political forces, not the least of which was the landslide victory of Labor over the Conservative Party.

How did this unexpected victory happen, despite the popularity won by Conservative British Prime Minister Winston Churchill as a “war leader”? It appears that as “national security” concerns subsided and hunger and unemployment began to take their toll over an impoverished population, Britons concluded that Labor, not Conservatives, would be more inclined and capable to guarantee “bread and butter” issues — what were increasingly seen as basic social rights, such as full employment, income security, public education, and health care. Popular demand for guaranteed basic rights was further strengthened by the success of socialist British Minister of Health Aneurin Bevin to secure the support of the medical establishment: in a masterful move, Bevin decided that offering well paid practitioners who agreed to join the NHS generous salaries would free them “from the necessity to drum up business from rich clients to pay for their basic income” (Glennerster 2007: 51). So if the birth of the NHS was a “historical accident,” it was certainly a very complex one.

So Gawande’s conclusion, given the glaring omission in his theory, is unsurprising: it is U.S. doctors, and their “culture,” that are the source of our high costs – doctors, that is, who respond to a perverse systems of incentives, which according to Gawande, is the way U.S. doctors are paid: more for doing more yet not better.

Now, while doctors may certainly be part of the problem, and while paying more for doing more, even if it is not good and frequently not necessary, is obviously a bad thing, why Gawande chooses to ignore the critical and obvious fact that no other industrialized economy, and many industrializing ones (like Taiwan), leaves over 70 percent of its population (even if Gawande has only counted 50 percent) at the mercy of profit seekers when it comes to financing medically necessary care, is anybody’s guess. (Elsewhere I have laid out, and many other excellent policy analysts, like PNHP doctor Don McCanne, have done so as well, why the only way to eliminate financial barriers to medically necessary care is treating health care as a social right and financing it collectively through a tax-based or social insurance system, incidentally the only way to allow the choices that matter – of doctors and medical establishments, not “health plans” or “preferred providers” lists).

But maybe had Gawande acknowledged the obvious, I suspect that his New Yorker article, where he insists that whether insurance is public or private (we are not told whether the profit motive matters) is not that important after all, would not have never become “required” reading in the White House. Indeed, he even might have been kicked out of the sanctuaries where our health care future is being written (or cooked!), as was the case with many brave doctors (Dr. Margaret Flowers comes to mind), who keep on insisting that our politicians put pe
ople before profits.

http://www.socialmedicine.org/2010/01/07/health-activism/its-the-financing-stupid-a-second-opinion-on-gawandes-cost-conundrum/