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Wednesday, August 1, 2007

Canadian docs stage private care putsch

The Canadian Medical Association's new "Medicare Plus" vision, announced by outgoing president Dr Colin McMillan (right) in a Charlottetown speech July 30, has stirred up the debate about the role of privately funded healthcare in Canada.

In the new CMA policy document (PDF), released the day of Dr McMillan's speech, the group asks governments and the public to:

  • Allow doctors to practise in the private and public systems at the same time;
  • Expand wait-time benchmarks to more areas of medical care;
  • Guarantee treatment within those benchmarks and, if they cannot be met, subcontract the private sector -- as has already been mandated to a limited degree in Quebec with Bill 33, following the Supreme Court's Chaoulli decision;
  • Create a national strategy to increase the number of healthcare workers;
  • Expand public insurance to cover individuals' "catastrophic" drug expenses and long-term care costs.
Reaction to Dr McMillan's bombshell has been largely negative, and, at times, dismissive:
"Any collection of doctors are entitled to their opinion and there are many things we agree with them on, but on the issue of physicians having a dual practice or two-tier system, we're not going down that road." - "Two-Tier" Tony Clement, federal Minister of Health

"[While] many doctors disagree strongly with proposals that would undermine public health care, the CMA leadership has chosen self-interest over public interest." - Dr Gordon Guyatt, Canadian Health Coalition

"Is the CMA SiCKO?" - Canadian Health Coalition

"Politicians should not look at this option for very long... It is hard to avoid the conclusion that the prime beneficiaries of the CMA's policy would be the CMA members." - The Globe and Mail editorial

"Rather that [sic] dismantling our public health-care system piece by piece, the CMA would do better to concentrate on solving challenges in Canadian health care within medicare..." - Danielle Martin, Canadian Doctors for Medicare

Not everyone's opposed to the CMA policy, however:
"Now that’s a refreshing look at health-care reality. Plus, it’s high time the official voice of 60,000 Canadian doctors entered the fray and realized Canada’s health-care system is about to kick the bucket unless it receives a massive injection of policy-change truth serum." - Bruce Strachan, former BC MLA, writing in the Prince George Citizen

“If there are ways to combine public money and private business practices in ways that make the health system more efficient, we should use them, and we certainly can't be afraid to discuss the options openly.” - Ottawa Citizen editorial

"In fact, the CMA's consideration of more private care is both cautious and modest... The doctors aren't exactly throwing open the doors to unregulated, jungle medicine. What they are doing is insisting that a level-headed discussion ensue, for the sake of patients, not profits. There's nothing radical about that." - Kingston Whig-Standard editorial

For their part, the CMA claim 62% of 1,802 Canadians surveyed support the plan (PowerPoint file).

What's next in the debate? Well, mark your calendars for August 19, when the CMA Annual Meeting kicks off and Brian "Dr Profit" Day takes the reins of the group. Unlike Dr McMillan, he's unlikely to wait a full year to let his opinions be known. (Read NRM's Q&A with Dr Day from last fall, after he was elected CMA president.)


Update, August 8, 2007: CMA Public-Private Interface Committee co-chairs Dr. Robert Hollinshead and Dr. Suzanne Strasberg defend the Medicare Plus plan in an op/ed to The Globe and Mail: "The physicians of Canada make no apologies for raising these issues on behalf of their patients. In fact, we think it is our responsibility."


Photo: CMA

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Better treatment and monitoring needed for pedophiles: Whitmore lawyer

The kidnap and rape of two Prairie boys by convicted pedophile Peter Whitmore (right) may have been prevented by better treatment and monitoring of sex offenders, writes Mr Whitmore's lawyer Daniel Brodsky in an open letter to Prime Minister Stephen Harper. Mr Brodsky is urging the PM to call an inquiry into the case; he says the government is not doing enough to prevent pedophiles from re-offending.

Mr Whitmore agreed to a plea bargain with the Crown last week. In exchange for a guilty plea, the Crown would not seek dangerous offender status. He has been sentenced to life in prison.

I spoke to Mr Brodsky last September, just after Mr Whitmore was arrested following the abduction of the two boys. He told me Mr Whitmore is a sick man who has absolutely no insight into his behaviour. The lawyer, who has represented the repeat offender several times, was disdainful about the way mentally ill criminals are handled by Correctional services: "Seventy percent of inmates have a mental illness," he said. "Almost none of them are getting treatment."

He adds that the convicts themselves - including Peter Whitmore - generally don't want to go to hospital:

"In the penitentiary, you're allowed to work, have recreation, conjugal visits - and not required to have any treatment. If he doesn't cause a problem, he'll be moved to lower security. In the penitentiary, he'll have rights. In a hospital, he'll have privileges."
He has reportedly requested 'chemical castration.' This usually involves administration of the birth control drug Depo-Provera to inhibit the testicles from producing testosterone. The treatment has not been proved to prevent sexual offender recidivism.

Photo: RCMP

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Tuesday, July 31, 2007

Proof of NB's "economic illiteracy"?

The FreeMarketCure blog picked up on our July 30 story about the unintended side effects of New Brunswick's orphan patient incentive for physicians. The incentive, according to some, is making it harder to find a doctor to take over retiring physicians' existing practices.

(Kevin, MD mentioned our story as well and received a few comments accusing doctors of being greedy.)

FreeMarketCure.com is a US website and video production company that advocates healthcare reform based on free-market economics, as its name suggests. (It also spends a great deal of time and effort trying to debunk claims that a universal, socialist healthcare system would be preferable in the United States. The writers' favourite targets are Michael Moore and Canada.)

Here's what their blogger David Catron had to say (in italics) about our NB article, followed by my responses.


"The National Review of Medicine highlights the economic illiteracy that permeates Canada’s health care bureaucracy."
The article dealt exclusively with one specific incentive in one province only.

"Last year, the provincial government of New Brunswick decided that physicians with full practices needed an incentive to take on new patients. However, like all bureaucrats trying to outsmart the market, they implemented a program whose unintended consequences outweighed any benefit the incentives may have provided. [...] "In other words, by selectively applying the incentive, the provincial government made the 'orphan patient' situation worse."
The incentive's unintended consequences may be frustrating, but nowhere does the article claim that the incentive has caused more harm than good.

In fact, data from previous years about NB orphan patients strategies indicate that the province may be on the right path in the long run, despite a few bumps in the road. For instance, the number of family physicians in the province accepting new patients rose 4.9% between 2001 and 2004, according to the Canadian Institute for Health Information (PDF; see page three).

As far as I can tell, no definitive data is yet available that can tell us what effect the incentive has had since it started in 2006 on the number of orphan patients in New Brunswick.

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Rosiglitazone survives FDA inquest

GlaxoSmithKline’s controversial diabetes drug Avandia (rosiglitazone) will probably stay on the market despite near-unanimous consensus among an FDA drug advisory committee that it poses a cardiac risk.

The committee voted 20 to three yesterday that Avandia indeed boosts myocardial infarction (MI) risk, but voted 22 to one that it should remain on the market. The committee agreed that the product should be accompanied by a “black box” warning.

Drug safety officer and committee member Dr David Graham estimated that the drug may have caused between 66,000 and 200,000 "serious" cardiac problems in patients thus far. But the advisory committee was frustrated by the available data, on which such dour safety estimates are based.

Dr Steven Nissen (left), whose May NEJM meta-analysis was responsible for kick-starting intense scrutiny of data on Avandia’s adverse effects, responded to the decision:

"I am very satisfied the committee voted to put a strong warning on the drug. This will allow patients and physicians to make decisions based on more information than we had."
It’s likely that the FDA will follow its advisors’ recommendations, according to Reuters. But committee chairman Dr Clifford J Rosen told the New York Times the way the drug is prescribed will probably change -- it shouldn’t be prescribed to patients with congestive heart failure, a history of cardiovascular disease, or patients taking nitrates or insulin.

For some background, see “Rosiglitazone study bears more bad news” in NRM's current issue.

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Monday, July 30, 2007

Death by internet meds spurs call for pharmacare

Marcia Bergeron's death by counterfeit-drug metal toxicity (which I wrote about in the current issue of NRM) is a reminder that Canada's public healthcare system has a big pharmacare-shaped hole in it, writes former Health Canada science advisory board member Leslie Millin in an editorial in today's Sudbury Star:

"Pharmacare would have been, in fact, a small step 40 years ago, when the administration of pharmaceuticals was a much smaller proportion of medical care. Now, because of the advancement of medical science and the inexorable industrialization of the pharmaceutical industry for profit, pharmacare would be a very large dose indeed.

"But it is not going to get any smaller."

Photo of Ms Bergeron: handout photo

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Homer's SiCKO moment

This great Simpsons clip accomplishes in 35 seconds what it took Michael Moore almost two hours to do.



That's from "Homer's Triple Bypass" (1992), in which Homer suffers a heart attack, then another when he learns the price of triple bypass surgery, then another during his private health insurance application process -- which leads the insurer to deny him coverage because of his preexisting condition. Dr Nick Riviera, the show's omnipresent quack, eventually offers the surgery for a bargain-basement price. The episode also features what may be the best line ever written for a cartoon physician: "The coroner?! I'm so sick of that guy!" Dr Nick exclaims at one point.

In a more recent episode, "Midnight Rx" (2005), Homer and company get fake Canadian healthcare cards and head to Winnipeg to buy prescription drugs -- not dissimilar to the woman from Flint, Michigan who tries (disingenuously) to acquire an OHIP card in Michael Moore's "SiCKO."

Life imitating art, or Simpsons prescience?

(Thanks to The Tyee)

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Oscar, the feline Grim Reaper

The uncanny mortality prediction abilities of Oscar the cat are described in a commentary in this week’s New England Journal of Medicine.

Dr David Dosa, a geriatrician at Steere House Nursing and Rehabilitation Center in Rhode Island, writes that the two-year-old adopted feline has become the home's harbinger of death.

The normally standoffish Oscar curls up next to a home’s residents when they’re about to die. Dr Dosa says Oscar has accurately predicted 25 deaths so far. When they see him nuzzling a patient, nursing home staff now head straight for the phone to call the family.

Where the cat get it’s predictive knack is not known. There isn't a great mass of scientific literature on the phenomenon. It may be due to the cat’s highly sensitive olfactory system -- one theory is that as organ systems begin to shut down, the body's aromatic bouquet scintillates and shifts rather noticeably for a cat. Another possibility is that the cat detects subtle changes in dying patients’ behaviour. Noticing smells and behavioural shifts are thought to be used by dogs trained to predict seizures, and detect cancer.

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