TPPs and all that again...

My previous post (June 18) has been echoed several times since, not by (known) reference by other commenters but by actual events. Readers might like to return and refresh their memories, but essentially I spoke of three factors –
. The US approach to “Free Trade” agreements;
. The role of Minister Tim Groser;
. The desire of US negotiators to make NZ’s Pharmac a key obstacle to achieving a FTA between NZ and US.

I have been slowly catching up with events since early June. Hey!! I is getting older and the enthusiasm and energy resources are very limited; most at this stage directed toward photography rather than current events. Then there was a very enjoyable week that recharged most of the batteries – the ones with remaining functional cells anyway… Hoosoever!

It started – in part – with this article in Granny Herald on June 15

And in reference to United States concerns over the state drug-buying agency Pharmac, which the US sees as anti-competitive, Mr Groser said the New Zealand was not about to negotiate away its public health system.
He said Pharmac was not perfect "and we are always open to suggestions of change, but we are not about to adopt a health system, via a trade negotiation, that allocates resources according to capacity to pay."

Come forward to 4 July and the wording has already started to morph –

Trade Minister Tim Groser has heaped praise on the Government's drug-buying agency, Pharmac, but still refuses to rule out possible changes to the agency as part of future free trade deals.
…
Green Party co-leader Russel Norman said the free trade agreement between Australia and the US had crippled Australia's Pharmaceutical Benefit Scheme, its equivalent of Pharmac.
"They didn't abolish it or its fundamentals ... but they made changes to the way it operates."
The overall effect, he said, was higher costs that were either passed on to consumers or picked up by the Government.

The question is not “What was the effect?”, but “Why was it changed?” The answer has to be that the Aus government decided it was more important to have an FTA with the US and to disregard any cost that might be incurred as a consequence of the changes. Rather than just take Russel Norman’s word for it, a quick hunt around the SMH turns up this op-ed piece from last March –

Last year the Rudd government proudly announced it had cut a new and tougher deal with the drug companies, represented by Medicines Australia, which would save the taxpayer $1.9 billion over five years.

…
…a health economist at the University of Sydney, associate professor Philip Clarke, and his colleague Edmund Fitzgerald, argue the deal still leaves our off-patent and generic drug prices much higher than they are in most developed countries. They quote the example of statins, the cholesterol-lowering drugs, where the patents of the various types have expired or soon will. Statins account for about 16 per cent of the total cost of the pharmaceutical benefits scheme.
They surveyed the wholesale price of Simvastatin 40mg in 10 developed countries and found our price was the highest: 50 per cent more than the next highest country and more than four times greater than the average price.
The lowest price was in New Zealand, which stages competitive tenders between the drug companies. Its price is just a fraction of our wholesale price of $1 a tablet. And even in the US, chains such as Kmart Pharmacy sell that statin for $15 for 90 tablets.
Clarke and Fitzgerald estimate that, compared with prices in England and Canada, the Rudd government's deal with the industry lobby will cost taxpayers and consumers $1.7 billion more over its five-year term. And that's just for the statin group of drugs.

It bears repeating; given the results that Pharmac are achieving why should NZ “fix” something that is working? That question is especially a propos when the drug barons are pushing the US on the other side of the table.
And, from that too, comes the biggest of all –
Will Groser, and eventually the Jonkey himself, be able to put political reality before ideology?

Experience tells me not. The poodle, sorry Jonkey had his tummy well and truly scritched last week in his visit to the Oval Room. Now watch him return home and find all of the things that are "wrong" with Pharmac.

On matters of health

For some while my left hand has had an itch to grab a (virtual) pen and write a long diatribe on the wrongs of the American health system. I actually got to collection of statistics from sources such as Congressional Budget Organisation, planning the direction that I would take.

But I am not going to do this for the simple reason that it is pointless. No one "system" is any better than another. And if America wants to continue its massive strides toward social extinction why the F*** should I care?

The epiphany came from a single page comparative I read in a National Geographic (of all places) last weekend. It comprised a short three paras, with a planomic showing health expenditure (total, not government funded alone) per head of population on one side with a line linking to average age expectancy at birth on the other.

I was looking at this and quickily found NZ (as I do) but for the life of me nowhere could I see the US! NZ was about 2/3s of the way down the page. Canada was above that, Britain further up again at about half way. No US. Then I found a red line that ended at about age 70, nearly opposite NZ on the spending side. It ran from there back up to the top printing margin on the left; US - $7,415 per head of population; printed in red which is why I did not see it immediately being very slightly red/green colour-blind.

What was not at all clear was whether this $7,415 php was the cost of providing medical services alone, or the "tax plus premiums" cost I had been seeking. From the data I have already dug out, I suspect it is the former. The true cost (tax and premiums paid to insurers) could well be higher again.

What I have learned through the exercise is that the American health system is all inclusive; it would cover dental (partially subsidised by the taxpayer in NZ), glasses (not subsidised), accident (covered separately from separate "tax") as well as basic health services (I pay the first $30 of every visit to the doctor).

So I can turn my back on the American health topic for good. America you are welcome to your unique (it is too, the only rich nation that does not provide universal health coverage) system.

TF, when you reach 65, will you be going on to Medicaid? Or will you continue working to pay your health insurance?

On matters of health - and great fortune...

I make little secret of the fact that, at age 13, I became epileptic. I had what I know as "Juvenile onset gran mal". I also know that I am one of the very lucky ones who "grow out of it".

There are many others who are greatly less fortunate.

I saw the headline link at (what used to be)Jack Grant's Random Fate blog.

My chest was to his back. My right leg was thrown over his right hip. At first he made a smacking noise with his lips, as if a cow was chewing his cud beside me. I thought I heard him ask for something. I might have just been falling to sleep myself. But this mouth thing caught my attention. My arms tightened around him. He started to shake. I thought, "Is he having another one?"

"I'm right here with you baby." I held him even tighter. He'd told me to hold him tight if this ever happened when we were together.

Read the whole article. It is sensitively and well written.

I want to pick up on the end of it.

He's had epilepsy for over fifteen years. He lost his license and his job fifteen years ago. Medicare says he's not "disabled enough." He has no insurance because after rent he has three hundred dollars per month on which he keeps himself alive. He goes to the free clinic every three months to wait in line for four hours to see his doctor and get his meds.

This is how a man who was Varsity all three years, MVP'd often, who then drove heavy machinery fifteen years for a city he loved, fell through the cracks. He's not disabled enough to receive any help from our government. This is the land of the free and the brave? I don't think so.

Those who fight and bellow at the perceived injustices of social health programmes might like to explain how their ideas would provide this man with the health services he requires.

Oh and so that you know, my health insurance carries a 5% loading for my juvenile epilepsy. I was able to get my driving license at 22, after 3 years clear of fitting and not being on (some fairly scary) drugs including phenobarbitone (barbiturate). I am lucky indeed.

On the state of health - 1

There was an interesting comment over at TF's place stating (and I can't for the moment think of a reasonable response to it) that the Federal government "has no place in providing health services". As should be well known to readers here, that is certainly not the case in NZ. Mind you, the commenter did continue to say that it was a State responsibility, and that perhaps is the reason why I am at a bit of a loss about it.

There is one very direct parallel between NZ and the US though, and it centres on the role of the private system and medical insurance providers.

To that end there was a very interesting and somewhat blood-chilling little article in SST this week...

RISING HEALTHCARE costs have reached crisis point, pushing families to give up their health insurance and fall back onto the straining state system, says Ian McPherson, chief executive of Southern Cross Medical Care Society.

The not-for-profit insurer saw claims rise by $61 million in the year to June and McPherson said factors behind the claims blowout included the amount private surgeons earned and costly new medical technologies with little or no proven clinical benefit.

For the time being, my salary package includes medical insurance through Southern Cross at a cost of something like $35 per week. That looks like increasing by a bit in the near future.

"How much will people be able to continue to pay and not object?" McPherson asked.

"We have seen a significant downgrading from policies that are far more general to policies covering the extreme emergencies. It is difficult for people to downgrade any more. There is a significant number sitting on the bottom rung and about to jump off into the public system again."

Exactly.

Rising costs for Southern Cross could also feed the already rapid rise in the state's healthcare bill. Consultant Paul Winton, author of a report in August – Health, New Zealand's untreated addiction – said current trends suggested healthcare costs could grow from 20% of core government spending to 40% in 15 years.

McPherson said Southern Cross had begun engaging with GPs on the premium-affordability crisis, and the subtext is clear – the insurer wants to see GPs direct patients away from the more expensive private surgeons.

"We are not going to tell GPs who to refer their patients to," McPherson said, but "we would like GPs to be mindful about the cost rather than referring out of habit. Giving them an incentive to help manage our budgets is something we are exploring with them now."

Southern Cross has been developing a network of affiliated providers, but McPherson said as yet it would be a step too far to require their use in the same way a car insurer would require a claimant to go to an approved panelbeater.

Now there is little wrong with the Southern Cross response to the problem so far as I am concerned.

The truth of the matter is though that McPherson's prognosis in the opening paras is only too true. Even given the present premium levels there is little chance that I will be able to afford the present cover into my retirement. There is no question that I will become increasingly reliant upon the public health service. Not that I have any problem with that, as it has certainly been "good value" for me.

McPherson said there were instances where it appeared that profit motive and not clinical outcomes were driving that price upwards.

He cited the example of robot-assisted prostatectomy surgery which costs $30,000 compared to the $15,000-$20,000 of conventional surgery, without evidence of faster recovery or better clinical outcomes.

Southern Cross's reaction in this case was to pay only a "contribution" to the cost of the robot-assisted surgery.

Why were surgeons using it? "Because it is fun. Because it is interesting. Because you can get a margin on your investment."

Hmmm, sounds a bit like "boys toys" no?

Let's set the parameters here.

First, medicine is about curing diseases, mending injuries, and providing palliative care for the dying.

Second, it is a very highly skilled and for most a stressful occupation. (I am basing that on the comments made to me by the three medical doctors in the club I belong to). People who fit those parameters in any field deserve to earn more than those of us who cruise below the radar doing little more than subsist. There is also, as any capitalist will tell you, the need and justification for recovering a return on capital invested; let's face it, I will tell you that as an accountant.

Terry Moore, president of the Private Surgical Hospitals Association, said: "We are conscious of the increases in costs which ultimately, if left unchecked will mean fewer people will be able to afford to go private themselves."

Moore said uncontestable clinical proof of new technologies could take years to emerge, but acknowledged they were stoking cost escalation along with wages and surgeons' fees.

McPherson also hit out at fees in his annual report to members last month. "We hear the argument that [surgeons] are part of a globalised workforce; we point out that if their prices increase to reflect overseas rates, fewer New Zealanders will be able to afford private surgical services."

Boscawen [right wing MP] is of similar mind, arguing that the globalised workforce is more of a westernised workforce, because the wages earned by quality doctors from India, for example, where cataract surgery is cheap, are having no effect on the fees charged by private surgeons here.

Moore countered: "Surgeons are generally independent practitioners and contractors so they pretty much set their own fees in a competitive market, but I don't think the fees have gone up much more than the medical inflation rate. They have become more efficient so they are probably earning more, but probably working harder for it and doing more procedures."

He said rising premium costs for health insurers were also driven by the sheer number of procedures being done, not just the cost of each one.

All true, well I have difficulty disagreeing with most of it so it must be. No confirmation bias here!

But there are some interesting contradictions. For example, the hospitals (Moore, above) are trying to argue that "economies of scale" ideas do not apply; "rising premium costs for health insurers were also driven by the sheer number of procedures being done, not just the cost of each one." I would have thought that (as my wife found out when she had cataracts removed from one eye) being able to "mass produce/production line" operations would lead to some savings. If it costs the insurer $4M to provide 1100 cataract operations then does increasing the number by 20% mean a 50% increase in cost? It does if "industry" is currently running at or above capacity.

There is a secondary impact too, coming out of the combination of developing technology (and that is everything including drugs and personal skills) together with societal expectations. The best indicator I can give for this effect I wrote on some while back (2006?? Sheesh!) is the example of herceptin - a treatment drug for a specific kind of breast cancer. That example ended up as a $3 million programme to treat roughly 20 women per year or about $150,000 each.

No one can blame those women for wanting (or deserving) the best possible treatment, and outcome. Exactly the same justification existed in the 1970's when open heart surgery was being developed by the likes of Barratt-Boyes and the other researchers in US, Europe and South Africa. Today, that surgery is routine. Auckland Hospital does two or three operations per day at a cost each of (I was told) about $75,000.

[To be continued...]

What really is wrong with NZ's health system?

If you thought that what I wrote about the US health system was "strong", then take a quick browse through Tracey Barnett's effort in last Saturday's Herald. (probligo health warning; this op-ed might endanger the health of well-meaning Americans). One of the milder cuts -

I love America. It's the only country in the world where citizens pack an AR15 to go a'courting their President. When an economy is stressed, the truly wacked fringes always manage to find centrestage.

I went back to visit family last month, and there was Old Glory, limping along with the biggest single tax revenue drop since the Great Depression, like Paris Hilton with maxed-out credit cards and nothing to wear.

Alongside, and regrettably not on the net, was a small table setting out the current health spends for eight nations as a percentage of GDP. A fair measure as it closely relates to average personal income and is devoid of currency considerations. So, from memory, NZ ranked about 4th on that list with 9.6% just behind Australia and Waaayyyy behind the US at something like 16%. Now that is truly, when you consider the size of the US defence budget and the fact that two concurrent wars is costing little more than twice that proportion, truly frightening thing to consider.

The point was made though, that at the present rate of increase health spending in NZ will reach 22% of GDP by the year 2020 and that is even more frightening.

John Armstrong applied his well-muscled left arm to what the government is currently trying to do.

Was there political interference? Or did the high-powered taskforce charged with reviewing the public health system tailor the final version of its report in full awareness of the acute political sensitivity over the health portfolio?

Or did the group's members simply change their minds at the last minute and drop some of the more contentious things they had been planning to recommend?
...
That is because draft copies of the report leave little doubt that something or someone persuaded the review group, which was chaired by former Treasury boss Murray Horn, to water down or remove some of its more controversial suggestions before the final version was presented to the minister.

Even in its final form, the report has a fair degree of political risk attached to it.

The review group's reform recipe would gut the Ministry of Health and set up a National Health Board which would be responsible for allocating funding of health services with the intention of improving access to services and hospital productivity.

The recommendations bear a marked resemblance to National's hugely unpopular health reforms of the early 1990s which were designed to get more efficiency into the delivery of health services by forcing hospitals to compete with one another.

...and so on.

There is a fairly large matter here in the middle though which has far more to do with medicine and only a secondary look in at money.

I think, with some certainty, that the Bible refers to "man's allotted span" of "three-score years and ten". Now the ol' probligo isn't making any promises to pull the plug at his 71st birthday bash.

One does have to wonder at the western, Judeo-Christian, desire for eternal life in this world in preference to the next.

It is late, I am tired and cranky.

Is it any wonder that health budgets are inflated though, when faced with this kind of problem (once again from Saturday's Herald) -

The flood of alcohol-related hospital admissions during weekends is compromising the ability of hospital staff to tend to general admissions, doctors say.

The situation has prompted doctors to call for a rise in the age at which people can buy alcohol, The Press reported.

Wellington emergency department specialist Paul Quigley said large numbers of young people were coming in with alcohol-related injuries.

"This stuff is all preventable and it's very frustrating when you have people with heart pains or serious respiratory problems having to wait because staff are dealing with teenagers who have broken their wrist or been in a fight because they are drunk," he said.

One emergency department said patient numbers could double on Thursday, Friday and Saturday nights.

The bulk of admissions by people under 30 at weekends was directly related to alcohol, Dr Quigley said.

There was little remorse, and often those admitted appeared pleased with themselves.

Leave them in the gutter. What say you?

What really is wrong with America's health services?

In some respects it is quite sad to read the right-wing ranting of the US Right (aren't they always?) against the Obama administration's attempts to make something of the "health system".

First question that comes to the probligo's rather twisted mind is the perennial "Why does it need fixing? Every administration in living memory has tried to fix - with varying degrees of success - America's "public health system".

Be clear here, if the proposals of the Obama administration is patterned on the British National Health then America has every right to "be afraid, very afraid". But that does not answer or avoid the question.

OK, first up is this -

As the Remote Area Medical Foundation’s huge, free health clinic winds up its eight-day run at the Forum in Inglewood this evening, organizers said they expected to be able to treat all patients who were given wristbands – or refer them to doctors who will provide free care.

During the organization’s first venture into a large, urban city -- and its longest-running health clinic in its 25-year history -- volunteer dentists and doctors helped deliver free medical care to thousands of patients. Many seeking care camped out overnight or slept in their cars; hundreds of others were turned away. Some had traveled from as far as San Francisco and Phoenix for the chance to be treated.

Final tallies were not available, but doctors performed an array of medical services, from root canals and mammograms to HIV tests and the dispensing of free eyeglasses.

Those final tallies are posted on Ramusa's website -

RAM LA Results

The following totals are from patient records in hand and, due to an unknown number of misplaced papers and lost data, are lower than actual numbers.

6,344 patients registered for 14,561 patient encounters (approximately 2.3 services per patient)

3,827 volunteers, largely non-medical support (It is believed that patient encounters could have doubled if medical professionals licensed in states other than California had been allowed to volunteer their services at this clinic.)

3,182 dental patients – 2, 274 teeth extracted and 5,438 teeth saved, 1,889 cleanings

2,266 vision care patients with 1,984 pairs of prescription eyeglasses made on site and fitted

8,775 general medical visits

Total value of care: $2,821,383

Thanks to everyone who made it possible for so many to receive so much during Remote Area Medical’s 8-day free clinic at The Forum in Inglewood, CA.

All that in 8 days.

But what is this saying? This is their Mission Statement -

The Remote Area Medical® (RAM) Volunteer Corps is a non-profit, volunteer, airborne relief corps dedicated to serving mankind by providing free health care, dental care, eye care, veterinary services, and technical and educational assistance to people in remote areas of the United States and the world.
Founded in 1985, Remote Area Medical® is a publicly supported all-volunteer charitable organization. Volunteer doctors, nurses, pilots, veterinarians and support workers participate in expeditions (at their own expense) in some of the world's most exciting places. Medical supplies, medicines, facilities and vehicles are donated.

OK, so Inglewood, CA is a remote part of the US, huh!

The other side of this came (serendipitously) through me old mates at ALD.

What are the alternatives to public (read government) health resources? Obviously, "private" providers. Capitalism in action. And this is how it works . OK, I accept that Wendell Potter might have a few irons to heat, but if a half of what he says is fact then it gives a fairly chilling picture.

...Potter, who is from Tennessee, read in a local paper about a free healthcare expedition being held in Wise County, Virginia. He decided to check it out. Walking through the fairground gates, Potter saw hundreds of people waiting in the rain while physicians attended to patients in animal stalls or on gurneys lying on the rain-soaked pavement. Tents had been pitched across the fairground lawns, creating a scene “like something that could’ve been happening on a battlefield or in a war-torn country.” Tears mixed with the rain to cloud Potter’s vision. “What I thought was: ‘Is this the United States?’ It was so remote from my reality. It just seemed impossible.”

RAM in action again...

But the most chilling thought expressed by Potter rings with total clarity in my personal experience of health insurance here in NZ.

Why are there so many in the US who do not have (private) health insurance? Many to most probsbly can not afford it. That simple.

Potter also provides a good reason why some people can not afford private insurance.

It is because they have been priced off the market... Read the whole interview.