Caesareans

The SMH has  a series this week going on caesareans – why they are on the increase in Australia, and increasing evidence of their long term riskiness.  About 30% of births in Australia are now by c-section. It’s a good series, which points out that as well as appearing to have higher risks of themselves (this BMJ article shows an increased risk of respiratory distress in babies born by c-section and this one shows increased risks to the mothers from c-sections in normal (not breech or cephalic) delivery), c-sections increase the risks of serious complications in subsequent pregnancies.

The series mostly refrains from blaming mothers who are “too posh to push” – previous articles I’ve seen on this topic  often simplistically suggest that the issue is that mothers demand c-sections. This opinion piece today is a relatively mild example – starting by talking about mothers demanding a c-section, rather than a natural birth.

In my, admittedly anecdotal, experience, the change in demand is much more nuanced. There are undoubtedly women who demand c-sections. But there are far more women, and medical professionals, who now have a different threshold for considering c-section. The changes are about how we (society at large) view risks, perceived and imagined, and our control over those risks.

The book Paradox of Choice, by Barry Schwartz describes how many people make choices to minimise their regrets, rather than maximise their chance of happiness. It seems to me that if you are on the slippery slope of things starting to go wrong with pregnancy and delivery, if you or your doctor chooses a c-section, you and the doctor can tell yourselves later that you have done everything you can to make things work. At that point, you are part of the universe of all possible women having a natural birth. You are part of a much smaller group which is now at an increased risk of your baby being injured, or something happening to your own body.

As my own doctor said when I asked him what the relative risks were of my various options, “I can tell you all the statistics, but you’ve got to remember that whatever happens, it’s going to be 100% for you”.

My own experience is somewhat illustrative. I’ve had two c-sections. The first was because I had high blood pressure, which was drifting upwards to dangerous levels, and even though I was one week overdue, my Bishop’s score was so low that an induction was highly likely to lead to a c-section anyway. I could have waited longer, but given that my high blood pressure persisted for a week after delivery, there was a reasonable chance that would have damaged my kidneys enough to permanently increase my blood pressure. Thirty years ago, I’d be surprised if I would have had a c-section. And maybe I would have been fine. But maybe Chatterboy or me would have been permanently damaged in some way by the experience. Statistically, I don’t know (and neither does anyone else) whether I should fit in the 50% of c-sections that are probably justified from the statistics, or the 50% that are doctors being overly interventionist.

My second c-section was made more likely by the first – having had one c-section means you can’t induce a subsequent birth (substantially increased risk of uterus rupture) and my blood pressure was high and creeping upwards, with ambiguous liver test results, so that I went for a c-section again. Again, I could have waited for natural labour, or my blood pressure to become unambiguously dangerous, but my doctor and I chose not to.

It’s clear from the literature that any intervention (pain relief, induction through any means, especially drugs) increases the chance of subsequent interventions. And that even after adjusting for the difference in women at Australian public and private hospitals, women in private hospitals generally end up with more interventions, including c-sections.

This article makes a similar point:

“People on higher incomes are more likely to use specialist services and when they do they are more likely to be charged higher fees,” Mr Van Gool said.

“However, if you are a public patient in an obstetric ward you might be primarily seen by midwives, whereas in the private sector you are cared for by the obstetrician – immediately you are dealing with a higher price.”

But there is also a cultural issue at play. Women who have private health insurance are very aware that they have paid for it. They would expect to be able to exercise more control over their experience. And a natural birth is inherently uncontrollable. Intervening by starting an induction, and having early pain relief will provide an illusion of control.

I don’t have any magic solutions, but I do think that our cultural attitudes to acceptable and unacceptable risks and how much control we want have changed substantially in the last 30 years ago, and that has been a big factor in the change in c-section rates.  Understanding that will be an important part of making any changes.

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Two tiers for health care

There was a fairly impassioned article in the SMH today about how the Australian health care system has very definitely become a two-tier health care system.

“the wealthy and privately insured get timely health care and the rest, unless they are critically ill, can wait.”

Except, as I blogged recently, if you are a child, in which case you mostly get superb care in the public health system, without regard to your income levels. An anecdote to support that. When Chatterboy was being checked in, we were asked whether we wanted to go public or private. There was no difference in care, we were told. But if he had been over 18, it would have been the difference between seeing the specialist, and seeing the resident.

Recent research commissioned by the NSW cancer council describes some of the human cost of the two tier system. For patients being treated for cancer, according to the SMH (this wasn’t in the summary article on the website):

“The report also revealed a gulf between different cancers in how much they cost the health system and individuals. People with prostate cancer bore 32 per cent and those with breast cancer 20 per cent of treatment costs, well above the 15 per cent average. The report said this was because “treatment of these cancers uses more GP and specialist services, and more pharmaceuticals, and thus individuals contribute more in the form of gap and co-payments”.

If you can’t afford to pay 15% of the cost of treatment, then it seems likely your treatment is going to suffer. You’ll probably have to wait longer for treatment. Your doctor will be less qualified. And to get the bulk-billed treatment you can afford, you will have to shop around to find a doctor to treat you cheaply. That doctor is probably not the most convenient, so while you are very sick, you’ll have to drag yourself out to an inconvenient doctor you can afford.

As the private health system has been propped up with legislative change (lifetime community rating) and tax incentives and rebates (it is cheaper for our family to have health insurance than not, even if we never claim a cent on it, because of the way the tax system works), the public system becomes the safety net, rather than a sytem that you can be happy to end up in.

In the end, health care must be rationed somehow. As society, we don’t have unlimited money to spend. And our rationing is a combination of using money, or using triage decisions by doctors within the amount of money available to the public system. But the relationship between those streams seems to have  changed.

For children, income plays a small part in determining what standard of care you receive. For adults, it’s playing an increasing part. I wonder whether this is because as a society our attitude to poor adults increasingly is that their poverty is self-inflicted.

At least children aren’t blamed for being born into a poor family (at least not in the health care system). But the implication of our increasingly two-tier health care system is that adults are less deserving of adequate health care if they are poor. And that is a sad reflection on society today.

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Somewhat socialised medicine

Since Wednesday, Chatterboy has been in Royal North Shore Hospital being treated for pneumonia. On Friday, when he’d turned the corner, the doctors admitted to us that they had been quite worried about him on Thursday, when nothing seemed to be working, and he was lying there, listlessly, on oxygen, not wanting to talk. He’s just come home this afternoon, alternating between wanting to run everywhere, and then sitting down because, “I still feel a bit tired.”

He was a public patient, and received what looked to me like superb care. And I say that even though he spent the first 16 hours of his time there in Emergency because they didn’t have enough beds.

He was in the very new Children’s Ward (new in the last three years at least, since he was last there), which has a school (two teachers who have resources to share out), a play area and a fairy garden attached. It was decorated with children’s paintings, and, while clearly a hospital, there had been an attempt made to cheer it up a bit with small decorative touches around the place. His TV was free, and there was a special entertainment unit available if needed, with DVDs and video games. He was in a four bed ward at first, and then a two bed ward with ensuite bathroom.

Family involvement was enouraged and welcome. Parents could visit any time, and were provided with a cot bed if they wanted to stay overnight (not especially comfortable, but better than a chair in the corner!). There was a special parent’s lounge with free coffee, tea and cereals.

He had two doctors involved in his case the whole time, plus assorted junior ones. They kept him in an extra night just to make sure (although they were pretty convinced) that he could get through the night without needing extra oxygen. The only slightly negative note was that a lot of the nurses seemed to be agency ones – leading to a lack of understanding of hospital routines (only noticeable to me at least, to be fair, on discharge).

And it was entirely free.

A lot of what impressed me about it was not so much the care -notwithstanding that the doctors seemed really thoughtful and interested in what was a slightly puzzling case – but the extra bits and pieces. Chatterboy’s spirits really lifted when he discovered the fairy garden. And he got very excited when the teacher brought some computer games for him to play, even before he was well enough to get out of bed.

I haven’t been a patient in a public hospital, but I imagine that the adults don’t get the same level of small luxuries, or even nice decoration. They’re generally paid for by the various children’s charities, which of course raise money for children, because who wouldn’t give money for sick children? But I’m sure they make a difference to the happiness of patients, and perhaps even their health (the signs in the children’s ward seemed pretty convincing on the importance of psychological health for their pediatric patients). It’s the kind of thing, though, that hospital administrators would find it hard to spend public money on – when the choice is some extra books or video games for the adults, or another of the latest hi-tech diagnostic machines.

I’m glad we look after our sick children so well. But I think (without much direct evidence, admittedly) our sick adults have been becoming second class citizens for some time.

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The greater good

We’ve been watching a depressing British TV show called Bodies – set in a hospital with an incompetent senior obstetrician. The storyline of the first series follows the various ways different doctors deal with the incompetence – from ignoring it, to trying to stop it happening subtly, to reporting it and then being suspended and punished by all the other doctors for breaking the code. “Doctors look after doctors” is a constant refrain.

At one point, one of the other senior doctors, explains why this works – (paraphrasing from memory) –

“If doctors were held to account for every single mistake they make, even if it cost a life, then there would be no doctors left. We all would have been struck off. So the code is that we don’t report mistakes – doctors look after doctors. The cost of that code is the occasional completely incompetent doctor, like Mr Hurley here.  That’s how it works, and if you go outside that, you’re on your own.”

It recalled to me a problem that I’ve been pondering for a while. The legal system is, mostly, great at picking up egregious cases of negligence, and punishing them with money. If your household appliance explodes, and injures you, you’ll generally get compensation, and that’s one of the reasons that most household appliances don’t explode – manufacturers know that it’s sensible to try and avoid that in products they make.

But the legal system doesn’t work well in sorting out issues that are more balanced. If a particular decision has both benefits and costs – particularly if they are to different people – then the legal system will only see the costs.

This Bodies example one such case – the senior doctor doesn’t trust the legal system, as he doesn’t think it will value society’s need to have enough doctors in the system, even if they aren’t all perfect. So instead, he takes it upon himself to play god, and let the incompetent doctors through, for the greater good. The legal system, on the other hand, in his view, would have punished so many doctors that there wouldn’t be enough to look after the rest of society.

My favourite example of this is the blood donation one – the Australian Red Cross stopped taking any blood donor who had lived in the UK, because of the remote risk of mad cow disease. This had real costs – lack of blood is a perennial problem in our hospital system, and there were almost certainly lives lost because of it – but no legal case brought by someone who caught mad cow disease from blood donation would have recognised those costs. And it’s hard to imagine a case being won by someone who has died or been left permanently damaged through lack of donated blood.

At some level, vaccination is also this kind of problem – all vaccinations have some form of side effects (generally only a sore arm, maybe a fever for a day or so). You get vaccinated because it will save some lives from people not dying from horrible diseases. But the lives saved aren’t necessarily those who get the worst side effects. If you can look at vaccination with a very cold-hearted logical eye, even a vaccine that causes a few deaths is likely to be a good thing for society as a whole, if it prevents a disease (say small pox) that would have killed a whole lot more.

If the legal system did somehow change to allow some form of “greater good” argument, it would be incredibly unpopular. If you’re the person who has suffered a grievous injury, you’re unlikely to be especially comforted by the fact that the act that caused your injury has also, coincidentally, helped others.

Managing to take into account some kind of “greater good” defence would probably require wholesale, unimaginable changes to our legal system. So it’s unlikely to happen. But as our society becomes more and more risk averse, we run the risk of making bad decisions that don’t look at the benefits to society as a whole of taking some risks. 

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Blood donation

I walked past an ad trying to find blood donors today. As a frustrated blood donor, it annoyed me.

I used to be a vaguely regular blood donor. From the time that I turned 18 (and became eligible) to around 28, I would have given blood maybe once or twice a year (a perfect record is once a quarter). I liked to think it was something I could do for the community.

But then the Australian red cross (in my view) succumbed to hysteria. It banned from blood donation anyone who had lived in Britain for more than six months since 1980. So I was banned for life. The reason? It was so long ago, you’ve probably forgotten the hysteria. Mad cow disease. As far as I know, no-one has ever demonstrably caught CJD from donated blood. The UK certainly continues to accept donated blood from its own population, without asking whether they are vegetarians.

So Australia rejected what was estimated at the time to be 5% of its blood donating population for a risk that was seen as remote at the time and still has never eventuated.

The trouble with this, is that there is a real risk to the population if there are low blood supplies. But that risk is difficult to sheet home to one individual. If there wasn’t enough blood available, then surgeries might be delayed, people might get fluids rather than blood, if the decision was marginal. It seems likely to me that having a 5% lower blood supply for the last 10 years has almost certainly caused some poorer outcomes in some Australian patients than would otherwise occur.

But for a risk that seems less and less likely by the year, we are willing to put up with these poorer outcomes, or the Australian Red Cross has decided to make that trade-off for us.

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Risk rating health insurance

After my previous post, and a few comments there, here’s some more detail on why I don’t think proper risk rated health insurance works particularly effectively for most people.

(by the way, the US market, from what I understand, doesn’t have individual health insurance rating to any large extent; you get your insurance coverage through your employer, and they average out the claims cost).

If we had individual risk rating for health insurance, there would be two key checkpoints. First, can you get insurance at all. Now a similar, but less risky product, is disability income insurance. For that product, most insurance companies will reject between 10 and 20% of applicants outright. Their risk of claim is so high, that it is not worth taking the risk of insuring them. I have no equivalent statistics, but I’d guess that at least twice as many people would fit into that category for health insurance.  Annika is an example of someone no insurance company would take on as an individual – if you know that next year the claims cost is going to be somewhere upwards of $500,000, as an insurance company, that’s the premium you’re going to charge, so as a parent, you’re going to start fundraising.

So (say) 40% of the population wouldn’t be able to get health insurance, probably at all. But that’s not the end of the story. You’ll probably get far more substantial exclusions than you do now. Pregnancy, for example, is unlikely to be covered. Far too predictable and expensive. From an insurance company perspective, if your alternatives are to charge an extra $1,000 (at least) for every woman of childbearing age, or to exclude it from coverage, you’re probably going to choose exclusion to avoid the adverse publicity.

Health insurance, if it was risk rated, would also be far more expensive for some people than others. My family (touch wood) is pretty healthy. But my parents, although “self-funded retirees” (code for lucky enough to have been in a public sector super scheme for a significant part of my dad’s working life) would have trouble affording health insurance that genuinely covered their risk of claim, particularly after my dad’s brush with cancer last year, and my mother’s two hip replacements.

So just by the nature of the predictability of health care costs, if you let insurance companies charge for risk, many people (even morally upright people who have managed to earn lots of money over their lifetime, and contribute to society) will be unable to afford or obtain insurance.

So society as a whole has to decide what is an acceptable level of healthcare for those unfortunate people who can’t get health insurance, and then (definitely a question to be answered second), how should that healthcare be funded?

In Australia, we’ve answered that question with medicare – generally acute care is funded well, chronic, non life threatening issues are not dealt with as effectively, but eventually, after quality of life issues.

But when we get to the funding question, we’ve had another stab. We’ve effectively decided that richer people can queue jump and slightly improve their quality of care (e.g. by choosing their specialist, and getting private rooms when they have surgery), but we’ve still spread the cost of that over the whole population who is willing to do pay for it. So there are two categories of health care, but you’re either in one or the other, with no gradations.

When the second, higher standard of health care started to become expensive, because the young healthy people couldn’t see the point, we used a carrot (tax incentive) and stick (punitive tax rates) approach to getting more healthy people into the system to fund the sicker, but “deserving” (read middle class) people. Up to 50% of people had health insurance after the carrot and stick were introduced. I think it’s declining again, because of the tensions inherent in a system where healthy people are somewhat voluntarily subsidising unhealthy people.

This has been a very rambling post. But my main point is that genuine risk rated insurance will leave a lot of people either uninsurable, or unable to afford insurance. Those people will very likely include a lot of people who have private health insurance now because they use the health system a fair bit. Your health status correlates fairly poorly with your economic ability to pay (particularly when you allow age rating).  That means your safety net is going to need to be pretty good.

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Health Care

I’ve been pondering a mammoth post on health care for a while. I’m not sure if I’ve got it in me tonight. Or ever. So here’s a few thoughts. Mainly from my angle as an actuary who manages insurance companies for a living.

Most places that try to privatize health care to some extent do it via an insurance system of some kind. There is an enormous problem with this. Insurance works best when the event you are insuring against (e.g. car accident) is pretty random. It works least when there are different parts of the community who have enormously different risks of the event occurring. If you think about health care, the chance of anyone needing health care is enormously variable, depending on their current state of health. Compare me (moderately fit, only visits to the doctor in the past 10 years for pap smears, except for pregnancy related things) with the family friend Hungry Boy shares his birthdate with (severely autistic, has just started to say a few words at age 3 and a half).

If you’re an insurance company determining a risk based premium, then Hungry Boy’s friend’s premium for medical related care is going to be an enormous premium compared with mine. There are a few random-seeming events in someone’s medical life – a colleague in his mid 30s having a stroke is a good example. But there are a lot more that are pretty predictable looking forward for a year if you look carefully at someone’s state of health.

So insurance without some method of grouping is never going to work well as a way of paying for health care – by having insurance, you’re very close to just asking people to pay the costs of their health care with the intervention of an insurance company to organise the payments.

Here in Australia, the method of grouping is to force insurance companies to charge everyone the same premium, regardless of health status, age, or sex. And to get enough people to take out insurance (including healthy people like me) the government has to massively subsidise it with the tax system, to the point where there is more money going to dental treatment through tax breaks for high income earners than there is actually for people who need dental treatment through the health system.

It does seem reasonable to allow massively rich people (like Kerry Packer) to pay for private health care. But I’m not sure that I can see that the outcomes for society as a whole, including the roughly 50% of people who take out private health insurance, are better than they would be if we took the money spent on private health insurance and used instead in the state system. Seriously rich people could still pay more, but the health of Australians as a whole would probably be better.

I probably need another post to explain why I seem such a socialist in this post (more than I am when you look at my political beliefs as a whole). I do believe that markets add value, but only when there is full information on both sides of the buy-sell spread, which is manifestly not the health care market for the individual patient.

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Medical care

I’d really like to write a thoughtful post about healthcare. I’m too tired, tonight, though. So I’ll just point you to a few US links.

Stayin’ Alive has an excellent series on what health insurance is, and why it’s a misnomer to call it insurance.
Half Changed World has a post on why she thinks the latest small reforms to health funding in Massachusetts won’t work.
Annika is a child who so far has come through some terrible illnesses with health insurance, but her luck is starting to run out as the reinsurer of the fairly small health insurer who insurers her family starts to run out of patience.
And this story from Badger is the scariest of all.

I think I’m reading too many US blogs on this topic, because I’m starting to think that our healthcare system is pretty good.

But I don’t our health funding system is sustainable long term – I read something this week talking about various ways in which it’s falling apart, but I haven’t been able to find it again. I’ll bookmark this to write some more.

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Over-using the hospital system

I had a scary night last night. D (aged 2 and three quarters) woke up at 2 am needing to go to the toilet, was trying to yell out to get help, and discovered that he couldn’t talk, and could barely breathe. So I heard some strange barking noises, went to investigate, and discovered a terrified child who was trying to simultaneously breathe and pull his shorts down. I was pretty sure (from the barking) that it was croup, but two years ago, when D had croup, I got a pretty severe lecture from the nurse treating him that if he had trouble breathing, I should take it very seriously.

After a brief confab with E, I called 000, and an ambulance came and took them both to hospital. He was absolutely fine – by the time the ambulance came, he was just wheezing a bit, and after some drugs at hospital, and an hour or so of observation, they were sent home in a taxi.

I’m now wondering whether to feel guilty about over-using our wonderful health system (all completely free, by the way). Should I have waited the extra two minutes it would have taken to make it clear that a drive to hospital would have been adequate (rather than an ambulance)? Should I have then given him some ventolin (from previous wheezing episodes), and put him to sleep in our room and listened to his breathing all night instead of using getting the hospital to check him out?

Certainly any parent of a child with asthma would deal with that kind of breathing trouble pretty regularly, I imagine. They would probably laugh at my alarm. But they would also have strategies to deal with the little episodes, that I don’t have. I also know that asthma, left untreated, can kill a child (it put one of my cousins in intensive care for a few days at age 20), and D has shown wheezing tendencies in the past.

Upper-middle class parents like me are more likely to have the sense of entitlement that leads them to just call the ambulance, rather than feeling a burden on the system and waiting until it’s clearly a matter of life and death.

So which is right? The over-use of the hospital system to make sure nothing terrible happens, or rationing yourself to make absolutely sure it’s necessary?

Most studies of the rationing of health care that happens when patients are charged for it show that patients don’t have enough understanding to decide which treatments are necessary, and which are not. The trouble is that charging for it is unlikely to change the use. I would still have called the ambulance, even if it cost me a fair bit of money, and the parent who is already worried about being a burden on the system would be even less likely to, as they would have the added worry about being able to afford it.

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Obesity again

The ABS has released their regular survey of Australians and their health. There is a wealth of detail in there, but 62% of men, and 45% of women (up 4% each from 5 years ago) were overweight or obese. Mostly, the increase is in the obese proportion, as people move from normal weight to overweight, and then again to obese. I’ve realised again that my eye has got used to people’s new proportions. One of my colleagues mentioned to me the other day that he was classified obese (BMI marginally over 30). If you’d asked me before the conversation, I wouldn’t have said he was overweight. But then if 62% of Australian men are overweight, that’s the man you’re used to looking at.

Just to put it into perspective, one of the health conditions asked about is diabetes. Right now, 3.5% of the population has it (or knows they have it – most estimates are that as many people again have Type II diabetes without knowing about it). Last survey, five years ago, it was 3.0%. It may not sound like much of a change, but it is a 15% increase.

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