You may not remember it much, but most of those of us who were forced to endure studying the epic poem, Beowulf were introduced to the concept of the weregild. In the 2007 CGI adaptation of Beowulf, apparently the side plot discussing the weregild was cut to make more time for Angelina Jolie's CGI-enhanced, naked, high heel wearing turn as Grendel's mom. Probably a smart decision by the producers in terms of the box office :)





The weregild was literally a "man price" you paid as compensation for killing someone, and there was a price on everyone from the dregs of society all the way for one prescribed for regicide (killing the king). It's a fascinating social compact that was used to try and temper blood feuds with their cycles of repeat violence and revenge. The Roman Catholic church eventually enacted their own version of "tort reform" on the weregild, condemning it and forcing elimination of the practice near the end of the 1st millennium AD.

From Wikipedia's entry,

The standard weregeld for a freeman appears to have been 200 solidi (shillings) in the Migration period, an amount reflected as the basic amount due for the death of a ceorl both in Anglo-Saxon and continental law codes. This fee could however be multiplied according to the social rank of the victim and the circumstances of the crime. For example, the 8th century Lex Alamannorum sets the weregeld for a duke or archbishop at three times the basic value (600 shillings), while the killing of a low ranking cleric was fined with 300, raised to 400 if the cleric was attacked while he was reading mass.

The size of the weregild was largely conditional upon the social rank of the victim. A regular enslaved man (ceorl) was worth 200 shillings in 9th century Mercian law (twyhyndeman), a nobleman was worth 1200 (twelfhyndeman). The law code even mentions the weregeld for a king, at 30000, composed of 15000 for the man, paid to the royal family, and 15000 for the kingship, paid to the people. An archbishop is likewise valued at 15000. The weregild for a Welshman was 110 if he owned at least one hide of land, and 80 if he was landless.

NOTE: For those interested, there's a fascinating catalog of such fines from the Salian Franks (a German dynasty)here, which covers the price of various offences, ranging from stealing your cow to gang raping your wife


Ok Rob, why are you talking about weregilds on Plastic Surgery 101 anyway?

There were several articles about healthcare I read this week that all kind of intersect at the fringe of the debate on healthcare and got me thinking about the equivalent of the modern weregild.

"A Place Where Cancer is the Norm", which describes Houston's MD Anderson cancer center.

"Cancer Society, in Shift, Has Concerns on Screenings" which describes a pullback from the American Cancer Society on just how effective mammograms and prostate cancer screening (via PSA tests) on affecting death from cancer.











"Can 'bundled' payments help slash health costs?" in USA Today

Sunday Night's 60 Minute's piece (click here to view)on more then $60 billion annual loss to Medicare fraud and how the Feds have been inept at policing it.

An article in Oregon's Statesman Journal, "Government Audits Are Hurting Small Business Owners" describing the federal government's Recovery Audit Contractor(RAC) program for Medicare fraud.

The articles on cancer screening and exotic treatments at MD Anderson hospital to me point towards a more strict cost-benefit analysis coming on cancer treatments. The tertiary chemotherapy drugs and adjuvant radiation treatments described are budget busters with very marginal utility in terms of outcomes. The care described in the article, where chemotherapy treatments were literally thrown against the wall to see what sticks, is not a sustainable model. We're going to asking more and more, "How much are 'x' additional months of this cancer patient's life worth?" in order to balance our health care budget. It is unavoidable that we don't end up with some federal utilization committee who's job it will be to tell us what we cannot do in terms of palliative care for cancer or other chronic diseases. Other countries already do this without much controversy, but President Obama won't touch this with a 10 foot pole.

The USA Today article on bundling payments seems unworkable in situations where physicians are not employees of the hospital or system involved. I would not trust a hospital corporation to distribute that money equitably to independent providers once they have it in their coffer. Would I have access to audit a hospital's books to make sure their accounting is accurate? What's the resolution process for disagreements on the balance sheet? Much like insurers, the temptation for them to slow-pedal payments to collect the interest would be impossible for them to resist. Except in certain "closed system" situations (where all MD's are employees)like the Mayo Clinic, the Cleavland Clinic, or the Kaiser network in California, this bundling would be a unacceptable working situation to most physicians.

The 60 Minutes piece on Medicare shows why no one who is familiar with healthcare believes that the federal government can run a single-payer system. They are unable to investigate or follow up on even the most blatant examples of fraud costing hundreds of billions over dollars a decade.


So what do they do instead? They reauthorize the "RAC" program to aim at providers and hospitals for fraud that may be pennies on the dollar compared to the fraud described in the 60 minutes piece. The feds have outsourced the Recovery Audit Contractor (RAC)program to incentivized companies to autopsy medicare billing going back over 3 years by hospitals and providers where any inaccurate billing (using our byzantine CPT system) is assumed fraudulent and due back with interest and penalties. Analysts expect that inaccurate coding underbills at least as often as it overbills, but do you know what these auditors have produced. What do you get however when you incentivize these companies to claim 8-12% of any recovery (but don't reward refunds)? You get 96%+ of these RAC audits finding overbilling only.

Rob

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There's an op-ed piece in today's Wall Street Journal by one Betsy McCaughey which has my blood pressure up. The article titled, "Hospital Infections: Preventable and Unacceptable" implies that any hospital acquired infection was preventable and should be remedied with class action lawsuits.

For someone who's bright like Ms. McCaughey, she shows little insight and understanding apparently into what drives and perpetuates many different types of infections. Nobody disagrees that common sense steps like hand washing and protocols for invasive intravenous (IV) access maintenance are important in limiting infections, it is both a dangerous and disingenuous idea to suggest that a goal of ZERO is attainable. It is impossible to achieve a failure rate of 0% for system or process, particularly one with infinite numbers of variables (as with a human population of patients). Unlike a Toyota, no two models of the human assembly line are exactly alike (even identical twins gradual accumulate differences due to environmental exposure).

Patients with more comorbities are going to have higher infection rates PERIOD. An overweight, diabetic, smoker (a frequent demographic for vascular disease patients in my neck of the woods) who has open heart surgery has more problems then others and an increased infection rate is more attributable to the patient's behavior rather then the hospital. Obese patients and smokers have higher rates of problems after elective plastic surgery (like breast reconstruction or reduction for instance)as well for that matter. You can be sure at some point, hospitals (and doctors) will be looking at patient demographic data to exclude higher risk patients from treatment at their facility whatsoever.

In referring to a list of "never events" recently laid out by Medicare for which they will not cover the cost of complications she blithely writes

"No wonder Medicare calls these infections "never events" Why should jurors reach a different conclusion in a lawsuit."

This coming from a bureaucrat and politician is hard to take. While we should always strive to be perfect, it's important to realize that there are processes which we can all agree on to attain low and reproducible rates of infection.

For a related writing here on Plastic Surgery 101 see the post "Medicare announces they won't pay for complications - How the F*** is this going to work?" that I wrote last year.


Cheers!
Rob

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Awhile back I'd written about (see here) the Democratic Governor of Wisconsin, Jim Doyle, raiding a trust fund set up (and paid for) by Doctors to stabilize medical-malpractice insurance costs in that state. Why? In order to avoid unpopular budget and spending cuts to balance his budget. That case is still being litigated.

Taking inspiration from his Democratic cohort, Pennsylvania's governor, Ed Rendell (D-Pa) has targeted their state's Medical Care Availability and Reduction of Error Fund to the tune of $400 million USD to cover deficits in their state's budget. A summary of this can be viewed in the AMA News, here.

This program known as "Mcare" has been successful in partially turning around Pennsylvania's climate for being a horrible state for doctor's to work in re. to med-mal conditions. MCare provides doctors with catastrophic coverage for medical malpractice. Doctors in Pennsylvania purchase $500,000 worth of insurance from a primary carrier and then another $500,000 worth of coverage from MCare. It was also a key component of limited tort reform in that state. On its Web site, the Pennsylvania medical society has posted the question, "Would you continue to practice in Pennsylvania if you no longer received relief (abatement) from MCare?" Nearly two-thirds of respondents said they would not.

FREE ADVICE: Ed, in a state struggling with access problems, I'm not sure that driving away health care providers is the way to go.

Governor Rendell has been progressive in trying to expand health care coverage in Pennsylvania (which is a good thing), but he has been unwilling to make hard spending cuts and unsuccessful in persuading his state legislature to fund his ideas thru taxes on tobacco and business not offering health insurance. He now is trying to play political hardball and quite willing to disrespect the health care providers in his state to do it. An article in today's Pittsburgh Post Gazette quotes the Governor as saying

"If I have to choose between taking care of doctors and taking care of someone who has cancer and doesn't have health insurance, it's an easy choice"

This is an unbelievably cynical "straw man" tactic (ie. setting up false alternatives to make a rhetorical point).

There's no plausible or logical link between Mcare and his political failures, but merely he sees a pot of "easy money" sitting around funding a successful program whose constituents (ie. doctors) don't have the resources to hurt him politically if he steamrolls them.


To Governor Rendell, I ask you:

PLEASE KEEP YOUR HAND OUT OF THE COOKIE JAR!


Rob

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Want to see a logical extension of federalized health care and the kind of rationing choices that will be made?

This story here is fascinating.

Richie Trezise, 35, a rugby-playing Welshman, lost weight to gain entry to New Zealand after initially being rejected for being overweight and a potential burden on the health care system.

His wife, Rowan, 33, a photographer, has been battling for months to shed the pounds so they can be reunited and live Down Under but has so far been unable to overcome New Zealand’s weight regulations.

Robyn Toomath, a spokesman for Fight the Obesity Epidemic and an endocrinologist, said the BMI limit was valid in the vast majority of people. She said she was opposed to obese people being stigmatised. "However, the immigration department’s focus is different," she said. "It cannot afford to import people into the country who are going to be a significant drain on our health resources.

"You can see the logic in assessing if there is a significant health cost associated with this individual and that would be a reason for them not coming in."blockquote>

The implications of this are interesting. Is it discrimination or is it making people take personal responsibility when you treat someone different based on what are (often) controllable health risk factors?

We've already clearly made this value judgement with smokers and we're moving that direction with obesity. It's clear that obesity (as opposed to be merely overweight), much like smoking, is a devastating drain on our resources from a systems level. This was federally recognized in this example from New Zealand. Expect to see some incentives for BMI parameters to more frequently appear in your health insurance policy or be sponsored by your employer, as they've clearly fingered this subgroup as an area for cost containment in their employee costs.

Rob

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Exhibit A: Wisconsin Democrat governor, Jim Doyle, is trying to do an audacious end run around the intent of a state-administered trust fund meant to control medical malpractice costs.

In 1975, the Wisconsin legislature set up a fund for physicians, hospitals, and other health professionals to contribute to called the Injured Patients and Families Compensation Fund. It was essentially a self-insurance "buffer" against rising med-mal costs and has been widely credited with stabilizing Wisconsin malpractice insurance premiums.

The assets of this fund are substantial, in excess of $735 million in 2007 (covering an estimated $685 million in potential liabilities). Such a large "pot of gold" has proven irresistible for Democrats in Wisconsin, and Gov. Doyle has proposed pillaging nearly $200 million to cover budget deficits the state is running up on their Medicaid program. While it's noble to fund a state's uninsured & under-insured, raping a successful program whose mandate and charter is very specific to the med-mal relief program is going to lead to a bitter court fight in Wisconsin between the Wisconsin medical association and Gov. Doyle.

In 2003 a state law declared the trust "for the sole benefit of health care providers participating in the fund and proper claimants. Monies on the fund may not be used for any other purposes of the state". Keep in mind that individual doctors have essentially been paying into this pool at somewhere between $8-10,000 annually for nearly 30 years. So in a nutshell, this Democratic proposal would turn an insurance program into a massive retroactive tax hike on providers while potentially causing the whole program to go insolvent (as assets would drop ~ $150 million below liabilities).

Gov. Doyle, you're the proud recipient of the inaugural Plastic Surgery 101 cheesehead award!

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Michael Moore was on MSNBC's Hardball with Chris Mathews Monday and was his usual obnoxious (I ironically mean that in a good way with Mr. Moore) self, promoting his documentary, "Sicko" and the idea that Socialized medical care is a panacea.


At least he had the honesty to admit that a number of Americans will receive "worse" care (at least in terms of convenient access) then they currently enjoy. The philosophical arguments about healthcare and how much it's a right versus a commodity is an important one to have, and, "Sicko" has galvanized the debate. A perfect storm exists for progress on this issue in that big business, labor unions, and the zeitgeist of the country all support a universal system in the abstract sense. The devil's in the details and $$$$ involved.

While federal systems enjoy popular support in other countries, it's not all milk & honey. It's ironic that as many as 15-20% of citizens are estimated to seek care outside the government run systems in western Europe that are lionized by activists. The system Moore champions (like only Canada, Cuba, & North Korea's - an unlikely triad) would not tolerate any private sector competition for care delivery or services as it would undercut the federal system and prove more popular with many patients with financial wherewithal. Write this down, THIS WILL NEVER BE ACCEPTED IN THE UNITED STATES, so I don't think that system is worth discussing in depth.

There's a real alternate take on the Canadian system celebrated by Mr. Moore in "Sicko" by the underground film hit "Dead Meat" which features Canadians frustrations with the reality of long waits for imaging studies, orthopedic surgery, cancer treatments, and even cardiac surgery. It's ironic in Canada that you can actually buy health insurance for your pet, but not yourself or child.

Anecdotes are a poor way to determine public policy, but it goes to show that you just don't get something for nothing.

Click on the screen below to watch "Dead Meat"

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USA Today's cover story today, "Is a little medical coverage that much better than none?" revisits the issue of "limited benefit" health insurance which I talked about in April's Plastic Surgery 101 post, "Tennessee's experiment in (slightly less than) universal healthcare coverage".

The philosophic issue is whether crappy health coverage is better then no coverage. On balance I'd say no for most people, as it will only encourage employer's to give fewer benefits and leave more people under-insured. This is a bumpy transition period towards Universal Healthcare I believe, and these type of plans were well-intentioned band-aids on a failing infrastructure. However, an approx. 15% annual growth rate in enrollees in limited benefit plans has the insurance companies scrambling to make a buck, which is now catching regulators attention. As a Doctor, I can promise you that anything insurance companies rapidily try to co-opt is going to bit you in the ass at some point.

Also illustrated in the USA-Today story is just how far patients have become removed from the cost of delivering health care as one of the people in the article seemed surprised (and indignant) that he'd actually received a bill from the Doctor!

Rob

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