Thursday, August 30, 2007

Heart Check? Blank Cheque!

I recently came across a group of clinics called Heart Check. Clearly there is some controversy about how they operate. They advertise "free" (subject to bulk-billing conditions) heart checkups on TV and radio and encourage patients (or customers) to spread the word amongst their friends and relatives. They even advertise via Shop-a-dockets!

My patients have been telling me about their visits to these clinics. On arrival the clients fill out a questionnaire which encourages them to report the most trivial of potentially cardiac-related symptoms. An on-site GP railroads them into describing any palpitations, chest, shoulder, arm or neck discomfort, shortness of breath on (extreme) exertion, smoking history, and any personal or family history of diabetes, ischaemic heart disease, hypertension, hyperlipidaemia, obesity or any form of cardiovascular disease. There is a minimalist history or examination otherwise.

They then automatically get an ECG, and barring someone who is going to keel over and die if they walk for 2 minutes, they are then recommended to have an exercise ECG. Anyone who reports palpitations gets a Holter monitor.

Depending on the results, you are either sent to hospital, a cardiologist, a surgeon, or a GP. By depending on the results, I mean that if you are a robot whose heart rate does not vary from 60 bpm ever, you might get sent to your GP with an "All Clear" report. Otherwise, you are almost guaranteed a referral to a specialist of some sort (though if you develop an AMI on the treadmill they terminate the test and call an ambulance). Even better, sometimes they send you to your GP to get a referral to a specialist.

This is not a new idea - I suppose it all started with screening tests such as the urine dipstick for glucose (looking for diabetes) and proteinuria (for early renal failure), breast cancer and prostate cancer screening (with mammograms, breast and rectal exams and serial PSAs), and now FOB tests (for possible early bowel cancer). These are all targeted as a public service, rather than a profit-making exercise. A great deal of thought has been put into working out the pre-test probabilities for these screening tests (well, maybe not for serial PSA). Ever since then a whole series of very questionable clinics have set up shop - ranging from those offering coronary calcium scoring to whole body CT scanning. Of course Heart Check is not alone in this business (WA Cardiology offers CT Coronary Angiography).

Now, I have mixed feelings about all of this. Firstly, I have to admire Heart Check's efficiency and protocol. It is almost an ideal setup for a surgical practice. Shoehorn your patients quickly and efficiently into a provisional diagnosis, investigation protocol and treatment plan. It doesn't matter whether they really have something wrong or not - there is always someone else to palm the patients off to afterwards. Get them in and out, and make a mint along the way. My accountant would love a practice like that.

After a great deal of consideration, though, I have decided that what they do is blatantly unethical. The fact is that they prey on public fears of heart disease. Like all good advertisers, they create a need by convincing the general public that they could have a hidden risk of dropping dead - all preventable by having an ECG. Even better - it's free!

They skirt around Medicare requirements by employing an on-site GP, even though the GP has no role other than to initiate these investigations, and in fact, does not even need to hold any qualifications such as an FRACGP. They perform an abbreviated stress test (on behalf of an off-site cardiologist), and consider abnormal what most sensible doctors would see as normal findings (so that the patients feel that they "found something"). They then take no responsibility for subsequent care, and refer off to a host of other specialists via the patient's normal GP.

And then they dare to claim it all on Medicare so that our taxes foot the bill. Generally there is a gap fee for anything other than the basic 12-lead ECG, but you wouldn't know it from the advertising. When noise-complaints group Noisewatch tried to stop Heart Check's rather annoying advertisements they lost out. Perhaps they might have had more luck if they'd focused on the last line in the ad: "It's fully covered by Medicare."

But how can I complain when they introduce patients back into the health system, ultimately providing me with a source of referrals, all of whom I can safely pat on the back and say that despite what the doctor at the Heart Check clinic told them, their tests results are well within normal range, their lack of symptoms are nothing to worry about, and send them on their way with a nice fat bill (again, largely subsidised by Medicare). Sometimes I even find something real, such as a hernia, on my clinical examination which I can, in turn, investigate and treat even though the patient never complained of anything in the first place!

Have I been seduced by the referral merry-go-round? Am I getting sucked into the unnecessary investigation whirlpool? Perhaps it is normal practice in somewhere like the US - but it seems decidedly out of place in Australia.

Friday, August 24, 2007

Bleeding Hearts in Private Hospitals

Obviously things were more complicated that they have been portrayed, and there is not enough information in the public domain to understand what was happening.

No doubt Craig Jurisevic was qualified to be an independent cardiothoracic surgeon. He had passed his exams and gained his fellowship. That does not automatically qualify him for accreditation to any particular private hospital.

Clearly Ross and Knight did not approve of his entry into private practise (at whichever hospital they worked at). Whether their reasons were financial, altruistic, or otherwise I do not know.

Perhaps they were asked their opinion by the Hospital's accreditation committee and they gave it honestly. Perhaps they actively tried to block his accreditation by portraying Jurisevic dishonestly. Perhaps what they did or did not say didn't matter, and the hospital itself would have made an independent decision about Jurisevic's accreditation based on other factors.

In any case, the ACCC saw the outcome and Ross and Knight's actions as stifling competition. That's why they prosecuted and succeeded.

Nevertheless, in a small, saturated or mature market, qualities such as overseas experience may be desirable. And if, in effect, the ACCC is saying that private hospitals must approve accreditation to everyone who applies (without regard to their other qualities, or lack thereof), then this is a big deal.

Let us say, for example, that Surgeon X has a reputation for poor results, or creating staff conflict, but is an otherwise qualified surgeon in his specialty. Do other surgeons in his specialty have the right to prevent his appointment in order to maintain quality or harmony at that private hospital? (NOTE: I am not implying anything about Craig Jurisevic here)

Does the hospital have a right to refuse accreditation on these "soft" criteria?

Would things have been different if Knight and Ross had threatened to withdraw services if Jurisevic were appointed, rather than saying that he was not qualified? The hospital has a reputation to protect, and not appointing a singular new surgeon in order to keep the business of two other surgeons would be merely a commercial decision.

Maybe the hospital felt that it had enough CT surgeons, and would not accredit another one unless they were "outstanding"?

Perhaps things are skewed because cardiac surgeons are a service profession (unlike most other specialties), and there are only a limited number of hospitals with coronary pump facilities. Maybe if your career is under the thumb of a cardiologist it makes you do weird things.

I'm sure Craig is a smart man, and has plenty of options to further his career. The ACCC's action was presumably to benefit Adelaide residents by maximising their access to cardiac surgical services. It was all about what Ross and Knight did, and little or nothing to do with Craig Jurisevic or his personal interests.

As for overseas or post-fellowship experience being desirable - there would be no issue if Craig's appointment to a public hospital were declined due to Ross and Knight's actions. A public hospital has every right to set it's standards as high as it likes before appointing another surgeon. As far as I am aware, a public hospital is not involved in a commercial marketplace, and therefore the ACCC and the Trade Practices Act has no jurisdiction.

But the rules for a Private Hospital are different - Craig Jurisevic did not miss out on a job, he missed out on a right to enter a competitive market for surgical services at that hospital. I wonder if the ACCC's win means that private hospitals will be compelled to maximise competition within their own walls. We might start sueing each other over whether our names appear more prominently around the hospital, as it may stifle business and competition. What a world.

Monday, August 20, 2007

ACCC strikes again

Doctors fined for breaching trading laws from The Australian, July 5 2007.
Doctors fined for breaching trading laws
July 05, 2007
TWO leading Adelaide heart surgeons have been fined a total of $110,000 for trying to stop a third surgeon operating on private patients in South Australian hospitals.
In a judgment handed down in the Federal Court today, John Knight and Iain Ross were each fined $55,000 and ordered to attend a compliance seminar after breaching competition laws.

In action brought by the Australian Competition and Consumer Commission (ACCC), Judge John Mansfield ruled that doctors Knight and Ross had come to an arrangement to hinder or prevent a colleague, Craig Jurisevic, from performing surgical services on private patients unless he underwent further training.

The judge said on six occasions between February 6, 2001 and March 9, 2001, Knight and Ross advised hospitals where Dr Jurisevic had wanted to work or surgeons who had been asked to support his applications, that he was insufficiently trained or had not completed his training.

This was despite Dr Jurisevic having been legally qualified and being admitted as a fellow to the Royal Australian College of Surgeons after completing the advanced surgical training program.

Judge Mansfield said Ross and Knight had also come to an arrangement with another surgeon, James Edwards, not to work at a hospital where he operated provided he did not work at a hospital where they performed surgery.

Judge Mansfield said the admitted conduct of Knight and Ross involving Dr Jurisevic stemmed from a decision by him not to take up an 18-month training position in Boston and to begin performing surgery on private patients in Adelaide instead.

"This upset Messrs Knight and Ross,'' the judge said.

He said it was not possible to determine the extent of loss suffered by Dr Jurisevic.

But he said the actions of Knight and Ross had raised barriers to other surgeons entering the Adelaide market.

"As a result ... newly qualified cardiothoracic surgeons in Adelaide were likely to consider they were, in effect, required to undertake further training, overseas or interstate, in order to practise as a cardiothoracic surgeon,'' Judge Mansfield said.

He said the result of this case should serve to ameliorate the impact of any such ongoing effect.

The judge said he also accepted that both Knight and Ross genuinely believed Dr Jurisevic needed more training and praised the two doctors for cooperating with authorities.

Their admissions had saved both the court's and the ACCC's time, he said.

In a statement Knight and Ross said their actions were motivated by concerns over patient safety.

"At all times, patient safety was very much in our minds,'' the surgeons said.

They also expressed concerns over the operation of competition rules on the medical profession.

"Whilst we recognise the importance of competition rules in the market place, we are concerned that the legislators have had insufficient regard to matters of patient safety in seeking to apply those rules to the medical profession,'' they said.

What bothers me about this case is how close a line we tread to breaking the law.

For example, doctors in Australia are not allowed to advertise their services. But when does marketing become advertising? How big an entry in the Yellow Pages is allowable? Is it OK to have a small sign outside your clinic, or a big sign outside your clinic, or a big billboard down the road?

When we give advice to each other about which areas are underserviced and would be better places to practise, is that inviting someone into a non-compete arrangement?

Judge Mansfield said the admitted conduct of Knight and Ross involving Dr Jurisevic stemmed from a decision by him not to take up an 18-month training position in Boston and to begin performing surgery on private patients in Adelaide instead.


But he said the actions of Knight and Ross had raised barriers to other surgeons entering the Adelaide market.

"As a result ... newly qualified cardiothoracic surgeons in Adelaide were likely to consider they were, in effect, required to undertake further training, overseas or interstate, in order to practise as a cardiothoracic surgeon,'' Judge Mansfield said.

Hang on, I thought that there was already an expectation that some form of post-fellowship training or experience was desirable. Perhaps this means I can cancel the PhD and the two unpaid overseas posts I had planned?

Saturday, August 04, 2007

Quiet Spell

NHS Blog Doc, Tea at Ten and The Psychiatrist Blog have all taken a break from blogging.

They won't admit it, but I suspect they are all taking time off to read the new Harry Potter Book. I finished it last week and have spent the last few days catching up on the sleep I missed out on.

You'll have to click through to the comments to get my impressions, just to avoid giving away spoilers.

Thursday, August 02, 2007

Haneef, Andrews, and Howard

The news keeps flying in thick and fast.

Haneef Update

I don't want to sound like a Haneef apologist. He may well be guilty, but I have no way of knowing. Neither does the Australian Court system. But Kevin Andrews thinks that he does.

Here is the advice from the Solicitor-General released by Kevin Andrews.

Notice the questions he was asked to answer?
I am asked to advise:

(1) whether there was material before the Minister on which he could validly make the decision to cancel the visa; and

(2) whether, on the material now known to the Minister, he could have made the same decision had the visa remained in force.

This legal advice is really a foregone conclusion. The test, as Mr Andrews eloquently points out, is whether he is reasonably satisfied that:
(b) the person has had an association with someone else, or with a group or organisation, whom the Minister reasonably suspects has been or is involved in criminal conduct
It matters little in a legal sense what the secret information consisted of. It does not matter whether he is a terrorist or not. There is enough publicly available information to draw the flimsiest of associations between him and an alleged terrorist - after all, if a lawyer who has represented a criminal in the past, irrespective of the fact that he is now a well-respected Federal Court Judge, would fail the character test, what hope does Dr Haneef has in distancing himself from his relatives?

Releasing a snippet of an online chat out of context, when this material has been translated from another language in the first place, hardly supports Kevin Andrews actions. Anybody who has been in an online chat knows full well that jokes, satire, cynicism, and innuendo are poorly depicted in transcripts - even with the smiley faces intact ;-P. Then try passing that through a translator! This information is not in a position to prove anything.

The only way for Kevin Andrews to justify his position is to show that there is an absence of material to dispel any direct or indirect criminality by Dr Haneef. This is a hard ask - how do you prove that something is not there without revealing everything? This is why Kevin Andrews has dug himself into a hole. He could have avoided all this by not cancelling Dr Haneef's visa in the first place and let the AFP and DPP do their job.

There was no reason to cancel the visa at that time. Dr Haneef could have been kept under surveillance or his activities curtailed while on bail. The AFP and DPP did not ask for his visa to be cancelled. They also did not ask for him to be deported. Indeed, if they really intended on placing any further charges, they would not want him to go to a country with no extradition arrangements.

The only reason to cancel the visa was to make the Government look decisive, pro-active, and create photo opportunities of an alleged terrorist in handcuffs wearing prison overalls in the back of a secure van caught by vigilant Australian authorities working under effective laws drafted by this Federal Government. Like photos of children overboard.

Coverage from The Australian, 1-2 August 2007:

Federalised Hospitals

John Howard and Tony Abbott have come up with a cunning plan to win votes and make friends. It involves lots of money. About $45 million worth. They have teamed up to directly fund the Mersey Hospital in Devonport, Tasmania with Federal money, to be run by a community trust.

There are a lot of unanswered questions about the nuts and bolts of this. Will the community trust operate under guidance from or in co-operation with the Tasmanian Department of Health? Will they do what they like? Will doctors and nurses be employed under Tasmanian agreements or Federal Workplace Relations laws? Will the Federal Government ask for DRG coding for case-mix funding? Or will this be an annual lump sum that the Hospital gets irrespective of activity? Is this $45 million dollars extra into the Tasmanian health system, or will the Federal Government deduct $45 million from the Tasmanian health care agreement?

Besides throwing money at a marginal electorate, does the Federal Government really know what it is doing? The last time they funded a hospital was before they got out of the Repatriation Hospital system.

John Howard says this is a trial. I think it is a doomed experiment to see how many votes they can buy. The money is certainly welcome - don't get me wrong! But if the Federal Government wants to take over isolated regional hospitals, I suspect that all the State Governments will be more than happy to hand them over. They are always the hardest to run, and hardest to staff. Despite the fact that they generally supply excellent, world-class services on a shoe-string, they are also never able to satisfy the local population.

It is only a matter of time before the locals realise that the Federal Government will be no better than the State Government at handing out money - and that Canberra is much further away than Hobart. But enjoy it while it lasts, guys. Get every cent of your promised $45 million before they have a chance to take it back.