A Transaction Based on Trust

Today I was also reading about legislation which is pushed by politicians to reduce safety standards in the trucking business and about the incidence of sleep apnea among truckers.

I am planning on writing another article on DOT physicals, the number of drivers with the diabetes who refuse to go on insulin because of the DOT regulations.

Whether it is safer to have a driver whose blood sugar is controlled with insulin or a driver whose blood sugar is not controlled.

The general feeling among the whole society that costs of goods need to keep reducing and that the profits need to go on raising leading to new problems in the society.

Where are we going?

Money driven medicine the real reason for healthcare costs so much

Maggie Mahar

the dream of reason did not take power into account

 Paul Starr the social transformation of American medicine

Starr’s history opens with a single, stark statement: “The dream of reason

did not take power into account.”‘ Medicine, perhaps more than any other

science, epitomizes the “dream of reason”—the Enlightenment hope that,

in the end, the human mind can tame nature and find order in chaos—or, in

the case of medicine, make sense of flesh. But that pure, scientific endeavor

does not unfold in a vacuum. It takes place in society, in a world of men. In-

evitably, those men will jockey for position.

Throughout most of the 20th century, the nation’s physicians won the

battle to control American medicine. For decades, they held virtually unchal-

lenged economic, moral, and political sway over what we now call the “health

care industry.” Doctors were able to gain dominion, in part because their pa-

tients wanted them to rule the nation’s health care system, and in part because because the normal market rules of demand and supply do not apply to medicine

In most industries, supply responds to demand. \X/hen it comes to decid-

ing what to pr0duee—and in what quantity—the supplier follows the cus-

tomer’s lead. Or as UCLA economist Thomas Rice puts it in T/96 Emnnlflw‘ If

llea/I/J Reuomidered, “In the traditional economic model, demand is key; sup-

ply is essentially along for the ride.” But in the case of health care, the sup-

plier (traditionally, the doctor) plays a much more active role in determining

what consumers believe they want—0r need. Indeed, health care providers

enjoy nearly unparalleled influence over demand for the very services that

they sell.

This is completely understandable. llealth care is different from other

“purchases” in large part because the customer faces so much ambiguity. Dr.

Atul Gawande, a surgeon at Boston’s Brigham and Women’s Hospital puts it

best in “complications: a surgeon’s notes on an imperfect science”

 “Medicine is an enterprise of constantly changing knowledge, uncertain information,

 Fallible individuals. . . . the core predicament of medicine, its uncertainty, [is] the

thing that makes being a patient so wrenching, being a doctor so difficult,

and being part of a society that pays the bills so vexing.“

While Coniumer Rqbortr can rate midpriced refrigerators briskly and

clearly, in a way that makes comparisons easy, it is all but impossible, even for

a physician, to he positive of the relative henefits of a great many medical

procedures.

“Uncertainty as to the quality of the product is perhaps more intense

here than in any other [market],” Kenneth Arrow, the Nobel laureate econo-

mist who launched the study of health care economics, observed in 1963.

“Recovery from disease is as unpredictable as its incidence . . . and further

there is a special quality to the uncertainty: it is very different on the two

sides of the transaction. The information possessed by the physician as to

" The information possessed by the physician as to

the consequences and possibilities of treatment is necessarily very much

greater than that of the patient, or at least so it is believed by both parties." ‘

This is what makes the purchase of health care so different from any

other purchase: it is a transaction based on trust.

Granted, today both physicians and patients enjoy access to far more in—

formation than ever hcfore, and “with all that we know nowadays about peo—

ple and diseases and how to diagnose and treat them, it can be hard to . . .

grasp how deeply the uncertainty runs,” Gawande writes. Yet as anyone who

has ever been seriously ill knows all too well, the more one learns about a disease and the odds of possible success with treatment, the more ambiguous the situation becomes".

A Transaction Based on Trust

It is not just the complexity of the human body , but the uniqueness of each

body that makes it so difficult to predict health care outcomes. Put simply,

health care is not a commodity. While two consumers may derive pretty much

the same value from the same midpriced refrigerator, a particular course of

treatment can have a drastically different effect on two different bodies. This

makes it difficult for heath care “shoppers” to rely on their friends’ experiences the way they might when choosing, say, a computer or a car.

Nor can the consumer rely on his own past experienceflihree out of four

health care dollars are spent on products and services that the patient has

rarely, if ever, purchased before—and probably hopes never to purchase

again." To make the consumer's dilemma even more wickedly difficult, when

purchasing health care, he knows that there are rm \varrants and no guaran-

tees. The patient cannot return an unsuccessful operation. r\nd if he winds

up unhappy with the outcome, he may find himself stuck with something far

worse than a bad haircut.

lt is not just the complexity of the human body, but the uniqueness of each

body that makes it so difficult to predict health care outcomes. Put simply,

health care is not a commodity. While two consumers may derive pretty much

How to reduce healthcare costs

not by replacing physicians with nurses but to produce more physicians

how to produce more physicians?

How to reduce irregular distribution of physician workforce?

Except for a few rich Republicans probably a few dermatologists or plastic surgeons they should be no resistance to a unified medical license, which is valid for all the states and territories of USA. In this day and age of computer networks and a nationwide NPDB there is absolutely no necessity to have separate state medical boards and separate state licenses.

Tort reform at the federal level

Six Reasons Why Health Care is not a Commodity

By Cynthis Levine-Rasky, Canadian Dimenion, September/October 2002

Why Health Care is not a Commodity

When I tell this story to my students, many of them are fooled. They associate public care with inferior service. Yet, despite the erosion of the public system, the contrast between these two facilities, the former fully private, the latter fully public, couldn't be greater.

In the fall of 200, my aging mother went for a walk to buy a birthday card at the shopping plaza near her home. While attempting to climb a curb, she fell and fractured her hip. After surgery in an acute-care hospital, she spent eight weeks in two different nursing homes.

Compare them:

Why Health Care is not a Commodity

When I tell this story to my students, many of them are fooled. They associate public care with inferior service. Yet, despite the erosion of the public system, the contrast between these two facilities, the former fully private, the latter fully public, couldn't be greater.

In place Number One, during the week it took to straighten out her medications, my mother was sent drugs she didn't use and failed to receive her necessary medications, including the correct kind of insulin. Errors were made in the scheduling of meal crucial for a diabetic. As a result, my mother's blood-sugar level rose to a value of 40, threatening a diabetic coma. When asked to explain, a nurse told us that it was likely psychological in cause. It took a few visits from the dietician to straighten out my mother's meals, although often the food was too bad to eat. With only one nurse for about 30 residents, there was usually a 20-minute wait for help after pulling a cord. Cleaning of rooms was perfunctory. Soiled laundry sat in clear plastic bags in the hallways and the broadloom smelled of urine. To conceal the persistent odours, automatic misters were mounted on the walls and sprayed fragrance at regular intervals.

In place Number Two, we didn't reach my mother's room before the nurses requested her medication list and dietary needs. They had it all straightened out in half an hour. Within two hours, she had seen the physiotherapist, the dietician and three nurses to learn about her medical history, her home support and her need for medical aids. The food was of good quality; we even met the cook when he came on his rounds. The place was cleaned thoroughly after each patient. There was no sign of garbage or odour. Each patient had a private phone. For what it was, the environment was cheerful.

Given promises of superior efficiency and service in private provision of health care, how many would guess that place Number One was the private facility? Yet it was recommended to us as one of the better nursing homes in the city. The care there cost $100 per day excluding the fees for a phone, wheelchair rental and transportation to the hospital for tests. When I tell this story to my students, many of them are fooled. They associate public care with inferior service. Yet, despite the erosion of the public system, the contrast between these two facilities, the former fully private, the latter fully public, couldn't be greater.

Public care is the only way to go. This is because health care is not a commodity.

Here's why. One: Need, Not Choice

Patients are in a position of need, not choice. Their survival can be dependent upon regular visits to a clinic or to a doctor. Unlike other products in the marketplace, if you need medical services to make you well or function normally you can't shop around for the best deal, nor can you compare makes and models, nor withdraw your consumer choice because the product is over-priced with the hope that if enough patients do the same the price will drop as supply exceeds demand. If you need medical care, you need it now. You've got to pay the price, whatever it is. Patients are at the mercy of the provider and they are unable to influence the competition and costs of services as in a free-market model. In fact, the reverse is more likely: the market manipulates patients to pay whatever cost is set by a private provider.

Two: Insufficient Information

Patients do not have the information necessary to make an informed consumer choice. Imagine Consumer Reports on dialysis units or magnetic resonance imaging devices (MRIs). Only specialists have the knowledge required to make such choices and patients are dependent upon their expertise for a referral. Patients trust that their doctor will make the best choices for treatment on their behalf. It's wrong to burden sick people with these decisions and unreasonable to expect them to do the research necessary to be informed about illnesses and their treatments. How many senior citizens even use the Internet?

Till the other day when my primary care physician ordered a vitamin D level I myself a physician did not know how much it cost and also came to know that the insurance company will not cover it even if I am diagnosed with vitamin D deficiency stating that it is a vitamin supplement and not covered under the rules.

Three: Profit Motive Inappropriate

Patients trust their health-care providers. The profit motive is inappropriate for health-care providers because it can interfere with the quality of care within a relationship of trust. Patients assume this relationship is based on the doctor's commitment to health, not to profit. The profit motive could encourage a practitioner to make unwise decisions like prescribing more drugs and recommending costly surgery since these represent opportunities to increase profits. Health-care providers motivated by profits may be tempted to select patients who require these interventions. But we expect our health-care workers to want to help us because they're interested in our well-being, not because we pay them to take care of us or because we pay more than someone else who will receive inferior care as a result.

Four: Maintaining Standards

Patients depend on the public regulation of standards in care. Like other concessions to companies in the private sector, private firms delivering health-care services may win exemptions from standards in technology, safety and licensing of technicians. How would quality be regulated? How could consumers as patients have an influence upon standards, given their circumstances? Given the narrow margin for error, a patient would be too sick to register an official complaint if something goes wrong during a procedure. Their family could do so on their behalf, but in terrible circumstances.

Five: Lower Cost

Private health care can't compete with the lower costs of public health care. In the U. S., where a private health-care system parallels a public one, health care takes up 14 per cent of the GDP, highest in the world. Canada spends about 9.5 per cent of its GDP on health care, less than Germany, France and other European countries respected for their vibrant social programs. Why is private health care more expensive? Like any other profit-making venture, private health care must create a 10-to-15 per cent return for shareholders. It also must cover costs that are non-existent in public organizations like marketing, advertising, taxes, compensation packages for senior executives and higher administrative costs. In March, 2000, the Toronto Star reported that the Australian government has to subsidize its private hospitals by $2.2 billion in operating costs. These hospitals are not a viable business without this assistance. Many studies show private health care is more costly than a fully public system. A 1999 article in New England Journal of Medicine states that No peer-reviewed study has found that for-profit hospitals are less expensive.

Six: Superior Quality

Private health care can't compete with the superior quality of public health care. Public health care saves lives. The Canadian Medical Association Journal just published a report on 15 studies on for-profit and not-for-profit U. S. hospitals. They found that patients treated in for-profit centres were 2 per cent more likely to die. While this may sound like a small number, given that the sample was 38 million patients between 1982 and 1995, this means that 760,000 people died in private facilities who might have lived had they been treated in public hospitals. More funds are diverted away from patient care toward other expenditures like marketing and executive salaries. The profit motive obscures the priority of saving lives.

The Alberta Model

The urgency in arguments for private health care is based on claims that the public system is unsustainable. We are told that if we want shorter waiting lists, more doctors and nurses and technicians, and better access to primary care and medical technologies, we will have to abandon our idea that medical care is a right, rather than a privilege. We are told to look to Alberta and its Health Care Protection Act for inspiration. The act allows for-profit clinics to be paid by public funds. Yet health-care costs in Alberta are not spiraling out of control. The province spends 33 per cent of its total budget on health care. At five percent of its GDP, this is one of the smallest shares for any province. According to Friends of Medicare, this figure has been stable for 20 years. From 1992 to 1998, Alberta's per-capita spending on health (adjusted for inflation) increased by less than one percent.

If there is no crisis in health-care spending, why then did the province rush to legislate for-profit services? Why is Alberta regarded as a pioneer in health-care reform if private health care remains unpopular, more expensive, of lower quality and less efficient? The only reason remaining is to tempt foreign investment into this new growth industry. Public health care safeguards private-sector incursion into Canadian Medicare. This is how it works: Health care is exempt from international free-trade agreements if it remains fully public. But with partial privatization in the form of user fees, home care, physiotherapy, or private clinics, foreign companies can claim the Canadian government is giving an unfair subsidy to those private companies now providing medical products and services. Since NAFTA guarantees free-market access and the elimination of trade barriers, partial privatization may be interpreted as the denial of access and a trade barrier. Alberta's Health Care Protection Act, therefore, may be defined as a government subsidy to a private health-care firm. Through an international arbitration tribunal, foreign companies can sue the Canadian government for lost revenue and for compensation for prohibiting access to the marketplace in health-care industry. This decision will not be open for appeal. This is how NAFTA may be used to force open the Canadian Medicare system to competition from private firms who want equal opportunity to compete in selling health products and services in Canada.

Through free-trade agreements, private, foreign firms are seeking inroads into this new and potentially lucrative business opportunity. The market is expansive. Canadians already pay privately for many medical services: nursing homes, drugs, home care, diagnostic services, alternative therapies, rehabilitation, ambulances. In June, 2000, the World Health Organization ranked Canada thirtieth for health care since we pay more out of our pockets for medical expenses than many other Western countries. In a 1999 poll of 2,381 Canadians, PriceWaterhouseCoopers found that seniors and disabled people were spending an average of $407 per month on home care. Friends of Medicare shows that 67 per cent of drugs are privately funded. And the home-care industry is growing. About 14 pages of the Sears catalogue is dedicated to home-care products. Recently discharged patients can choose among several kinds of stethoscopes, grab bars, toilet seats, examination gloves, incontinence aids, walkers, wheelchairs and blood-pressure monitors. Although some provinces may cover some of the costs for some individuals, the range of products now marketed to the individual consumer reflects the possibilities of this new niche.

The challenge lies in persuading supporters that the so-called crisis in health-care costs lies not in increased demand nor in abuse of the system. It lies in the government's withdrawal from the public sphere. The state values its relationship with business more highly than its relationship with the public. Accumulated effects of government cutbacks have caused the problems we face. Federal contributions to health-care costs dropped from 50 per cent in the 1960s to less than 15 per cent in the 1990s. Funding has improved recently with federal reinvestment of billions of dollars in health care, but, by this time, things have become so bad that these funds had to be applied to servicing accumulated debts and to improving the services that deteriorated during the years of cutbacks. Instead of attributing problems to lack of stable financing and supportive policies, we turn it around and blame the users of the system.

We must highlight the fact that a fully public health-care system works well. It fulfils the demands for cost effectiveness, quality and equity that Canadians (and others) traditionally associate with our national health-care program. Yet the system is under attack. Without a fight, it will most certainly be compromised. It already is. We must develop a collective response to the spin generated by supporters of privatization: that health care is better paid for, owned and delivered by private hands. Just like any other commodity. But health care is not a commodity. It is a public good. It must be in public hands.

Cynthia Levine-Rasky is a sociologist and contract instructor at York University. She teaches Canadian social problems and sociology of education and writes on white racialization. In her spare time she works in the community garden at York and in her own urban backyard in Toronto.

Canadian Dimension, 2B-91 Albert Street, Winnipeg, Manitoba, Canada, R3B 1G5

Subscription Hot Line: 1-800-737-7051

(c) Material posted at this website may be reproduced if you obtain permission from Canadian Dimension.

In the fall of 200, my aging mother went for a walk to buy a birthday card at the shopping plaza near her home. While attempting to climb a curb, she fell and fractured her hip. After surgery in an acute-care hospital, she spent eight weeks in two different nursing homes.

Compare them:

Why Health Care is not a Commodity

When I tell this story to my students, many of them are fooled. They associate public care with inferior service. Yet, despite the erosion of the public system, the contrast between these two facilities, the former fully private, the latter fully public, couldn't be greater.

In place Number One, during the week it took to straighten out her medications, my mother was sent drugs she didn't use and failed to receive her necessary medications, including the correct kind of insulin. Errors were made in the scheduling of meal crucial for a diabetic. As a result, my mother's blood-sugar level rose to a value of 40, threatening a diabetic coma. When asked to explain, a nurse told us that it was likely psychological in cause. It took a few visits from the dietician to straighten out my mother's meals, although often the food was too bad to eat. With only one nurse for about 30 residents, there was usually a 20-minute wait for help after pulling a cord. Cleaning of rooms was perfunctory. Soiled laundry sat in clear plastic bags in the hallways and the broadloom smelled of urine. To conceal the persistent odours, automatic misters were mounted on the walls and sprayed fragrance at regular intervals.

In place Number Two, we didn't reach my mother's room before the nurses requested her medication list and dietary needs. They had it all straightened out in half an hour. Within two hours, she had seen the physiotherapist, the dietician and three nurses to learn about her medical history, her home support and her need for medical aids. The food was of good quality; we even met the cook when he came on his rounds. The place was cleaned thoroughly after each patient. There was no sign of garbage or odour. Each patient had a private phone. For what it was, the environment was cheerful.

Given promises of superior efficiency and service in private provision of health care, how many would guess that place Number One was the private facility? Yet it was recommended to us as one of the better nursing homes in the city. The care there cost $100 per day excluding the fees for a phone, wheelchair rental and transportation to the hospital for tests. When I tell this story to my students, many of them are fooled. They associate public care with inferior service. Yet, despite the erosion of the public system, the contrast between these two facilities, the former fully private, the latter fully public, couldn't be greater.

Public care is the only way to go. This is because health care is not a commodity.

Here's why. One: Need, Not Choice

Patients are in a position of need, not choice. Their survival can be dependent upon regular visits to a clinic or to a doctor. Unlike other products in the marketplace, if you need medical services to make you well or function normally you can't shop around for the best deal, nor can you compare makes and models, nor withdraw your consumer choice because the product is over-priced with the hope that if enough patients do the same the price will drop as supply exceeds demand. If you need medical care, you need it now. You've got to pay the price, whatever it is. Patients are at the mercy of the provider and they are unable to influence the competition and costs of services as in a free-market model. In fact, the reverse is more likely: the market manipulates patients to pay whatever cost is set by a private provider.

Two: Insufficient Information

Patients do not have the information necessary to make an informed consumer choice. Imagine Consumer Reports on dialysis units or magnetic resonance imaging devices (MRIs). Only specialists have the knowledge required to make such choices and patients are dependent upon their expertise for a referral. Patients trust that their doctor will make the best choices for treatment on their behalf. It's wrong to burden sick people with these decisions and unreasonable to expect them to do the research necessary to be informed about illnesses and their treatments. How many senior citizens even use the Internet?

Till the other day when my primary care physician ordered a vitamin D level I myself a physician did not know how much it cost and also came to know that the insurance company will not cover it even if I am diagnosed with vitamin D deficiency stating that it is a vitamin supplement and not covered under the rules.

Three: Profit Motive Inappropriate

Patients trust their health-care providers. The profit motive is inappropriate for health-care providers because it can interfere with the quality of care within a relationship of trust. Patients assume this relationship is based on the doctor's commitment to health, not to profit. The profit motive could encourage a practitioner to make unwise decisions like prescribing more drugs and recommending costly surgery since these represent opportunities to increase profits. Health-care providers motivated by profits may be tempted to select patients who require these interventions. But we expect our health-care workers to want to help us because they're interested in our well-being, not because we pay them to take care of us or because we pay more than someone else who will receive inferior care as a result.

Four: Maintaining Standards

Patients depend on the public regulation of standards in care. Like other concessions to companies in the private sector, private firms delivering health-care services may win exemptions from standards in technology, safety and licensing of technicians. How would quality be regulated? How could consumers as patients have an influence upon standards, given their circumstances? Given the narrow margin for error, a patient would be too sick to register an official complaint if something goes wrong during a procedure. Their family could do so on their behalf, but in terrible circumstances.

Five: Lower Cost

Private health care can't compete with the lower costs of public health care. In the U. S., where a private health-care system parallels a public one, health care takes up 14 per cent of the GDP, highest in the world. Canada spends about 9.5 per cent of its GDP on health care, less than Germany, France and other European countries respected for their vibrant social programs. Why is private health care more expensive? Like any other profit-making venture, private health care must create a 10-to-15 per cent return for shareholders. It also must cover costs that are non-existent in public organizations like marketing, advertising, taxes, compensation packages for senior executives and higher administrative costs. In March, 2000, the Toronto Star reported that the Australian government has to subsidize its private hospitals by $2.2 billion in operating costs. These hospitals are not a viable business without this assistance. Many studies show private health care is more costly than a fully public system. A 1999 article in New England Journal of Medicine states that No peer-reviewed study has found that for-profit hospitals are less expensive.

Six: Superior Quality

Private health care can't compete with the superior quality of public health care. Public health care saves lives. The Canadian Medical Association Journal just published a report on 15 studies on for-profit and not-for-profit U. S. hospitals. They found that patients treated in for-profit centres were 2 per cent more likely to die. While this may sound like a small number, given that the sample was 38 million patients between 1982 and 1995, this means that 760,000 people died in private facilities who might have lived had they been treated in public hospitals. More funds are diverted away from patient care toward other expenditures like marketing and executive salaries. The profit motive obscures the priority of saving lives.

The Alberta Model

The urgency in arguments for private health care is based on claims that the public system is unsustainable. We are told that if we want shorter waiting lists, more doctors and nurses and technicians, and better access to primary care and medical technologies, we will have to abandon our idea that medical care is a right, rather than a privilege. We are told to look to Alberta and its Health Care Protection Act for inspiration. The act allows for-profit clinics to be paid by public funds. Yet health-care costs in Alberta are not spiralling out of control. The province spends 33 per cent of its total budget on health care. At five percent of its GDP, this is one of the smallest shares for any province. According to Friends of Medicare, this figure has been stable for 20 years. From 1992 to 1998, Alberta's per-capita spending on health (adjusted for inflation) increased by less than one percent.

If there is no crisis in health-care spending, why then did the province rush to legislate for-profit services? Why is Alberta regarded as a pioneer in health-care reform if private health care remains unpopular, more expensive, of lower quality and less efficient? The only reason remaining is to tempt foreign investment into this new growth industry. Public health care safeguards private-sector incursion into Canadian Medicare. This is how it works: Health care is exempt from international free-trade agreements if it remains fully public. But with partial privatization in the form of user fees, home care, physiotherapy, or private clinics, foreign companies can claim the Canadian government is giving an unfair subsidy to those private companies now providing medical products and services. Since NAFTA guarantees free-market access and the elimination of trade barriers, partial privatization may be interpreted as the denial of access and a trade barrier. Alberta's Health Care Protection Act, therefore, may be defined as a government subsidy to a private health-care firm. Through an international arbitration tribunal, foreign companies can sue the Canadian government for lost revenue and for compensation for prohibiting access to the marketplace in health-care industry. This decision will not be open for appeal. This is how NAFTA may be used to force open the Canadian Medicare system to competition from private firms who want equal opportunity to compete in selling health products and services in Canada.

Through free-trade agreements, private, foreign firms are seeking inroads into this new and potentially lucrative business opportunity. The market is expansive. Canadians already pay privately for many medical services: nursing homes, drugs, home care, diagnostic services, alternative therapies, rehabilitation, ambulances. In June, 2000, the World Health Organization ranked Canada thirtieth for health care since we pay more out of our pockets for medical expenses than many other Western countries. In a 1999 poll of 2,381 Canadians, PriceWaterhouseCoopers found that seniors and disabled people were spending an average of $407 per month on home care. Friends of Medicare shows that 67 per cent of drugs are privately funded. And the home-care industry is growing. About 14 pages of the Sears catalogue is dedicated to home-care products. Recently discharged patients can choose among several kinds of stethoscopes, grab bars, toilet seats, examination gloves, incontinence aids, walkers, wheelchairs and blood-pressure monitors. Although some provinces may cover some of the costs for some individuals, the range of products now marketed to the individual consumer reflects the possibilities of this new niche.

The challenge lies in persuading supporters that the so-called crisis in health-care costs lies not in increased demand nor in abuse of the system. It lies in the government's withdrawal from the public sphere. The state values its relationship with business more highly than its relationship with the public. Accumulated effects of government cutbacks have caused the problems we face. Federal contributions to health-care costs dropped from 50 per cent in the 1960s to less than 15 per cent in the 1990s. Funding has improved recently with federal reinvestment of billions of dollars in health care, but, by this time, things have become so bad that these funds had to be applied to servicing accumulated debts and to improving the services that deteriorated during the years of cutbacks. Instead of attributing problems to lack of stable financing and supportive policies, we turn it around and blame the users of the system.

We must highlight the fact that a fully public health-care system works well. It fulfils the demands for cost effectiveness, quality and equity that Canadians (and others) traditionally associate with our national health-care program. Yet the system is under attack. Without a fight, it will most certainly be compromised. It already is. We must develop a collective response to the spin generated by supporters of privatization: that health care is better paid for, owned and delivered by private hands. Just like any other commodity. But health care is not a commodity. It is a public good. It must be in public hands.

Cynthia Levine-Rasky is a sociologist and contract instructor at York University. She teaches Canadian social problems and sociology of education and writes on white racialization. In her spare time she works in the community garden at York and in her own urban backyard in Toronto.

Canadian Dimension, 2B-91 Albert Street, Winnipeg, Manitoba, Canada, R3B 1G5

Subscription Hot Line: 1-800-737-7051
(c) Material posted at this website may be reproduced if you obtain permission from Canadian Dimension.

Yes! I understand that innovation needs to be rewarded. (Innovation does not stop even when it is not adequately rewarded or for that matter punished like Galileo Galilei ) But I question the amount of reward

One important point to remember is that coronary stenting has not been shown to reduce heart attacks or prolong survival outside the setting of an acute heart attack. 

Do you think that a physician who developed a cardiac stent should be rewarded with a wine yard in Napa Valley? Or do you think that a physician who is striving to improve the health of a single patient who has unhealthy habits by spending the extra 15 or 20 minutes to counsel the patient needs to be given an extra $20?

From the  skeptical cardiologist

"

SHOULD YOU GET A STRESS TEST AFTER YOUR STENT OR BYPASS OPERATION IF YOU FEEL FINE?

OCTOBER 24, 2015 3 COMMENTS

If you’ve had a coronary stent implanted or undergone bypass surgery, it is common to wonder about the status of the stent or the bypass grafts or the coronary arteries that maybe had a 50 or 60% blockage and were left alone.

This is especially likely if there was little or no warning that you had really severely blocked coronary arteries.

After all, you are thinking: “doesn’t it make sense to monitor these things and stay on top of them; be proactive?”

It certainly seems reasonable on the surface, and for many years, routine stress testing of patients without symptoms on an annual basis, was the norm.

However, this practice is much more likely to cause harm than to benefit patients and is recognized by the American College of Cardiology as one of 5 things that patients and physicians should question as part of the “Choosing Wisely” campaign (see here).

“Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes.”

Studies have shown that stress testing less than two years after a coronary stent, very rarely change management.

The American College of Cardiology, American Society of Echocardiography and the American Society of Nuclear Medicine are all in agreement that stress testing less than two years after a coronary procedure is “inappropriate,” and more than two years after the procedure is “uncertain.”

Why Do Cardiologists Order These Tests If They Are Inappropriate?

There are 3 reasons, and they are representative of the major factors driving all over-testing in medicine.

1. Financial. Cardiologists frequently benefit from stress tests they order in multiple ways. First, they may own the nuclear camera used in the test and the more stress tests performed in their office, the more money they will make from the technical remuneration for the procedure. The cardiologist also frequently interprets the test results and receives a professional fee for both supervising and interpreting the nuclear images. Finally, if the test is abnormal, the cardiologist may then recommend additional testing, which he may perform (cardiac catheterization, stent) or interpret (coronary CT angiogram).
2. Defensive medicine. It is not uncommon for cardiologists to be sued for NOT performing a test or procedure when the patient’s outcome is bad. On the other hand, I have never heard of a cardiologist being sued for DOING an inappropriate stress test.
3. Keeping the customer happy. Too often patients feel that if their doctor is performing frequent tests on them, he is being vigilant, proactive and “staying on top of things.” They don’t realize the down sides to the extra testing and the lack of benefit.

Not uncommonly, patients switching to me from another cardiologist indicate that they have been getting an annual stress test and are disappointed to hear that I am not recommending one.

They may think that I’m lazy or not up on the latest techniques in cardiology. Usually in this situation I have to spend a fair amount of time trying to teach them about the possible downsides of over-testing.

In the case of stress nuclear testing, harm comes from two sources:

1. Radiation. Stress nuclear tests typically utilize the radio tracer Technetium-99 and result in a radiation dose of around 15 mSv. This is about 10 times the radiation from a typical coronary calcium scan. A chest x-ray gives 0.02 mSV and the annual background radiation in the US is 3 mSv.
2. False positives. Nuclear imaging is very susceptible to images which appear to show abnormalities of blood flow, which in reality are just due to soft tissue (breast, diaphragm, fat) interposed between the heart and the camera. These can be interpreted as due to a heart attack or blocked coronary artery when everything is actually fine with the artery.  False positives then lead to additional testing such as a cardiac catheterization, which carries risks of bleeding, heart attack, stroke and death.

One important point to remember is that coronary stenting has not been shown to reduce heart attacks or prolong survival outside the setting of an acute heart attack. Therefore , if you’ve already had a cardiac catheterization that either resulted in bypass surgery or a stent of one artery, it is highly unlikely that a subsequent catheterization/further procedures will lower your heart attack or dying risk.

Certainly, if you have a change in symptoms that suggest that your coronary artery disease has progressed, this is an appropriate reason to consider stress testing. Such symptoms include shortness of breath on exertion and chest discomfort, especially if it occurs during activity. Diabetics often don’t have symptoms that warn them of a problem, therefore, we should consider stress testing more frequently and at a lower threshold for them.

For most people, however, more is not always better when it comes to cardiac testing and, in many circumstances, can be worse.

Here’s to choosing wisely,"

unhappy meals by Michael Pollan

I think this is a pun on the happy meals of McDonald's

"Of course it’s also a lot easier to slap a health claim on a box of sugary cereal than on a potato or carrot, with the perverse result that the most healthful foods in the supermarket sit there quietly in the produce section, silent as stroke victims, while a few aisles over, the Cocoa Puffs and Lucky Charms are screaming about their newfound whole-grain goodness."

why-i-recommend-the-mediterranean-diet/