Basing Pay-for-Performance on Outcomes

By Uwe E. Reinhardt
The New York Times
October 15, 2010

In last week’s post I presented the flow chart (at link below), exhibiting the path from the production of health care proper to human well-being, and I asked where in this process one should monitor the performance that we might seek to encourage through financial incentives.

I noted that adherence to what is thought to be best clinical practice for given medical conditions is the most widely used approach to measuring performance, even though it is generally agreed that a better way is to measure performance by clinical outcomes — that is, changes in the health status of patients (Box B in the chart). Much work is now under way to move in that direction.

Unfortunately, measuring performance by clinical outcome is easier said than done.

All of these experiments (mentioned in the article) with pay-for-performance are fledgling efforts, because the science of outcome measurement has yet to scale many methodological hurdles. Furthermore, in practice the approach will work only if the providers of health care find them sufficiently accurate and fair to sign on. And economic theory tells us that to make the approach effective, it must be backed with significant financial incentives. So far, in many instances, the sums of money at stake have been rather small.

Several readers of last week’s post saw in my enumeration of the difficulties of measuring performance a rejection of the idea. Not at all. The task is indeed daunting, but that does not mean we should back away from it. Rather, we must be patient and not expect too much too soon.

Basing Pay-for-Performance on Outcomes (Oct. 15):
http://economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/

The Uncertainties of Pay-for-Performance (Oct. 8):
http://economix.blogs.nytimes.com/2010/10/08/the-uncertainties-of-pay-for-performance/

Two published responses to Professor Reinhardt:

2. Don McCanne
San Juan Capistrano, CA
October 15th, 2010

Where are the science and art of medicine headed? Is the health care professional’s role to asses the needs of the patient and try to meet those needs? That alone is a daunting task when you consider studies that show that patients are receiving only about half of the care that they should be receiving.

Will the guidelines for medical care become a complex algorithm of process and outcomes, with the health care professional understanding that the goal and rewards will be found in mastering and optimally executing the measurement junctures within that massive maze? Will these measurements be samplings, or will almost everything be measured (a not so far-fetched concept in this day of computerization)? What burden in time and effort will this entail?

How about the real world? When the child with diabetes who you have been caring for comes in because of being depressed over the fact that her parents just split up, are you going to ignore her immediate overwhelming concern because you are too busy checking to see that you are complying with the glycohemoglobin and whatever other process and outcome junctures on which you will be rewarded?

When the goal is to do our best to see that everyone has the highest quality care that we can manage to pay for, it would be sad to see us caught up in the science of measurements when the greater need is in the art of medicine.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/?permid=2#comment2

9. Dr. Robert Centor
Birmingham
October 15th, 2010

We must thank Dr. Reinhardt for 2 stimulating posts on P4P. He has pointed out the problems of P4P. But I fear he still believes that P4P could work, despite growing evidence to the contrary. Physicians have multidimensional tasks with each patient. We must make accurate diagnoses; we must treat diagnoses and symptoms; we must communicate with patients and help them make diagnostic and treatment decisions. We must balance the treatment of multiple diseases and weigh the risks and benefits each potential treatment decision.

Implementing a P4P scheme focuses attention on the measurables and decreases attention to those things that are not measured. The NHS P4P project demonstrates that very well. Focusing on prompt visits led to a decrease in physician-patient continuity. Focusing on some parameters led to a degradation in other parameters.

P4P sounds like it should work, but many physicians believe that it cannot work, because no metric can evaluate the extent of our professional responsibilities.

We could look at preventable errors (such as central line infections) and penalize hospitals for unacceptable rates. But we should only do that when we can establish that we have a proven method to achieve the goal. I picked this example because of Dr. Peter Provonost’s excellent work on this particular issue.

Dr. Reinhardt suggests that we use outcomes, but what outcomes should we measure. How do we place a metric on accurate diagnosis? We can study the reasons for diagnostic error, but measuring diagnostic errors represents a most complex and perhaps unsolvable problem?

How do we measure the physician patient interaction? This interaction includes history taking, patient education and patient motivation. Some suggest we use patient satisfaction scores, but those have major flaws and suffer from intense grade inflation.

How do we measure an appropriate balancing for the management of 5 (or more) diseases? How do we assess the appropriate prioritization of medications? How do we value decreasing polypharmacy by not treating every performance indicator to its fullest?

How do we value appropriate referrals to palliative care? How do we put a number on excellent comfort care?

I thank Dr. Reinhardt for shining a light on this problem. While I disagree with his belief that P4P is a solvable problem, I agree that we have not yet solved the problem.

http://community.nytimes.com/comments/economix.blogs.nytimes.com/2010/10/15/basing-pay-for-performance-on-outcomes/?permid=9#comment9

As part of the current fervor over implementing reform, considerable attention has been directed to controlling spending and improving quality by changing reimbursement methods from those based on volume and complexity of services to models based on measurements of clinical practices and health care outcomes.

Professor Reinhardt suggests that we must not expect too much out of these efforts in the immediate future; I indicate that the science and art of medicine provide far greater benefits than those measurements of process and outcomes could ever adequately assess; and Dr. Centor provides a precise explanation of why current concepts of P4P (pay for performance) miss the target.

The magic of the highly touted accountable care organizations seems to be based on these same principles. It is likely that the magic will turn out to be only sleight-of-hand, at best.

Our policymakers would be much more productive if they would shift their attention from dinking around with P4P to crafting a financing system that would ensure that everyone would have affordable access to an efficient health care delivery system with a robust primary care infrastructure. PNHP can help our policymakers define that system, if only they will finally listen.

UCSC employees face tough health care decisions as popular plan changes

By Tovin Lapan
Santa Cruz Sentinel
October 13, 2010

UC Santa Cruz employees think they have been unfairly burdened by the systemwide changes to health care coverage made for 2011.

Faculty, staff and unions representing UCSC workers have all raised concerns that one of the most popular plans on the Santa Cruz campus is no longer offered at a discounted rate and is in some cases 150 percent more expensive than the other alternative being offered, which would require switching physicians.

When the details of the new coverage options were released earlier this week UCSC employees immediately noticed that in many cases it would be difficult to maintain their current doctors at a similar cost to years past. The plan that is no longer discounted covered physicians under the Sutter Health Network, which includes the Palo Alto Medical Foundation and Santa Cruz Medical Clinic. Approximately 60 percent of UCSC employees are affiliated with Sutter Health Network, according to UCSC spokesman Jim Burns.

Open enrollment for UCSC employees will begin Oct. 25, at which point many people will have to choose between paying higher premiums or leaving their doctor.

“The staff members I’ve talked to are pretty furious, and that frustration comes from lack of representation at the level of the office of the president,” UCSC Graduate Program Coordinator Marissa Maciel said. “In order for my premium not to go way up I have to leave my doctor of the last 10 years and change my child’s pediatrician.”

UCSC Campus Provost and Executive Vice Chancellor Alison Galloway called the increases in health care costs “disappointing” and expressed that the UCSC administration has pointed out the difficult situation its employees face to the Office of the President.

“I’m particularly concerned about our many employees who are currently enrolled in the HealthNet HMO plan,” Galloway wrote in an e-mail. “While an alternative version of that plan is being made available, it apparently will offer fewer providers. A sizable number of employees will face the prospect of finding new doctors. We’ve expressed our concerns about these issues – more than once – to UC leaders.”

http://www.santacruzsentinel.com/ci_16329342

Comment:

By Don McCanne, MD

When Congress wrote the Patient Protection and Affordable Care Act (PPACA), they did not want to disturb the very large sector of health insurance coverage that seemed to be working well – the employer-sponsored health plans. It was decided that high-quality plans, such as that of the employees of the University of California at Santa Cruz, should be protected so that the plans would always be there when the employees needed them, that is if they wouldn’t mind choosing between paying much higher premiums or losing their established physicians.

Jerking around provider lists, dramatically increasing premiums, pumping up deductibles and other forms of cost sharing, and manipulating benefits are all market tools used liberally by the private insurers. They are used to benefit the insurers, even if at the expense of the insured.

Compare that to our public insurance program – Medicare. Medicare doesn’t even have provider lists. You can go anywhere and see any physician who is willing to see you. Adjustments in premiums are very modest, unlike the double digit increases typical of the private insurers. Medicare cost-sharing adjustments are also very modest, unlike the financial barriers to care being erected by the private insurers. Medicare benefits do not diminish but have actually increased through the years. Medicare needs further improvement, but at least it’s not headed downward in the same direction as the private plans are.

It’s interesting to note that more recent releases from the Department of Health & Human Services and other public agencies have shortened the name of the Patient Protection and Affordable Care Act (PPACA) to simply Affordable Care Act (ACA). Just as they gave up on insuring everyone, it looks like they also have given up on patient protection. If we had an improved Medicare for all, everyone would be covered and patients actually would receive the protection they need. It’s not too late to change.

UCSC employees face tough health care decisions as popular plan changes

By Tovin Lapan
Santa Cruz Sentinel
October 13, 2010

UC Santa Cruz employees think they have been unfairly burdened by the systemwide changes to health care coverage made for 2011.

Faculty, staff and unions representing UCSC workers have all raised concerns that one of the most popular plans on the Santa Cruz campus is no longer offered at a discounted rate and is in some cases 150 percent more expensive than the other alternative being offered, which would require switching physicians.

When the details of the new coverage options were released earlier this week UCSC employees immediately noticed that in many cases it would be difficult to maintain their current doctors at a similar cost to years past. The plan that is no longer discounted covered physicians under the Sutter Health Network, which includes the Palo Alto Medical Foundation and Santa Cruz Medical Clinic. Approximately 60 percent of UCSC employees are affiliated with Sutter Health Network, according to UCSC spokesman Jim Burns.

Open enrollment for UCSC employees will begin Oct. 25, at which point many people will have to choose between paying higher premiums or leaving their doctor.

“The staff members I’ve talked to are pretty furious, and that frustration comes from lack of representation at the level of the office of the president,” UCSC Graduate Program Coordinator Marissa Maciel said. “In order for my premium not to go way up I have to leave my doctor of the last 10 years and change my child’s pediatrician.”

UCSC Campus Provost and Executive Vice Chancellor Alison Galloway called the increases in health care costs “disappointing” and expressed that the UCSC administration has pointed out the difficult situation its employees face to the Office of the President.

“I’m particularly concerned about our many employees who are currently enrolled in the HealthNet HMO plan,” Galloway wrote in an e-mail. “While an alternative version of that plan is being made available, it apparently will offer fewer providers. A sizable number of employees will face the prospect of finding new doctors. We’ve expressed our concerns about these issues – more than once – to UC leaders.”

http://www.santacruzsentinel.com/ci_16329342

When Congress wrote the Patient Protection and Affordable Care Act (PPACA), they did not want to disturb the very large sector of health insurance coverage that seemed to be working well – the employer-sponsored health plans. It was decided that high-quality plans, such as that of the employees of the University of California at Santa Cruz, should be protected so that the plans would always be there when the employees needed them, that is if they wouldn’t mind choosing between paying much higher premiums or losing their established physicians.

Jerking around provider lists, dramatically increasing premiums, pumping up deductibles and other forms of cost sharing, and manipulating benefits are all market tools used liberally by the private insurers. They are used to benefit the insurers, even if at the expense of the insured.

Compare that to our public insurance program – Medicare. Medicare doesn’t even have provider lists. You can go anywhere and see any physician who is willing to see you. Adjustments in premiums are very modest, unlike the double digit increases typical of the private insurers. Medicare cost-sharing adjustments are also very modest, unlike the financial barriers to care being erected by the private insurers. Medicare benefits do not diminish but have actually increased through the years. Medicare needs further improvement, but at least it’s not headed downward in the same direction as the private plans are.

It’s interesting to note that more recent releases from the Department of Health & Human Services and other public agencies have shortened the name of the Patient Protection and Affordable Care Act (PPACA) to simply Affordable Care Act (ACA). Just as they gave up on insuring everyone, it looks like they also have given up on patient protection. If we had an improved Medicare for all, everyone would be covered and patients actually would receive the protection they need. It’s not too late to change.

Coburn: Private health insurance may end soon

By Randy Krehbiel
Tulsa World
October 12, 2010

“There will be no insurance industry left in three years,” Coburn told the Republican Women’s Club of Tulsa County.

“That is by design. You’re going to make insurance unaffordable for everyone — which is what they want. Because if there’s no private insurance left, what’s left? Government-centered, government-run, single-payer health care.”

http://www.tulsaworld.com/news/article.aspx?subjectid=262&articleid=20101012_262_0_hrimgs995333

Senator Tom Coburn, M.D.
http://coburn.senate.gov/public/

And…

Nursing Economics: Is U.S. Health Care Evolving Toward a Single-Payer System? An Interview with Health Care Economist Paul Feldstein, PhD

Interview by Peter I. Buerhaus, PhD, RN, FAAN
Medscape Family Medicine
October 13, 2010

Peter Buerhaus: Looking to the future, do you think the passage of health reform legislation and its implementation could eventually lead to the adoption of a single-payer system?

Paul Feldstein: It is hard to say where we are going, particularly because the legislation creates health insurance exchanges which will be overseen by an insurance regulator. The insurance regulator will have the authority to set the benefit package and influence whether a state approves or denies rate hikes by insurance companies. I can see a scenario where there is very little cost containment and little pressure to keep insurance premiums from rising substantially. And, if there is a weak mandate for individuals to purchase health insurance, then the resulting adverse selection is likely to cause insurers to increase their premiums. People will become dissatisfied with the premium increases and some may become more supportive of a government-funded public insurance option. By heavily subsidizing government-provided health insurance and undercutting private insurers, many people will switch to lower-cost public insurers because studies show that people are willing to switch insurers for not much of a price difference. Eventually, if many individuals purchase public insurance, we could end up with a single-payer system or something close to one.

http://www.medscape.com/viewarticle/726680_5

Paul J. Feldstein, Ph.D.
http://merage.uci.edu/Faculty/FacultyDirectory/FacultyProfiles.aspx?FacultyID=18

The majority of progressives predict that a single payer system is inevitable because the nation will no longer tolerate the increasing costs of health care. On the other side, many conservatives and libertarians predict that a single payer system may be inevitable because health plans will no longer be affordable in a regulated insurance market. Senator Tom Coburn and Professor Paul Feldstein represent the latter view.

Senator Coburn has been nicknamed “Dr. No” because of his conservative, anti-government, obstructionist approach to legislation. His views can be dismissed as those of a right-wing ideologue.

Prof. Feldstein, on the other hand, presents a more intellectual discourse of his position on health care financing. In a conversation we had during a forum at which we both appeared (Eighth Tamkin Symposium at the University of California at Irvine), Prof. Feldstein indicated to me that he was a dedicated follower of the teachings of his mentor at the University of Chicago – Milton Friedman. I probably need not say more.

The full interview of Prof. Feldstein (link above) is worth reading if you wish to better understand the sincere framing of single payer concepts from the perspective of a free-market intellectual. Although I say that his framing is sincere, it is distorted by what I believe to be exaggerated potential adverse consequences of single payer and by his failure to include certain inescapable benefits of single payer which, specifically, more than offset the deficiencies. He also repeats many of the trite criticisms of single payer that are based more on ideology and less on solid policy science, supposedly proving points by citing what are actually exceptions.

So while those on the right threaten us with the inevitability of single payer, the supporters of health care justice preach the inevitability of single payer. It looks like it’s not if we’ll have single payer, but when. But it won’t happen until we all understand that the financing mechanism of the Patient Protection and Affordable Care Act is not an avenue to reform, but a barrier that must be displaced. What we put in its place is where we totally disagree.

I might add that my conversation with Prof. Feldstein was in 2006, long before the recent reform process was underway, and at that time he told me that he believed that eventually we would have a single payer system, as much as he lamented the prospect. He is a very bright individual.

Wolters Kluwer Pharma Solutions

Sample represents more than 80% of the dispensing activity within the United States for retail prescriptions, inclusive of largest retail chains.

While payers still greatly influence patient access to treatment, increasingly, patients are weighing treatment cost and benefit, especially of new prescriptions.

2009: Commercial Rx Claims – New Rx

85.59% – Dispensed to patient
8.08% – Denied by health plans
6.33% – Abandoned by patients
Brand Rx – 9.30% abandoned
Generic Rx – 5.50% abandoned

http://www.wolterskluwerpharma.com/Press/Pharma%20Insight%202009%20-%20Media.pdf

Comment: 

By Don McCanne, MD

This study covered 80 percent of the retail dispensing activity within the United States. It included patients for whom our health care system is working, at least theoretically. These individuals gained access to a physician, received one or more prescriptions, and then attempted to have the prescription filled by a retail pharmacy.

Private health plans that should be assisting patients in receiving the care that they should have, denied over 8 percent of the new prescriptions recommended by physicians.

Of all new prescriptions, over 6 percent were prepared but then abandoned by patients, primarily because of the high out-of-pocket costs of the prescription.

We need a health care system that ensures that all of us receive the health care that we need, including prescription drugs. A single payer national health program – an improved Medicare for all – would do just that. No one would walk away from a pharmacy empty handed.

Pharma Insight 2009

Wolters Kluwer Pharma Solutions

Sample represents more than 80% of the dispensing activity within the United States for retail prescriptions, inclusive of largest retail chains.

While payers still greatly influence patient access to treatment, increasingly, patients are weighing treatment cost and benefit, especially of new prescriptions.

2009: Commercial Rx Claims – New Rx

85.59% – Dispensed to patient
8.08% – Denied by health plans
6.33% – Abandoned by patients
Brand Rx – 9.30% abandoned
Generic Rx – 5.50% abandoned

http://www.wolterskluwerpharma.com/Press/Pharma%20Insight%202009%20-%20Media.pdf

This study covered 80 percent of the retail dispensing activity within the United States. It included patients for whom our health care system is working, at least theoretically. These individuals gained access to a physician, received one or more prescriptions, and then attempted to have the prescription filled by a retail pharmacy.

Private health plans that should be assisting patients in receiving the care that they should have, denied over 8 percent of the new prescriptions recommended by physicians.

Of all new prescriptions, over 6 percent were prepared but then abandoned by patients, primarily because of the high out-of-pocket costs of the prescription.

We need a health care system that ensures that all of us receive the health care that we need, including prescription drugs. A single payer national health program – an improved Medicare for all – would do just that. No one would walk away from a pharmacy empty handed.

World Health Organization
(Accessed October 11, 2010)

Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. This country has made important gains in providing primary health care since the Alma Ata Declaration in 1978. All health indicators show steady gains and the health status of the population has improved. Infant, maternal and under-five mortality rates have all decreased over the last decades, with a marked increase in life expectancy at birth.

Like most transitional societies, a wide range of therapeutic choices are available in Bangladesh, ranging from self care to traditional and western medicine. The public sector is largely used for in-patient and preventive care while the private sector is used mainly for outpatient curative care.

The Public Sector

The primary care in the public sector is organized around the Upazila Health Complex (UHC) at sub-district level which works as a health-care hub. These Units have both in- and out-patient services and care facilities. Most commonly, they have in-patient care support with 31 beds, while some UHC have over 50 beds. Many UHC Units have a package service called “comprehensive emergency obstetric care services” (EOC) available, with an expert gynaecologist, an anaesthetist and skilled support nurses on duty round-the-clock, and basic laboratory facilities. At a lower tier, the Union Health and Family Welfare Centre (UHFWC) are operational, constituted with two or three sub centers at the lowest administrative level, and a network of field-based functionaries. The public sector field-level personnel are comprised of Health Assistants (HAs) in each union who supposedly make home visits every two months for preventive healthcare services, and Family Welfare Assistants (FWAs) who supply condoms and contraceptives pills during home visits. Recently some of the female HAs and FWAs have been trained as birth attendants (skilled birth attendants – SBAs), to provide skilled services within a household setting.

The Private Sector

In the private sector, there are traditional healers (Kabiraj, totka, and faith healers like pir / fakirs), homeopathic practitioners, village doctors (rural medical practitioners RMPs/ Palli Chikitsoks-PCs), community health workers (CHWs) and finally, retail drugstores that sell allopathic medicine on demand. In addition to dispensing medicine, sellers at these mostly unlicensed and unregulated retail outlets also diagnose and treat illnesses despite having no formal professional training.

http://www.whoban.org/health_system_bangladesh.html

And…

Physician’s obligations to patients

By Dr. Delwar Hossain
The New Nation – Bangladesh’s Independent News Source
October 10, 2010

Doctors of medical background are usually brilliant and talented groups of people of our country. They are the cream of the society and pride of this country.

High moral values and strict ethical practice should be observed in the physicians simply because they are considered next to Allah by the sick people. In true sense they are the deputy of almighty Allah in this world. Unfortunately with the few exceptions they are indulged in immoral activities and unethical practices of all sorts. I think it is not too late to rectify ourselves now.

Malpractices of all sorts have engulfed the physicians of all categories and money appears as the single most important driving factor. Money is an important factor but should not be the only factor for our profession.

Cesarean operation is a life saving method for mother and baby. It was invented only for selective and complicated labor. It is still used as such in the West. But quite different picture is seen in our country. When this facility was first available in our country several decades ago hardly 10% labor was done by it. It was used only in cases of its valid indications. But now around 50% (varies 40% to 95%) labors are done by it across the country and in majority cases injudiciously. It becomes the easiest method of earning a lot of money within shortest possible time! If we become an exploiter instead of a perfect technical person how can we be able to protect the interest of a patient?

Cases of gross negligence on the part of physicians are being reported in paper now and then. These are nothing but the tip of the ice-burg only. One of my known persons decided to deliver their baby by Cesarean section. He managed to get the best anesthesiologist and gynecologist. Patient started muscle twitching on the operation table during later part of operation. On inquiry it was found that Oxygen cylinder ran out of oxygen! And the anesthetist was found upstairs in computer game! By this time patient incurred irreparable brain damage. Then she was transferred to Dhaka to Singapore and attended by both the British and the American specialists. But did not get any benefit. Now she is deeply unconscious, has been bed-ridden for last one and a half decades, on life saving measures. She and her family life had gone to hell.

http://nation.ittefaq.com/issues/2010/10/10/news0680.htm

Comment: 

By Don McCanne, MD

Can a health care system in a transitional society such as Bangladesh provide lessons for a modern industrialized nation like the United States? Well, yes. See how many lessons you can find here.

Health System in Bangladesh

World Health Organization
(Accessed October 11, 2010)

Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. This country has made important gains in providing primary health care since the Alma Ata Declaration in 1978. All health indicators show steady gains and the health status of the population has improved. Infant, maternal and under-five mortality rates have all decreased over the last decades, with a marked increase in life expectancy at birth.

Like most transitional societies, a wide range of therapeutic choices are available in Bangladesh, ranging from self care to traditional and western medicine. The public sector is largely used for in-patient and preventive care while the private sector is used mainly for outpatient curative care.

The Public Sector

The primary care in the public sector is organized around the Upazila Health Complex (UHC) at sub-district level which works as a health-care hub. These Units have both in- and out-patient services and care facilities. Most commonly, they have in-patient care support with 31 beds, while some UHC have over 50 beds. Many UHC Units have a package service called “comprehensive emergency obstetric care services” (EOC) available, with an expert gynaecologist, an anaesthetist and skilled support nurses on duty round-the-clock, and basic laboratory facilities. At a lower tier, the Union Health and Family Welfare Centre (UHFWC) are operational, constituted with two or three sub centers at the lowest administrative level, and a network of field-based functionaries. The public sector field-level personnel are comprised of Health Assistants (HAs) in each union who supposedly make home visits every two months for preventive healthcare services, and Family Welfare Assistants (FWAs) who supply condoms and contraceptives pills during home visits. Recently some of the female HAs and FWAs have been trained as birth attendants (skilled birth attendants – SBAs), to provide skilled services within a household setting.

The Private Sector

In the private sector, there are traditional healers (Kabiraj, totka, and faith healers like pir / fakirs), homeopathic practitioners, village doctors (rural medical practitioners RMPs/ Palli Chikitsoks-PCs), community health workers (CHWs) and finally, retail drugstores that sell allopathic medicine on demand. In addition to dispensing medicine, sellers at these mostly unlicensed and unregulated retail outlets also diagnose and treat illnesses despite having no formal professional training.

http://www.whoban.org/health_system_bangladesh.html

And…

Physician’s obligations to patients

By Dr. Delwar Hossain
The New Nation – Bangladesh’s Independent News Source
October 10, 2010

Doctors of medical background are usually brilliant and talented groups of people of our country. They are the cream of the society and pride of this country.

High moral values and strict ethical practice should be observed in the physicians simply because they are considered next to Allah by the sick people. In true sense they are the deputy of almighty Allah in this world. Unfortunately with the few exceptions they are indulged in immoral activities and unethical practices of all sorts. I think it is not too late to rectify ourselves now.

Malpractices of all sorts have engulfed the physicians of all categories and money appears as the single most important driving factor. Money is an important factor but should not be the only factor for our profession.

Cesarean operation is a life saving method for mother and baby. It was invented only for selective and complicated labor. It is still used as such in the West. But quite different picture is seen in our country. When this facility was first available in our country several decades ago hardly 10% labor was done by it. It was used only in cases of its valid indications. But now around 50% (varies 40% to 95%) labors are done by it across the country and in majority cases injudiciously. It becomes the easiest method of earning a lot of money within shortest possible time! If we become an exploiter instead of a perfect technical person how can we be able to protect the interest of a patient?

Cases of gross negligence on the part of physicians are being reported in paper now and then. These are nothing but the tip of the ice-burg only. One of my known persons decided to deliver their baby by Cesarean section. He managed to get the best anesthesiologist and gynecologist. Patient started muscle twitching on the operation table during later part of operation. On inquiry it was found that Oxygen cylinder ran out of oxygen! And the anesthetist was found upstairs in computer game! By this time patient incurred irreparable brain damage. Then she was transferred to Dhaka to Singapore and attended by both the British and the American specialists. But did not get any benefit. Now she is deeply unconscious, has been bed-ridden for last one and a half decades, on life saving measures. She and her family life had gone to hell.

http://nation.ittefaq.com/issues/2010/10/10/news0680.htm

Can a health care system in a transitional society such as Bangladesh provide lessons for a modern industrialized nation like the United States? Well, yes. See how many lessons you can find here.