Which direction for universal Canadian health care?

Which direction for universal Canadian health care?

POLICY AND PEOPLE False accounts for false teeth in Germany people were arrested. According to Peter Scherler, head of the taskforce against fraud of...

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False accounts for false teeth in Germany people were arrested. According to Peter Scherler, head of the taskforce against fraud of the Lower Saxony branch of AOK, the Globudent case is

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he biggest financial scandal in the health system of post-war Germany has hit dentists and dental import companies. Thousands of dentists are allegedly implicated in a fraud entailing the purchase of dentures from foreign laboratories at a fifth of the normal price. The scandal exploded on Nov 19 when the German media announced that prosecutor Herbert Mühlhausen was investigating the import firm Globudent and around 500 dentists who were buying Chinese dentures imported via Hong Kong. According to investigations by the statutory health insurance fund AOK, Globudent would approach dentists to offer dentures at bargain prices, persuade them to invoice for the German prices, and then give the dentists between a fifth and a third of the price difference in cash. Globudent would initially pay German prices to the Hong Kong intermediary dealer before making monthly visits to return the profit in cash to Germany. In the days after the announcement, Globudent headquarters and many dentists’ surgeries and homes were searched for documents, and four


A scandal to get your teeth into

the tip of the iceberg: “In the meantime we have found around 20 more import companies that we suspect have been doing the same . . . We estimate that the original 50 million sum would amount to hundreds of millions and several thousand dentists could be involved.” He adds that the fraud has probably been going on for years. Jürgen Weitkamp, president of the German Dentists Association, attempted to play down the damage to their members: “It means of course a loss of trust among patients . . . We feel responsible, if not directly

affected. Those affected are the Associations of Statutory Insurance Dentists (KZVs), who let past the bills . . . But this story is not completely unexpected, we have been actually warning our colleagues for years against the use of foreign dentures.” Scherler is less complacent: “What I find worse is that the patients’ pockets are also affected. In some insurance policies, patients are liable for co-payments of up to 40%.” Asked about how to avoid cases like this in the future, he says: “There are ways to control laboratories and oblige them to say exactly where all their materials come from. I would like to see authorities other than statutory insurance funds controlling the laboratories and that is possible without changing any law.” Rolf Jürgen Löffler, head of the National Association of Statutory Insurance Dentists, says: “If the charges against dentists were to be proved, they can expect to be sanctioned by their KZVs. The sanctions at our disposal range from financial penalties to the suspension of their licences.” Claudia Orellana

Which direction for universal Canadian health care?


lthough the “road map” for the future of universally accessible, publicly funded health care for Canadians was laid out last week, the drivers of the 40-year-old, Can$100 billion (US$ 64 billion) system are saying that they will continue to head off in other directions. After 18 months of submissions and interim reports, Roy Romanow—the $15-million, oneman Royal Commission on the Future of Health Care in Canada— unveiled his long-awaited final recommendations on necessary reforms to stave-off the perceived crisis in the health-care system. The 356-page blueprint argues the federal government must invest as much as $28 billion every 5 years to ward-off the advent of private, forprofit medical services, which constitute a “perversion of Canadians’ values to accept a system, where money, rather than need, determines who gets access to care”. Romanow told a Nov 28 press conference: “In the coming months, the choices we make, or

the consequences of those we fail to make, will decide medicare’s future.” If adopted by federal and provincial governments, the 47 recommendations would also result in the creation of a host of new “targeted” cost-shared programmes, including ones to: support home care for the terminally ill, mentally ill, and people just released from hospitals; shorten waiting lists for diagnostic services; reform delivery of primary care through expansion of full-service one-stop family health clinics (at which doctors are funded through capitation); cover so-called catastrophic drug costs for families paying more than $1500 per year for pharmaceuticals; and attract more health professionals to rural and remote areas, by linking rural residents to doctors through telehealth technologies. Of other recommendations is the establishment of a new independent agency to manage the approval and pricing of new prescription drugs. However, federal finance minister John Manley is already musing

THE LANCET • Vol 360 • December 7, 2002 • www.thelancet.com

about the capacity of the treasury to fund the reforms, whereas several provincial governments— led by those in Alberta, Ontario, and Quebec—have shown extreme displeasure at the notion that the bulk of new federal monies should be earmarked for targeted programmes. Of many other provincial complaints are accusations that the recommended watchdog—National Health Council—to oversee reform and improve financial accountability within the system constitutes a form of bureaucratic overkill and an invasion of their constitutional jurisdiction over medicare. Prime Minister Jean Chretien has already announced a first ministers’ meeting in January to hammer out the details of reform. But it is anybody’s guess whether the extensive provincial carping is mere posturing for the negotiation table or genuine opposition to measures that curb the development of private health systems. Wayne Kondro


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