A Front-Row Seat as a Health Care System Goes Awry

The New York Times, January 20, 2009, by Claudia Dreifus — Over a long medical career, Dr. Robert L. Martensen, 62, has been an emergency room and intensive care unit physician, treating an estimated 75,000 patients. He has taught bioethics and medical history at Harvard Medical School and Tulane University in New Orleans. After Hurricane Katrina wiped out his home and Tulane professorship, Dr. Martensen moved to Bethesda, Md., to direct the National Institutes of Health Office of History. Recently, Farrar, Straus & Giroux published Dr. Martensen’s critique of the American health care system, “A Life Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era.” We spoke in New York City during his book tour and later on the telephone. An edited version of the conversations follows.

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Brendan Smialowski for The New York Times

“Most Americans die in hospitals or nursing homes, and neither is configured to take care of dying patients.” – Robert L. Martensen

Q. THE KEYSTONE OF PRESIDENT-ELECT BARACK OBAMA’S HEALTH CARE PLATFORM INVOLVES SETTING UP A NATIONAL SYSTEM OF COMPUTERIZED MEDICAL RECORDS. WILL THAT SOLVE OUR HEALTH CARE PROBLEM?

A. Shared electronic records are valuable. They will reduce error. It may save money because it could cut down on duplicate testing. But the health care crisis is of much greater magnitude than that.

In addition to all the issues around health insurance and who pays, we have a system that costs more than any in the world and where almost everyone is unhappy. Patients feel, “Nobody is listening to me.” Hospital administrators are unhappy because the bottom line has become paramount and their mission has gotten lost. The heads of the large professional organizations feel there is no center anymore; it’s just atomized interest groups, hustling and scrambling. Physicians are disgruntled by their inability to practice the way they’d like. Many are quitting.

This is nothing that technology will fix. The problem is money, people and systems. It’s not that electronic records aren’t worth doing. But to present this as the solution is inadequate.

Q. In your book, you particularly criticize the American way of dying. Why do you feel that this aspect of health care is on the wrong track?

A. Most Americans die in hospitals or nursing homes, and neither is configured to take care of dying patients. There’s little palliative care available, and often the payment structure of health insurance doesn’t support it.

So you end up with situations where a 90-year-old with organ failure is brought to an emergency room and the doctors go, “Let’s tune her up.” Or if the patient starts failing at the nursing home, they’ll say: “No one dies here. Let’s get her to the emergency room.” It’s not unusual in the last six months of a patient’s life that they’ll be shuttled between the nursing home and hospital 6, 8, 10 times and subjected to a lot of painful and expensive interventions. The patient is artificially maintained that way until their body gives out.

I’ve done ethics consults for hospitals where patients have been in the I.C.U. for six months. An elderly woman has gone from a serious neurological problem to end-stage renal disease, with no hope of ever being able to move a finger and no one told the family, “Your mom is dying.” When it was finally said, the relatives were furious.

Q. WHAT SHOULD DOCTORS SAY INSTEAD?

A. I think doctors should get comfortable with being realistic. If it is the case, the doctor should bring up the idea that this disease process might be fatal. Right now, we say, “I can’t take away a person’s hope,” as if doctors were bestowing life. You have to support those hopes that are realistic, not this fantasy land.

I’ve seen how a lot of these interventions are inhumane. If you resuscitate an older person, you may break their ribs during C.P.R. If you put them on a ventilator, you may end up sedating them so heavily they are barely conscious.

Q. CAN THERE BE SUCH A THING AS A GOOD DEATH?

A. My father had one. He was a systems engineer. In his 80s, he developed serious pulmonary problems, and he was very savvy about how things can go wrong in complicated systems, which hospitals are. To make sure that nothing was done to him that only technically extended his life, he made sure that his wife, doctor and hospital had copies of his medical directives. He didn’t have an extended period of dying because he avoided being put on a ventilator. My father died comfortable, surrounded by people who loved him. He was lucid till about five minutes before his death.

I think that’s what I’d want for myself, too. It’s not easy to get. I’ve seen situations where people leave specific directives and the hospitals still resuscitate them.

Q. For many years you worked as an emergency room physician. Why that specialty?

A. An emergency room is where the rubber meets the road in medicine. In terms of the arrays of things you see, every shift is different. I like that. I like doing general care, with the spice aspect. I like making diagnoses.

I had a patient one time: he was 19, from Bangladesh. He had high fever and lumps under his armpit. I had just been reading Daniel Defoe’s “Journal of the Plague Year,” where Defoe described patients with buboes, these walnut-sized lesions from the plague. And that’s what flashed through my mind when I saw this ashen kid. He had bubonic plague, it turned out.

Q. Is the lesson of this story that doctors, as part of their training, should read more history and literature?

A. It would be of immediate benefit. If I hadn’t read Defoe around that time, I might have misdiagnosed my patient, given him antibiotics and sent him home, which was a homeless shelter. The infection could have spread quickly.

Actually, a lot of E.R. doctors have nonmedical interests. It’s a specialty that while you’re doing it, you’re fully present. When your shift is done, you leave it behind. A surprising number of emergency room physicians are artists, even writers.

Q. Do you still practice?

A. No. Six years ago, I was working at a hospital in the Middle West. The other hospital in the region had shut down, and we were the hospital of last resort, seeing double the patients. I was responsible for 60 in eight hours — people with gunshot wounds, heart attacks, children with meningitis. Conditions made it impossible to practice good medicine. I felt like I was skating on thin ice. I just wanted out. My story is not unique. But I miss patients. I miss the E.R.

This page presents the fundamentals of our current healthcare system and single payer.

Index

1. Our Current Healthcare System

2. Single Payer versus Socialized Medicine

3. Healthcare in Canada and Elsewhere

4. Arguments for Single Payer (Single Public Healthcare Insurance)

5. Motivating Others to Get Interested

1. Our Current Healthcare System

Our current healthcare system is not only broken; it is in crisis.

The problems with our current system are numerous. Recently Rand Corporation found that much of the care delivered in the United States in sub-standard. “Using 439 indicators of quality developed by multi-specialty expert panels, the analysts found that participants received only 54.9% of recommended care—a proportion that varied little across the categories of preventive, acute and chronic care.” This report included some of the best hospitals to be found in this country.

There are other major problems:

There is great inefficiency in the present healthcare system.

In California, there are hundreds of private insurance companies, hundreds of government insurance programs, and even more private health care funding sources, and thousands of different benefit plans.

With a major portion of health dollars going to “administration” costs, including large executive salaries, commissions, and stockholder dividends, fewer dollars actually go to health care.

7 million Californians are uninsured. Millions more are underinsured

Costs are rising for premiums, co-pays, and deductibles for less coverage.

People have fewer choices.

Hospitals, emergency rooms and trauma centers are closing.

Half of personal bankruptcies are caused by medical bills.

For-profit managed care maximizes profit (not our health) and rations care.

Lack of insurance is the 7th leading cause of death in the United States.

World Health Organization ranked the U.S. health care system 37th in the world in a composite ranking based on specific population-based healthcare outcomes, such as life expectancy and infant mortality; the U.S. was ranked 55th for fairness.

The United States is the only industrialized country that does not have universal health care.

2. Single Payer versus Socialized Medicine

Senate Bill 840 would create a publicly-funded, not for profit health care system. There would continue to be both public and private care providers. Providers would choose how and where they want to practice medicine just as they do today.

Cost-effective, simplified finance and administrative framework for providing universal health coverage. Framework is adapted to a state or nation’s unique needs and resources.

State or nation establishes a health insurance plan that covers all residents.

Health Fund collects and disburses all health care dollars.

Purchasing Fund implements bulk purchasing and gets discounts on pharmaceuticals and durable medical equipment.

Plan administered by a single agency. Administration uses only 1%-5% of the budget. Current administrative costs are between 27%-30%.

Billions of dollars are saved by finance, purchasing and administrative consolidation.

Savings are used for health care services and provider reimbursement.

Plan is financed by a progressive state tax and by federal dollars already spent on health care. New taxes replace health insurance premiums, co-payments and deductibles.

95%-99% of each tax dollar goes to health care services and provider reimbursement. (Today only 70%-73% of each health care dollar goes to health care).

Medical decisions are made by medical providers and patients.

Patients choose their own providers.

Quality of care is improved through equitable distribution of resources, public participation in policy making, provision of preventive care to everyone, risk adjusted budgets that pay the true costs of care, integrated statewide health care data bases used to perform comprehensive planning, public access to non-confidential information, linkage of research and innovation to health care needs, use of evidence-based medical practices and pharmaceuticals, return of decision-making to providers and patients and a system of consumer advocates with authority to resolve complaints.

3. Healthcare in Canada and Elsewhere

This is an interview with Tom Barnard, M.D., who has practiced in both the United States and Canada.

Tom Barnard, MD, talking to Esther Wanning, 3/5/05

Dr. Barnard practiced in Petaluma, CA, for one year in 1994-1995. He then returned to Canada

TB: I’m originally from the states and I was trained at Cornell and Rochester, and I finished my training in family medicine and anesthesia. …I was married to a woman whose family was from Ontario, and she and I were both interested in working in poor and underserviced places. We moved to the north of Ontario, and I ran an ambulance program in the remote part and took care of people in native reserves. I did anesthesia; I delivered babies; I was a coroner. That was really the golden age of the Canadian system, before the conservative economics in health care really took hold and prior to the time when very expensive medical technologies and increasingly expensive drugs became such an issue in terms of affordability. It was a totally marvelous experience compared to what I had seen in the US. We’d see a sick kid in a remote town and fly her out and take her to where she could get the best care. Completely without a fee. People had everything available to them.

Since then, the Canadian system – as many other health care systems around the world — has come under a lot of financial pressure, in part because of the conservative fiscal economics over the last couple of decades, and in part because medical technology and pharmaceuticals have become so horribly expensive. But one of the real advantages of each province’s having its own mandate is that they have a good ability to regulate drug costs. By and large the costs are much less here than in the states, though of course it depends on the particular drug.

EW: I read an article by Malcolm Gladwell in the New Yorker saying that the generic drugs cost as much or more in Canada as they do here.

TB: That’s crap. I live so close to the border that I see some patients who come over here. A couple of weeks ago, I saw a woman with breast cancer, who was on a five-year protocol of post-surgery tamoxifen. She was living on $6 or $800 a month, and her drug was costing her something like $150 US for a two-month supply. I wrote her a prescription and at the pharmacy in my building it cost $10. This was a generic tamoxifen, made by the same country that produced the tamoxifen she used in the United States. Metforman, which is a commonly used drug for diabetes has been available in Canada as a generic for a long time. In the States it’s still under patent, and the difference in cost is at least ten times. I have a pharmacist friend who sees patients who come over by the busload here and for the most part the drugs are at least 30% cheaper here. On an individual basis, sometimes you have a really cheap generic drug in the states.

You know you pay for the drug research through your taxes. The basic research is done by the Candace Perts of the world at the NIH, perhaps at universities. Not to say that the drug industry is all bad, but what they tout as costs of research are probably widely inflated. And I can tell you as a physician, the drug companies spend a whole lot of money on marketing. But the television ads aren’t allowed in Canada. I think the private industry can have a role in educating people, say about diabetes, etc., what the possible treatments are, but never mentioning specific drugs.

In Canada, the industry itself has created a pretty stringent set of guidelines. They don’t take you and your wife out to dinner anymore. It’s very carefully controlled. And any dinners they put on are oriented toward education rather than any particular product. The other night for instance they had Paul Richter from Harvard on a teleconference. He’s a sterling researcher. He certainly wasn’t promoting a drug.

My office is completely computerized and every exam room has a computer connected to a high-speed line. I had a lady the other day who said, well, I have this Rothman-Thompson syndrome, and I said “What’s that?” So right then, I looked it up and got a whole printout.

I’m involved in a study at the University of Toronto, where they’re taking docs in the field and teaching physicians how best in a time-efficient way to do evidence-based medicine. It’s a struggle you know, because you don’t have an infinite amount of time. I think of docs working for HMO’s in the states where there’s a certain amount of pressure to see a lot of patients. The fee for a visit to a family practitioner is not huge, and also there’s a large shortage of doctors. in Ontario alone there are probably a thousand or so family physicians lacking for this population. So our practices tend to be quite large.

While there are always downsides to any approach, I think it makes a lot of sense to have one insurance company that’s not for profit, run by the state or some non-political organization.

When I worked in Petaluma I had to give my credentials to 33 insurance companies. Here, the billing part of medical practice is such a dream. I see a patient, I write a little code onto a piece of paper, I leave it on my secretary’s desk, and she does the billing right there. At the end of the day it goes directly from the computer to the ministry of health and we get paid once a month, direct deposit in the bank . It takes like—no time.

EW: So you never have to have a conversation about whether they’ll pay for it?

TB: Oh no, that virtually never happens. If it’s a medical emergency. I may call a consultant or a cat scan radiologist or the MRI guy and say, “Hey Joe, can I get Sally in right away?” But that’s really a courtesy call.

EW: But that’s not saying who’s going to pay for it, which is the first question here.

TB: No, no question about that. Never an issue. The only issue is that publicly funded systems like this may have a problem in capacity. For example, there may be an MRI scanner on every street corner in San Francisco. In Canada, on the other hand, there are several MRI scanners in a city the size of Windsor. So when you need an immediate scan you have to push some buttons. If it’s not urgent you might not get it the same day or even the same week. A system that’s built around trying to conserve medical resources doesn’t have that redundancy in the equipment. If you need a hip replaced because you broke your hip, you can get that done today or tomorrow. If you need a hip replaced because you’ve got osteoarthritis, it may take a few months. And that’s because there are relatively fewer operating rooms, etc. There isn’t a medical arms race, where you can get the surgery done at any clinic as long as you’re willing to pay for it. But sometimes I think procedures are done in the US for reasons of remuneration rather than medical necessity.

EW: And here if you don’t have the insurance, you may not have the necessary procedure done at all.

TB: Believe me, that year in Petaluma was a real eye-opener. When I was there docs were going bankrupt. I made an okay living, but that area, we were practically poverty-stricken.

Here, I have to say honestly, it really is a pleasure to see people and not to worry about whether they can afford the care. That said, things come up. Not everybody here has coverage for medication. And some therapies are covered and some aren’t. Massage therapy, for instance, you now have to have supplemental insurance. Many of my patients work for the auto industry locally. They for the most part have supplemental plans where you get a certain amount of massage therapy or reflexology.

Some of the experiences I had that year in Petaluma were astonishing. I worked at a free clinic one night every couple of weeks, in a soup kitchen kind of place, and I was amazed at the level of pathology of the people who came into that clinic. And most of these people were workers with no insurance. They had the kinds of things that in Canada you would only see in a textbook, like thyroid disease, that had gone untreated for two years. And you’d think, “My God, what year is this?” Or I’d see some poor Hispanic grandmother who had metastatic breast cancer, and she’d known she had had this lump for a least a year, but she wouldn’t go see someone because she didn’t have insurance. God, it was really heartbreaking, and that stuff would never happen here. You see a lady with a breast lump here — and I have a huge population of migrant workers and people without financial resources — and that person here would have all the care and there would be no question about whether they could afford it.

There are many positive sides to this system. With a single insurance system there’s just a huge administrative saving. It’s not that I don’t have my frustrations. We all do. But in terms of getting care for people, this system is marvelous. Honestly, the waits are pretty rare.

Another thing. By and large, malpractice issues are not a concern for physicians here either. First of all, we have malpractice insurance from a plan run by physicans called the Canadian Medical Practice Association. It’s a fantastic thing, it’s really cheap. Maybe Canadians aren’t that litigious, but God, I’ve been in practice thirty years, and I’ve never been sued. Our costs for malpractice I think are around $2,000 a year; it’s not even on the radar screen. Here the coverage is completely seamless.

EW: I would assume that part of the reason that docs are sued so little is that people think of their physicians as their friends and their advocates, whereas here, they often think of the doc as the advocate of the insurance company. And when you feel that your physician is denying you care when he’s putting money in his pocket, the relationship suffers.

TB: That doesn’t happen here at all. Ethically, we should be the person’s advocate for care, and there’s no reason here that you would be concerned about the cost of the procedure.

EW: Tell me about something else. Here, the high-paid specialists are the least likely to go for a single-payer plan as apparently they suspect their incomes will plummet.

TB: Here, we had an earning cap for certain classes of physicians of $450,000 dollars. It was just elimininated in the current round of negotiations. It would depend on where you worked. And you might do some surgery outside the cap. But in a city like Windsor which is relatively underserved for ophthomology and where there was no cap, it could be $750,000, and this is without overhead issues. In the states you might easily have a 50% overhead. My overhead here is 25%. My secretary-receptionist does all my billing and takes care of it all in a minute.

There are a few things people pay out of pocket for, like a professional drivers’ physical.

EW: But there’s no copay for the usual services. People here worry about the idea of not having copays and envision lines of hypochondriacs filling people’s offices.

TB: I have to tell you that has not been my experience. Honestly, most people just don’t come for fun. I have a lot of people who might be hypochondriacal, but I don’t see them a lot. That objection I think is based more on somebody’s personal bias than on reality. If you really look at it, look at the Rand Corporation studies or whatever, it seems that what copayments do is to delay reasonable care, and then people get sicker. I think by and large what you want at a primary care level is accessibility and affordability. You want that level of care to be very accessible. And beyond that, ideally, what you want is to be able to access the secondary and tertiary levels of care without worry about whether the patient can afford it. And I think this system does that really well.

It’s not that I don’t complain, and say to myself, geez, I’m only getting $30 for this visit. But I earn a few hundred thousand a year, really working very reasonable hours, and most primary care physicians in the states don’t have that luxury. I think the system has been very good to me.

I really like what I do every day. Medicine’s fun, it’s great, you can really help people, and especially when you’re not worried about whether the patient can afford a chest X-ray.

EW: I don’t know why more specialists aren’t buying into the single-payer idea. They hate the system too, the phone calls, the insurance company clerks.

TB: I think it’s a question of the devil you know. The big thing with single payer that needs to be emphasized for a state like California is that it is true that you don’t want it to be a political football. You want some sort of free-of-politics person running it who is like a judge or a czar who the people feel comfortable with and who they can trust and who isn’t going to be under the hand of some political party, which will change accessibility. If the Canadian system has a problem it’s that it’s a bit of a political football. The Conservatives –who are like the Republicans– get elected and the next thing you know there is all this downsizing. Then the liberals elected and it changes. That part is a little frustrating. But despite all those little fluctuations, for the most part what people see is pretty much good access to care, unquestioningly. Your kid gets leukemia, she gets care, you don’t pay, there’s no question. There are ancillary costs, driving here and there, but the system even covers a lot of that. There may be a problem if someone needs a heart transplant and there may not be a lot of hearts available, but that’s a problem in the states too.

My brother died in NY essentially of leukemia because he didn’t have insurance and couldn’t afford a bone marrow transplant. He may not have lived anyway of course, but to not even have access to care….you can’t have a decent society like that.

EW: Is there anything you miss about practicing here?

TB: I can’t say I do. You can certainly get MRI and CT scans in a minute, but you’d have to justify any of that with the insurance carrier, and that wasn’t very pleasant. Here, I’m able to get good care for people and really advocate for them without worrying about whether they can afford it.

Again, the big thing is you don’t want to feel like a pawn of the state, an employee of a state system. While all docs understand that they have to work for the most part within some kind of insurance system, we want the least intrusive system possible and one that remains affordable and gives care to everybody.

It’s really important to support the poor and the children. We’re learning now that a society that ‘s not taking care of it’s young and its pregnant moms and babies will reap the horrible negative returns. Without adequate care in the first years, they wind up with diabetes and hypertension and cardiovascular disease later. The more we understand that, the more we realize that, by God, we have to provide decent care for them because otherwise we’re going to go bankrupt taking care of them later. In the U.S., you’re not caring for the disenfranchised people, who paradoxically you will get the most savings from.

It’s a simple math problem. George Bush is going to have to get that. If you’re so bloody conservative, add up the numbers and see where you should put some resources. It’s crazy not to be doing that, not to mention the human tragedy, but even on an economic level it makes no sense.

EW: I don’t know why that doesn’t penetrate and I don’t know why businesses won’t buy in.

TB: Businesses here are very comfortable with the idea that their employees get great health care, and they save a bundle. That’s a huge advantage for Canadians.

On a human level, this kind of system is tremendously reassuring. I think California could do a grand job of putting together a big not-for-profit plan that would take care of everybody and save a hell of a lot of money. And I think the docs come out doing better, not worse, financially.

Again, it’s math. Figure out how much you’d save by not having billing complications. And consider the anxiety of having procedures halted in the hallway because the insurance clerk decided it wasn’t going to be covered. I had that experience, and it was catastrophic. Of course, docs don’t want to feel that they are going to be poor because the system changes over. And they won’t be. The cardiologists here make a damn good living. There was recently a neurosurgeon here who moved to Michigan, but it had to do with the hospital not buying him the right equipment, and he was mad. He was making as much money here as he’s making in Michigan. That was not the issue. I think a lot of that stuff is more emotion and hype than reality. I don’t think many docs move to the US. A lot of docs have moved from Ontario to Alberta, where they have oil revenues and pay a lot.

VITAL SIGNS

Americans down on the U.S. health-care system

Dutch rate theirs most favorably of 10 industrialized nations

By Kristen Gerencher, MarketWatch

July 13, 2008

SAN FRANCISCO (MarketWatch) — International comparisons of health-care systems can be tricky to tease out, but the Dutch appear most satisfied with their system and Americans the least satisfied, according to a new survey of 10 industrialized countries.

The Dutch system was most popular with its citizens while adults in the U.S. were itching for national reform the most, according to Harris Interactive, which cited three separate data sets.

A third of Americans said they believe the U.S. system “has so much wrong with it that we need to completely rebuild it,” while only 9% in the Netherlands hold such a sentiment about their health-care system. Twelve percent of Spaniards favored a complete overhaul, compared with 15% in France, 17% in New Zealand, 18% in Australia and 20% in Italy.

People in the Netherlands also were most likely to say their health-care system works well and needs only minor changes, with 42% holding that view vs. 29% who said so in France. About a quarter of participants in Canada, New Zealand and Australia were fairly satisfied with their health care. The U.S. and Italy were least likely to want minimal changes, with only 12% and 11% supporting just minor tweaks, respectively.

Americans are fed up with the headaches in their system, but that’s generally not due to the quality of care they receive, said Uwe Reinhardt, professor of economic and public affairs at Princeton University. Had the survey asked participants about their most recent hospital stay, for example, the U.S. likely would’ve scored higher, he said.

“What Americans are upset about is the unbelievable hassle of having to select health insurance, maybe not getting it … losing insurance when they lose their job,” Reinhardt said. “The American citizen is massively insecure.”

Doctors and nurses routinely hear demoralizing news that U.S. medicine is inferior “when the real problem is the way we finance health care and the hassle of claiming insurance,” he said.

Americans’ feelings about the U.S. health-care system have remained stable over the last decade, with roughly twice as many saying they want a complete overhaul compared with other nations, said Karen Davis, president of the Commonwealth Fund, a private foundation in New York that has tracked the issue.

What’s more, Americans’ personal share of medical expenses is the highest in the industrialized world, Davis said. In 2007, 30% of Americans reported having out-of-pocket medical expenses of more than $1,000 in the last year compared with 19% of Australians, 12% of Canadians, 10% of Germans and New Zealanders, 5% of Dutch and 4% of Britons.

Accounting for success

The Dutch financing system has been transitioning to a new model in the last year, where residents contribute payroll taxes into a central fund, Reinhardt said. Then they receive a voucher to buy coverage from nonprofit or for-profit private insurers.

Those polled as the change went into effect may have been reluctant to add any more reforms — even though the system functions pretty much the same way as before, he said.

“The system is so tightly regulated and so many transfers are made among people to make sure everyone can afford the insurance and everyone has access to the same care that it’s really just a social insurance system in disguise,” Reinhardt said. “It’s not even vaguely close to the U.S. system.”

Dutch health care also addresses patients’ need for medical attention during nonbusiness hours, Davis said. “The Netherlands has this amazing off-hours system of care so you can always get a nurse or doctor at night or in the evening.”

It’s not just Dutch patients who seem satisfied. In 2006, only 3% of physicians in the Netherlands said they thought their system needed a complete overhaul compared with 9% of U.K. doctors and 16% of doctors in the U.S, according to the Commonwealth Fund.

In some countries that have universal coverage, a sense of pride pervaded the participants’ answers, along with a smaller dose of concern about the systems’ sustainability. In Great Britain, nearly 70% agreed that the National Health Service must be maintained because it’s “crucial” to British society, according to the Harris Interactive survey. But 24% called it a “great enterprise” that probably can’t be maintained in its current form.

Contemplating trade-offs

Majorities in France (70%) and Britain (59%) said their health systems are the envy of the world. Still, nearly as many in France as in the U.S. said fundamental changes are needed to make the system work better. Half of American adults said so compared with 47% of French adults.

Victor Rodwin, professor of health policy and management at New York University’s Wagner School of Public Service, said the French and Danish have among the highest satisfaction rates in European polls of health-system perceptions.

“The French tend to defend their system because they look across the channel and see the British system of rationing and they say that’s not for them,” he said. “They look across the Atlantic and see the U.S. number of uninsured and high prices and say that’s not for them.”

At the same time, some French physicians complain that they’re underpaid and that the system is weighed down by wasteful spending and a lack of responsiveness to consumer preferences, Rodwin said.

In France, people automatically receive a standard, generous insurance benefit that includes prescription drug coverage, he said. They have no deductibles but small copayments. The system is financed largely through taxes.

“What makes France unique is there’s such good access not only to primary care, which you also get in Britain, but also to specialty care,” Rodwin said. “And there’s a high premium on patient choice.”

To be sure, France has one of the most expensive health-care systems in Europe, with expenditures totaling about 11% of its gross domestic product. The U.S. spends 16% of its GDP on health care. Cost containment has been an issue in France for the last 20 years, but unlike the U.S., lawmakers there aren’t talking about national health reform, Godwin said.

Still, cost concerns are growing, he said. “There is an increasing realization that this cannot last forever. There’s constantly new technology and pressure to cover all this and deliver it to the entire population.”

Harris Interactive tapped three sources for its findings. The data for France, Italy, Spain and Germany come from an FT/Harris Poll conducted in June 2008 for the Financial Times. The data for the U.S. and Great Britain come from a Harris Interactive survey conducted for the International Herald Tribune and France 24 in May 2008. The data for the Netherlands, Canada, New Zealand and Australia come from a Harris Interactive survey conducted for the Commonwealth Fund between March and May 2007. End of Story

Kristen Gerencher is a reporter for MarketWatch in San Francisco.

Copyright © 2008 MarketWatch, Inc. All rights reserved.

A Chronicle report:

Two women, two cancers, two health-care systems

– Tom O’Brien

San Francisco Chronicle

Thursday, December 29, 2005

After a long time away, you see with new eyes.

I moved back to the United States with my Canadian wife and two small boys after living 15 years in Toronto and Ottawa. U.S. health care now looks both expensive and scary, leading me to conclude that we’d do better with an entirely different system.

Nowhere has this been put in sharper relief than in the story of two colleagues. Struck in March with cancer, an American colleague worried about death, insurance loss and bankruptcy. In contrast, a Canadian colleague and cancer victim had only her disease to fight.

Susan was on sick leave when I came to work at my new job in August. She was middle-aged and single with a grown family and well liked in my office. She was undergoing chemotherapy to treat breast cancer and not able to work. Our employer supported her beyond the normal period of sick days and vacation.

But the scary question for anyone but the rich hit with a catastrophic illness in the U.S. health-care system is: How long will an employer’s support go on if the battle goes far beyond the time allotted for sickness and vacation? Susan worried about the loss of health-care coverage and what ensues — second-rate care, bankruptcy, choosing between timely drug therapies and even modest necessities. She died this month before those fears were realized. But had she lived, she and her family would have confronted the excruciating battle survivors have to fight with insurance companies, employers and health-care providers over cost, length and quality of treatment.

In contrast, my former colleague Kathleen back in Canada was gripped by uterine cancer, which had spread to her intestines. While she was locked in a life-and-death battle for 18 months, she didn’t have to worry about losing her health care and choosing which bills to pay. Canadian Medicare covers everyone for everything in hospitals and doctors’ offices, including some elective procedures. This means no health care-caused bankruptcies. No fights with insurers. No insurance-driven financial worries. Kathleen could save her energy for battling her cancer instead. She did recover, and while her recovery was not necessarily the direct result of differences in care systems, there is no question that she would have suffered more with the burden of financial worries related to her health-care needs.

I hear stories here about Canadians lining up for basic medical care. But despite plenty of doctor appointments, occasionally bringing my children to the ER, and having had a heart procedure myself, I didn’t witness any delays for necessary (let alone emergency) care. In survey after survey, Canadians support public, nonprofit health care by a wide margin.

And why not? Compared to the United States, Canada has much lower infant-mortality rates and a longer life expectancy, according to data from the World Health Organization. Canadian women get just as many mammograms, for example, as do American women. This is achieved despite spending far less per person on health care — 10 percent of per capita GDP in Canada goes to health care versus 15-plus percent in the United States, according to WHO research.

After 40 years of private health care in America and 15 years of Canada’s Medicare, I’ll take the latter. But of course, I can’t; it’s not available here. I love my country but not the private health-care system that abandons many people and worries even more.

Few Americans know that every other industrial country in the world has a health-care system more or less like Canada’s. I think even fewer realize that we do, too — it’s called (U.S.) Medicare. The system that boosted the health of Americans 65 and older is similar to Canada’s system for everyone. They’re both “public, not-for-profit, single-payer” systems with low overhead costs. So why not extend Medicare to every American?

Our seniors like it. Sure, it will raise the cost of this government program by billions of dollars, according to even the most conservative estimates. But it will save money for both individuals and employers who now purchase private health insurance. After all, it’s not how much of your income you pay, it’s how much you keep. You’ll keep more under Medicare-for-all, and every child, woman and man would get the timely health care they need.

Give people the opportunity to face and fight their illnesses, not their insurance companies.

Tom O’Brien joined the California Nurses Association (www.calnurse.org) upon moving back to the United States in August.

4. Arguments for Single Payer (Single Public Healthcare Insurance)

Universal Single Payer Insurance will do the following:

It establishes a single publicly accountable trust fund.

It collects the dollars and pays the bills for comprehensive care delivered by both private and public sector providers.

Everyone will always be insured.

Only single payer financing and administration saves enough money to provide high quality, comprehensive coverage for all

Californians., according to the Healthcare Options Project(2002).

There are other important points:

Security—No one ever loses their insurance, if they remain residents of California. Californians who work out of state for a California-based firm and senior Caliifornians who retire out of state but choose to continue paying into the California system will not lose coverage.

Choice— Everyone can choose their doctors.

Comprehensive Benefits –Benefits include prescription drugs and mental health care.

High Quality—Doctors and patients decide on care; safe staffing ratios are in place in hospitals. There will be offices of the Consumer Advocate throughout the state.

Simple Administration —A single administration minimizes paper work for individuals and providers.

Cost Effective —Sound financing provides health care for all Californians without spending more. Cost control is achieved through global budgets, bulk purchases of drugs and durable medical equipment,

Good Public Policy—A sound single payer plan fosters personal responsibility and community solidarity.

5. Motivating Others to Get Interested

Perhaps getting people to look at how many areas of our lives can be improved would prompt them to be interested in, indeed get involved with, the effort to bring a better healthcare system to our state.

A universal care with single payer financing would provide reliable, quality coverage for all Californians for life. If you want or need to change jobs, you will not love your insurance. A “pre-existing” condition inhibits people’s ability to change employment.

Why not create a health-focused—not profit based—administrative system. For the first time, California will have an independent, non-profit administrative team to oversee the system, manage costs, and maintain quality. A better healthcare system would bring together all stakeholders—providers, consumers, hospitals, public health experts—to identify and help solve local service problems.

Quality of care will be greatly improved by funneling all data from providers into one place.

Fraud can be better contained by utilizing a single data collection system.

California’s business climate would be improved by contolling healthcare costs. All California employers will pay an affordable health insurance premium based on their payroll, resulting in a level playing field among competing business.

And since all employees will also contribute their fair share to premiums, labor-management strife over healthcare should end.

With no deductibles or out of pocket costs to pay, California families could save from $300 to $3,000 per year while business could save from $300 to $2,000 per employee (see Lewin Group study).

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SINGLE-DIGIT GAINS – Having a long ring finger signals success as a financial trader, according to a study of 44 male traders in London published in the journal Proceedings of the National Academy of Sciences. The longer the ring finger compared with the index finger, the higher a trader’s earnings are, the study found. Previous research has found the digit ratio reflects how much testosterone an unborn baby was exposed to in the womb. Those exposed to high levels are deemed more sensitive as adults to testosterone, which creates feelings of confidence and encourages risk-taking.SINGLE-DIGIT GAINS – Having a long ring finger signals success as a financial trader, according to a study of 44 male traders in London published in the journal Proceedings of the National Academy of Sciences. The longer the ring finger compared with the index finger, the higher a trader’s earnings are, the study found. Previous research has found the digit ratio reflects how much testosterone an unborn baby was exposed to in the womb. Those exposed to high levels are deemed more sensitive as adults to testosterone, which creates feelings of confidence and encourages risk-taking.

The Boston Globe, January 20, 2009 — Genetic engineering is not new in the plant world. For example, scientists have tricked crops into producing their own insecticides by inserting genes from other organisms that make the bug-killing substances. But for the first time, researchers from MIT have tinkered with plants’ own metabolic machinery to make new compounds that could become drugs to treat cancer or other diseases.

Sarah E. O’Connor, an associate professor of chemistry at MIT, and her colleagues worked with the periwinkle plant because it naturally produces vinblastine, which is used to treat Hodgkin’s lymphoma, and other alkaloid compounds that hold promise for fighting other cancers and hypertension. Based on earlier work in O’Connor’s lab, the researchers knew feeding different chemicals to periwinkle cell cultures results in production of different compounds.

Taking that a step further, they genetically altered an enzyme involved earlier in the biosynthetic process so the plant cells would eat specific starter materials they wouldn’t ordinarily accept, leading them to make compounds they wouldn’t otherwise produce. Depending on the starter materials chosen, the resulting compounds could be tailored for high effectiveness and low toxicity, overcoming problems found in naturally produced plant compounds.

“This work demonstrates the power of genetic engineering to harness the potential of complex plant-derived natural product pathways,” the researchers write.
BOTTOM LINE: Plants can be genetically reprogrammed to produce compounds that may become drugs to treat cancer or other diseases.
CAUTIONS: The genetics and biochemistry of the pathway in producing these compounds is not fully understood.
WHAT’S NEXT: Exploring production of more compounds that could become drug candidates.
WHERE TO FIND IT: Nature Chemical Biology, Jan. 18.

Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

MedPageToday.com. Jan. 20, 2008, by Charles Bankhead — Minor reductions in calculated doses of cancer drugs could lead to substantial cost savings without more risk to patients, an Australian clinician said here.

For example, a 10% reduction in the calculated oxaliplatin (Eloxatin) dose for advanced colorectal cancer could reduce costs $17,905 per year for stage III disease and $25,876 for stage IV, said Kathryn Field, MBBS, of the Royal Melbourne Hospital.

The savings would come from “rounding down” to avoid wasting most of an ampule of drug, which often happens during dosing based on a patient’s body surface area, she said at the Gastrointestinal Cancers Symposium.

“Such a small dose reduction likely would not compromise efficacy, although this is contentious and may not apply to all tumor types,” said Dr. Field.

A small survey of local oncologists showed that most would be willing to accept dose reductions, although opinions varied by circumstances, she added.

Rounding down is not uncommon in the U.S., said Jennifer Obel, M.D., a medical oncologist at North Shore Health System in Manhasset, N.Y. However, the practice varies by the type of cancer, the drug being used, and individual patient characteristics.

Dosing of chemotherapeutic drugs is commonly based on a patient’s body surface area, said Dr. Field. The method is imprecise and leads to considerable waste with no assurance that a patient received the most appropriate dose.

For example, she noted, a drug might come premeasured in 100-mg and 50-mg ampules. If a patient’s calculated dosage is 160 mg, then 40 mg would go unused. Rounding the dose down to 150 mg would avoid the waste and its associated cost.

For her analysis, Dr. Field reviewed the records of 104 patients with stage III colorectal disease treated with oxaliplatin over two year and 173 patients with stage IV disease treated over five years. She found that 13 patients per year received oxaliplatin dosed within 10% of 150 mg on the basis of body surface area.

Assuming each patient received 10 cycles of therapy, Dr. Field calculated the potential cost savings if the patients had received 150 mg of oxaliplatin instead of the calculated dose. The results showed a savings of almost $18,000 per year for patients with stage III disease and almost $26,000 annually for patients with stage IV colorectal cancer.

Although oncologists have embraced body surface for dosing chemotherapy, they also recognize that “the picture is much more complicated than just taking into account a patient’s height and weight,” said Dr. Obel, a spokesperson for the American Society of Clinical Oncology.

“Oncologists use body surface area, but they realize it’s an imperfect science,” she said.

“I think in practice oncologists [round down],” Dr. Obel added. “We know what the vials are, and we are rounding inherently in practice. I don’t think oncologists would be uncomfortable with a 10% rounding.”

Primary source: Gastrointestinal Cancers Symposium Proceedings.
Source reference:
Field K, et al “Dose rounding of chemotherapy treatment: What is the potential impacton treatment costs and is it acceptable to oncologists?” ASCO GI 2009; Abstract 407.

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Joe Raedle/Getty Images
IMPORTS Asia dominates in antibiotics.

The New York Times, January 20, 2009, by Gardiner Harris — In 2004, when Bristol-Myers Squibb said it would close its factory in East Syracuse, N.Y. — the last plant in the United States to manufacture the key ingredients for crucial antibiotics like penicillin — few people worried about the consequences for national security.

“The focus at the time was primarily on job losses in Syracuse,” said Rebecca Goldsmith, a company spokeswoman.

But now experts and lawmakers are growing more and more concerned that the nation is far too reliant on medicine from abroad, and they are calling for a law that would require that certain drugs be made or stockpiled in the United States.

“The lack of regulation around outsourcing is a blind spot that leaves room for supply disruptions, counterfeit medicines, even bioterrorism,” said Senator Sherrod Brown, Democrat of Ohio, who has held hearings on the issue.

Decades ago, most pills consumed in the United States were made here. But like other manufacturing operations, drug plants have been moving to Asia because labor, construction, regulatory and environmental costs are lower there.

The critical ingredients for most antibiotics are now made almost exclusively in China and India. The same is true for dozens of other crucial medicines, including the popular allergy medicine prednisone; metformin, for diabetes; and amlodipine, for high blood pressure.

Of the 1,154 pharmaceutical plants mentioned in generic drug applications to the Food and Drug Administration in 2007, only 13 percent were in the United States. Forty-three percent were in China, and 39 percent were in India.

Some of these medicines are lifesaving, and health care in the United States depends on them. Half of all Americans take a prescription medicine every day.

Penicillin, a crucial building block for two classes of antibiotics, tells the story of the shifting pharmaceutical marketplace. Industrial-scale production of penicillin was developed by an American military research group in World War II, and nearly every major drug manufacturer once made it in plants scattered throughout the country.

But beginning in the 1980s, the Chinese government invested huge sums in penicillin fermenters, “disrupting prices around the globe and forcing most Western producers from the market,” said Enrico Polastro, a Belgian drug industry consultant who is an expert in antibiotics.

Part of the reason these plants went overseas is that the F.D.A. inspects domestic plants far more often than foreign ones, making production more expensive in the United States.

“U.S. companies are more regulated and are under more scrutiny than foreign producers, particularly those from emerging countries. And that’s just totally backwards,” said Joe Acker, president of the Synthetic Organic Chemical Manufacturers Association. “We need a level playing field.”

The Bush administration spent more than $50 billion after the 2001 anthrax attacks to protect the country from bioterrorism attacks and flu pandemics; some of that money went to increase domestic manufacturing capacity for flu vaccines.

Even so, officials have said that during a pandemic the United States would not be able to rely on vaccines manufactured largely in Europe because of possible border closures and supply shortages. And the situation is similar with antibiotics like penicillin; researchers have found that during the 1918 flu pandemic, most victims died of bacterial infections, not viral ones.

The Centers for Disease Control and Prevention has a stockpile of medicines with enough antibiotics to treat 40 million people. If more are needed, however, the nation lacks the plants to produce them. A penicillin fermenter would take two years to build from scratch, Mr. Polastro said.

Dr. Yusuf K. Hamied, chairman of Cipla, one of the world’s most important suppliers of pharmaceutical ingredients, says his company and others have grown increasingly dependent on Chinese suppliers. “If tomorrow China stopped supplying pharmaceutical ingredients, the worldwide pharmaceutical industry would collapse,” he said.

Since drug makers often view their supply chains as trade secrets, the true source of a drug’s ingredients can be difficult or impossible to discover. The F.D.A. has a public listing of drug suppliers, called drug master files. But the listing is neither up to date nor entirely reliable, because drug makers are not required to disclose supplier information.

One federal database lists nearly 3,000 overseas drug plants that export to the United States; the other lists 6,800 plants. Nobody knows which is right.

Drug labels often claim that the pills are manufactured in the United States, but the listed plants are often the sites where foreign-made drug powders are pounded into pills and packaged.

“Pharmaceutical companies do not like to reveal where their sources are,” for fear that competitors will steal their suppliers, Mr. Polastro said.

China’s position as the pre-eminent supplier of medicines is a result of government policy, said Guy Villax, the chief executive of Hovione, a maker of crucial drug ingredients with plants in Portugal and China.

The regional government in Shanghai has promised to pay local drug makers about $15,000 for any drug approval they garner from the F.D.A. and about $5,000 for any approval from European regulators, according to a document Mr. Villax provided.

“This shows that there has been a government plan in China to become a pharmaceutical industry leader,” Mr. Villax said.

The world’s growing dependence on Chinese drug manufacturers became apparent in the heparin scare. A year ago, Baxter International and APP Pharmaceuticals split the domestic market for heparin, an anticlotting drug needed for surgery and dialysis.

When federal drug regulators discovered that Baxter’s product had been contaminated by Chinese suppliers, the F.D.A. banned Baxter’s product and turned almost exclusively to the one from APP. But APP also got its product from China.

So for now, like it or not, China has the upper hand. As Mr. Polastro put it, “If China ever got very upset with President Obama, it could be a big problem.”

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Jack Mock

Researchers have created an invisibility cloak of sorts, though it looks more like a yellow bathmat than Harry Potter’s famous cloth. The cloak is shown lying over a bump on a flat surface. Both the bump and surface are covered in a reflective coating. The cloak makes it appear that microwaves hitting the bump are actually reflecting off a flat surface.

Unlike Harry Potter’s, the real deal will likely be cheap, easily reproducible

MSNBC.COM, Discovery Channel, January 19, 2009, by Eric Bland — An invisibility cloak for visible light could be made within six months, say scientists from Duke University, who, in a new paper published today in Science, explain how to hide objects from a dramatically extended range of wave lengths.

“I think that within six months it’s certainly viable [a cloak for visible light],” said David Smith, a professor at Duke University and author of the Science paper.

“A large number of folks are looking at it, and I think it’s a matter of coupling the right material to the right device.”

A metamaterial is a material with unique properties that derive from its physical structure, not its chemical make up. To manipulate light, the microscopic surface of a material must be much smaller than that of the wave length of light being used.

Smith’s original 2006 invisibility cloak provided invisibility to longer microwaves, letting them flow around the object and regroup on the other side. As you move through microwaves and into the infrared (and soon, visible light) wavelengths become shorter, so the microscopic structure of the material has to get even smaller.

Advances in nanotechnology are making it easier to create ever smaller structures that can manipulate ever smaller wavelengths, said Smith.

To conduct the experiment, the scientists assembled a roughly 20- by 4-inch platform and covered it with the mirror-like metamaterial. Then they covered a roughly 1-square-inch rounded bump in the same metamaterial, placed it on the other surface, and shined infrared light on the set up.

Any normal curved material would scatter the light at a variety of different angles. The metamaterial covered bump instead reflected light back towards the source like a flat surface would do, hiding the bump underneath.

The Duke cloak does have its limitations. It only works in two dimensions. Both the background and the hidden object must also both be wrapped in the metamaterial.

It also has advantages. Unlike Harry Potter’s one-of-a-kind invisibility cloak, a real invisibility cloak will likely be cheap and easily reproducible. It took Smith and his colleagues about nine days to design and implement the experiment.

The scientists used hobby-level circuit boards; Smith’s rough estimate was that it took about $1.00 in circuit boards to cloak the one-inch bump on the metamaterial.

“If you were to commercialize this technology it would cost next to nothing,” said Smith.

Hiding a small bump is great for science, and for hiding things in general, but invisibility technology has a much wider range of uses besides mere concealment.

Just as one example of many, Smith says that cloaking technology could remove cell-phone interference in buildings, letting people have clear conversations even inside an elevator.

“We are just scratching the surface,” said William Padilla, a professor at Boston College who is developing a metamaterial to hide objects in the terahertz range. “There are hundreds of possible applications for this. We just need to think creatively about how it can be used.”

© 2009 Discovery Channel

URL: http://www.msnbc.msn.com/id/28679694/