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In a follow up to yesterday's post about Britian's terror over the idea that it might end up with a privatized, "American-style" health care system, today we're turning our gaze northward toward Canada. I mean, surely someone must covet our magnificent medical machine, and if not the Canucks, then who?
I've heard all the same horror stories you have about Canadian health care, but I decided to ignore what "they" say and do some actual investigating of my own when a friend of mine uprooted and moved his entire family, including three small children, back to Canada after many years in the U.S. primarily so that they could once again have full access to affordable medical care. My investigations turned up surprising - and for an American with medical issues, extremely frustrating - results. But The Incidental Economist says it all better than I could in a post summarizing Americans' misunderstanding of Canadian health care, complete with pretty charts and graphs. They point out the following:
Doctor emigration - Despite what you may have heard, doctors are not flocking to the U.S. from Canada - indeed, more doctors move TO Canada from the U.S. than the other way around.
Patient emigration - Canadian citizens aren't flocking to the U.S. to utilize our magnificent health care. While they acknowledge that wealthy Canadians might prefer to undergo certain rare procedures in American hospitals, the fact remains that the vast majority of Canadians prefer to utilize their single-payer system for the vast majority of treatment options available to them (at little or no cost, mind you).
Doctor satisfaction - Canadian doctors tend to report higher levels of satisfaction with practicing medicine in their country than American doctors do in ours.
Infant mortality - Despite the massive amount of money we spend on our health care, the U.S. continues to have one of the highest infant mortality rates of any industrialized nation - higher than Canada's or Britian's. Incidentally, also higher than Hungary, Taiwan, Cuba, South Korea, and Andorra, wherever that is.
Rationing (the biggie) - Let's have a word about the process of treatment rationing. One of the horror stories you've probably heard about the Canadian system is that it rations surgical procedures. I hated that idea too, until I learned first-hand that another word for "rationing" is "triage." Their single-payer system does not arbitrarily determine a number of procedures and only allow that many. What it does do is rank the availability of procedures based on their degree of medical necessity. In other words, it might take longer for a patient who needs a hip replacement to get that procedure than it does for, say, a cancer patient to get a tumor removed, because the latter procedure is more immediately life-threatening and therefore takes priority. I don't know about you, but God forbid I ever get cancer, I'd trade a quick hip replacement to get diagnosed, have the tumor removed, and be on the mend in the same week - as another Canadian friend of mine was. Meanwhile my own American family member, diagnosed with the same cancer at almost exactly the same time, waited almost two months for her first surgery, which didn't get it all, and another month for her second. Anecdotal evidence? Sure, but it's damn well enough to get me taking a second and third look at our system.
So to sum up, the Brits don't want our medical system. The Canadians don't want our medical system. Babies born in South Korea have a better chance of survival than ours do. Profit-based medicine is at the root of the vast majority of the billions of dollars we spend every year due to health care fraud, leaving us spending more per capita than virtually any other nation in the world, yet receiving less medical care or coverage. What exactly would it take for us to reconsider privatized medicine in the U.S.?
We in the U.S. have a rather uncharming tendency to think that our way is always the "right way," regardless of potential evidence to the contrary, and nowhere is this tendency clearer than in our discussions about national health care. Ask your average U.S. citizen about "socialized medicine" and you'll likely get a response that is almost pathologically hostile to the very concept of taxes paying for medical coverage. We reinforce our distrust of public health care initiatives by recounting horror stories of "someone we know" who was once forced to endure the barbaric overtures of a publicly subsidized medical system, somewhere far away.
The reality of socialized, or publicly subsidized, medical systems are far less frightening to most of the world - probably because the U.S. is the only industrialized nation in the world that doesn't have one. Indeed, most other countries view our method of "health care for those who can afford it" as the barbaric type. Case in point is yesterday's L.A. Times foreign correspondence article, "British Fear American-Style Health Care":
Ask a Briton to describe "American-style" healthcare, and you'll hear a catalog of horrors that include grossly expensive and unnecessary medical procedures and a privatized system that favors the rich. For a people accustomed to free healthcare for all, regardless of income, the fact that millions of their cousins across the Atlantic have no insurance and can't afford decent treatment is a farce as well as a tragedy.
But critics here warn that a similarly bleak future may await Britain if a government plan to put more power in the hands of doctors and introduce more competition into the NHS succeeds — privatization by stealth, they say.
So frightening is the Yankee example that any British politician who values his job has to explicitly disavow it as a possible outcome. Twice.
"We will not be selling off the NHS, we will not be moving towards an insurance scheme, we will not introduce an American-style private system," Prime Minister David Cameron emphatically told a group of healthcare workers in a nationally televised address last week.
In case they didn't hear it the first time, Cameron repeated the dreaded "A"-word in a list of five guarantees he offered the British people at the end of his speech.
"If you're worried that we're going to sell off the NHS or create some American-style private system, we will not do that," he said. "In this country we have the most wonderful, precious institution and also precious idea that whenever you're ill … you can walk into a hospital or a surgery and get treated for free, no questions asked, no cash asked. It is the idea at the heart of the NHS, and it will stay. I will never put that at risk."
Ironically, citizens of countries with some form of subsidized medicine or universal health insurance which guarantees basic medical care to everyone regardless of medical history or ability to pay are in many ways more informed about the problems of a privatized health care system than we who actually have one tend to be. So regardless of your individual stance on socialized medicine, in the internet age as our world gets ever smaller, it is important for us as global citizens to remember that the "right way" to do something is almost always a matter of perspective...and sometimes we could learn a thing or two from people with a different perspective.
UPDATE 6/15/11 - It seems the Canadians aren't interested in cloning our health care system either.
Health care fraud is a hot topic both in Washington and around the country, as well it should be. But if you bring up the subject of fraud in the health care system at your local town hall meeting (by which of course I mean bar, er, church luncheon) what you will most likely hear is an impassioned diatribe about the various and sundry ways that "entitlement programs" are allowing lazy miscreants to "get rich off the system." The vitriol directed at programs labeled "socialized medicine" or "Obamacare" is as thick as it is pervasive. But take a closer look at where money travels in the U.S. health care system, and you'll find that the vast majority of fraud costing billions of U.S. tax dollars is not perpetrated by individual members of the public, but by the health care system itself. If crap always rolls downhill, then money always rolls into the pockets of corporate health care executives...and a fair percentage of that money is ill-gotten indeed.
Here is the one statistic you most need to know if you are either so brave or so masochistic as to voluntarily enter into a discussion about health care fraud these days: 3% - 10%. Somewhere in the spectrum that lies between three (3%) and ten (10%) percent of health care claims is the amount of health care fraud that is perpetrated on the consumer side of the fraud equation, according to the Internal Revenue Service (and if anyone knows their numbers, you can be sure it's the IRS). That figure translates to approximately $13.5 billion, which sounds like a lot of money - and it is - but keep on reading, because we're nowhere near the big numbers yet.
First, that estimate includes more than just fraudulent claims by consumers, it also includes fraudulent claims sent by physicians' offices themselves due either to a mistake (maybe) or a systematic attempt to increase profits (more likely) in an age of overwhelming and ever-increasing insurance demands.
Second, while the government itself acknowledges that only a maximum of 10% of claims are likely to be fraudulent, even its own health care initiatives overwhelmingly treat the majority of claimants with the presumption of either mistaken eligibility or a fraudulent claim, and good luck to the consumer trying to prove otherwise. For example, the Social Security Administration "awards" an average of only 28% of initial disability claims - denying an average of 72%. Let me say that again. That's 72% of claims denied, compared to a maximum 10% fraud rate. Now you do the math.
Third, and most important to the fraud discussion, all of this financial jargon gets put into some major perspective when we actually consider the downright obscene amount of money people aren't talking about - the money attached to fraud on the corporate side of the equation.
In recent days, federal investigators have turned the spotlight toward what appears to be a repeated and systematic abuse of federal regulations by health care executives striving to further increase their already inflated profit margins, even with the rest of the country suffering a severe recession. In fact, according to ABC News, large players in the health insurance industry reportedly increased their profits by 56% in 2009 - primarily by dropping coverage for consumers. So that company that denied your claim to pay for your recent check-up tests because it couldn't be expected to pay for everyone's check ups probably made a profit in the high millions, if not billions, of dollars last year. If you're shaking your head right now, be sure to take a look through Business Insider's article, "15 Executives Who Get Paid Millions To Deny You Health Care Coverage." To give you a sense of what we're talking about here, these 15 people alone get paid between $800,000 and $38 million each per year to run health care companies with reported yearly revenues anywhere between $2.2 - $81 billion (that's billion with a "b") in 2008. If you crave more recent numbers, you can read about the top 10 most highly paid pharmaceutical executive salaries in 2010, which ranged from approximately $14 - $29 million last year (incidentally, these numbers include only salaries - no bonuses or executive perquisites which actually raise the figures significantly higher). That, my friends, is the kind of money for which people will do - and have done - just about anything.
Which is why the feds are now turning up the heat on the health care industry. Fines alone seem to have done little to dissuade health care companies from engaging in all kinds of fraudulent tactics, from promoting off-label uses of pharmaceuticals to encouraging kickback schemes, in order to increase their profit margins. Corporations have been all too happy to sign over some giant sized checks, only to pass along the cost to consumers in the form of higher prices and less coverage. Now feds are reviving a dusty statute called the Park Doctrine in an effort to hold these high powered executives personally and criminally responsible for the behavior of their companies...and the execs aren't happy about it. So in other words, they want to continue commanding salaries in the multi-million dollar range to run these companies, but they don't actually want to be held responsible for anything their companies do.
The feds say they got frustrated with repeat violations and decided to start using enforcement tools that were already on the books but had been allowed to languish. By some estimates, health care fraud costs taxpayers $60 billion a year, galling when Medicare faces insolvency.
"When you look at the history of health care enforcement, we've seen a number of Fortune 500 companies that have been caught not once, not twice, but sometimes three times violating the trust of the American people, submitting false claims, paying kickbacks to doctors, marketing drugs which have not been tested for safety and efficacy," said Lewis Morris, chief counsel for the inspector general of the Health and Human Services Department.
"To our way of thinking, the men and women in the corporate suite aren't getting it," Morris continued. "If writing a check for $200 million isn't enough to have a company change its ways, then maybe we have got to have the individuals who are responsible for this held accountable. The behavior of a company starts at the top."
In other words, federal prosecutors seem to feel that the guys making muti-million dollar salaries to run health care-related companies should be held accountable for the activities of those companies. Obviously, the executives feel it is unfair to hold them personally accountable in any way, which makes a lot of sense to m...no wait, that makes no sense at all.
The example currently making headlines is that of Forest Labs, a pharmaceutical company that recently settled a $313 million lawsuit with the Department of Justice which alleged multiple fraudulent activities:
...Forest Laboratories...agreed to a $313 million settlement. The misbehavior: selling an unapproved drug, marketing another drug off-label, and lying to FDA inspectors during a visit.
The company's Forest Pharmaceuticals unit pleaded guilty to criminal charges of marketing its unapproved thyroid drug Levothroid--and ignoring the agency's warnings to stop. The plea also covers charges of "misbranding" its antidepressant drug Celexa, which basically means that it promoted the drug for off-label use. In this case, Forest pushed Celexa for use in children even though it was only approved for use in adults, an FDA statement says.
Prosecutors also say that Forest sales reps paid doctors to persuade them to prescribe Celexa and its successor drug Lexapro, giving them cash "disguised as grants or consulting fees," plus expensive meals and entertainment, such as Broadway tickets, a deep-sea fishing trip, and pro baseball tickets. Forest "expressly denies" those claims, despite its agreement to pay some $148 million to settle those and other civil complaints.
The settlement riled the feathers of Forest shareholders, some of which went so far as to publicly demand the resignation of CEO Howard Solomon. Federal investigators have taken the recriminations one step further, threatening to hold Solomon personally responsible for the company's actions and ban him from the pharmaceutical industry altogether. Solomon of course feels that he is being unfairly persecuted, and I for one plan on getting around to crying a veritable river of tears on his behalf just as soon as I can figure out a way to afford my own prescriptions.
But Forest Labs is hardly a lone wolf in the pack of industrial fraud. In recent years, several health care-related companies have paid out copious settlements for wrongdoing, including (but not limited to):
- Pfizer - $2.3 billion
- Eli Lilly - $1.4 billion
- AstraZeneca - $520 million
- Quest Diagnostics - $302 million
- Boston Scientific - $296 million
- Mylan Pharmaceuticals, UDL Labs, AstraZeneca & Ortho-McNiel - $124 million
- Omnicare Inc. - $98 million
- WellCare Health Plans - $80 million
And those are just the big numbers - there are plenty more multi-million dollar and smaller settlements that add up.
So the next time someone wants to bemoan the prevalence of health care fraud in this country, you can pull out the big guns. We have all been socialized, institutionalized if you will, into thinking of health care fraud as something lazy, impoverished people do in order to milk the system. The reality is much more insidious. There is no point in discussing health care fraud without addressing the massive profits systematically and illegally garnered by health care companies at the expense of American consumers, leaving many of us in the impossible situation of having to choose between paying for our health care or paying our rents or mortgages. After all, if we don't find a way to make it less profitable for corporations to screw the American public on such a massive scale, how effective can we ultimately expect any reform effort to be?
