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Medicare privatisations have growing pains
POLICY AND PEOPLE
Canada’s doctors post reward for abortionists’ killers anadian doctors have announced that they are prepared to dig deep into their pockets to post a substantial cash reward for information leading to the arrest of the killer of abortion provider Barnett Slepian, from Buffalo, New York, USA or the person who undertook sniper attacks on Canadian abortionists. Police suspect that there is a link between Slepian’s murder and three earlier rifle attacks in Canada in which physicians Jack Fainman, Garson Romalis, and Hugh Short were shot through the windows of their homes on or near the Nov 11 Remembrance Day holiday (see Lancet 1997; 350: 1528). In the wake of Slepian’s murder, the Canadian Medical Association
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(CMA) last week (Oct 26) proposed to match reward contributions made by its provincial affiliates to a maximum Can$250 000, which would ultimately create a $500 000 reward—the second largest ever offered in Canada. Concern is rising over whether younger doctors, who may fear for their lives, are prepared to offer terminations. The CMA says it was prompted to offer the reward by the severe gravity of the situation. However, the offer did little to inspire the federal government to follow suit as Solicitor-General Andy Scott and Justice Minister Anne McLellan last week rejected bids by police and doctors that Canada provide special funding for the international task force which is
trying to hunt down the sniper. McLellan told reporters her department will offer help but not cash. “Clearly, the lead department on this issue is the Solicitor-General. But if there are things we can do through my prosecutors or other departmental officials, we want to be as co-operative as possible.” But physician Henry Morgentaler called on Ottawa to address the shootings as a conspiratorial act of terrorism, telling reporters that “to my mind, this is a criminal terroristic activity, which is designed to scare off abortion providers and gives the message that, ‘if you continue to help women, your life is in danger’”. Wayne Kondro
Medicare privatisations have growing pains n 1997, the Republican-led US Congress passed legislation to encourage more private-health companies to participate in Medicare. In 1998, lawmakers and Medicare officials are paying a high price as some private providers are demanding higher payments and others are simply dropping out of the programme. In the massive spending bill to end the session, Congress had to add US$1·7 billion to payments to providers of home health-care services. While the home-health programme has been a particular source of fraud and abuse, the new payment system Congress imposed in 1997 was causing even well-run providers to shun patients they feared might become expensive. At the same time, the new
I
system had caused hundreds of agencies to close altogether. The clamour for change was such that one rally on Capitol Hill featured a 2·5-mile-long signed petition demanding changes to the payments system. Potentially more serious is the exodus from Medicare of nearly 100 managed care plans. The combination of lower payments and overly bureaucratic regulations has prompted 42 plans not to renew their contracts to provide coverage to Medicare patients and 53 others to cut back on the areas they cover. 414 000 Medicare beneficiaries will have to find alternate coverage by Jan 1, 1999—as many as 50 000 live in counties where there is no other managed care plan they can join.
While those affected by departing plans represent only a small fraction of the estimated 17 million Medicare beneficiaries who have opted to join HMO’s, the trend is in the opposite direction to the one lawmakers predicted when they passed the 1997 Balanced Budget Act. This act created a new portion of the programme, called Medicare plus Choice, which was supposed to give beneficiaries more choices of more types of managed care plans. But with reduced payments, private plans have been slow to sign up. Many people will be waiting to see if Congress will revisit managed care payment policy when it reconvenes in January. Julie Rovner
EU plans to address long working hours of junior doctors
T
he European Commissioner for Social Affairs, Padraig Flynn, said he intends to include junior doctors in the EU’s legislation on the 48-hour working week. Speaking to the Irish Medical Times, the Commissioner said he is determined that junior doctors be included in the directive, despite objections from health authorities. He said he expects to get full support from his fellow Commissioners when he introduces new proposals for working hours in mid-November. “It is my intention that it [the 48hour directive] will be applied to all
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workers including junior doctors but the detailed arrangements and the transitional period to achieve the aims of the directive has to be agreed by the council of ministers”, he said. He added that details concerning training, on call, and education time for junior doctors have to be taken into account in drawing up the specifics for the legislation. The overtime directive already has provisions for senior hospital doctors but until now junior doctors have been excluded. Health and financial authorities throughout Europe have expressed concern over limiting doctors’ hours—most
of whom work 78 hours a week or more—because of the cost of hiring more hospital doctors and scheduling problems. Patients’ organisations and safety authorities have mounted campaigns to bring in overtime limits on the grounds that patients are at risk. Hospital doctors throughout Europe have stressed that fatigue caused by long hours and the lack of time off leads to mistakes and additional stress. Overtime is also a reason cited by some young doctors for dropping out of medicine. Karen Birchard
THE LANCET • Vol 352 • November 7, 1998
Canada’s doctors post reward for abortionists’ killers anadian doctors have announced that they are prepared to dig deep into their pockets to post a substantial cash reward for information leading to the arrest of the killer of abortion provider Barnett Slepian, from Buffalo, New York, USA or the person who undertook sniper attacks on Canadian abortionists. Police suspect that there is a link between Slepian’s murder and three earlier rifle attacks in Canada in which physicians Jack Fainman, Garson Romalis, and Hugh Short were shot through the windows of their homes on or near the Nov 11 Remembrance Day holiday (see Lancet 1997; 350: 1528). In the wake of Slepian’s murder, the Canadian Medical Association
C
(CMA) last week (Oct 26) proposed to match reward contributions made by its provincial affiliates to a maximum Can$250 000, which would ultimately create a $500 000 reward—the second largest ever offered in Canada. Concern is rising over whether younger doctors, who may fear for their lives, are prepared to offer terminations. The CMA says it was prompted to offer the reward by the severe gravity of the situation. However, the offer did little to inspire the federal government to follow suit as Solicitor-General Andy Scott and Justice Minister Anne McLellan last week rejected bids by police and doctors that Canada provide special funding for the international task force which is
trying to hunt down the sniper. McLellan told reporters her department will offer help but not cash. “Clearly, the lead department on this issue is the Solicitor-General. But if there are things we can do through my prosecutors or other departmental officials, we want to be as co-operative as possible.” But physician Henry Morgentaler called on Ottawa to address the shootings as a conspiratorial act of terrorism, telling reporters that “to my mind, this is a criminal terroristic activity, which is designed to scare off abortion providers and gives the message that, ‘if you continue to help women, your life is in danger’”. Wayne Kondro
Medicare privatisations have growing pains n 1997, the Republican-led US Congress passed legislation to encourage more private-health companies to participate in Medicare. In 1998, lawmakers and Medicare officials are paying a high price as some private providers are demanding higher payments and others are simply dropping out of the programme. In the massive spending bill to end the session, Congress had to add US$1·7 billion to payments to providers of home health-care services. While the home-health programme has been a particular source of fraud and abuse, the new payment system Congress imposed in 1997 was causing even well-run providers to shun patients they feared might become expensive. At the same time, the new
I
system had caused hundreds of agencies to close altogether. The clamour for change was such that one rally on Capitol Hill featured a 2·5-mile-long signed petition demanding changes to the payments system. Potentially more serious is the exodus from Medicare of nearly 100 managed care plans. The combination of lower payments and overly bureaucratic regulations has prompted 42 plans not to renew their contracts to provide coverage to Medicare patients and 53 others to cut back on the areas they cover. 414 000 Medicare beneficiaries will have to find alternate coverage by Jan 1, 1999—as many as 50 000 live in counties where there is no other managed care plan they can join.
While those affected by departing plans represent only a small fraction of the estimated 17 million Medicare beneficiaries who have opted to join HMO’s, the trend is in the opposite direction to the one lawmakers predicted when they passed the 1997 Balanced Budget Act. This act created a new portion of the programme, called Medicare plus Choice, which was supposed to give beneficiaries more choices of more types of managed care plans. But with reduced payments, private plans have been slow to sign up. Many people will be waiting to see if Congress will revisit managed care payment policy when it reconvenes in January. Julie Rovner
EU plans to address long working hours of junior doctors
T
he European Commissioner for Social Affairs, Padraig Flynn, said he intends to include junior doctors in the EU’s legislation on the 48-hour working week. Speaking to the Irish Medical Times, the Commissioner said he is determined that junior doctors be included in the directive, despite objections from health authorities. He said he expects to get full support from his fellow Commissioners when he introduces new proposals for working hours in mid-November. “It is my intention that it [the 48hour directive] will be applied to all
1532
workers including junior doctors but the detailed arrangements and the transitional period to achieve the aims of the directive has to be agreed by the council of ministers”, he said. He added that details concerning training, on call, and education time for junior doctors have to be taken into account in drawing up the specifics for the legislation. The overtime directive already has provisions for senior hospital doctors but until now junior doctors have been excluded. Health and financial authorities throughout Europe have expressed concern over limiting doctors’ hours—most
of whom work 78 hours a week or more—because of the cost of hiring more hospital doctors and scheduling problems. Patients’ organisations and safety authorities have mounted campaigns to bring in overtime limits on the grounds that patients are at risk. Hospital doctors throughout Europe have stressed that fatigue caused by long hours and the lack of time off leads to mistakes and additional stress. Overtime is also a reason cited by some young doctors for dropping out of medicine. Karen Birchard
THE LANCET • Vol 352 • November 7, 1998