Category Archives: politics

healthy habits, nutrition, policy, politics

Dream Food Label

Nice sounding food labelling system. As Bittman suggests, at least a decade away…

 

http://www.nytimes.com/2012/10/14/opinion/sunday/bittman-my-dream-food-label.html

My Dream Food Label
By 

Published: October 13, 2012

WHAT would an ideal food label look like? By “ideal,” I mean from the perspective of consumers, not marketers.

Multimedia
The Proposed Nutrition Label: A Quick Read, Out Front
 Right now, the labels required on food give us loads of information, much of it useful. What they don’t do is tell us whether something is really beneficial, in every sense of the word. With a different set of criteria and some clear graphics, food packages could tell us much more.

Even the simplest information — a red, yellow or green “traffic light,” for example — would encourage consumers to make healthier choices. That might help counter obesity, a problem all but the most cynical agree is closely related to the consumption of junk food.

Of course, labeling changes like this would bring cries of hysteria from the food producers who argue that all foods are fine, although some should be eaten in moderation. To them, a red traffic-light symbol on chips and soda might as well be a skull and crossbones. But traffic lights could work: indeed, in one study, sales of red-lighted soda fell by 16.5 percentin three months.

A mandate to improve compulsory food labels is unlikely any time soon. Front-of-package labeling is sacred to big food companies, a marketing tool of the highest order, a way to encourage purchasing decisions based not on the truth but on what manufacturers would have consumers believe.

So think of the creation of a new food label as an exercise. Even if some might call it a fantasy, the world is moving this way. Traffic-light labeling came close to passing in Britain, and our own Institute of Medicine is proposing something similar. The basic question is, how might we augment current food labeling (which, in its arcane detail, serves many uses, including alerting allergic people to every specific ingredient) to best serve not only consumers but all contributors to the food cycle?

As desirable as the traffic light might be, it’s merely a first step toward allowing consumers to make truly enlightened decisions about foods. Choices based on dietary guidelines are all well and good — our health is certainly an important consideration — but they don’t go nearly far enough. We need to consider the well-being of the earth (and all that that means, like climate, and soil, water and air quality), the people who grow and prepare our food, the animals we eat, the overall wholesomeness of the food — what you might call its “foodness” (once the word “natural” might have served, but that’s been completely co-opted), as opposed to its fakeness. (“Foodness” is a tricky, perhaps even silly word, but it expresses what it should. Think about the spectrum from fruit to Froot Loops or from chicken to Chicken McNuggets and you understand it.) These are considerations that even the organic label fails to take into account.

Beyond honest and accurate nutrition and ingredient information, it would serve us well to know at a glance whether food contains trans fats; residues from hormones, antibiotics,pesticides or other chemicals; genetically modified ingredients; or indeed any ingredients not naturally occurring in the food. It would also be nice to be able to quickly discern how the production of the food affected the welfare of the workers and the animals involved and the environment. Even better, it could tell us about its carbon footprint and its origins.

A little of this is covered by the label required for organic food. Some information is voluntarily being provided by producers — though they’re most often small ones — and retailers like Whole Foods. But only when this kind of information is required will consumers be able to express preferences for health, sustainability and fairness through our buying patterns.

Still, one can hardly propose covering the front of packages with 500-word treatises about the product’s provenance. On the other hand, allowing junk food to be marketed as healthy is unacceptable, or at least would be in a society that valued the rights of consumers over those of the corporation. (The “low-fat” claim is the most egregious — plenty of high-calorie, nutritionally worthless foods are in fact fat-free — but it’s not alone.)

All of this may sound like it’s asking a lot from a label, but creating a model wasn’t that difficult. Over the last few months, I’ve worked with Werner Design Werks of St. Paul to devise a food label that, at perhaps little more than a glance (certainly in less than 10 seconds), can tell a story about three key elements of any packaged food and can provide an overall traffic-light-style recommendation or warning.

How such a labeling system could be improved, which agency would administer it (it’s now the domain of the F.D.A.), which producers would be required to use it, whether foods should carry quick-response codes that let your phone read the package and link to a Web site — all of those questions can be debated freely. Suffice it to say we went through numerous iterations to arrive at the label we are proposing. We put it out here not as an end but as a beginning.

Every packaged food label would feature a color-coded bar with a 15-point scale so that almost instantly the consumer could determine whether the product’s overall rating fell between 11 and 15 (green), 6 and 10 (yellow) or 0 and 5 (red). This alone could be enough for a fair snap decision. (We’ve also got a box to indicate the presence or absence of G.M.O.’s.)

We arrive at the score by rating three key factors, each of which comprises numerous subfactors. The first is the obvious “Nutrition,” about which little needs to be said. High sugar, trans fats, the presence of micronutrients and fiber, and so on would all be taken into account. Thus soda would rate a zero and frozen broccoli might rate a five. (It’s hard to imagine labeling fresh vegetables.)

The second is “Foodness.” This assesses just how close the product is to real food. White bread made with bleached flour, yeast conditioners and preservatives would get a zero or one; so would soda; a candy bar high in sugar but made with real ingredients would presumably score low on nutrition but could get a higher score on “foodness”; here, frozen broccoli would rate a four.

The third is the broadest (and trickiest); we’re calling it “Welfare.” This would include the treatment of workers, animals and the earth. Are workers treated like animals? Are animals produced like widgets? Is environmental damage significant? If the answer to those three questions is “yes” — as it might be, for example, with industrially produced chickens — then the score would be zero, or close to it. If the labor force is treated fairly and animals well, and waste is insignificant or recycled, the score would be higher.

These are not simple calculations, but neither can one honestly say that they’re impossible to perform. It may well be that there are wiser ways to sort through this information and get it across. The main point here is: let’s get started.

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A version of this op-ed appeared in print on October 14, 2012, on page SR6 of the New York edition with the headline: My Dream Food Label.

 

Published: October 13, 2012

The Proposed Nutrition Label: A Quick Read, Out Front

MAMA C’S ORGANIC TOMATO SAUCE This contains organic tomatoes, extra virgin olive oil, and fresh herbs; it’s even refrigerated, so it contains no preservatives.

 

Since Mama C runs an organic operation with a full-time labor force receiving benefits, the score here is superhigh all around, and the label is green.

0-5

6-10

11-15 points

CHOCOLATE FROSTED SUPER KRISPY KRUNCHIES Fifty percent sugar; almost all nutrients come from additives. But it does contain 10 percent of the daily allowance of fiber.

 

It’s barely recognizable as food in any near-natural form, and it’s made from hyper-processed commodity crops. However, workers in the plant are full time and receive benefits (and no animals are harmed), so a couple of points there (environmentally, however, the welfare is negative, so these points are mitigated): 2. Thus, red.

 

healthy habits, nutrition, policy, politics

With US food labeling, the times, they are a changing…

Impressive changes in US food labeling.

Introducing the label, Mrs. Obama said, “Our guiding principle here is very simple: that you as a parent and a consumer should be able to walk into your local grocery store, pick up an item off the shelf, and be able to tell whether it’s good for your family.”

http://www.nytimes.com/2014/03/05/opinion/bittman-some-progress-on-eating-and-health.html

The Opinion Pages|CONTRIBUTING OP-ED WRITER

Some Progress on Eating and Health

For those concerned about eating and health, the glass was more than half full last week; some activists were actually exuberant. First, there wasevidence that obesity rates among pre-school children had fallen significantly. Then Michelle Obama announced plans to further reduce junk food marketing in public schools. Finally, she unveiled the Food and Drug Administration’s proposed revision of the nutrition label that appears on (literally, incredibly) something like 700,000 packaged foods (many of which only pretend to be foods); the new label will include a line for “added sugars” and makes other important changes, too.

If the 43 percent plunge in obesity in young children holds true, it’s fantastic news, a tribute to the improved Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which encourages the consumption of fruits and vegetables; to improved nutrition guidelines; to a slight reduction in the marketing of junk to children; and probably to the encouragement of breast-feeding. Practically everyone in this country who speaks English or Spanish has heard or read the message that junk food is bad for you, and that patterns set in childhood mostly determine eating habits for a lifetime.

None of this happened by accident, and the lesson is that policy works.

The further limitations on marketing junk are more complicated. Essentially, producers won’t be able to promote what they already can’t sell (per new Department of Agriculture regulations), meaning that vending machines or scoreboards cannot encourage the consumption of sugar-sweetened beverages. (Promotion of increasingly beleaguered diet sodas would be allowed.)

Mrs. Obama’s tendency to see the reformulation of packaged foods as an important goal is on display here: Snacks sold in schools (both in vending machines and out) will have to meet one of four requirements, like containing at least 50 percent whole grain or a quarter-cup of fruits or vegetables.

These proposed rules are better than nothing but filled with loopholes. Manufacturers will quickly figure out how to meet the new standards, and the improvements, though not insignificant, will not go far in teaching kids that the best snack is an apple or a handful of nuts. (One way to really clobber junk food would be to prevent companies from taking tax deductions on the marketing of unhealthy foods, a move that’s in a bill sponsored by Congresswoman Rosa DeLauro of Connecticut.)

Still. It beats calling ketchup a vegetable.

The label change is huge. Yes: It could be huge-er. Yes: It’s long overdue. Yes: It may be fought by industry and won’t be in place for a long time. And yes: The real key is to be eating whole foods that don’t need to be labeled.

But by including “added sugars” on the label, the F.D.A. is siding with those who recognize that science shows that added sugars are dangerous. “This is an acknowledgment by the agency that sugar is a big problem,” says the former F.D.A. commissioner David Kessler, who presided over the development of the last label change, 20 years ago. “It will allow the next generation to grow up with far more awareness.”

Big Food has long maintained that it doesn’t matter where sugar or indeed calories come from — that they’re all the same. But “added sugars” declares the industry’s strategy of pumping up the volume on “palatability,” making ketchup, yogurt and granola bars, for example, as sweet and high-calorie as jam, ice cream and Snickers. Added sugar turns sparkling water into soda and food-like objects into candy. Added sugar, if you can forgive the hyperbole, is the enemy. This is not to say you shouldn’t eat a granola bar, but if you know what’s in it you’re less likely to think of it as “health food.”

There are a couple of other significant changes, including more realistic “serving sizes” (a serving of ice cream will now be a more realistic cup instead of a half-cup, for example), the deletion of the “calories from fat” line, which recognizes that not all fats are “bad,” and some changes in daily recommended values for various nutrients.

Mrs. Obama, who is sometimes seen (by me among many others) as overly industry-friendly, was behind the push for these changes, or at least highly supportive of them. And she deserves credit: It’s a victory, and no one on the progressive side of this struggle should see it as otherwise.

The label is hardly messianic. In fact, the F.D.A. tacitly acknowledges this by offering an alternative, stronger label, which approaches the kind of “traffic light” labeling I’ve advocated for, and which there’s evidence to support. The alternative has four sections, including “Avoid Too Much” and “Get Enough”; the first includes added sugars and trans fat, for example, and the second, fiber and vitamin D.

Michael Taylor, the F.D.A.’s deputy commissioner for foods and veterinary medicine — and the guy who supervised the new label’s development — told me that the alternative label is essentially a way to further “stimulate comments.” It may be that it’s also a demonstration of the agency’s will, designed to show industry how threatening things could get so Big Food will swallow the primary label without much complaint.

Although the ultimate decision is the F.D.A.’s, the Grocery Manufacturers’ Association statement last week said in part, “It is critical that any changes are based on the most current and reliable science.” These are, and marketers are going to have a tough time claiming otherwise. In other words, we’re going to see some form of new and stronger label, period.

Introducing the label, Mrs. Obama said, “Our guiding principle here is very simple: that you as a parent and a consumer should be able to walk into your local grocery store, pick up an item off the shelf, and be able to tell whether it’s good for your family.”

This label moves in that direction, but it could be much more powerful. Kessler would like to see a pie chart on the front of the package: “That would help people know what’s real food and what’s not.” Michael Pollan also suggests front-of-the-box labeling: “I think the U.K. has the right idea withtheir stoplight panel on the front of packages; only a small percentage of shoppers get to the nutritional panel on the back.” And the N.Y.U. nutrition professor Marion Nestle (who called this label change “courageous”) says that “A recommended upper limit for added sugars would help put them in context; I’d like to see that set at 10 percent of calories or 50 grams (200 calories) in a 2,000-calorie diet.” (I wrote about my own dream label, which includes categories that probably won’t be considered for another 10 years — if ever — back in 2012.)

What else is wrong? The label covers a lot of food, but it has no effect on restaurant food, takeout, most prepared food sold in bulk (do you have any idea what’s in that fried chicken at the supermarket deli counter, for example?) or alcohol.

The Obama administration and the F.D.A. have made a couple of moves here that might be categorized as bold, but they could have done so three or four years ago; these are regulations that can be built upon, and do not require Congressional approval. But by the time they’re in effect it may be too late for this administration to take them to the next level.

In short, it’s not a case of too-little-too-late but one of “it could’ve been more and happened sooner.”

But that’s looking backward instead of forward. If we see a decline in obesity rates, more curbs on food marketing and greater transparency in packaged food, that’s progress. Let’s be thankful for it, then get back to work pushing for more.

complex adaptive systems, cool, data saving lives, facts & data points, healthcare, management and leadership, policy, politics, rapid learning health systems, research methodology

A couple of terrific safety quality presentations

 

Rene Amalberti to a Geneva Quality Conference:

b13-rene-amalberti

http://www.isqua.org/docs/geneva-presentations/b13-rene-amalberti.pdf?sfvrsn=2

 

Some random, but 80 slides, often good

Clapper_ReliabilitySlides

http://net.acpe.org/interact/highReliability/References/powerpoints/Clapper_ReliabilitySlides.pdf

healthy habits, nutrition, policy, politics

Reformulation and marketing restrictions to prevent childhood obesity

 

 

http://www.foodnavigator.com/Product-Categories/Sweeteners-intense-bulk-polyols/EU-eyes-reformulation-and-marketing-restrictions-to-cut-childhood-obesity/

EU eyes reformulation and marketing restrictions to cut childhood obesity

By Caroline Scott-Thomas+

03-Mar-2014

The plan includes tougher limits on all marketing to children - not just television advertising

The plan includes tougher limits on all marketing to children – not just television advertising

Related tags: EU Action Plan, Childhood obesity, Marketing to children

Related topics: Sugar, salt and fat reduction, Marketing, Legislation, Carbohydrates and fibres (sugar, starches), Food safety and labelling, Sweeteners (intense, bulk, polyols)

Restricting marketing to children and continuing to cut salt, fats and added sugar in processed foods are among initiatives put forward in a plan to tackle childhood obesity, agreed by EU member states in Greece last week.

RELATED NEWS:

WHO decries ‘deadly’ promotion of cheap, convenient food
High cost of fruit and vegetables linked to higher body fat in young children: Study
Healthy snacking trend boosts sugar-free fruit ingredients
EU programme aims to boost kids’ fruit and milk consumption

The action plan was agreed by the High Level Group on Nutrition and Physical Activity at a conference in Athens, and includes a range of voluntary initiatives intended to promote healthy environments and balanced diets, encourage physical activity, restrict advertising to children, and support ongoing efforts to slash levels of salt, fats and added sugar.

Childhood obesity is on the rise in Europe, the European Commission said, adding that about one in three children aged six to nine was overweight or obese in the region in 2010 versus one in four children in 2008. It said member states spent an estimated 7% of their healthcare budgets on treating weight-related problems.

The new strategy includes encouraging industry to make commitments in areas such as marketing, food reformulation, food distribution, catering and physical activity, with a specific focus on children, young people and the most deprived.

Referring to marketing restrictions in particular, it said limits on advertising to children should extend beyond television advertising to include all marketing, “including in-store environments, promotional actions, internet presence and social media activities”.

Taxation, subsidies and pricing

The plan also refers to making “the healthy option the easier option” – a strategy that could include taxation and subsidies for particular foods, or encouraging manufacturers to price reformulated foods at a lower level than standard versions.

Proposals included “encouraging reformulation of less healthy food options and taking nutritional objectives into consideration when defining taxation, subsidies or social support policies”.

In response to the plan, trade body FoodDrinkEurope said it hoped to continue a partnership approach to tackling childhood obesity in Europe.

“European food and drink manufacturers reaffirm their commitment to fight childhood obesity by means of ongoing and possibly new actions and initiatives targeted at children and parents through the established platforms for action at European and national level,” it said in a statement.

complex adaptive systems, healthy habits, nutrition, policy, politics

In defense of sugar

Interesting, detailed, slick presentation on the biochemistry and epidemiology of fructose on health

He discloses significant industry engagements (coca cola, dr pepper etc.)

Does present the view (shared by Katz) that it shouldn’t be about single nutrients, but diet and activity overall.

This seems to be industry-backed smoke to confuse the discussion.

http://media.soph.uab.edu/PresenterPlus/norc-sievenpiper-20140214/main.htm#

Title: Sugars and cardiometabolic health: A story lost in translation?
Presenter: John L. Sievenpiper, MD, PhD
Date: February 11, 2014
Description: NORC Seminar
SugarsOK
healthcare, policy, politics

McAuley on health funding

A measured piece mainly having a crack at PHI.

https://newmatilda.com/2014/02/24/real-problems-our-health-system

Three Ways To Fund Our Health System

By Ian McAuley
The argument over $6 GP co-payments is little more than a distraction from the real task – untangling our incoherent system of health funding, writes Ian McAuley

Health Minister Peter Dutton is on the right track when he says he wants “to start a national conversation about modernising and strengthening Medicare”.

Our health arrangements serve us well, but as John Dwyer, Emeritus Professor of Medicine at UNSW, pointed out in an ABC interview last week, there are inefficiencies to be addressed. There are what economists call technical inefficiencies — too many bureaucrats in overlapping state and federal jurisdictions and in private insurance firms, poor use of information technology, rigid workforce demarcations and a lack of integration between different care providers. That’s just to name a few!

More seriously there are what economists call allocative inefficiencies — in particular high attention to treating illness contrasting with neglect of public health measures which could prevent illness.

These problems won’t be solved by half-baked ideas such as a $6 co-payment for GP services, a proposal which, in terms of transaction costs alone, is stupid, and which, if it could have any effect in reducing demand, would have its greatest impact on those for whom $6 is a burden. In fact if, as former Coalition policy advisor Terry Barnes suggests, if the $6 were to be covered by private insurance, there would be a huge increase in both private and public costs of health care.

Unfortunately the $6 proposal has commanded attention. It’s as if it has been put out as bait to draw attention away from other possible ideas of the Coalition Government, such as an extension of private insurance — which would do much more damage to health care affordability than a small co-payment.

If that is the Government’s strategy, Medicare’s defenders have taken the bait, digging into hard positions to defend the status quo, conveniently ignoring the fact that there are already significant co-payments in health care (such as the $37 payment for prescription pharmaceuticals), and ignoring the fact that all comparable countries, including those with much more socially inclusive systems such as Sweden, have co-payments before public insurance picks up the tab.

The Labor Party, rather than articulating any coherent principles on health funding, has opportunistically joined the chorus criticising the $6 co-payment.

A national conversation should start with an honest definition of the problem. It is not about an “unsustainable” health budget. Even if we deal with inefficiencies, it is to be expected that as our population ages, and as therapies become available, we will spend more on health care, and whether we spend it from our own pockets or from our taxes is a secondary issue — we will still pay for it. After all, we are spending more on eating out, but we don’t construe that as a “problem”.

Language counts. Some refer to public spending on health care as “social” spending, as if it is in a different category to spending on “real” government services such as roads and defence, and it has been caught up in the language of “entitlement”. As IMF Managing Director Christine Lagarde said on ABC’s Q&A last week:

“Investing in health, investing in education, making sure there are equal opportunities for all, is something where public money is needed … it is not a question of entitlement.”

A national conversation takes time and good faith. A government can lead the process if it helps people extract themselves from hard “positions” and articulate their interests. People need to break from assumptions, such as the idea that the present division of state and federal arrangements will stay, that pharmacies are necessarily separate from GP practices, that co-payments necessarily involve cash upfront (perhaps they could be liabilities to Centrelink), or that without private insurance private hospitals will not survive.

On funding, the basic question to put to the community is the extent to which we want to share our health care costs with one another. Do we want comprehensive sharing, funded through our taxes, or are we willing to pay some more from our own pockets — with protection, of course, for those for whom such payments would be too burdensome?

That question has never been put to the Australian community. Dutton is right — we need a national conversation.

It is possible that we do want a completely free system, and are willing to pay the higher taxes to support it. We may be willing to take risks in most parts of our lives, but because of the randomness of illness and accident we may want to pool our health care costs. We may place high value on social solidarity expressed through a universal free system of health care.

Alternatively, it is possible that, because we are wealthier than in previous times, we are happy to take more personal responsibility. Because health care is skewed towards high users, most Australians, most of the time, could easily pay for all their needs without any support from third parties such as Medicare or private insurers.

We may opt for a safety net to kick in only after we have made a reasonable contribution. Presumably that would be a much fairer and more sensible safety net than the present haphazard mess of free and charged services.

If, in response to community consultation, Australians opt for a high level of sharing and are willing to pay the required taxes — perhaps through a higher Medicare levy — politicians should respect that decision. They should not paternalistically override the community’s wishes by asserting we will be better off with lower taxes.

And they should avoid shifting the cost of sharing to private health insurance — a high-cost mechanism which does what the Australian Tax Office and Medicare do at much lower cost and with much greater equity. It makes no sense if, in an obsession with budgetary costs, we save $1.00 in official taxes only to have to pay $1.10 or $1.80 in “taxes” to BUPA, Medibank Private or NIB for the same or an inferior service.

If Australians opt for more personal responsibility, dealing with minor health care transactions as they do with other goods and services, then defenders of Medicare should respect that choice, and not complain when they see fees introduced for some previously free services. Rather they should ensure there are no barriers to those who are too poor or who lack liquidity to cover upfront payments. And governments should prohibit private insurers from covering those payments, for to do so would negate the discipline of markets (“moral hazard” in the quaint language of the insurance industry) and drive up costs for all users.

Those who remember the 1987 election will recall that the Liberal Party proposed a $250 uninsurable upfront payment — about $800 in today’s terms. It was sound policy, consistent with their platform of self-reliance, but it was poorly explained, and then as now private insurers had no interest in self-reliance — their business model is about subsidised corporate reliance.

In short, there are three ways to fund health care — on the “left” a completely tax-funded scheme, on the “right” a more market-based scheme with a high level of upfront payments, and in a space of its own private health insurance, which disingenuously combines all the worst aspects of socialism and capitalism, with none of their compensating merits.

data saving lives, facts & data points, file note, healthcare, policy, politics, rapid learning health systems

Australian Medicare Fraud

The quoted estimate seems a bit under…

http://www.abc.net.au/news/2014-03-06/australians-defrauding-medicare-hundreds-of-thousands-of-dollars/5302584

Video: 

Australian Medicare fraud revealed in new figures, 1,116 tip-offs so far this financial year

By medical reporter Sophie Scott and Alison Branley

Updated Fri 7 Mar 2014, 1:23am AEDT

New figures show Medicare is being defrauded of hundreds of thousands of dollars each year.

Figures released to the ABC show the Federal Government has received more than 1,000 tip-offs of potential Medicare frauds to date this financial year.

It comes as debate continues over a proposal put to the Commission of Audit to charge a $6 co-payment for visits to the doctor, which would reduce costs to the health system.

The Department of Human Services says its hotline has received 1,116 Medicare-related tip-offs since July 1, 2013.

Officers have investigated 275 cases, which has translated into 34 cases submitted to the Commonwealth Department of Public Prosecutions and 12 convictions.

The value of those 12 cases adds up to an estimated $474,000, with fraudsters ripping off an average of almost $40,000 each.

Department figures suggest most of the frauds come from outside the doctor’s office.

Ten of the 12 prosecutions this year were members of the public. One involved a medical practice staff member and one a practice owner.

“The Department of Human Services takes all allegations of fraud seriously and seeks to investigate where sufficient information is provided to do so,” a spokeswoman said.

The annual review of doctors’ use of Medicare, the Professional Services Review, showed at least 19 doctors were required to repay more than $1 million between them in 2012-13.

One doctor billed Medicare for seeing more than 500 patients in a day, and more than 200 patients on several other days.

Other cases uncovered by the ABC include:

  • Former police officer Matthew James Bunning has been charged with 146 Medicare frauds between 2011 and 2013. Investigators allege the 46-year-old removed Medicare slips from rubbish bins behind Medicare offices around Melbourne to produce forged receipts and illegally claimed more than $98,000 from the Government.
  • In January last year Korean student Myung Ho Choi was sentenced in a NSW district court to five years in prison for a series of fraud and identity theft charges that included receiving at least five paper boxes filled with blank Medicare cards intended for use in identity fraud.
  • In August last year NSW man Bin Li was sentenced in district court to seven years in prison for charges that included possessing almost 400 blank cards, including high quality Medicare cards, and machines for embossing cards.

Nilay Patel, a former US-based certified specialist in healthcare compliance and law tutor at Swinburne University of Technology, says the fraud figures are the “tip of the iceberg”.

“There is a lot more that we do not know and that really comes from both camps from the patients and the medical service providers,” he said.

He says Australia is falling behind the United States at preventing, detecting and prosecuting healthcare frauds.

“The safeguards [in Australia] are quite inadequate, the detection is more reactive that proactive and whatever proactive mechanisms that are there I think they are woefully underdeveloped,” he said.

Relatively ‘smallish’ but unacceptable problem: Minister

Federal Government authorities say they do not think Medicare fraud is widespread.

Minister for Human Services Marise Payne says the number of Medicare frauds are low compared to the number of transactions.

“I think when you consider that we have 344 million Medicare transactions a year it is a relatively smallish [problem] but that doesn’t mean it’s acceptable,” she said.

“One person committing a fraud effectively against the Australian taxpayer is one person too many.”

Ms Payne says the department uses sophisticated data matching and analytics to pick up potential frauds as well as its tip-off hotline.

The merger of Medicare with Centrelink also allows the bureaucracies to better share information and leads.

“The work we have done in that area is paying dividends,” Ms Payne said.

“There is more to do. The use of analytical data and risk profiling is highly sophisticated in the Centrelink space and we want to make sure we achieve the same levels in the Medicare space.”

The Australian Federal Police says it does not routinely gather statistics on the number of fake or counterfeit Medicare cards.

However, a spokesman says detections of counterfeit Medicare cards are rare.

“Intelligence to date indicates that the majority of Medicare cards seized that are of sufficient quality, are used as a form of identity, not intentionally to defraud Medicare,” a spokesman said.

A Customs and Border Protection spokeswoman says blank or fraudulent Medicare cards are not controlled under the Customs regulations and it is unable to provide seizure statistics.

The federal Ombudsman says he has not conducted any review or investigations into Medicare but did contribute to a 2009 inquiry into compliance audits on benefits.

The Medicare complaints detailed in the Ombudsman’s annual report relate to customers disputing Medicare refunds, not frauds.

‘People are just looting the money’

Sydney man Tahir Abbas is sceptical about the Government’s claims that Medicare fraud is not widespread.

Mr Abbas detected at least 10 false bulk billing charges on his Medicare statement between November and January valued at almost $750.

He was not in the country when many of the charges were incurred.

The charges were from a western Sydney optometrist who told the ABC they were unable to explain the discrepancies.

They said while Mr Abbas was billed, they never received payment.

How many times do we go and check our statements for Medicare particularly. Maybe with credit cards, bank details but not with Medicare. These people are just looting the money.

Victim of Medicare fraud Tahir Abbas

 

The owner told the ABC the system would not allow them to receive bulk billing payments for more than one check-up in a two-year period.

Mr Abbas said he believed his card had been misused by others for their own benefit.

“I was very disgusted to be honest,” he said.

“It’s all bulk-billed and they are charging the Government. But in a way the Government is charging us so we are paying from our pocket – it’s all taxpayers’ money.”

He has urged people to check their Medicare statements.

“How many times do we go and check our statements for Medicare particularly. Maybe with credit cards, bank details but not with Medicare.

“These people are just looting the money.”

Medicare has told Mr Abbas they are investigating.

High-tech Medicare cards needed?

Technology and crime analyst Nigel Phair from the University of Canberra says the Medicare card is an easy to clone, low-tech card that has been around for three decades.

While it is low in value for identity check points, it is a well-respected document.

 

“The Medicare card carries no technology which gives it additional factors for verification or identification of users,” he said.

“It’s just a mag stripe on the back, very similar to a credit card from the 1990s without any chip or pin technologies, which are well known to be the way of the future.”

He says Medicare is vulnerable to abuse because people’s data is stored in many places such as doctors’ surgeries and pharmacies.

“It’s very easy to sail under the radar if you’re a fraudulent user. And like all good frauds you keep the value of the transactions low but your volume high,” he said.

“Because all we do have is anecdotal evidence and no hard statistics, we really don’t know how bad this issue is.”

Ms Payne does not support upgrading the quality of Medicare cards.

“The advice I have is that that is not really a large source of fraud and inappropriate practices,” she said.

Do you know more? Email investigations@abc.net.au

 

Topics: fraud-and-corporate-crime, health, health-administration, health-policy, government-and-politics, federal-government,law-crime-and-justice, australia

First posted Thu 6 Mar 2014, 12:00pm AEDT

data saving lives, healthcare, management and leadership, policy, politics, rapid learning health systems

NHS data might save lives

Numbers in medicine are not an abstract academic game: they are made of flesh and blood, and they show us how to prevent unnecessary pain, suffering and death.

Tim Kelsey is the man running the show: an ex-journalist, passionate and engaging, he has drunk more open-data Kool-Aid than anyone I’ve ever met. He has evangelised the commercial benefits of sharing NHS data – perhaps because he made millions from setting up a hospital-ranking website with Dr Foster Intelligence – but he is also admirably evangelical about the power of data and transparency to spot problems and drive up standards. Unfortunately, he gets carried away, stepping up and announcing boldly that no identifiable patient data will leave the Health and Social Care Information Centre. Others supporting the scheme have done the same.

This is false reassurance, and that is poison in medicine, or in any field where you are trying to earn public trust. The data will be “pseudonymised” before release to any applicant company, with postcodes, names, and birthdays removed. But re-identifying you from that data is more than possible. Here’s one example: I had twins last year (it’s great; it’s also partly why I’ve been writing less). There are 12,000 dads with similar luck each year; let’s say 2,000 in London; let’s say 100 of those are aged 39. From my brief online bio you can work out that I moved from Oxford to London in about 1995. Congratulations: you’ve now uniquely identified my health record, without using my name, postcode, or anything “identifiable”. Now you’ve found the rows of data that describe my contacts with health services, you can also find out if I have any medical problems that some might consider embarrassing: incontinence, perhaps, or mental health difficulties. Then you can use that information to try and smear me: a routine occurrence if you do the work I do, whether it’s big drug companies, or dreary little quacks.

http://www.theguardian.com/society/2014/feb/21/nhs-plan-share-medical-data-save-lives

The NHS plan to share our medical data can save lives – but must be done right

Care.data, the grand project to make the medical records of the UK population available for scientific and commercial use, is not inherently evil – far from it – but its execution has been badly bungled. Here’s how the government can regain our trust
The Guardian, doctor looking at medical data
‘If the government gets it right, they can save a vital data project, and allow medical research that saves lives on a biblical scale to ­continue,’ writes Ben Goldacre. Photograph: Hans Neleman/Getty Images

Everything would be much simpler if science really was “just another kind of religion”. But medical knowledge doesn’t appear out of nowhere, and there is no ancient text to guide us. Instead, we learn how to save lives by studying huge datasets on the medical histories of millions of people. This information helps us identify the causes of cancer and heart disease; it helps us to spot side-effects from beneficial treatments, and switch patients to the safest drugs; it helps us spot failing hospitals, or rubbish surgeons; and it helps us spot the areas of greatest need in theNHS. Numbers in medicine are not an abstract academic game: they are made of flesh and blood, and they show us how to prevent unnecessary pain, suffering and death.

Now all this vital work is being put at risk, by the bungled implementationof the care.data project. It was supposed to link all NHS data about all patients together into one giant database, like the one we already have for hospital episodes; instead it has been put on hold for six months, in the face of plummeting public support. It should have been a breeze. But we have seen arrogant paternalism, crass boasts about commercial profits, a lack of clear governance, and a failure to communicate basic science properly. All this has left the field open for wild conspiracy theories. It would take very little to fix this mess, but time is short, and lives are at stake.

The care.data project was promoted in two ways: we will use your data for lifesaving research, and we will give it to the private sector for commercial exploitation, creating billions for the UK economy. This marriage was a clear mistake: by and large, the public support public research, but are nervous about commercial exploitation of their health data.

Now the teams behind care.data are trying to row back, explaining that access will only be granted for research that benefits NHS patients. That is laudable, but potentially a very broad notion. It’s one we would want to unpack, with clear, worked examples of the kind of things they would permit, and the kind of things they would refuse. But that’s not possible because, bizarrely, the specific principles, guidelines, committees and regulations that will determine all these decisions have not yet been clearly set out. This poses several difficulties. Firstly, the public are being asked to support something that feels intuitively scary, about the privacy of their medical records, without being told the details of how it will work. Secondly, the field has been left open to conspiracy theories, which are hard to refute without concrete guidance on how permissions for access really will work.

That said, many criticisms have been absurd. There has been endless discussion around the idea of health insurers buying health records, for example, and using them to reject high-risk patients. Call an insurer right now and see how you get on: within minutes you will be asked to declare your full medical history, waive confidentiality and grant access to your full medical notes anyway.

Many have complained about drug companies getting access to data, and this is more complex. On the one hand, arrangements like these are longstanding and essential: if medicines regulators get a few unusual side-effect reports from patients, they go to the drug company and force them to do a big study, examining – for example – 10,000 patients’ records, to find out if people on that drug really do have more heart attacks than we’d expect. To do this, the UK health regulator itself sells industry the data, in the past from something called the GP Research Database, which holds millions of people’s records already. This needs to happen, and it’s good. But equally, people know – I’ve certainly shouted about it for long enough – that the pharmaceutical industry also misuses data: they hide the results of clinical trials when it suits them, quite legally; they monitor individual doctors’ prescribing patterns to guide their marketing efforts, and so on. The public don’t trust the pharmaceutical industry unconditionally, and they’re right not to.

Trust, of course, is key here, and that’s currently in short supply. The NSA leaks showed us that governments were casually helping themselves to our private data. They also showed us that leaks are hard to control, because the National Security Agency of the wealthiest country in the world was unable to stop one young contractor stealing thousands of its most highly sensitive and embarrassing documents.

But there is a more specific reason why it is hard to give the team behind care.data our blind faith: they have been caught red-handed giving false reassurance on the very real – albeit modest – privacy threats posed by the system.

Tim Kelsey is the man running the show: an ex-journalist, passionate and engaging, he has drunk more open-data Kool-Aid than anyone I’ve ever met. He has evangelised the commercial benefits of sharing NHS data – perhaps because he made millions from setting up a hospital-ranking website with Dr Foster Intelligence – but he is also admirably evangelical about the power of data and transparency to spot problems and drive up standards. Unfortunately, he gets carried away, stepping up andannouncing boldly that no identifiable patient data will leave the Health and Social Care Information Centre. Others supporting the scheme have done the same.

This is false reassurance, and that is poison in medicine, or in any field where you are trying to earn public trust. The data will be “pseudonymised” before release to any applicant company, with postcodes, names, and birthdays removed. But re-identifying you from that data is more than possible. Here’s one example: I had twins last year (it’s great; it’s also partly why I’ve been writing less). There are 12,000 dads with similar luck each year; let’s say 2,000 in London; let’s say 100 of those are aged 39. From my brief online bio you can work out that I moved from Oxford to London in about 1995. Congratulations: you’ve now uniquely identified my health record, without using my name, postcode, or anything “identifiable”. Now you’ve found the rows of data that describe my contacts with health services, you can also find out if I have any medical problems that some might consider embarrassing: incontinence, perhaps, or mental health difficulties. Then you can use that information to try and smear me: a routine occurrence if you do the work I do, whether it’s big drug companies, or dreary little quacks.

This risk isn’t necessarily big, but to say it doesn’t exist is crass: it’s false reassurance, which ultimately undermines trust, but it’s also unnecessary, and counterproductive, like hiding information on side-effects instead of discussing them proportionately. To the best of my knowledge, we’ve never yet had a serious data leak from a medical research database, and there are plenty around already; but then, we are standing on the verge of a significant increase in the number of people accessing and using medical data. There are steps we can take to minimise the risks: only release a subset of the 60 million UK population to each applicant; only give out the smallest possible amount of information on each patient whose records you are sharing; suggest that people come to your data centre to run their analyses, instead of downloading records, and so on. But, while the care.data project might be planning to do some of those things, the ground rules haven’t been properly written out yet.

In any case, even safeguards such as these can be worked around. There are companies out there operating in the grey areas of the law, aggregating data from every source and leak they can find, generating huge, linked datasets with information from direct marketing lists, online purchases, mobile phone companies and more. Who’s to know if someone will start quietly aggregating all the small chunks of our health data?

This, of course, would be illegal. As Tim Kelsey and others are keen to point out, re-identifying or leaking data in any way would be a “criminal offence”. But as this project lands, we’re all becoming rapidly aware that incompetence, malice and creepiness around confidential data is policed with a worryingly light touch. Private investigators have little trouble obtaining confidential data from staff in the police force, banks and tax offices, for example.

Here’s why: it took a long time for anyone to realise that Steve Tennison, a finance manager in a GP practice, had accessed patients’ records on 2,023 occasions over the course of a year, although this was relevant to his work on only three occasions. The majority of records he snooped on belonged to young women: he repeatedly accessed the record of one woman he had gone to school with, and that of her son. The maximum penalty for this is a fine, with a ceiling of £5,000 in magistrates courts. Tennison was fined £996, in December 2013. This is why the public feel nervous, and this is what we need to fix.

It’s painful for me to write critically about a project like care.data, because I love medical data, and I know the good it can do. We have a golden opportunity in the UK, with 60 million people cared for in one glorious NHS. Opt-outs would destroy the data, and the growing calls for an opt-in system would be worse: opt-in killed people by holding back organ donation, and more than that, it would exacerbate social inequality around data, because the poorest patients, those most likely to be unwell, are also the least engaged with services, the least likely to opt in. They would become invisible.

So here’s my advice: if you’re thinking of opting out – wait. If you run care.data – listen. There are three things the government can do to rescue this project.

Firstly, make a proper announcement about what you will do in the six-month delay. You cannot rely on blind trust when it comes to sharing private medical records, so explain that you’ll be coming back soon with a clear story. Sort out the governance framework, present unambiguous rules and principles explaining how data will be shared, list the specific clinical codes you’re proposing to upload, then give real-world examples of the kind of access applications that would be approved, and the kind that would be rejected. This is fair, and sensible.

Secondly, show the public how lives are saved by medical research. This needs examples, from the vast archives of medical research on cancer, heart disease and more. Alongside that, give a clear nod to the small risks, and an explanation of how they will be mitigated. Never be seen to give false reassurance on these risks; if you do, you will lose patients’ trust for ever.

Lastly, we need stiff penalties for infringing medical privacy, on a grand and sadistic scale. Fines are useless, like parking tickets, for individuals and companies: anyone leaking or misusing personal medical data needs a prison sentence, as does their CEO. Their company – and all subsidiaries – should be banned from accessing medical data for a decade. Rush some test cases through, and hang the bodies in the town square.

If the government do all this, they have a good chance of saving a vital data project, and permitting medical research that saves lives on a biblical scale to continue. If the government try to fudge – with half measures, superficial PR and false reassurance – then care.data will fail, and it might well bring down other sensible public health research with it. Lives are at stake. This cannot be left to the last minute in the six-month pause, and time is precious. It’s February. If you’re thinking of opting out, please don’t. But mark your diary for May.

complex adaptive systems, cool, healthcare, meaning, policy, politics, quotes & aphorisms, rapid learning health systems, research methodology

A clear head shot from Jeffrey…

Not one stakeholder group left untrashed…

Great Einstein quote – the original definition of insanity presumably:

‘The significant problems we face cannot be solved at the same level of thinking we were at when we created them’

PDF: Braithwaite Delusions of health care JRSM 2014

The medical miracles delusion

Army ants subscribe to a simple rule: follow the ant
in front. If the group gets lost each ant tracks
another, eventually forming a circle. According to
crowd theorist James Surowiecki, one circle 400m
in circumference marched for two days until they
all died.1
Humans are not ants, but we often trudge together
along the same trail, neglecting to look around for
alternatives. Mass delusions involve large groups
holding false or exaggerated beliefs for sustained periods.
Humanity has a long, sorry list of these shadowthe-
leader epidemics of collective consciousness which
appear obviously wrong only in hindsight. Some last
for centuries: early alchemists intent on transmuting
base metals into gold and the Christian Crusades of
Europe’s middle ages, for example. Others have correlates
which resurface decades or centuries later:
McCarthy’s persecution of alleged communists in
the 1950s harked back to the Salem Witch hunts of
16th century America just as the 2008 Global
Financial Crisis had much in common with the
‘South Sea Bubble’ which slashed 17th century
Britain’s GDP.
In the educated 21st century, too, we blithely trust
in economic and political systems which are stripping
the earth’s resources, altering the climate and facilitating
wars. Are we then similarly mistaken, en masse,
about the capabilities of the health system?
Most of us believe in the miracles of modern medicine.
We like to think that the health system is
increasingly effective, that we are implementing
better treatments and cures with rapid diffusion of
new practices and pharmaceuticals and that there is
always another scientific or technological breakthrough
just around the corner promising to save
even more lives; all at an affordable price.
We maintain the faith despite multiple contraindications.
Modern health systems consistently deliver
at least 10% iatrogenic harm.2 Despite very large
investments and intermittent but important interventional
successes, such as checklists in theatres3 and
clinical bundles in ICU,4 there is no study showing
a step-change reduction in this rate, systems-wide.

Only half of care delivered is in line with guidelines,5
one-third is thought to be waste,6 and much is not
evidence-based,7 notwithstanding concerted efforts to
optimise that evidence and incorporate it into routine
practice.8
The reality is that progress is slowing, and medicine
seems to be reaching the limits of its capacities.
The potentially disastrous problems of antibiotic
resistance, for example, are yet to play out. This is
only one point among many. New technologies such
as the enormously expensive human genome project
have provided only marginal benefits to date. We still
do not have the answers to fundamental questions
about the causes of common diseases and how to
cure them. Many doctors are dissatisfied and increasingly
pessimistic.9,10 It must also be remembered that
although death is no longer seen as natural in the
modern era, everyone must die. Yet, we inflict most
of our medical ‘miracles’ on people during their last
six months of life. Le Fanu describes this levelling off
and now falling away of health care progress in The
Rise and Fall of Modern Medicine.11
Every major group of stakeholders has its own
specific delusion which acts to augment the metalevel
medical miracles delusion. Thus, the overarching
delusion is buttressed by a set of related ‘viruses
of the mind’, to borrow Richard Dawkins’ evocative
phrase.12
Although politicians think and act as if they are
running things, modern health systems are so complex
and encompass so many competing interests that no
one is actually in charge. Then, bureaucrats – acting
under their own brand of ‘groupthink’ – assume their
rules and pronouncements provide top-down stimulus
for medical progress and improved clinical performance
on the ground. Yet coalface clinicians are relatively
autonomous agents, so there can only ever be
modest policy trickle down.13,14
Researchers, too, support the medical miracles
industrial complex. The electronic database
PubMed holds some 23 million articles and is growing
rapidly. Every author hopes it will be his or her
results that will make a difference, yet there is far less

take up than imagined and comparatively little
investment in the science of implementation8 – translating
evidence into real life enhancements.
Nor are clinicians or the patients they serve
immune. While frontline clinicians strive to provide
good care, many myopically assume their practice is
above average; the so-called Dunning-Kruger
effect.15,16 Of course, statistically, half of all care clinicians
provide is below average. And notwithstanding
decades of public awareness, patients believe modern
medicine can repair them after decades of alcohol,
drugs, sedentary lives and dietary-excesses, despite
evidence to the contrary.
Meanwhile, the media’s unremitting propensity to
lend credibility to controversial views and to hone in
on ‘gee whiz’ breakthroughs – while ignoring the
incremental and the routine – fuels unrealistic expectations
of what modern medicine can deliver.
Throughout history, mass delusions have been
aligned with mass desires for favourable outcomes.
In the pursuit of medical miracles all of our interests
line up in a perfect circle. We seem more like army
ants than we think.
Just as the Global Financial Crisis was a wake-up
call for the serious consequences of blind fiscal faith
we must begin to manage our expectations of the
health system. Progress is always in jeopardy when
the real problems are obscured.
The challenge is to harness the tough-minded
scepticism needed to tackle this widely held ‘received
wisdom’. One realistic way forward is to encourage
stakeholders – politicians, policymakers, journalists,
researchers, clinicians, patients – to first consider
that their own and others’ perspectives are simply not
logically sustainable. This may be achieved through
genuine inter-group discourse about the health
system, where it is at, and its limitations.
As is so often the case, Albert Einstein said it best,
in a typically neat aphorism: ‘The significant problems
we face cannot be solved at the same level of
thinking we were at when we created them’.17 If we
can humbly accept that we need new perspectives
for healthcare – and radically different ways of
thinking – we will be better placed to free ourselves
from the hold of these peculiar viruses of the mind.