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This page created April 2000 by Michael Wynne
This page and the one which follows it look at the collection of data in the marketplace and the collection of data about the marketplace. This page describes how much of the data on this site was collected.
What are the implications for the collection
of data of the fragmentation imposed by the marketplace and of the
competitive environment. Data is clearly commercially sensitive.
Where can we find it? What sort of data do you find? How reliable is
it? The collection of data under an alternate system is considered.
Contents
1. Collecting Reliable Data - (contents)
Commercial considerations:- In the marketplace and particularly in the US marketplace, the problem of fragmentation is far greater than in Australia. Each fragment is both fiercely competitive and protective. Not only is the cost of this service more than double that in the United Kingdom, but it is almost double that in Australia. Commercial considerations prevent the collection of accurate data relating to standards of care across the spectrum of the services. Only that commercially compromising data demanded by law and that elicited by regulatory inspection is readily available. It suffers from all the problems of information extracted under duress - the minimum required. It is consequently fairly crude data which gives a limited perspective. It is easy for marketplace advocates to develop a series of arguments based on the "there is no reliable evidence that" argument.
Data as a threat:- The disclosure of data and its evaluation is a potential threat to corporations. Adverse findings pose a serious threat to their businesses. Data can be used in marketing by competitors. It is their duty to protect their shareholders from this risk. They consider this sort of information as "commercially sensitive". My own experience is revealing. During a discussion with a multinational hospital administrator regarding intensive care standards in his hospital I offered the assistance of our own intensivist in helping organise and train staff. He told me that it was not company policy to allow this sort of access to information by people outside the company's system.
Government data:- There is sometimes enough data from a number of government sources to draw clear conclusions. Useful sources include investigations by federal agencies such as the General Accounting Office (GAO) in the USA. These investigations have some power to access information not otherwise available. Their findings are posted on the www. The GAO reports into aged care confirm the allegations made by community groups about poor care and needless deaths due to neglect.
Statements and evidence given at government hearings are very useful. Many documents were tabled at the "Profits of Misery" hearing into the misuse of children in specialty hospitals in Washington in April 1992. Reports like this can be obtained from the government office in Washington, but don't expect a response unless you go in person. Sensitive reports might be bought out by those who don't want them read. Sometimes the statements made by witnesses are not published.
FOI releases can be useful if the relevant department is motivated to be cooperative. I found NSW and West Australian Departments of Health very helpful after their advice that applications for hospital licenses by Australian Medical Enterprises be rejected was ignored in 1993. Both willingly released documents. FIRB was very helpful in 1998 after the deputy treasurer allowed Sun Healthcare into Australia despite the objection of government departments. Theye were less so in 1993 when I inquired about the way in which Tenet/NME was welcombed.
Australian data:- Crude government data about standards of care is also available in Australia. When using Australian data we should recognise that the vast majority of private hospitals here are not for profit and are not listed on the sharemarket. We are not talking about the same thing as the USA.
The figures from the USA compare not for profit care, the equivalent of our private system with for profit corporate care which is listed on the sharemarket. This is the sort of care which the business community and our political establishment is promoting and which they are encouraging. At this time it plays only a minor part in patient care. We cannot compare our data with the USA.. When we talk of private medicine in Australia we are talking about who pays and not about who provides the care. This is not what I am criticising.
Australian data does raise questions about our health system but any debate using these figures is about a public system versus a not for profit private system. We do not yet have any Australian data to support a debate about for profit care. For this we must turn to countries where a significant portion of the care has been supplied by corporate interests for a sufficiently long time for the corporate belief systems to become accepted and legitimate, and for the consequences to apparent. Only the USA qualifies.
Australian data reveals that even though there have been increases in the availability of emergency and intensive care facilities in the private sector, the private case mix is still less complex than that in public hospitals and is dominated by relatively minor surgical procedures1. Medical admissions are less frequent. Sicker people use the public system. The only major study of adverse events in Australia shows that such events are just as likely to occur in private hospitals where the mix of cases is minor as they are in public hospitals where more serious problems are treated. In fact some insured patients will go public when they have major illness or surgery. Even though the private hospitals provide less taxing care to less complex cases the cost of care per patient day is greater in the private system.
Duckett and Jackson2 examined publicly available data and concluded that the public hospitals in Victotria provided care at a lower cost per case. They also provided it at higher levels of technical, allocative and dynamic efficiency.
A recent editorial in the Medical Journal of Australia reviews two articles in the same journal3. The first shows that acute coronary artery disease is investigated much more readily in the item of service private sector than in the cashed strapped public system. As a result many more receive treatment. We might argue that public patients are disadvantaged, or that private patients are being overserviced but this is spurious.
Someone who has paid to have access to sophisticated and expensive care which is rationed in the public system will expect to get it and their doctors will offer it. We should expect this. The real question raised is about rationing - when and how we should ration. What were the criteria for rationing and who decided that coronary care should be rationed rather than some less life threatening condition? What cost benefit assessment was done? Was it transparent? What are the ethical issues and how were they addressed? Was the community aware that care for cardiac disease was being rationed? Would they have allocated more funds had they known?
The second article reveals that the treatment of coronary artery disease is more expensive in the privatte sector than in the public. The costs were the same. It seems that the additional expense was in the way charges were levied. We need to know why when neither were taking a profit. Socially and ethically doctors are committed to providing equally good care regardless of the patients ability to pay. Taxpayers now make a much larger contribution to private care. Why should their taxes pay more for something which can be provided more cheaply and effectively in the public system? It is also quite wrong for care to be rationed in public hospitals while government is paying much more money for affluent patients to receive the same care in private hospitals.
(1. Lawrence C - unpublished
parliamentary paper
2. Duckett SJ & Jackson TJ, MJA 172, 1 may 2000 p439
3. Bett N, "Coronary revascularisation in the private and public
sectors" Editorial MJA 173,18 Sept 2000 p285)
International Data:- Studies in other countries do reveal outcomes which are relevant to Australia. Cataract surgery has been the model for the introduction of a privatised market system in several states in Canada. It has been promoted as more efficient and by inference cheaper. Some governments are using this to press for greater privatisation. A recent study examining available data shows that the private option has been more expensive, less equitable, and that the waiting times for surgery are longer. There is also considerable useful information from Canada illustrating the way ideology drives the political process.
A recent investigation by the World Health Organisation found that the National Health System in the UK was not only the cheapest (half the US) but also provided one of the best services in the world - this is despite considerable unhappiness about the health service in that country. It is clear that such a system does have problems and limitations. A fully nationalised health system is only one of the alternatives to a corporatised market system..
Personal experiences:- Personal perceptions are useful when they are congruent with other data. The findings documenting adverse events in public and private systems referred to above is congruent with my own experience of public and private medicine in 3 countries over many years. The private sector in Australia does perform much better than those elsewhere including the USA. This may be because of the strength of our dominant not for profit system and the control which our strong professional system exerts over members and the care they provide.
I admit myself to a private hospital when I want comfort but when I am seriously ill and still have a reasonable life expectancy then I want to be in a public ICU or in a bed close to the ward sister in a public ward. When my son became acutely ill and required sophisticated care he went into the public hospital despite his insurance cover. In my small private practice I have advised my own private patients requiring surgery with potential serious complication to come as intermediate patients in the public system or to become public patients. Most have been happy to do so.
I am aware from my colleagues that as a consequence of the serious underfunding of the public system by the present government the public ICU's, like the rest of the system are in serious difficulties. Well trained senior staff are leaving for the private sector. As the WHO study reveals a public system is very efficient and cost effective when it is properly funded, when its staff are motivated and when it is not stifled by bureaucracy and an excessive emphasis on process.
Reports from the Press:- The media, particularly the press is often heavily criticised as sensationalist. The US press has behaved with great responsibility and has been the driving force in maintaining pressure for investigation and action. They have carried the public's message long before regulators or government acted. Accused of sensationalism and creating a feeding frenzy they have been repeatedly shown to be correct. Corporate interests have been protected by politicians and political processes. The press have exposed this.
There was for example little sign of activity after the Texas government settled their fraud action with Tenet/NME in 1991. My assessment is that there were strong pressures on politicians to allow the matter to blow over. The press across the country did not let the matter drop. They kept publishing new stories in state after state during 1992 maintaining the pressure. It was not until 1993 that the FBI mounted a full scale national investigation.
It is interesting that in spite of sustained pressure and clear information linking Tenet/NME's practices to board members none were prosecuted and those who retired received multimillion dollar packages. It was the next layer down which went to prison. A similar pattern has emerged in the multiple scandals since that time. Many are prosecuted but I am not aware of a single board member who has gone to prison. In Australia we have done much better. Bond and Scase have both been pursued.
Analyses in the Press:- There have been a large number of in depth analyses by newspaper reporters and many are very insightful. The press have been particularly skilful in weaving human stories into their analyses. These have been very important in exposing the human side, the suffering and mental anguish. In setting the experiences of the system against the stark formality of the fraud actions and the calculating inhumanity of the marketplace they have laid bare in story after story the human cost of what has happened in health care in that USA and the reasons for it.
It is essential that this human dimension be clearly understood when examining economic models such as that proposed to the World Bank. There are real people out there and these dry models with their mechanistic arguments are ultimately acted out by real humans. There are real human consequences when they are applied.
The people who control the system: - A number of reports describe the corporate businessmen who ultimately make decisions which impact on care. We can reach conclusions about the sort of people who will be involved in any marketplace system in Australia - their empathy, their ability to understand the suffering of others and their willingness to ration humanely and with empathy when this is essential. We can compare this with similar reoports of US businessmen who have rorted the system and their patients.
There are many reports which reveal how
individuals and corporate groups have responded in dysfunctional ways
to the pressures which are generated by the health care market. Will
the market model proposed by Graeme Samuel to the World Bank attract
similar people? Will it generate similar market pressures?
Information about the corporate marketplace and the corporations which provide care is not always readily available. One has to go actively looking for it with a specific objective in mind. It can be found.
Court Material:-The sort of information required for making decisions about probity before granting hospital licenses can often be obtained from court material. This can be a source of relevant data about corporate policies and practices as well as the care provided. Internal company documents are often tabled in court. Most of this information never becomes public and some of it is available for only a short period of time prior to settlement. Almost all government fraud actions in the USA have been prosecuted through the civil courts and have been settled out of court. Thera are usually agreed nothing proven public statements traded in return for a better settlement. Even criminal actions are settled out of court. One has to know where to go to find material and who to talk to. Sometimes one can go directly to witnesses. I received very revealing transcripts of conversations with hospital administrators from one witness. Many similar documents from across a spectrum of companies provide a picture of the extent of problems in the "industry".
Being Suspicious:- My own correspondence with the Texas attorney general in regard to Tenet/NME revealed a very different picture to the joint press release publicly available after a multimillion dollar fraud settlement. Tenet/NME had used this in claiming its innocence in Australia. Their claims had been accepted in NSW.. The court documents from the action by the US Security and Exchange Commission seeking injunctions to restrain Tenet/NME gave a graphic account of the way medical care was provided, quite different to the public information. Tenet/NME did not challenge the action and as no evidence was lead these matters were not fully reported in the press.
Doctors who gave evidence to the April 1992 senate inquiry into the misuse of children in psychiatric care (Profits of Misery) were even more specific about the way care was retarded, suggesting that children were deliberately stressed in order to keep them in hospital longer. Finding, visiting and talking to these witnesses yielded a harvest of information and documents.
Releasing Documents:- When I visited the USA in 1993, the US justice department was investigating Tenet/NME across the country. Investigators and lawyers acting for various parties could only express their revulsion at what they were finding. They were very angry. I was well informed and learned the content of much of the evidence. I would have received this material as soon as it was tabled in court but Tenet/NME pleaded guilty and settled the action. The materialnever became public and the US public was never aware of all the disturbing material prepared for the prosecution and what it revealed. I received only some preliminary material - internal corporate documents tabled in the early stages of the action. These document were useful because they put in question the assertions made by the company in Australia before its licence application was approved by Justice Yeldham.
Persistence:- McCabe an administrator in a Tenet/NME substance abuse hospital alleged that he was fired for refusing to pay bounty for admissions and for not complying with directives in regard to patient care issues. When the US federal government investigation commenced he filed an action for wrongful dismissal. When I phoned him from Australia he refused to speak to me. I then spoke to his lawyer who explained that the case had been settled for a considerable but undisclosed sum in an agreement which prohibited McCabe from even talking about it. A single press report early in the case indicated the nature of the evidence. This interested me and I kept asking about this case and the material as I travelled. Lawyers in New York, whom I visited about another matter they were prosecuting against the company had secured copies of all the documents in this case during the short period they had been tabled in the Colorado court. When I mentioned my disappointment they were produced. These were the documents which caused New South Wales Health Department to strongly advise Justice Yeldham to reject hospital licenses. They contained damning copies of instructions to corporate staff regarding care.
Probably only the government which appointed Yeldham and the corporate community knew that he was at risk of improper influence because of his clandestine sex life.
(Yeldham had recently been investigated by the ICAC. The ICAC Operation TAMBO revealed that police were selling this sort of information to business groups around that time.)
Drawing Parallels:- Soon after the investigation of Columbia/HCA commenced a similar claim to that by McCabe was filed by an administrator alleging that she was fired because she refused to follow instructions to pay kickbacks to doctors and to implement practices which would have compromised care. Like the McCabe case there was only this one brief press report. As the company had abandoned its attempt to enter Australia I did not follow it up. I had already spoken to doctors and knew of these practices and that they were common in corporate hospitals.
Patient Care Issues:- Because of the difficulties, patient care issues are seldom prosecuted by government. It is left to individuals. Patient care actions contain a wealth of information relating to standards of care and corporate practices. Very few of these come to court and the agreements usually contain clauses gagging the complainant. Tenet/NME paid US $135 million to the children whom it had imprisoned in its psychiatric hospitals. The settlement prohibited them from disclosing information and speaking publicly of their experiences. I too took action against a Tenet/NME hospital internationally and reached a bitterly negotiated agreement with nondisclosure/retraction clauses. I rejected many of the clauses they offered. Had I signed these I could not have continued to expose their practices.
Internal corporate documents are often used in these patient care complaints. I received valuable material from some of the actions taken by children in Dallas and Fort Worth before these cases were settled.. It was because I visited these lawyers and spent time discussing and correlating my experiences and concerns with theirs that I received their support and copies of documents. I have also spoken to and corresponded with other lawyers in the USA. A remarkable amount of unsourced material arrived in my mail. I also received from one of these court actions the company's, own internal report acknowledging appalling conditions in one of its hospitals. Someone had leaked it.
Maintaining Contacts:- During my 1993 trip many were as concerned and angry about HCA (now Columbia/HCA) as they were about Tenet/NME. At the time I made contacts and spoke to many but collected only a small amount of material. When Columbia/HCA announced its plans to enter Australia I was able to very quickly obtain a large amount of material from these people and from the contacts they gave me.
And Managed Care too:- Officials from the managed care group Kaiser visited Australia some years ago, presumably looking for opportunities. It had already commenced its large losses. The Texas insurance department had recommended it be fined US $3 million for denying care to people who needed it. Kaiser went to court in an attempt to suppress the documents. I already had an email network. As often happens these damning documents had already been leaked and were available in the Australian states Kaiser was visiting by the time the court rejected their application. In many cases the courts will agree to suppress documents because they breech patient confidentiality. In this instance the court refused to do so.
State authorities were also supplied with the information that after a number of patients died in a Kaiser owned facility state investigators found such serious staffing problems and deficiencies in care that they closed the hospital and started investigating Kaiser's other hospitals.
Another court action revealed that Kaiser advertised a free and independent arbitration system in regard to patient complaints. Instead it was a Kaiser appointed committee. In the particular instance the committee had deliberately procrastinated in settling a matter for several months because the patient was dying and under the particular situation the amount to be paid would be much less once he had died. The misery and anguish as this dying man and his family struggled through the arbitration system and frustrating delays was not a consideration. The judge was scathing when the had the guts to challenge Kaiser's behaviour in court..
I obtained all this information about Kaiser by sitting at my desk and using contacts. Had I gone to the USA I am confident I could have obtained much more, not only about this company but about others. People were and are angry. This is the only US HMO which has come Australia's way. Aetna is in New Zealand and made a visit I think to South Australia. Our well informed profession would have given it a very hostile reception and would not have signed contracts with it. Without contracts with doctors it would not have a market. Aetna is now in financial trouble, despite a massive takeover. Its shares have plummeted. It has sold its Canadian holdings and is selling elsewhere.
Managed Care - A Tide of Anger:- There are many accounts of adverse events in managed care and I receive a large amount of information. I have not specifically sought these as Australian doctors have been well informed and these companies have not come our way. There is for example the case of a doctor who was praised and given a bonus for denying care to a man who died. She resigned and gave evidence at a senate hearing instead. There are many other similar incidents.
Doctors, nurses, lawyers, judges, consumer groups, patient advocacy groups and large numbers of ordinary citizens know what is happening. Many have written articles explaining the deficiencies and the problems in managed care. The medical author of one of the most perceptive of these was promptly "delisted" by his HMO.
People inside talk and some even become whistle blowers. In psychiatry, in head injuries, in rehabilitation, in nursing homes, in domiciliary aged care, investigations have shown that the outcry by nurses and/or community groups was soundly based. They acted long before the regulators or the justice department. Their track record is excellent and they cannot be simply discredited when they make allegations about managed care.
Even in Australia it was not until the Kerosene baths in Victoria reached the press that government took any real account of the complaints of the nurses and acted. The evidence could no longer be ignored. We now know that the problems have been nation wide and that little was done about them. As in the USA it was the "for profit" homes cutting the fat.
The "not for profit" homes seemed to perform much better. Our aged care system was turned into a competitive marketplace in 1996. Regulatory controls were removed. The US experience it seems was directly relevant to what was soon to happen in Australia but our leaders were not prepared to learn from the experience of others.
How to Use this Information:- The problem with this vast body of information is that it is not the sort of data on which scientific studies can be performed. The purists maintain the claim that there is no evidence - or no "reliable" evidence. The studies from government surveillance data, imperfect as it may be does show consistent patterns. This is particularly damning in aged care.
Drawing Conclusions:- It is easy to get the sort of information I have described when the effort is made. There is so much of it. Individual items can be easily challenged or discredited in various ways by corporate PR strategies. They do not make up the sort of scientific evidence which can be published to confront the "there is no evidence argument". It is the ease with which information is obtained and the amount of information which is so disturbing. With so much smoke there can only be a large fire. It throws such a broad shadow across all of the major corporations that obvious common sense conclusions can be reached. It is clear that the well documented material from companies like Tenet/NME reflects patterns of thought across the entire marketplace, and the sort of practices which occur very commonly.
What is revealed by all of this is that despite all of the talk of reform and change, market systems have imposed their reforms on health care without setting in place any sort of data collecting system. There has been no system of planned scientific measurement of the changes introduced. To assess what is happening information must be sought indirectly. Little comes from the corporations and the information which they release is skewed and unreliable. It is only released as advertising or in defensive press releases.
Intelligent changes to any system require carefully planned strategies for measuring all anticipated outcomes and processes. All information must be accessible so that unanticipated adverse effects are quickly detected. It is clear from an examination of the way the market operates that the market is not capable of operating in this way. It is competitively aggressive. It imposes its solutions and then seeks to justify them retrospectively. The need for real transparency in handling all data rather than "marketplace transparency" render marketplace models like that proposed by Samuel unsuitable for the 21st century.
I do not want to try to develop another theoretical model because I believe that planning for the future is the role of the community, not for me, not for the market and not for Mr Samuel, not even for Dr Wooldridge. It should be the subject of wide ranging and ongoing debate
My gut feeling is that the Australian community even at this early stage of corporate experience does not believe that other people should be making money out of their misery.
Lets hypothesise that instead of a disruptive competitive marketplace we develop an integrated cooperative not for profit community service. This is developed and coordinated by the community and by not for profit providers of care. Its only motive is to balance the funding which can be provided - by whatever means is decided - against the human needs of the community. A set of cooperating clinical and administrative services uses a networked system of ongoing digital record keeping and data collection, keeping a continuous record of the sort of care provided, the complications and costs.
With modern technology it is possible not only to insist on high quality record keeping but to have ongoing processing incremented as each event is recorded. (I will not address how patient confidentiality can be preserved at this point). This information is continuously available so that each local community group involved in organisation can monitor its own services, compare it with their own perceptions, compare it with others, participate in discussing failures, assess them in the light of local conditions and be involved in steps to correct them or improve services. They can develop pride in their own efforts. At the same time there would be ongoing oversight of cost and care in each sector by those in other sectors and centrally. They would help one another.
Lessons from the Data:- The available information indicates that the arguments for privatisation cannot be based on economic benefit nor on efficiency. The market has not performed well in either area. There are good arguments for facilities where patients can have more comfort than the community can or need provide -- and where they can safely undergo treatment which the community does not feel it need be responsible for. These objectives can be much better met by a cooperating not for profit system than by a marketplace. Systemic pressures to abuse the system would be minimal. In contrast for profit groups have consistently responded to market pressures by misusing the system and the trust of patients. Their track record is dreadful.
A move drawing public and not for profit systems together cooperatively is very attractive. It does offer increasing choice for the public , combining teams, sharing staff, and providing more cost effective and sophisticated services. By removing competition we remove the principle impediment to the collection of reliable data. One church group in Brisbane has had a complete range of public hospitals and private hospitals on its campus for years so integrating the two systems but not yet as extensively as I have suggested. It not only works well but it is popular with patients and staff.
It is not as integrated as it might be because of the different funding sources and because the private hospitals are required by government to indulge in unproductive competitive practices. The grouping has responded to this requirement that it modify its culture and take on a competitive ethic by setting up a corporate structure complete with public relations departments and ongoing piped advertorials on the telephone system.
Rationalisation of Services:- I do not believe that it is desirable for every hospital to provide all services. An example is the provision of prolonged ongoing intensive care. To be economically viable and attract doctors and patients in a market based system competing corporate hospitals must do so. We simply do not have the volume of ever present support staff, the supervised teams of residents and specialist trainees to adequately provide the best possible service efficiently across the spectrum of private hospitals.
I am not suggesting that they are not strongly motivated or that the service provided is bad. Our not for profit system would not tolerate that. While the not for profit sector remains dominant they will set the standards by which hospitals are judged. Services could be better rationalised by an integrated cooperating system fusing public hospitals and not for profit facilities under the umbrella of a broad community health service.
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