India and Pakistan celebrate 71 years of Independence today. The British National Health Service owes them a debt of gratitude.
Great Britain’s national dish is famously chicken curry, but South Asia’s impact on this Sceptred Isle extends far beyond food. It is a testament to how ingrained into the British psyche the stereotypical Indian doctor has become that in 2005 a poll of Brits found the doctor they’d most like to consult is a 30-something South Asian female. In 2010 the BBC even ran a popular TV series simply entitled ‘The Indian Doctor’ following a story played out across the UK in the 1960s and 1970s, that of a humble family physician from the Indian subcontinent finding his feet in a country that asked him to come over and save the still-young ‘National Health Service’.
In 1948, India and Pakistan were not yet one year old when the NHS was created. Over subsequent years, recruitment drives encouraged young doctors to make a new home in the UK. Tens of thousands answered the call and it is no exaggeration to say the NHS would not have survived without them.
Now a swollen behemoth comprising some 1.8 million staff, the NHS is the world’s fifth largest employer. It is estimated to have a bewildering shortfall of 100,000 staff. Unsurprisingly almost 40% of Tier 2 (skilled) visa applications to the UK are to take up positions in the NHS. Yet over the last 13 years, South Asian doctors have been made to feel less welcome. In the first four months of 2018 alone, 400 visa applications from Indian doctors were rejected.
This is the second part of Dr. Jha’s conversation with Dr. Jonathan Cusack, who was the former supervisor and mentor of Dr. Bawa-Garba, a pediatrician convicted of manslaughter of fetal sepsis in Jack Adcock. Read the first part of this series here.
Dr. Jonathan Cusack versus the General Medical Council
I spoke with Dr. Jonathan Cusack, consultant neonatologist at Leicester Royal Infirmary (LRI), and former supervisor and mentor of Dr. Bawa-Garba, the trainee pediatrician convicted of manslaughter for delayed diagnosis of fatal sepsis in Jack Adcock, a six-year-old boy with Down’s syndrome. We had drinks at The George, pub opposite the Royal Courts of Justice.
In the first part of the interview we discussed the events on Friday February 18th, 2011, the day of Jack presented to LRI. In the second part of the interview we talk about the events after fatal Friday – how the crown prosecution service got involved, the trial, the manslaughter charge, the tribunal and the General Medical Council.
The Role of Dr. O’Riordan
Saurabh Jha (SJ): After Jack’s death what was Dr. Bawa-Garba’s immediate reaction?
Jonathan Cusack (JC): I think it’s one of those moments one neither forgets nor recalls. I imagine the most overwhelming feeling was one of incredulity. How and why did Jack decompensate? It’d have struck her as physiologically implausible. Though she was experiencing that grief familiar to all pediatricians when a child dies, she was trying to understand why. She didn’t know that he died from Group A Streptococcal septicemia, then.
The train sped along from Seattle to Portland on a spectacular summer morning, following the track along the waterways of the lower Puget Sound. One of my daughters lived in Portland at the time, so I found myself on the train frequently. Like most of us, I don’t seek out conversations with strangers while traveling, which is unfortunate, as I have had transformative moments when I decide to engage and treat fellow passengers as fellow humans.
That day the train was crowded, and I didn’t have the option of keeping my distance. I found myself at a table with two women—both physicians and both of whom had left the conventional healthcare system because the chaos had disgusted and beaten them down. They didn’t know one another before that crowded train ride but weren’t surprised when they’d so quickly found common ground.
I asked them what piece of our healthcare system was most broken? They both immediately answered, speaking at the same time: “How we die. End of Life.” This was in 2012, and how we die in America was not front-page news. (Atul Gawande’s Being
Mortal wasn’t published until two years later.) I was taken aback and asked for more information. I quickly learned two devastating statistics: that end-of-life care is the number-one factor in American bankruptcies and that although 80 percent of Americans want to die at home, only 20 percent do.
After Dr. Hadiza Bawa-Garba was convicted for manslaughter for delayed diagnosis of fatal sepsis in Jack Adcock, a six-year-old boy who presented to Leicester Royal Infirmary with diarrhea and vomiting, she was referred to the Medical Practitioners Tribunal (MPT). The General Medical Council (GMC) is the professional regulatory body for physicians. But the MPT determines whether a physician is fit to practice. Though the tribunal is nested within the GMC and therefore within an earshot of its opinions, it is a decision-making body which is theoretically independent of the GMC.
The tribunal met in 2017, 6 years after Jack’s death, to decide whether Dr. Bawa-Garba, after the manslaughter conviction, should be allowed to practice medicine again, whether she should be suspended for a year, or her name be permanently erased (“struck off”) from the medical register. The GMC wanted Dr. Bawa-Garba to be struck off from the medical register because they felt that her care of Jack fell so short of the expected standard, that her return to practice would not only endanger patients but undermine public confidence in the medical profession. The GMC expected the MPT to agree with its uncompromising stance, and the MPT might well have, and probably would have, but for the efforts of Dr. Jonathan Cusack, a consultant neonatologist at Leicester Royal Infirmary (LRI), and a former supervisor and mentor of Dr. Bawa-Garba’s.
Cusack is unassuming even by British standards. You will not find him on social media or taking selfies. A soft-spoken northerner with a steely nerve and an uncompromising deference to facts, Cusack is both old-school and new-school. He has that unassailable integrity which is immeasurable but instantly recognizable. But he’s also savvy – and understands the British medical, regulatory and legal systems inside out. If Dr. Bawa-Garba’s license is reinstated, Cusack’s role would be akin to that of the code breakers in the Second World War. Dr. Bawa-Garba trusts him implicitly. Her legal team can’t function without him.
Cusack was loyally involved in both the rehabilitation of Dr. Bawa-Garba’s clinical confidence after Jack’s death, and her trial. I met him after the first day’s appeal hearing in the pub opposite the Courts of Justice. Originally hesitant to speak to me, being the ostentatious expat Brit that I am, he agreed to an interview on the condition that I not make too much of a song and dance about his contribution. I promised that I wouldn’t. I lied.
Jessica DaMassa decides the the way to deal with mourning Croatia’s loss in the World Cup Final is to make you suffer through my explanation of what’s wrong with the Trump Administration’s decision to screw over health plans and destabilize the exchanges. Oh and Higi gets a mention too — Matthew Holt
A ‘single-payer’ plan is a target on the back of its supporters. But what about a ‘Medicare Public-Private Partnership’?
MOUNT VERNON — In February 2017, President Trump famously said: “Nobody knew health care could be so complicated.” Nobody other than about 99.9 percent of the almost 300 million people in the U.S. with insurance, that is. Yesterday, I received a copy of “Get to know your benefits,” the 236-page “booklet” for my new health plan. Like most people, I’ll never read the book, but its weight alone says “complicated.”
And it’s safe to guess that Trump also will never read his Federal Employee Health Plan information, even though one Aetna choice available to him has a “brochure” of only 184 pages. Thinking about the amount of information available to health insurance plan consumers, I began to wonder what Health and Human Services Secretary Alex Azar meant, also last February, when he said, “Americans need more choices in health insurance so they can find coverage that meets their needs.”
Presumably, were we to have more choices, we could study the hundreds of pages of information about each available plan and make better choices. According to the federal Office of Personnel Management, federal employees who live at 1600 Pennsylvania Ave., Washington, D.C. 20500, have a choice of 35 monthly plans. Too bad the president doesn’t live in Maine, where he’d have only 20 plans to study!
Risk adjustment in health insurance is at first glance, and second, among the driest and most arcane of subjects. And yet, like the fine print on a variable-rate mortgage, it can matter enormously. It may make the difference between a healthy market and a sick one.
The market for individual health insurance has had major challenges both before and after the Affordable Care Act’s (ACA’s) risk adjustment program came along. Given recent changes from Washington, like the removal of the individual mandate, the market now needs all the help it can get. Unfortunately, risk adjustment under the ACA has been an example of a well-meaning regulation that has had destructive impacts directly contrary to its intent. It has caused insurer collapses and market exits that reduced competition. It has also led to upstarts, small plans and unprofitable ones paying billions of dollars to larger, more established and profitable insurers.
Many of these transfers since the ACA rules took effect in 2014 have gone from locally-based non-profit health plans to multi-state for-profit organizations. The payments have hampered competition not just in the individual market, which has never worked very well in the U.S., but in the small group market, which arguably didn’t need “help” from risk adjustment in many states.
The sense of urgency to fix these problems may be dissipating now that the initial rush for market share under the ACA is over and plans have enough actuarial data to predict costs better. There has been an overall shift to profitability. But it would be a serious mistake to think that just because fewer plans are under water, the current approach to risk adjustment isn’t distorting markets and harming competition.
Amid fresh political rancor and legal machinations in the ongoing war over the Affordable Care Act (ACA), there’s a bright spot: Medicaid. At least for now.
This matters. True to predictions made by Obama and supporters when the ACA became law (2010), it has taken years and a lot of blood, sweat and tears to get to this moment.
As a reminder, the U.S. Supreme Court in 2012 ruled that states could opt out of the ACA’s Medicaid expansion—leaving each state’s decision to participate in the hands of governors and state lawmakers.
On June 7, after a 4-year pitched political battle, Virginia became the 33rd state (plus DC) to expand Medicaid under the ACA. The Virginia expansion is projected to encompass 400,000 low-income Virginians.
The state swung in favor of expansion after Democrats gained the governorship and more seats in the legislature in 2016. But, importantly, key moderate Republicans relented.
Four other non-expansion states could join Virginia over the next year or two. They are Maine, Idaho, Utah, and Nebraska.Continue reading…
The Administration proposal that would enable small employers to band together to purchase health insurance by forming Association Health Plans has several good features. Large companies do pay about 15% less, apples-to-apples, for health insurance than small businesses because they negotiate lower administrative fees, get larger discounts on health care prices and avoid premium taxes and risk charges by self-insuring. Allowing small business to replicate what boils down to volume discounts also appeals politically to many as a market-based alternative to government intervention. Reliance on Association Health Plans could result in substantial volume discounts, but, in the end, would be like paying $10 for a tube of toothpaste that retails for $100, a big discount and a rip-off price.
Even though the largest companies get very deep discounts, there is substantial research showing that their net costs are much higher than everywhere else because we in the United States pay higher prices for health care goods and services. One need to look no further than the benchmark large corporate purchasers who continue to pay about 40% or 50% more than Medicare for the same health care to see how excessive health care prices for private payers are. And this disparity is likely to get worse. While hospitals gobble up other hospitals and doctors’ practices and gain near monopoly market power to raise prices, employers of all sizes remain highly fragmented and, as a result, impotent price negotiators.
A better approach to health care cost containment than Association Health Plans hides in full view. Continue reading…
Lawton Burns and Mark Pauly, economists at the Wharton School, just published an article that should be required reading for all policy makers and health services researchers. The article, entitled “Transformation of the health care industry: Curb your enthusiasm,” appears in the latest edition of the Milbank Quarterly.
Burns and Pauly undertook an enormous task and executed it well. They first sought to explain the assumptions underlying Managed Care (MC) 2.0 – the proposals promoted by the managed care movement in the wake of the HMO backlash of the late 1990s. Then they evaluated the probability that the MC 2.0 proposals will work as advertised. To do that, they looked at the relevant research and then at the social conditions that are impeding the implementation of those proposals. That’s a lot to bite off.
This is an unusually valuable article because of its scope, organization, and documentation. I will summarize it first, then discuss it in more detail. I’ll close with a discussion of my one serious criticism of this excellent paper: The authors, having made it clear they think the current “value-based” approach to cost containment is doomed, profess to see no solutions to rising health care costs.
Testing a mantra
Burns and Pauly are among the small minority of health services researchers who seem to be curious about the powerful norms that influence their profession but which are rarely acknowledged and never studied. They do not come right out and say, “Our profession resembles a religion more than a scientific discipline,” but you get the feeling they might agree with that statement if you could talk to them over coffee. They communicate their interest in the undiscussed norms both in the way they treat health policy jargon (they view it with some skepticism) and in their willingness to declare that fundamental assumptions underlying MC 2.0 were never tested.