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INTERNATIONAL
INTERNATIONAL
HEALTH CARE
The International pages have languished because of more
pressing issues in the USA and Australia.
This page gives an overview of the
material in the section.
INTERNATIONAL
INTERNATIONAL
INTERNATIONAL
INTERNATIONAL
INTERNATIONAL
INTERNATIONAL
INTERNATIONAL
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International Expansion
of Corporate Medicine
Health care
corporations have increasingly seen themselves as
Global players. Starting in the USA but spreading
globally the market focus in health has been on
growth and globalisation. Companies from Generale
de Sante Internationale in Europe and Mayne Health
in Australia, from pharmacology to managed care
have joined the rush. Fraud pressures and market
saturation in the USA have driven companies to buy
into other markets to insulate them against their
local problems. I have not written at length about
this but some pages address some of the
issues.
- The
Dominance of the US market and US marketplace
Ideas
This page was written some time in early
2000 after the chairman of Australia's National
Competition Council (NCC), Graeme Samuel's
speech to the world bank calling for urgent
global health care reform using economic levers.
This page examines the pervasiveness of US
corporate market thinking in health care and its
globalisation.
- A
RASH OF NEWS ARTICLES ABOUT OPPORTUNITIES IN
FOREIGN COUNTRIES
This
page started as the covering sheet for a
collection of revealing articles extolling the
opportunities in foreign countries published in
the US magazine Modern Healthcare in November
1997. These were circulated to politicians and
others. This was the era of managed care
expansion. The clash of culture between the
market and the ethic of the community and the
professions is obvious as is the morality of the
bevy of experts who marketed themselves as
international consultants and advised
corporations in the sort of behaviour most of us
would be ashamed of.
- Managed
Care Part III : Globalisation of Managed
Care
This page written in late 2003 covers some
of the same material and includes extracts from
those above and many other press reports. The
material gives a good insight into the wild
enthusiasm of US businessmen and the strong
reservation of informed
professionals.
- Is
Market Medicine really Sweeping the
World?
The claim that market medicine is the way of
the future and is sweeping the world is
challenged. This page written in 2000 briefly
examines the failure and abandonment of many
market solutions in the United Kingdom,
Australia, New Zealand and Canada.
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HEALTH AND
WORLD TRADE
HEALTH
AND WORLD TRADE
AGREEMENTS
In 2000 the powerful US Coalition of Service
Industries (CSI), a body which represented service
industries including large health care giants
enlisted the support of the US government to press
for a whole range of social services including
health care to become part of the WTO international
trade process by default. I wrote this page at this
time. The WTO process ran into so much trouble that
most of these proposals have not seen the light of
day. Health and international trade agreements
remain very much of a threat in Australia and in
Canada and have excited opposition. The idea is far
from dead and it is likely to come hidden in words.
I have not had the time to follow this
up.
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THE
WORLD BANK
The world bank is
understandably heavily influenced by economists. In
giving loans for health care it has exerted strong
pressures and conditions which forced developing
nations into market models of care. In February
2002 Graeme Samuel, chairman of Australia's
National Competition Council gave a speech to the
world bank urging all countries to rapidly adopt
his proposed model of care, one which like managed
care operated through a complex series of economic
levers and regulatory processes. To anyone who had
practiced medicine and who had worked in developing
countries this was the height of folly and terribly
dangerous. I was apoplectic!
My criticisms
link to other pages of the web site including many
in the corporate practices section which were
written in response. Some could do with more
editing. This provides another pathway into the
site.
CRITICISM
OF GRAEME SAMUEL'S SPEECH to the World
Bank
: INTRODUCTION
I wrote a long
and detailed criticism and sent it to Samuel. He
ignored it. Some of the web pages on this site were
developed from this criticism - which was not one
of my best. I shortened and narrowed down some of
the material and it is still here. I tried to
contrast the world of Samuel's cold mechanistic
economic model with the world of real people
subjected to a full blown health care marketplace
in the USA. This is the introductory page to the
criticism.
The Response of ordinary
citizens
The following
pages giving the raw responses of ordinary US
citizens to corporate chains. The intense anger and
disgust of ordinary people who encounter the
corporate health system when they are vulnerable
and in need is put here to contrast it with
Samuel's mechanistic academic model.
- ILA
SWAN'S
WARNING
-- This is an unpublished letter to a Canadian
newspaper written by a Californian citizen who
has exposed extensive exploitation of the aged
in nursing homes in her state. This is an appeal
from the heart by someone who has experienced
the US system and responded to her experience.
She urges Canadians to protect their system and
not allow a US style for profit system.
- HOW
THE COMMUNITY VIEWS CORPORATE NURSING
HOMES
-- when the Director of HCFA for California
spoke to a collection of family members and
their lawyers she showed herself so out of touch
and so resistant to addressing the problems that
there was intense anger. Hundreds wrote or sent
emails calling for her resignation - these show
the depth of feeling generated by the corporate
chains and the politicians who support them.
Read the emails.
Criticism
of a speech by Graeme Samuel to the World Bank, on
29 February 2000
Introducing
competition in the public delivery of health
care services
--
This is the text of Samuel's speech. Samual
proposes a complex market model for the the
delivery of public health care internationally. It
is built around a series of independent roles each
of which depends on contracts, market forces and
increased competition. The system relies for its
success on regulation and oversight.
- Criticism
Number 1
: INTRODUCTION
This first page looks at Samuel's model from
outside the marketplace paradigm. It points to
fundamental errors in logic, and an ideological
bias as exhibited by ignoring critical evidence
and common sense. It looks at fundamental
inaccuracies in Samuel's model. It looks at the
development of market thinking within one social
structure, the market, and its applicability to
the rest of society. It points to the
difficulties of arguing within marketplace
thinking. The market has appropriated the
discourse and the language we use, then modified
meanings for its own public relations purposes.
It uses these to claim success in meeting the
community's values and objectives but this is
often no more than an illusion.
- Criticism
Number 2
: THE RELEVANCE OF OTHER MARKETPLACE DOMAINS :
THE PROCESS OF CRITICISM
This page further explores the flawed
argument that Australia is different and that
because the market has worked in other
industries it will work in health
care.
- Criticism
Number 3
: Satisfaction and Affordability
The page confronts the arguments that
declining satisfaction, declining affordability,
declining care, and a need for stability call
for a market based system. It makes the point
that each of these factors is greater in a
corporate market context than in not for profit
or public care. During 2003 and 2004, long after
this criticism was written, a series of studies
have indicated that for profit care not only
results in a higher mortality and morbidity but
is much more costly than not for profit
care.
- Criticism
Number 4
: Spiraling Technology Costs - An aging
population
The page contests the extent of the problem
and points out that the market is responsible
for much of the problem. If funds are short ithe
market would ration for profit. Alternatives
would be much more appropriate. Since the
criticisms were written in 2000 hard data and
analyses have shown that the threat of prices
spiraling out of control is
unsupported.
- Criticism
Number 5
: Better Educated Consumers and Choice
The argument that the market improves choice
is countered by pointing out that managed care
and corporations such as Columbia/HCA and
Tenet/NME have in practice limited choice.
Corporate marketing and education have clouded
issues making choice more difficult. Samuel's
view of the way medicine is currently organised
is misleading.
- Criticism
Number 6
: A reform blueprint
Samuel's claim to a system which displays
"internal consistency" and is tightly
"articulated" goes to the heart of the problem -
the use of a single unconfronted market paradigm
ignoring alternate understandings and
interpretations is stupid and has been
disastrous in the USA. A broadly based
reflective system is never totally consistent.
While one paradigm may dominate different
paradigms give different understandings and
challenge consistency. This allows balanced
decsion making in areas where there are
problems. Experience and available evidence both
show that the market paradigm is innapropriate
for health and aged care.
- Criticism
Number 7
: Performance dimensions for a reformed health
care system
Claims to better access to care, greater
equity, more efficiency, better quality, and
accountability are challenged by pointing out
that the market elsewhere has performed poorly
in each. This is what you would expect. It is
clear that the meaning and use of words is
different to that outside the marketplace.
Interestingly in 2004 Professor Leeder makes the
same observation in regard to the USA. (See New
Doctor Autumn 2004 http://www.drs.org.au/new_doctor)
- Criticism
Number 8
: The reform model : description and
analysis
The page responds to the model by showing
its similarity to other market systems by
linking to other pages on this web
site.
- Criticism
Number 9
: Roles, Competition and Cooperation
Samuel's model hinges around a series of
defined and competing economic roles. In
criticism the page points to the complexity and
difficulties as well as the discordant ethos
introduced. I contrast it with the benefits of a
cooperative system. Samuel acknowledges his
dependence on oversight and regulation. To
underline the difficulties in this page looks at
problems in data collection, failures in
oversight and accreditation, and the reality of
market and political power structures as these
impact on health care in the marketplace. The
structure, the logic and the profit ethos are
criticised. A very similar system in the USA has
failed.
- Criticism
Number 10
: Clarifying different roles in health care
provision
As Samuel acknowledges most funding comes
from government or insurers (read HMO). It is
capped. Samuel's roles relate to spending this
money using funders, purchasers, providers and
regulators who are all competing for their share
of the cake. This is exactly what they have in
the USA and it is called managed care. Samuel's
purchasers, called "Health Improvement Agencies
or HIAs", is where he sees the maximum benefit.
They are for all practical purposes the hated
and dysfunctional Health Maintenance
Organisations (HMOs). The page looks at how
these have operated in the US
marketplace.
- Criticism
Number 11
: The role of competition in health care :
Health Care as a Market Based Industry
Samuel's reemphasis on market principles is
met by looking at trust in health care. His
claims to efficiency, empowerment and addressing
conflict of interest are addressed by examining
these in the real world. His criticism of
professionalism is met by examining the adverse
impact of the market on professional value
systems and trust. Samuel's claim that other
countries are embracing market reform is
disputed and his advocacy of more private sector
involvement is challenged. Market reform of
health care has been imposed on the community
and has been opposed by large sections of the
community.
- Criticism
Number 12
: COMPETITION - Provider competition
Samuel's claims about providers are disputed
on the basis that this is simply managed care.
The pressures towards competition for market
share and profits both of which are best met by
compromising care are described, as is the
disempowerment of consumers and the
community.
- Criticism
Number 13
: PURCHASER COMPETITION
Samuel's purchaser is a thinly disguised HMO
in a managed care system. From Samuel's speech
it is difficult to understand just how this
would relate to the patient and citizen for whom
the service is purchased. The page examines
corporate integration, market control,
enforcement of contracts and the difficulties
for not for profit providers.
- Criticism
Number 14
: Key benefits of a competitive model
The page examines the claims that competition
will reduce costs, improve quality and ensure
equity by showing that it has done the exact
opposite. In fact these are the criticisms of
marketplace medicine. Studies since this
criticism was written show that the market model
increases costs, increases mortality and
morbidity, and has a very different
understanding of equity. A Royal Commission in
Canada has rejected all of these claims. Samuel
seems to live in a looking glass
world.
- Criticism
Number 15
: Getting from here to there - Staged
Implementation
It is suggested that Samuel is telling us
how to get from where we are to somewhere we
don't want to be and most certainly should not
be. Criticisms are made.
- Criticism
Number 16
: Answering some common criticisms --
Introduction
Samuel side steps the major criticisms which are
of his starting points, the market, profit
motives and competition. He seems to consider
them unchallengeable self evident "goods". The
page looks at government, community, contracts
and common sense in order to meet Samuel's
defense of other criticisms.
- Criticism
Number 17
: Answering some common criticisms -
Accountability related concerns -
multinationals
Governments faith in the free market's
ability to self correct impacts on their
willingness to hold corporations accountable.
The track record in the USA and Australia shows
that they don't. The willingness to embrace
multinationals is addressed by examining their
disturbing conduct.
- Criticism
Number 18
: Answering some common criticisms - Efficiency
related concerns
Samuel doesn't actually claim that his model
will reduce costs and his claims to quality are
already disproved. Samuel's response to many of
the criticisms is simply to ignore evidence and
claim the opposite. The page deals with cost,
efficiency, integration, quality, the flow of
information, assertions about the USA, control
of decisions, choice, information sharing,
breech of contracts and private provider
failure.
- Criticism
Number 19
: Answering some common criticisms - Equity and
access related concerns
The page looks at the diversion of funds
from care to profit and market activities. It
comments on universal access, altruism, as well
as commitment to research and
training.
- Criticism
Number 20
: Conclusion
Samuel's conclusion is addressed by summarising
the criticisms of the points he
reiterates.
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HEALTH
CARE IN CANADA
There has not been time to write at length
about Canada. The page gives an outline and some
links but much has happened since it was written in
2000. This includes the Romanow Royal
Commission.
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CANADA
PAGES
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NEW
Zealand
empty
page
This is a page which has not been written. New
Zealand was one of the countries which
enthusiastically adopted health care reform. There
was a backlash against this which brought the
labour party to power in 2000
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EUROPE
Generale
de Sante Internationale
(GSI)
The French company GSI was the largest hospital
corporation in Europe. It bid to buy Tenet/NME's
Australian holdings in 1995. It was involved in
insavoury practices and was accused of providing
"factory" care in the UK. Australians unearthed all
this and publicised it. GSI backed away. This page
was put on the www in 1998. In 1997 Mayne Nickless
and Columbia/HCA bid for GSI but French Authorities
were kept informed of both company's conduct. It
was bought by European groups and I think broken
up.
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Health
Services in
Singapore
Singapore was where I first learned about
Tenet/NME and heard of its business practices - but
I was unable to get evidence to confirm this.
When I voiced my concerns a defamation action
was taken against me - an action that was never
prosecuted. A Singapore doctor later described some
of these matters in court. Tenet/NME no longer
operates in Singapore.
This is a short
account of the health system in
Singapore.
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National
Medical Enterprises (NME but renamed Tenet
Healthcare) in Singapore.
This company
operated in Singapore from 1985 to 1996 when it
departed under a cloud. It was here that I first
set out to challenge NME and force its conduct into
the open. In 1993 a Singapore doctor described some
of the company's conduct in court.
- Singapore
- allegations of trading in
patients
This is part of my submission to Tenet's ethics
committee in 1996 - a submission challenging the
probity of those who worked in Singapore and
their suitability to hold high office in health
care. It describes and quotes the allegations
made by the doctor.
- The
Singapore Court
Transcripts
These court documents finally put an end to
Tenet's ambitions in Australia. This link is to
a published paper I wrote in 1996 and describes
how they were used to accomplish
this.
- Vista
Healthcare and its National Medical Enterprises
Heritage
Tenet/NME vacated Singapore in 1996 but by 1997
a new company had been formed in Singapore and
it was headed by Michael Ford who had been
president of NME's International Division and
had been based in Singapore. The directors were
largely past US and Singapore Tenet/NME staff.
It was an "international health care adviser" to
other companies. It was very experienced in the
way Australia's regulations worked and how to
get around them.
- TAKING
ON NATIONAL MEDICAL ENTERPRISES
(NME)
This page tells the story of my involvement
in confronting and blowing the whistle on
Tenet/NME in Singapore and
Australia.
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