During 1997 and 1998 I corresponded with a
number of groups about aged care. This was a letter to the Australian
Consumers Association. I was critical of their marketplace consumer
focus which I feel plays into corporate hands and serves to reinforce
the corporate position. I was later also critical of an article in
their magazine Choice which described the attempt to oppose "managed
care" as "managed scare".
25 February 1998
Australian Consumers Association
57 Carrigan Road
Thank you for returning the material I sent you and for the articles from Choice which I enjoyed reading. I don't believe we are excessively far apart in our thinking but I feel your articles miss critical issues. I am stimulated to touch on a few of the issues. Please don't consider this as something rigid. What we don't need in health care is very clear. Which of the several alternatives is best is an open issue. Rebuilding a sound medicare system is one of these. It is tried and tested. It has public support. I deliberately don't push any easy looking alternative strongly. To do so would open me to criticism and divert the attack on corporate medicine. Instead I stress the need for open and honest discussion by people who are knowledgeable but who are not "stakeholders".
Fees:- I don't feel too strongly about who or how health is paid for but I feel very strongly about who provides it and who makes how much profit from it. I was therefore very reassured to see that with the exception of the cardiac surgeons average fees were much closer to the schedule fee than the AMA fee. This means that the bulk of specialist surgeons are charging the scheduled fee and are being responsible. My impression was that many more were using the AMA rates. Gap payments are less than I thought.
The issue of for-profit medicine:- I feel that all groups are shying away from the fundamental issue which lies behind managed care and many of the other threats. That is the provision and control of health care by corporations whose prime purpose in involving themselves in health is not to provide care but to make money for demanding shareholders who never see the consequences for patients. Profit priorities and the cost of services are in direct conflict. The only way to make the sort of profits expected by profit driven corporate insurers and providers is to deny services, charge more and skimp on the services themselves, principally by cutting quantity and quality of staffing. Good care involves giving people your time, your empathy, gentleness and discussing wisely. This is something which is not reflected in outcome measures. Managed care in various forms is one aspect of the corporate model but is potentially more dangerous for care as both corporate insurer and corporate provider take their cut before providing services. Economic rationalist perspective's see the corporatisation of health care as inevitable and desirable. One need only examine our minister of health's public statements and his policies as set out in his speeches. They so closely mirror statements by corporate health care executives in the USA that you wonder whether government health policy is already being made in US board rooms as Ron Williams predicted. The threat is not managed care but corporatisation and managed care is a part of this. Medicare helps put a brake on this but it is potentially vulnerable to the sort of abuses and misuses which have characterised medicare and medicaid in the USA. The government has a clear policy of contracting the care of medicare patients to corporate providers. Consumer choice will have little impact. This is really a very unethical way of rationing care for public patients.
Tactics and the real issues:- Those more thoughtful AMA senior staff to whom I have spoken are aware of the corporate problem and many corporate supporters have now changed their views. Read Dr Arnold's article in the MJA on competition and his article in Australian Medicine attacking the concept that medicine is an industry. We share the same view about the misuse of language to create a distorted perspective. This view of language is based on a common experience. We live in what Saul calls a corporatist society. AMA members are part of that society. Corporatist views and practices are accepted as self evident and are not challenged. (eg the use of "stakeholder" negotiations as a legitimate government decision making process). For the AMA to directly attack the fundamental validity of economic rationalist and corporate beliefs would destroy their credibility and render them ineffective. The AMA would lose the support of members most of whom are liberal party supporters. Managed care is hated by the profession in the USA and there is mounting opposition from all sections of the US community. It is a catchword which allows the AMA leadership to oppose what is happening and push the envelope of social consciousness away from corporatist ideas. When I talk about corporate misconduct my colleagues now immediately call it managed care which has become a dirty word. They can put it into an easy pigeon hole as something they don't like.
I used the same technique when living in an apartheid society. I maintained a prominent public profile and good relations with all groups and so remained in a credible "insider" position. I used my position to target key weaknesses and issues in order to undermine belief patterns and move community perceptions . Had I adopted a directly confrontational stance in that society I would have destroyed my credibility and rendered myself totally ineffective. As a credible insider I could say and do things which would have resulted in a banning order had I been confrontational. In Australia the political situation and my position are different. I have seen no need to build that sort of credibility here. I therefore use the position of an "outsider". I attack very strongly and directly to destroy the credibility of the corporate position. My credibility is always attacked by them and questioned by the establishment. It is repeatedly restored by unfolding events, particularly in the USA.
The funding of health care:- My views about the funding of health care are not very strong. Like you I believe medicare has been an excellent system and I am reassured by your figures and agree that scare tactics are being used to drive economic rationalist policies. I do think that there are clouds on the horizon because of increasing costs, longer training periods reducing working life, an aging population and increasing unemployment. A smaller and smaller number of payers will be funding an increasingly costly health service. Preventive health measures which prolong life increase costs as these elderly have more chronic illnesses and require more care. The argument that prevention reduces costs is fallacious. Our culture is increasingly corporatist and selfish. The young may become more and more self interested and incentive driven, so less willing to fund aged care properly. We need to use available time to anticipate these events and explore possible solutions.
I too see the threat of a two tiered system when the user pays. At the same time philosophically I tend to favour a system which encourages personal responsibility. I would not be opposed to a system in which all patients pay something according to their means and in which they are all protected from excess expenses by the medicare system cutting in. Medical savings accounts and aged care savings accounts could be encouraged with tax rebates. Aging citizens could ensure their future without being reliant on government. I have worked in a system which was means tested but the level was set rigidly and far too low. This did result in a two tiered system. Fortunately the system was humanitarian and a phone call to the medical superintendent of the public hospital and the pathologists indicating that I would not be charging a particular patient who was having financial difficulties was sufficient to secure free treatment. To avoid a tiered system I think that there should be only a single system for providing care but that payments could be linked to means.
For any funding system to work it must be taken out of the immediate control of the government and of for profit businessmen. It should be determined by community needs and not the next election, corporate expansionist ambitions or profit goals. The public system is under-funded because politicians refuse to raise taxes for this. Funds needed to run existing hospitals effectively are squandered in pre-election hospital building sprees.
The provision of health care:- I have been a quiet critic of some aspects of the current hospital based individualised practitioner system for some time. While obviously desirable and very plausible the various objective systems of measurement and accreditation which are supposed to control standards in such a system are difficult to implement effectively and are often unreliable. They distort the situation. In my view they are used to pacify public and political anxiety and serve as a public relations tool. They add to costs. This is not to suggest that they are totally useless or that the profession does not make very genuine efforts to make them work. I suspect that the same objectives could be met more effectively in other ways.
My own view is that medical services might be best provided by integrated "not for profit" medical service structures run by the community and the profession for the benefit of the community. Such structures would transcend individual hospital boundaries and extend into the community. They would operate across all hospital systems. While patients may opt to pay for more expensive hotel services in a "select private hospital", the medical services would be provided by individuals who worked within the same services.
This sort of system is however two edged. I also see the sense of commitment and personal responsibility assumed by individual doctors for their patients as very important for dedicated care. I have watched with alarm the reduction of hospital resident's hours by rostering, a very old fashioned and discredited view. The resident is expected to walk off and leave his or her sick patient to an on call person who has not been involved in care. At present most, but not all residents are sufficiently imbued with the medical ethic of personal responsibility not to do so but this may change. For example I cannot imagine what my father, a GP would have thought of handing his patients over to an after hours service whose staff he had never met. This would have been unthinkable! If he was not available then arrangements were made with someone he trusted. The other side of this responsibility was a relationship of mutual honesty, trust and integrity but not necessarily paternalism! Corporate healthcare, the financial competition which Choice supports to reduce costs, and excessive consumerism effectively destroy all this. I would like to see costs tailored to meet the services which the community decides it needs and not wasted in aggressive advertising and other unproductive competitive practices.
I have worked in a limited system of multi-centre cooperating specialists in which we were able to maintain individual responsibility for patients within an integrated professional system. It was cooperative and supportive system. We collected and analysed all patient data. Each patient's problem was critically discussed. It worked very well. I believe the idea deserves a cautious trial and might prove useful. Peer review and on going audit are built in and many of the legal problems which force doctors to overservice could be addressed.
These are only a few rough unformatted thoughts. I am not going to discuss the numerous issues such as rationing of care. The MJA has accepted a letter I have written about this. There is also the issue of the right of individuals to buy care which is rationed and for which they do not qualify. To put such matters under the control of "for profit" hospital managers whose prime responsibility is to their shareholders is frightening.
As indicated I have clear views about what is unacceptable. I am reassured by your view of medicare and don't believe that it is necessary to suddenly change the whole system to a for-profit one. What is needed is open discussion and the careful trial of ways of improving and meeting potential difficulties before they engulf us.
Evidence based medicine:- One of the difficulties with what is happening is well illustrated on page 11 of the choice article on Medicare. This is revealing of the limitations of the sudden pressure for evidence based medicine which we have all tried to practice for most of this century. Giving it a name like this simply adds it to the oversimplified black and white jargon of our politically correct discourse. Distortion follows as this fails to recognise that community perceptions and the views of interest groups play an important part in decisions. Like others you quote Caesarean section as a measure of obstetric standards. This reinforces a strong community perception fuelled by midwives, natural childbirth support groups and feminists critical of male obstetricians. These groups have been very suspicious of and have even opposed studies which try to examine the effects of vaginal delivery.
My own studies and those done around the world show quite clearly that vaginal delivery causes severe damage to the pelvic floor in a large number of individuals. The anal sphincter is silently torn in a third of first deliveries and there is a degree of denervation of all pelvic floor muscles and sphincters due to stretching of the nerves. Attempts to avoid caesarean sections by forceps or vacuum extraction are particularly damaging. Pelvic floor exercises help but do not prevent the problems. The lives and relationships of a number of young women are ruined by sexual difficulties. There are some truly tragic cases. As women get older large numbers undergo untold misery as a result of urinary problems, prolapse and a variety of defecatory problems. I deal with these women, investigate their problems and try to treat them. Vast numbers of operations are performed on very poor denervated tissues with sometimes limited or only temporary benefit. Most of this would be prevented by caesarean section. Obviously this must be set against the psychological considerations and the risks of caesarean section to mother and baby. At the very least mothers should be fully informed and be allowed to make a rational choice about the method of delivery. Caesarean section is no longer a measure of obstetric failure.
The issues surrounding caesarean section are therefore primarily social, like abortion and euthanasia. They are not medical and it is quite wrong to use this as a measure of the standard of obstetric practice. I would regard the increase in caesarean sections as a measure of good scientific obstetric practice and an indication that the many Queensland obstetricians, who have listened as I have presented the evidence to them are talking to their patients properly. The lower incidence in public hospitals reflects the reluctance of midwives to accept the evidence which has been presented to them as well. There are also greater social pressures on doctors in the public system. Male obstetricians are under particularly strong pressures and find it very difficult.
At the very least a highly contentious index is being used as a public measure of standards. This is quite wrong and its use in support of evidence based medicine is particularly revealing. On the evidence more women would be better off and healthier if they had caesarean sections for all their deliveries. If evidence based medicine is to be standard practice then all pregnant woman should be advised to have a caesarean section! Whether we want to have all children "untimely ripped" from their mothers womb is of course a very valid social concern but it has nothing to do with evidence! I never advocate caesarean section as a preferred method of delivery because of the social considerations.
Clearly I am strongly supportive of recording information and of evaluating it. I have spent most of my life doing so. What I am concerned about is the rush to find something which is easy to measure and then waving it about as a yardstick of care by evaluating the information within quite the wrong context - as if it were the final arbiter of standards. Caesarean section is only one example.
I attach a few more newspaper reports from the USA which may interest you. I also send the letter which Alpha wrote to FIRB in response to the objections to Sun's entry. This was recently released under FOI. As you can see from my criticism I set about by dismembering it and exposing it as the deceptive document it really is. If I was acting as an "insider" I would adopt a slightly different approach.
Best wishes in your efforts. I will be away for a few months so will not be in a position to send you many more documents.
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