April 2006

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Failure of Medical Malpractice Law

April 15, 2006 in HC Statistics, Medical Studies, Public Policy | 2 comments

The problems with the Medical Malpractice system in the US have been well-documented. President Bush has presented proposals to cap punitive damages in malpractice litigation. Other others have decried the fact that despite a large number of negligence cases each year, very few patients bring suit to court. Below are two studies which should give the reader a more informed perception of how malpractice law functions in the United States today.

This first study is by Brennan, Sox and Burstin (1996). These authors find that iatrogenic injuries in New York account for 3.7% of all hospitalizations and negligent iatrogenic injuries account for 1.0% of hospitalizations. Below is their data for the number of people filing suits:

Cases Malpractice Suits %
No adverse Event 29,952 24 0.1%
Adverse Event 1,163 13 1.1%
Negligence 314 9 2.9%
Totals 31,429 46

A second report by Studdert, Mello and Brennan (2004) confirm some of the Brennan, et al.’s findings. Citing a Medical Insurance Feasibility Study, 4.6% of all hospitalizations in California involved iatrogenic injury and 0.8% of all hospitalizations involved negligent iatrogenic injuries. These numbers are similar to the 3.7% and 1.0% which Brennan, et. al. estimate.

There are three issues here which I would like to touch on.

The first is that despite conventional wisdom that physician are nearly infallible, 3-5% of all hospitalizations are due to doctor error. One of the greatest risks facing the American medical system is…well…the American medical system. The easiest and most effective way to decrease the error rate is to integrate Information Technology (IT) into the medical field. The Healthcare IT Guy has some good suggestions.

Malpractice suits are not common. Less than 3% of people who receive negligent physician care actually sue. One must note that it is difficult for a patient to determine if negligence has occurred. ‘Do I feel sick because the treatment is not working or is this the doctor’s fault?’

Although only one in a thousand people who receive no medically induced injury sue, these ‘no injury’ cases make up over half of the malpractice caseload.

Brennan, Sox, Burstin (1996) “Relation Between Negligent Adverse Events and the Outcomes of Medical-Malpractice Litigation” New England Journal of Medicine Vol 335 (26).

NHS Doctors prefer private insurance

April 14, 2006 in International Health Care Systems | 1 comment

In England, all residents receive free medical care from the National Health Service (NHS), which is run by the Department of Health. Many critics of nationalized health care would say that publicly provided medical care is often of inferior quality to that of medical care provided in the private market. A recent Times (UK) article (“Doctors opt to have private operations“) substantiates that claim. The article cites a recent survey of 500 physicians, in which 41% elected to pay for private insurance even though 90% of those surveyed worked for the NHS. Why would a physician pay for medical care when they received free medical care from the NHS:

“Dr Sarah Burnett, a consultant radiologist in London who worked in the NHS for 15 years, said she took out private medical insurance while she was employed in the state service because she was unimpressed with the level of care she witnessed first hand.

‘NHS treatment is not a pleasant experience in any way — from the standard of the food, to ward cleanliness and the chance of catching MRSA,’ she said.”

Iqbal Quadir’s vision of Development

April 13, 2006 in Health Care in Developing Nations | Permalink

Iqbal Quadir is not your typical investment banker. Inspired by the non-profit Grameen Bank‘s success in his native country of Bangladesh, Quadir has created a variety of initiatives which allow the private sector to be the driving force for development in the Third World. CNN and The Economist (“Power to the People“) both report of Quadir’s initiatives to bring cell phone service, power, and other clean water to the developing world using entrepreneurs. For instance, Emergence Energy is one of his ventures which aims to establish small, neighborhood power plants in Bangladesh that can provide electricity to a handful of homes. Below is an excerpt from the Economist article on Quadir’s clean water program:


At the same time, Mr Quadir is pursuing two other bottom-up initiatives. The first, CleanWater, is dedicated to supplying safe drinking water to Bangladeshi villages, where arsenic contamination is a grave problem. Rather than relying on aid agencies or governments to install equipment, Mr Quadir hopes to license a chemical preparation that can remove arsenic from water and make it safe to drink. The chemical would then be distributed and sold, like salt, via a network of local entrepreneurs; Mr Quadir estimates that buyers would have to spend around $3 per person per year on the chemical to ensure a safe water supply, which is well within reach of most villagers. Again, this initiative would create jobs, provide a wider societal benefit, and give people the means to solve a serious problem themselves.

“Child Protection and Child Outcomes” – Joseph Doyle

April 11, 2006 in Academic Articles, Public Policy | 1 comment

According to U.S. Department of Health and Human Services, over 1% of all children below the age of 12 were victims of maltreatment in 2004. Child abuse cases appear frequently on the news and it is truly a sad situation. Most people’s first reaction is that we need more stringent supervision of parents and the government should take kids away from abusive homes more frequently.

In the seminar I attended today, Joseph Doyle (“Child Protection and Child Outcomes: Measuring the Effects of Foster Care“) argues that in the case of Illinois, the government may be putting too many kids into foster care. Doyle has gotten access to the Illinois Department of Child and Family Services’ Child Abuse and Neglect Tracking System (CANTS) and has matched children in foster care with other data sources which track 1) delinquency, 2) teen pregnancy and 3) employment status and wages.

In his estimation, Doyle uses variation in an investigator’s propensity to send a child to foster care as an instrument for the likelihood a child is sent to foster care. More explicitly, the instrument is the investigator’s prior removal rate (the percentage of previous cases which he/she has sent to foster care. Since the cases are assigned in a cue to investigators (with the exception of children who are Spanish speakers) he has a quasi-experimental setup. He uses fixed effects as well for each (zip code*county*Spanish Speaking) cell.

Doyle finds that marginal child placed in foster care is 10%-20% more likely to be arrested, 10-20% more likely to become pregnant as a teenager, and 10% less likely to be working when they become an adult than the marginal child who was not placed in foster care. This does not mean that society should completely abandon the foster care system. Since severely abused children will be placed in foster care no matter which investigator is assigned and abuse free homes will never be assigned to foster care, Doyle’s coefficients only measure the impact of foster care on the marginal children. The above estimates represent a Local Average Treatment Effect (LATE). Abuse in foster care homes does occur and having the idealistic view that foster care is always a safe haven for these children may be naïve. The policy implication is that children should be assigned to foster care less frequently than is the current status quo in Illinois.

Pro-Life Nation

April 10, 2006 in Current Events | Permalink

“On ‘Meet the Press’ in October 2004, when Tim Russert, the host, asked Jim DeMint, a South Carolina Republican representative then in the middle of what turned out to be a successful campaign for the U.S. Senate, to explain his position in favor of a total ban on all abortion procedures. DeMint was reluctant to answer Russert’s repeated question: Would you prosecute a woman who had an abortion? DeMint said he thought Congress should outlaw all abortions first and worry about the fallout later. ‘We’ve got to make laws first that protect life,’ he said. ‘How those laws are shaped are going to be a long debate.’

Russert refused to leave the congressman alone. ‘Who would you prosecute?’ he persisted.

Finally DeMint blurted, ‘You know, I can’t come up with all the laws as we’re sitting right here, but the question is, Are we going to protect human life with our laws?’

In El Salvador, the law is clear: the woman is a felon and must be prosecuted.”

This Sunday’s New York Times magazine has an interesting article (“Pro-Life Nation“) on abortion in El Salvador. Many countries such as Chile, Malta, and Colombia outlaw abortion, but El Salvador is one of the few who prosecutes the mother seeking the abortion as a felon. Penalties are stiff in El Salvador:

“…the abortion provider, whether a medical doctor or a back-alley practitioner, faces 6 to 12 years in prison. The woman herself can get 2 to 8 years. Anyone who helps her can get 2 to 5 years. Additionally, judges have ruled that if the fetus was viable, a charge of aggravated homicide can be brought, and the penalty for the woman can be 30 to 50 years in prison.”

Another problem which arises is that physicians in El Salvador have an obligation to both protect doctor-patient confidentiality and to accumulate evidence for the prosecution of an abortion case.

Whichever side you fall on in the debate on abortion, the article is certainly an interesting one.

How the Amish Drive Down Medical Costs

April 9, 2006 in Supply of Medical Services | Permalink

It is common knowledge that healthcare institutions such as the government (through Medicare and Medicaid) and HMOs are able to negotiate with hospitals for low prices due to their market power. Most individuals who pay out of pocket for medical services can expect face prices which are 30%-50% higher than those of Medicare patients.

A Wall Street Journal article on February 21, 2006 (Page B1) describes how Amish and Mennonite elders negotiated with the Heart of Lancaster Regional Medical Center in order to secure less expensive medical care for their fellow worshipers. After many members had visited clinics in Tijuana, Mexico for treatment, the Anabaptists decided a better option was to negotiate their own group rates with the local Medical Center for services such as orthopedic surgery, biopsies and childbirth. The elders threatened to abandon usage of the facility in favor of flying to Tijuana for the procedures if their demands for discounts were not met. As part of the final agreement, the members of the Anabaptist community were required to pay for 50% of the procedure up front in order to insure they would receive the discount. The WSJ continued:

Heart of Lancaster wasn’t worried about risking steep losses if elaborate surgeries went awry: Anabaptist patients generally don’t want such procedures. “If you’re paying out of pocket, you’ll hunt for bargains,” says Lee Christenson, chief executive of Heart of Lancaster, who bargained with the Anabaptist elders. “Basically, the Amish won’t pay for health care they don’t need.”

Where there is no doctor

April 8, 2006 in Health Care in Developing Nations | Permalink

Interested in the medical field but not a doctor?  Looking to help those in developing countries who are live without access to a physician?  A great resource to use is Where there is no doctor, a classic text published by Hesperian Books.  I recently bought a copy in Spanish (Donde no hay doctor) while I was in El Salvador and the book is spectacular.  Diseases, symptoms and treatments are described thoroughly but simply; pictures abound to help clarify the narration.  Dr. David Morley called it “The best medical book written in the last 10 years…”  One customer from Malawi stated that:

“Everything and anything you need to know about healthcare. We live in the heart of Africa where there are no doctors, and mysterious illnesses and bacteria keep popping up. Since we have this book there is much less cause for worry. Don’t leave home without it!”

Unlike most the publishers of most reference guides, the Hesperian Books encourages individuals to copy relevant sections of the book and distribute them to needy communities as long as the material is provided at no cost.  Since the book has been translated into over 70 languages, literate populations in developing countries now have a resource to educate themselves on their own healthcare needs.

Healthcare in El Salvador V: War and Peace

April 7, 2006 in Uncategorized | Permalink

One of the largest healthcare risks in many countries is war. Between 1980 and 1992, El Salvador experienced a violent civil war between the right-wing military government and the FMLN (Frente Farabundo Mari para la Liberacion Nacional) communist guerrilla forces. The conflict began to boil over in 1977 when armed forces arrived at Universidad Centroamericana and assassinated six Jesuit priests who were defending the rights of the poor. After the assassination, the archbishop Oscar Romero cut off ties with the government and vehemently spoke out against the government’s repressive policies. After tolerating his outspoken behavior for three years, the government decided to end Romero’s advocacy; Romero was assassinated in 1980 and a civil war ensued.

The village where I stayed (Ciudad Romero) was a FMLN stronghold. As the war began, the government attacked and the villagers fled to Honduras. The military of Honduras, however, was friendly with the right-wing Salvadoran government and the community lived for six months surrounded by military personnel from both countries. As the health of the villagers began to deteriorate and food became scarce, the UN and Panama decided to offer the villagers refuge in Panama. The community lived in the Panamanian jungle for eleven years until the peace accords were signed in 1992 and they were allowed to return and re-establish their town in the Usulatan province.

Today there is an uneasy peace, but discord between the two groups is strong. The divide between the right wing ARENA party in power and the left wing FMLN party has led to central government to spend money mostly in the areas which support ARENA. For instance, Ciudad Romero had no health clinic, but the nearby village of Isla de Mendez–in which a majority of the population still supports the right wing cause–does have a health clinic paid for by the central government.

El Salvador is a turbulent country, where earthquakes, volcanoes, hurricanes and war are a constant threat. One can only hope that this fragile peace will remain and that the quality of life for the Salvadorans will improve in the future.

I would like to thank all the Salvadorans who showed me such gracious hospitality while I was visiting their country. In particular: a Leonides, por compartir sus conocimientos; a Christino por su amable sonrisa y por cantarnos sus rancheros; a Lorena por su belleza escondida; a Carlos y Maribel por prepararnos la comida bien rica; a Jenni y Katia por su inocencia, y a Carlitos, el gran pintor, por el dibujo que me diste. Gracias.

Healthcare in El Salvador IV: Healthcare system

April 6, 2006 in Health Care in Developing Nations | Permalink

In El Salvador, one finds two parallel health care system.  The first uses state-of-the-art technology, qualified doctors, and physician spend ample time with patients.  The second employs third world technology, treats severe illnesses superficially, and doctors are overworked.  Which of these systems is run by the government?  Which of these systems serves the poor?

As you probably guessed, the first healthcare system described above involves doctors in private practice with a fee for service (FFS) provider payment system.  Using the private physician and medical facilities is expensive; only the wealthy can afford these procedures.  The poor are relegated to using the free government hospitals and clinics.  These facilities do an adequate job of providing immunizations, prenatal care and educational material, but do not have the funds or the staffing to perform surgical procedures which in the U.S. would be considered routine.  Many Salvadorans I spoke with complained that doctors in the public hospitals treat all serious diseases the same: they give patients an aspirin and tell them to grin and bear it since surgery or other complicated procedures are not available.

Also, one notes a distinct difference between urban and rural clinics serving the poor.  Both provide only the most basic of services, however, rural physicians do have more time to spend with patients due to the lower population density.  One physician in the village of Isla de Mendez told me he only saw about 25-30 patients per day and about half of these were educational prenatal visits.  The residents of Isla de Mendez, however, do not have access to medical care on weekends because the physician returns to his home three hours away in the city of San Miguel.  In an urban clinic, patient volume is much higher and wait times of many hours is common, but physicians are available on weekends for emergencies.

The central government also employs promotores, workers who visit villages (such as Ciudad Romero) who do not have a clinic and educate the population about public health risks.  Unfortunately, it seems that the promotores are not very effective since the villagers do not hold these workers in as high esteem as physicians.  Further, since the promotores travel from village to village, they rarely establish a strong bond with the community to make sure that the educational information they impart is implemented.

Healthcare in El Salvador III: Waste Disposal

April 5, 2006 in Health Care in Developing Nations | 2 comments

Plastic bottles strewn on the street, trash fires burning in front of homes, and primitive latrines…El Salvador is pretty much the antithesis of a stereotypically pristine European city. While in the US, we take trash collection for granted–we put our waste into the trash/toilet and it is taken away–in El Salvador waste disposal does not operate as smoothly.

Many residents in rural villages do not have access to trash collection and thus resort to burning their garbage under a pile of leaves. The smoke from burning mounds pollutes the air and the smell is potent. In addition to problems of cigarette smoke and excess dust from dirt streets, the burning of trash has contributed to a high rate of respiratory disease in El Salvador. The burning of garbage made from plastic pollutes the air even more than the typical household refuse. The solution to the problem that one NGO came up with was to have a trash compost area for each house where biodegradable waste could be buried under a layer of dirt and leaves in order to reduce air pollution. The waste would slowly decompose and air pollution—and thus respiratory disease—could be reduced. Paved streets would also reduce pollution from the dust spewed into the air from passing cars and farm animals but this solution is more expensive (although it does have the economic benefit of decreased transportation costs).

Another problem rural El Salvador faces is the disposal of human waste. Since the water level is only 10-15 feet below the ground in the low-lying Bajo Lempa region, allowing residents to defecate into the ground can pollute drinking water, leading to parasitic diseases. One NGO has used raised latrines to solve this problem. The latrines have a concrete box located above ground and below the toilet. Feces fall from the toilet into the chemical lined concrete box in which the chemicals dry the human feces into a solid mass. The feces/chemical mixture can them be removed from the area below the latrine and be used for fertilizer. The cost of one of these raised latrine units is around $600 per unit.

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