- Email: [email protected]
Crisis cards
related to patient care". HCA officials disputed the GAO’s conclusions, pointing out the Medicare reporting rules were vague and did not expressly forbid these types of expenditure. HCA officials added that employee meetings where such entertainment costs are incurred boost company morale and increase staff effectiveness. It would be better, said Mr Jack Bovender, HCA executive vicepresident and chief operating officer, if Congress spent its time trying to reduce unnecessary paperwork, citing a recent study that estimated that the administrative costs of health care in 1991 cost$125.6 billion-17% of the nation’s total health-care expendi-
Profits, pay, and perks Health care in the US has become 1985, for example, the median CEO dominated by businessmen who are pay was 54 times that of a staff nurseoften more concerned about payby 1992 it was 85 times. cheques, profits, and "perks" than : Auditors from the US General patient care, said witnesses at a Con- Accounting Office (GAO) told the gressional hearing on the financial committee that the cost of care now practices of the US health-care indus- includes some questionable expenses. At the committee’s request, the GAO try held by the Subcommittee on Oversight and Investigations of the investigators examined the$2.1 milCommittee on Energy and Commerce. lion administrative and office exOne witness, Graef S Crystal, an penses filed by the Hospital Corporreof America (HCA) in its on executive ation expert compensation, of the Medicare costs report and found that on the chief ported earnings executive officers (CEOs) of 26 major $1.1million were either "unallowable, US health-care companies. The questionable, or unsupported". lowest paid CEO in the group earned Among the costs that GAO judged to in while 000 be unallowable were$17 755 for alco$700 1992, Crystal said, holic beverages served at employee one executive, profiting from stock options, earned more than$127 mil- functions and$51013 for enterlion. Crystal found that the median tainment, including$14 225 for a "theme party",$3500 for a singing CEO in his sample earned between $2.5 million and$2.9 million in 1992, group, and$1710 for a sailing regatta. depending on whether statistical out- "While Medicare costs principles do liers were excluded, and that pay of not specifically discuss these type of entertainment costs", the GAO said, executives was rising far faster than that of other health-care workers. In : "such costs, in our opinion, are not
tures.
Commenting on his committee’s investigations, chairman John D Dingell, a Michigan Democrat, concluded, "Too many in the medical marketplace have been only too willing to take financial advantage of the absence of a comprehensive national health policy". Michael McCarthy
to be significant in man. Powles said that although 2 cases have been reCrisis cards ported, the women were on twice the dose (40 mg daily) to be used in the UK trial. About 6 million women worldwide have The House of Commons Select Committee received tamoxifen, and he felt that the lack on Health has rejected proposals by the of reports of liver carcinoma was reassurRoyal College of Psychiatrists for introducing. The trialists admitted that there is ing community supervision orders for probably a small undefined risk of endomebut trial cancer, pointed out that this mentally ill patients being treated out of disease is treatable and preventable. hospital.l The committee has instead tamoxifen reduces expressed interest in crisis cards, a form of Furthermore, mortality advance directive or treatment contract Lancet 339: 1-15 and and 1992; (see 71-85) which the patient makes when well. has protective effects of the drug in heart The committee believed that, as prodisease and osteoporosis. : posed by the college, the consent that Approval for the trial has not been would be obtained from the patient for a without The Medical controversy. Research Council withdrew its support on community supervision order would not be "real" and that the proposals focused too the grounds of liver toxicity in rats and the much on medication as treatment. The ethical issue of giving an anticancer drug to committee was also concerned about the healthy women (see Lancet 1992; 339: 735). extent to which a person’s freedom might The trial has, however, been approved by be limited by the proposals and by insuffithe Committee on Safety of Medicines and cient support from other groups for the by a large ad-hoc national ethics committee. Local ethics committee approval college’s proposals. The committee does will be sought by the individual recruitacknowledge, though, that there are many ment centres. The trial is double-blind, important legal and philosophical issues placebo-controlled, and randomised and about advance directives that have to be : similar trials are underway in Australia and addressed. the USA. Switzerland, France, Nether-
unlikely
Prophylactic tamoxifen The Department of Health has approved the tamoxifen trial in healthy women at high risk of breast cancer. 15 000 women with a 1 in 6 lifetime risk of breast cancer will be recruited from the autumn. Women have to meet one of the entry criteria. For those aged 45-65 these criteria are: a firstdegree relative aged under 50 with breast cancer; a first-degree relative with bilateral disease; two affected first or second degree relatives; nulliparity and an affected firstdegree relative of any age; biopsyconfirmed lobular carcinoma in situ
(LCIS) or atypical aplasia; or biopsy findings of proliferative disease and breast cancer in a first-degree relative of any age. In women aged 35-44 the criteria are: a first-degree relative with bilateral disease diagnosed at less than age 40; two firstdegree relatives diagnosed at less than age 50; or biopsy-proven LCIS. No teratogenicity studies have been done for tamox-
pregnant or at risk of will not be recruited. pregnancy At a press conference on July 9, the main trialists (Prof M Baum, Dr T Powles, Dr J Cusick) said that for the 85 women who have become pregnant while on tamoxifen no fetal abnormalities have been reported. The trialists believe that the risk of liver tumours (see Lancet April 24, p 1086) is .
ifen,
168
so
women
lands, Austria, Spain, Germany, Finland, . Vivien Choo
and Denmark may participate, and the trialists hope that about 50 000 women will eventually be recruited world wide.
Stephanie Clark
v
1
House of Commons Health Committee. Community supervision orders. London: HM Stationery Office. 1993: Pp 36. £10. ISBN 0-10-021-243-3.
Profits, pay, and perks Health care in the US has become 1985, for example, the median CEO dominated by businessmen who are pay was 54 times that of a staff nurseoften more concerned about payby 1992 it was 85 times. cheques, profits, and "perks" than : Auditors from the US General patient care, said witnesses at a Con- Accounting Office (GAO) told the gressional hearing on the financial committee that the cost of care now practices of the US health-care indus- includes some questionable expenses. At the committee’s request, the GAO try held by the Subcommittee on Oversight and Investigations of the investigators examined the$2.1 milCommittee on Energy and Commerce. lion administrative and office exOne witness, Graef S Crystal, an penses filed by the Hospital Corporreof America (HCA) in its on executive ation expert compensation, of the Medicare costs report and found that on the chief ported earnings executive officers (CEOs) of 26 major $1.1million were either "unallowable, US health-care companies. The questionable, or unsupported". lowest paid CEO in the group earned Among the costs that GAO judged to in while 000 be unallowable were$17 755 for alco$700 1992, Crystal said, holic beverages served at employee one executive, profiting from stock options, earned more than$127 mil- functions and$51013 for enterlion. Crystal found that the median tainment, including$14 225 for a "theme party",$3500 for a singing CEO in his sample earned between $2.5 million and$2.9 million in 1992, group, and$1710 for a sailing regatta. depending on whether statistical out- "While Medicare costs principles do liers were excluded, and that pay of not specifically discuss these type of entertainment costs", the GAO said, executives was rising far faster than that of other health-care workers. In : "such costs, in our opinion, are not
tures.
Commenting on his committee’s investigations, chairman John D Dingell, a Michigan Democrat, concluded, "Too many in the medical marketplace have been only too willing to take financial advantage of the absence of a comprehensive national health policy". Michael McCarthy
to be significant in man. Powles said that although 2 cases have been reCrisis cards ported, the women were on twice the dose (40 mg daily) to be used in the UK trial. About 6 million women worldwide have The House of Commons Select Committee received tamoxifen, and he felt that the lack on Health has rejected proposals by the of reports of liver carcinoma was reassurRoyal College of Psychiatrists for introducing. The trialists admitted that there is ing community supervision orders for probably a small undefined risk of endomebut trial cancer, pointed out that this mentally ill patients being treated out of disease is treatable and preventable. hospital.l The committee has instead tamoxifen reduces expressed interest in crisis cards, a form of Furthermore, mortality advance directive or treatment contract Lancet 339: 1-15 and and 1992; (see 71-85) which the patient makes when well. has protective effects of the drug in heart The committee believed that, as prodisease and osteoporosis. : posed by the college, the consent that Approval for the trial has not been would be obtained from the patient for a without The Medical controversy. Research Council withdrew its support on community supervision order would not be "real" and that the proposals focused too the grounds of liver toxicity in rats and the much on medication as treatment. The ethical issue of giving an anticancer drug to committee was also concerned about the healthy women (see Lancet 1992; 339: 735). extent to which a person’s freedom might The trial has, however, been approved by be limited by the proposals and by insuffithe Committee on Safety of Medicines and cient support from other groups for the by a large ad-hoc national ethics committee. Local ethics committee approval college’s proposals. The committee does will be sought by the individual recruitacknowledge, though, that there are many ment centres. The trial is double-blind, important legal and philosophical issues placebo-controlled, and randomised and about advance directives that have to be : similar trials are underway in Australia and addressed. the USA. Switzerland, France, Nether-
unlikely
Prophylactic tamoxifen The Department of Health has approved the tamoxifen trial in healthy women at high risk of breast cancer. 15 000 women with a 1 in 6 lifetime risk of breast cancer will be recruited from the autumn. Women have to meet one of the entry criteria. For those aged 45-65 these criteria are: a firstdegree relative aged under 50 with breast cancer; a first-degree relative with bilateral disease; two affected first or second degree relatives; nulliparity and an affected firstdegree relative of any age; biopsyconfirmed lobular carcinoma in situ
(LCIS) or atypical aplasia; or biopsy findings of proliferative disease and breast cancer in a first-degree relative of any age. In women aged 35-44 the criteria are: a first-degree relative with bilateral disease diagnosed at less than age 40; two firstdegree relatives diagnosed at less than age 50; or biopsy-proven LCIS. No teratogenicity studies have been done for tamox-
pregnant or at risk of will not be recruited. pregnancy At a press conference on July 9, the main trialists (Prof M Baum, Dr T Powles, Dr J Cusick) said that for the 85 women who have become pregnant while on tamoxifen no fetal abnormalities have been reported. The trialists believe that the risk of liver tumours (see Lancet April 24, p 1086) is .
ifen,
168
so
women
lands, Austria, Spain, Germany, Finland, . Vivien Choo
and Denmark may participate, and the trialists hope that about 50 000 women will eventually be recruited world wide.
Stephanie Clark
v
1
House of Commons Health Committee. Community supervision orders. London: HM Stationery Office. 1993: Pp 36. £10. ISBN 0-10-021-243-3.