Healthcare
File: c:/ddc/Angel/BestIntentions/Healthcare.html
Date: Mon Jan 14 19:41:08 2008
Fri Jun 06 21:50:09 2008
Sun Jan 10 15:43:29 2010
Thu Aug 23 14:10:11 2012
Mon Jul 21 20:37:12 2014
(C) OntoOO/ Dennis de Champeaux
Soft physicians create stinking wounds.
(Old Dutch proverb)
It is probable that we could either halve or double the money now being spent
on health without significantly affecting our longevity.
(W.H. Forbes, New England Journal of Medicine 277:71 (1967))
If you think health care is expensive now, wait until you see what it
costs when it's free!
(Anonymous)
This chapter was written before Obamacare was enacted. Nothing has changed in a sense at a high level. Except what was called "benefits" provide by companies became yet another tax on them. In addition, the out of control price-tag of healthcare, in terms of percentage of GDP, increased further to around 20%.
Healthcare is a necessity that must be dealt with at all levels. Individuals are concerned with personal worries. The society at large struggles with optimum care for acceptable costs compatible with high ethical standards. All stakeholders in all nations are faced with continuous changes because no system has been found that satisfies all parties, while medical advances for newer practices keep introducing newer problems due their hefty price tags and/or with ethical conundrums.
The medical 'machine' is a large system, discussed all the time, by
many experts and we can only touch on a few topics. Our topics fall
into two categories:
- Issues with the supply side of healthcare, and
- Topics with the demand side ranging from individuals to the society
Before diving into the fray, we must mention the amazing progress made in the previous century. Longevity is on the rise worldwide from less than 30 in 1900 to over 70 in 2000. Infection diseases, a major killer, has been pushed back with better hygienic practices and by the availability of antibiotics, which we hope will be used more prudently to preserve its magic. Surgery with none or minimal blood loss has become routine due to increasing professionalism. Patient-type customized drugs are in the works. Medical knowledge has increased explosively and we understand the bio-chemical mechanics of the body way better. More and more diseases can be traced back to gene complexes. We see the glimpses of the potential of stem cells. Surgeons have developed minimal and even non-invasive techniques. Remote controlled robots allow more precise interventions. The manipulation of genes - with their pros and cons - open up possibilities that will go way beyond we can consider at this junction.
Lets return to the current realities, more US specific than the other chapters.
We include at the demand side those that pay for the services. Employers have been offering benefits since the Second World War, supported by tax incentives. The public sector participates also at the demand side with the federal government paying for services through Medicare, Medicaid and the Veterans benefits and local governments through subsidized community hospitals, and programs like Medi-Cal.
The public sector participating at both sides is a warning flag. Bureaucracies need continuous trimming to fight bloat. Trimming a large regulatory and administrative organization for healthcare has failed thusfar because 'unlimited' amounts of tax monies are feeding it.
A physician needs, obviously, good people skills, which entails more and more treating patients as competent adults. People skills were in the past likely the most important requirement for a good physician. Now physician must be also an expert, abstract information problem solver. Information technology has penetrated the society in the previous decades and has transformed virtually every segment: except medical diagnosis. That does not mean that people skills are less important. People skills are in need more than ever, because nowadays the patient is more informed and has undergone a change of attitude that the physician has to deal with.
The term 'hypochondria' was introduced around 1600. It stands for being overly concerned about one's health condition, a specific version of paranoia. The medical profession has now coined the term 'cyberchondria', which is hypochondria facilitated by web searches. This condescending term is a sad defense against the public becoming more self-responsible due to unfortunate experiences with physicians making wrong decisions (4-10% wrong diagnosis - personal communication). We do not have yet the term 'cyberphobicdoc' and hopefully the medical community will soon 'partner up' with information power tools to improve the quality of their services.
Information technology to support diagnosis is just one functionality that is lacking. Electronic patient records, eRecords, have been under discussion since the 70-ies. They are still not standard practice. Concerns about privacy are a pleasant, unreal, excuse for their absence. They would eliminate misunderstandings between the different experts dealing with a patient.
Drug interaction conflicts are another problem that would disappear with the availability of eRecords. A physician prescribing a drug for a patient using a smart device would obtain instantaneous feedback in case of a conflict (which could be overruled if warranted). A pharmacist is at this junction typically the watchdog for drug interaction conflicts. Their decisions are vulnerable due to the absence of eRecords. Credit card size info units (carried by patients) were discussed already over twenty years ago. Such a card would contain the total health history of the patient. Memory sticks with a few gigabytes would be a fine alternative.
The universal availability of eRecords is long overdue. What is the answer of the medical establishment if it is accused of gross negligence that is costing substantial damages, including loss of life, due to preventable mistakes? Transparency is increased by eRecords. Physicians providing quality work need to agree that lousy colleagues, currently able to hide, must be flushed out.
Electronic messaging has been around for 40+ years. It has only recently become possible for a patient to contact the own primary care physician. Counter forces can still hamper technical progress. The Netherlands blocked effectively patient-physician messaging by prohibiting a physician to be reimbursed for tele-advice when the patient reports a new concern. The permitted charge for acceptable tele-advice is just half of the charge for an office visit. Physicians are obviously not keen to provide messaging at all given what the iron fist of the Dutch government has ruled. Whether or not lobbying by physicians themselves has produced this situation is anyone's guess. This ruling resembles what happened from North Africa to Afghanistan in the time of the Romans. Maintained roads supported transportation by oxcarts. Transportation shifted around AD 500 to the use of camels and roads were not maintained any longer. It took thousand years before roads and wheeled transportation was introduced again. Why? A tax ruling in Palmyra Syria to favor camel drivers made usage of oxcarts non-competitive. Lets hope that the situation in The Netherlands does not last a millennium.
The license of a pilot expires if refresher courses are not taken. Good idea for physicians too. Surgeons need even more rigorous periodic re-evaluations.
How does one select a new primary physician, dentist or a surgeon for a needed intervention? One can ask one's friends, but so what? Some must be better than others. Shopping around does not work. They do not advertise their prices. There is no public database that describes the experiences of patients for a physician.
Seidman, in [Seidman], proposes that a patient fills in a postcard after each encounter that will be processed by an independent organization that maintains a public database. However, we must be careful here. Remember the problem with "failing schools"? Schools recruit their children from regions with different native cognitive skills. Hence a school's results must be calibrated against its input. Same story for the responses to a physician performance. Patients may be 'enlightened' or may be resentful, they may be relatively healthy or they may have multiple chronic conditions, they may be relative young or they may be seniors. Thus a physician's (and organization's) 'report card' must be calibrated against a comparable basket of clients and should be accompanied with a characterization of the clientele.
Still, why are there no price tags? This topic goes both ways. Superior physicians cannot be reimbursed for their superior service. The public cannot select value for price. The latter is 'sensitive' - as we will elaborate below.
Diseases are not fairly distributed over the population. As a rule of thumb we have that 20% of the people account for 80% of the need for care. To make matters worse, those patients can have more than one condition that requires attention. Lawrence wrote a whole book [Lawrence] advocating a team approach to take care of those type of patients. These teams are different from traditional teams. They need to be assembled, temporarily, for a specific patient. Thus a physician may have to participate in multiple, patient-centered teams. Physicians are traditionally not team players, they were hero soloists, adored by patients who's lives were saved. The education of physicians in The Netherlands has started the incorporation of working in teams. However, for such a team to function properly there is a missing component: the patient's eRecord accessible by all members on a patient's team, so that all members are 'on the same page'.
The quality of medical staff has decreased in the previous decades as described by Seidman, [Seidman]. Experiences of his wife in 2004 as an outpatient at Kaiser Permanente are described in detail. She dealt with nine of their physicians (all named) who failed to diagnose her correctly, prescribed 'absurd' medication and even declared her to be depressed. A physician outside of Kaiser solved her problem. This has a happy ending. Not so for those (also named) who recently died in Kaiser hospitals due to errors, for which Kaiser was "sorry". The details are very worrisome.
The Dutch press reported in 2007 November that over 40% of the nursing staff has a deficiency to do calculations. Thirty percent of those interviewed admitted having made calculation mistakes for giving medications. Fifty percent knows colleagues making mistakes as well. Here we encounter cognitive decline in action, as we alluded to in the chapter on Public Education.
The medical profession is quite closed. After gaining trust, one can get inside stories. We do not want to breach the trust by providing details. It suffices to say that negligence and arrogance in this profession leads to the equivalent of manslaughter, hidden from the public. A Dutch 2007 report estimated 1500 yearly deaths due to mistakes. [The population size is 16M. The discussion in the press about traffic fatalities (811 in 2006) is going on for decades. There is no discussion about the medical fatalities.]
| 1878 | lung tumors are 1% of all cancers seen at autopsy in the Institute of Pathology of the University of Dresden |
| 1918 | 10% |
| 1927 | 14% |
| 1929 | Fritz Lickint published a paper in which he showed the relationship between smoking and lung cancer |
| 1940 | Nazi Germany paper by Muller shows again the relationship |
| 1949 | An American student reports the same |
| 1950 | Doll and Hill in England arrives at the same conclusion |
| 1964 | Surgeon General of the US recommends: stop smoking |
| 1999 | 158,900 deaths in US, over 1 million worldwide/ year |
In short, there is a 35-year time lag between the first known publication about the relationship between smoking and lung cancer and the recommendation to stop smoking. What did the medical community do in the intervening period? Earning money by treating patients. What have they done since 1964? Earning more money. We have been suing cigarette producing companies now for decades. Why have we never held the medical community accountable for their lack of professional responsibility to urge prohibiting a lethal drug that costs the society dearly in lost lives and in expensive treatments?
Demographic case:
| 1900 | World population at 1.6B |
| 1972 | MIT world simulation study predicting dire consequences for the 21st century due to the combination of population growth, pollution and resource exhaustion [Meadows] |
| 1980 | World population at 4.4B surpasses the Earth's capacity to feed the population without using fertilizer, which depends on cheap energy [Meadows2] |
| 2000 | World population at 6B |
| 2006 | World wide acknowledgment that climate changes is real and has already had impact with widely felt disastrous consequences [Gore] |
| 2007 | Medi-Cal pays for 46% of all births in California [Medi-Cal] |
| 2011 | World population at 7B |
In short, physicians have been earning money by delivering babies at ever increasing rates. No professional organization of physicians has participated in the sustainability discourse regarding the world's demographics. Welfare state entitlement side effects causing the deterioration of their gene pools has been ignored by them as well [Dawkins].
The appendix has a news item regarding a woman without a partner, who was "obsessed with having children since she was a teenager", and which had six children through in vitro fertilization. One of the six children is autistic. This woman wanted to have more children and she delivered an octuplet, also through in vitro fertilization. The author goes out of her way to avoid critiquing this situation, except by quoting the grandmother and using the journalistic trick of an anonymous source: "Others worried that she would be overwhelmed trying to raise so many children and would end up relying on public support."
Bypassing the question why this woman's peculiar ego caused her decisions, the questions remain why her requests were honored by the medical professionals involved, and why does the society allow this scenario to unfold in the first place? Why should these extravagant behaviors, which are detrimental to the society, be funded by the taxpayer? Sin tax addiction:
The introduction of Medicare in the sixties entailed determining for each state what procedures were common and the proper reimbursement level for these procedures. It turned out that medical practices varied widely, which could only be explained by systemic local fraud. The HMO/PPO layer was created to keep on eye on the billing stream. The medical community has complained since then about having to justify planned procedures, which proves that the oversight function works. The problem now is that the HMO/PPO layer itself has grown out of control.
The states and the federal government jointly fund Medicaid, a 'small' but typical program. It reimburses hospitals and physicians for providing care to qualified people who cannot finance their own medical expenses. Seidman calculates in [Seidman] that the administrative overhead, including outsourcing, of the Medicaid program in 2003 was $63B, being 29% of the total expenditures.
| Population segment | Size | Total use | Average use per member |
| Total population | 280M | $1.4T | $5K |
| Medicare & Medicaid | 41M | $442B | $10.7K |
| Insured | 194M | $883B | $4.3K |
| Uninsured | 45M | $125B | $2.8K |
We need to add that the uninsured paid out of pocket $733; the balance is being paid from other sources. Diminishing the plight of the uninsured is not our goal here, but we do want to suggest that the non-stop drumbeat by politicians about the uninsured has deflected attention away from the out of control US price tag that is twice as much (as percentage of GDP) than, for example, Japan, which, moreover, delivers better quality to its population.
That being squared away, we must focus on those who are insured: 235M people out of a population of 280M (currently above 300M indeed). While employers demand increased contributions from employees, the employees are still subsidized and have favorable group rates. The 65+ segment is heavily subsidized as well by Federal programs. In addition, consumers have been herded in large programs in which virtually anonymous healthcare suppliers are hardwired as well. In other words, consumers cannot use their spending money in a transparent market where suppliers compete for eager clients.
Lack of consumer-supplier market forces explains to a great extend the problems we encountered at the supply side: there are no forces in place for suppliers to innovate, to advertise a superior track record, to go the last mile - in marketing lingo.
However, this is not the full story: Why have nations created arrangements where these market forces are absent?
Societies are still struggling with the consequences of both sources
of unfairness. Insurance is the standard solution for obtaining
protection against 'acts of gods'. A simple solution would be that an
insurance company would not be allowed to distinguish applicants
regarding age, gender, claim history, etc. This solution is actually
not simple. We have still the following fundamental problems:
-P1- What is to be done for those who cannot afford premiums?
-P2- What is to be done for those who do not sign up, who need
services anyway and cannot pay?
-P3- Too many people have imprudent lifestyles. How do we deal with
the consequences for society of these choices?
The first two problems are well known and are discussed all the time. The third problem is a composite of two distinctly different topics, which are typically too sensitive for public discourse. We need to disentangle them here anyway, and we label them P3A and P3B.
The P3A problem consists of imprudent lifestyle choices that have direct impact only on the person that makes these choices. Typical examples are: smoking, drinking, gluttony, risky sports, reckless driving, dangerous sexual practices, etc.
An increasing segment of the population in welfare states are overweight. A medical intervention was denied to a patient in the UK due to being overweight. Should we broaden denials to other imprudent lifestyle choices?
A patient received a $200K heart bypass surgery and was smoking again while still recovering. Should insurance companies exclude payments for these type of patients?
The P3B problem consists of putting children in the world that cannot be sustained without support from the society. This problem is way more controversial and intractable than all the other ones combined.
A 2009 November news snippet claims that the stigma of food-stamps has faded while: "The food (program) ... helps feed one in eight Americans and one in four children." [NYT] Why did the parents put these children in the world is an impossible question to articulate these days, but requires careful pondering anyway.
Charity was traditionally - and to this day as well - helping those that have fallen on hard times. Most societies have taken the lead by passing laws so that taxes can be channeled to support those in need. These solutions work satisfactory when we ignore the long term side effects. However, we need to have a closer look at its impact on the P3B problem. Those who produce children, which need assistance for their survival, are statistically the least successful to function in the modern society. Due to statistic heritability of physical and cognitive traits their children will statistically also belong to the least successful [Pinker]. If this group procreates faster and relatively more, the society contains a negative feedback loop.
Why bother? Who cares? Society takes care of these children anyway, right? Well, those who put children in the world who need assistance is not limited to, say, teenagers, unwed mothers, recent immigrants, or any other favored minority. By now, after several generations have been going through the feedback loop, it is a great majority of the population in the welfare states. That is hard to believe for sure.
The following US statistics support our claim:
- 95% of those paying federal income tax pay only 39% (2007) of what is
collected and hence a large majority has subsidized social services
for, among others, healthcare and public education
- The average family received in 2006 $3,000 more in services than it
paid in taxes [AARP]
A Dutch report [CPB] devoted to the graying of the society mentions in passing:
In fact, this study finds that future generations will still experience a positive net benefit from the government; they receive more in the form of expenditures (education, pensions, etc.) than they contribute through taxes and social security contributions. In the baseline projection for sustainable policies, future generations can expect a positive net benefit of about 7% of their lifetime wealth. For the generation born in 2006, this amounts to some 56,000 euro in present-value terms per person, corresponding to a yearly 'benefit' of roughly 1800 euro.The average Dutch citizen being economically net-consumers is presented in a positive way through the perspective of the beneficiary's benefits (which is about $2,500/person, substantially more than in the US). The Dutch society achieves this generosity through being a natural gas exporter, by the usual taxation on companies and by substantial taxation on the top 10%: 53% of the total (1999). A (naive?) proposal to use immigrants to help pay for the 65+ population was critiqued because the average citizen is already a cost to society.
In short: the institutionalized compassion of helping those in need without strings attached has fueled a negative feedback loop, which has increased the need for assistance to the point where a great majority is not self sufficient any longer.
The negative feedback loop we have described is not the full story of why majorities now need extensive system assistance. The Economy chapter describes other forces.
The Netherlands went in 2006 through a reorganization. Everyone has mandatory insurance. Financial assistance is available for those who cannot pay premiums. Employer contributions to premiums remain mandatory. Waiting lines have been increasing. Those in the 20-30 age bracket have the highest rate of failing to pay the mandatory premiums.
The US has a mixed system with (nearly free) care for the 65+ population and voluntary contribution to premiums by large and midsize companies. Companies are shifting the costs gradually to the employees due to exorbitant premium increases in the previous decade. This is causing an increase of the number of people without insurance. Politicians try to 'fix' the situation with legislation, which basically introduces another tax for companies. These maneuvers lead to extensive discussions and a never-ending stream of opinions in the media, but, as mentioned above, it deflects attention away from the 'crazy' price tag of US healthcare (16% of GDP, 2008). Really sad is that the nation's gigantic yearly expenditure of now over $2T is not yielding superior results. Instead it fuels a large ring of administrators, bureaucrats, regulators, etc. of 'vultures' that circle around those that provide care, who are themselves stuck in dysfunctional patterns. The title of Seidman's (a retired neurosurgeon) [Seidman] is a horrendous summary: "Inevitable Incompetence, Soaring Medical Costs, Dangerous Medical Care".
The situation is the same at the demand side. Employers cannot offer those services to their employees due to conflict of interest. The public sector does not worry about cost control because they are at both sides of the equation and the money is produced by taxation anyway. The public pays nothing beyond token co-payments and hence is also not motivated to pay for a self-help service.
Politicians are good in creating new entitlements but cost saving is not their department.
The Great Depression justified the introduction of social security, which helped the poor to have a decent income after retirement. Social security not being a pension system allowed the premiums to be artificially low for decades until the population explosion subsided, thereby causing the sudden panic that the system will go bankrupt - a scenario conveniently ignored for half a century.
The Second World War required to keep wages low and justified an employer paid healthcare system for the employees and their families. The omission of a sunset clause for this arrangement has been crucial for subsequent developments.
The elderly had trouble in the 50-ties paying for health insurance (which was only 5% of GDP in 1950). Social security benefits were insufficient, [Medicare1964]:
A 1964 Senate study estimated that only 50 percent of the policies issued to retirees provided comprehensive coverage (75 percent or more of the average hospital bill), meaning only 1 in 4 older Americans had adequate hospital insurance protection.The solution was a replication of the Social Security, pay-as-you-go, pseudo taxation system. While the need was obvious, not everyone was in full agreement, [Medicare1965]:
Senators and administration officials alike understood that they were "legislating in perpetuity" and would face strong pressures to expand the program (U.S. Senate Hearings 1965: 134). They also knew that Medicare would create a vast new public dependence on the federal government for financial security in old age, continuing the pattern set by Social Security in 1935. Senator Mundt (R., S.D.) described it as "another step toward destroying the independence and self-reliance in America which is the last best hope of individual freedom for all mankind" (U.S. Cong. Rec.-Senate 9 July 1965: 16122).This was another step to reduce financial self-responsibility: saving a nest egg for old age, or alternatively shifting looking after one's parents to the society.
Rigorous process improvement processes - widely applied in other disciplines - have not yet been discovered in the healthcare field.
Standardization, computerization and process improvement are huge opportunities to improve quality and reduce costs.
Finding the 'sweet-spot' between these two extremes is yet another huge opportunity. It is quite unlikely that a system can be invented once and for all that realizes the sweet-spot because there are multiple stakeholders and the surrounding society is never stable. Large corporations deal with this phenomenon by frequent reorganizations using - in essence - process improvement processes. Nations must do the same to avoid, for example, the fate of the out of control situation in the US with its 18% of GDP devoted to healthcare.
These decisions have the side effect that market forces driven by the public disappeared. Some believe that this is the cause for the out of control US expenditures and they propose to give control back to the consumer. Brook recommends in [Brook]:
The solution to this ongoing crisis is to recognize that the very idea of a "right" to health care is a perversion. There can be no such thing as a "right" to products or services created by the effort of others, and this most definitely includes medical products and services. Rights, as our founding fathers conceived them, are not claims to economic goods, but freedoms of action.This proposal is 'social fiction' given that a great majority of the US population is currently directly or indirectly subsidized (by employers and entitlement programs that are funded by taxes) for obtaining social services. The general public can therefore not play the role of individual consumer in a healthcare market.You are free to see a doctor and pay him for his services--no one may forcibly prevent you from doing so. But you do not have a "right" to force the doctor to treat you without charge or to force others to pay for your treatment. The rights of some cannot require the coercion and sacrifice of others.
By contrast, the rejection of the entitlement mentality in favor of a proper conception of rights would provide the moral basis for real and lasting solutions to our health care problems--for breaking the regulatory chains stifling the medical industry; for lifting the government incentives that created our dysfunctional, employer-based insurance system; for inaugurating a gradual phase-out of all government health care programs, especially Medicare and Medicaid; and for restoring a true free market in medical care.
Such sweeping reforms would unleash the power of capitalism in the medical industry. They would provide the freedom for entrepreneurs motivated by profit to compete with each other to offer the best quality medical services at the lowest prices, driving innovation and bringing affordable medical care, once again, into the reach of all Americans.
Private sector companies are forced to always scrutinize overhead expenditures. Hence it is no surprise that employers confronted with double digit premium increases during the last decade are slowly dismantling the free/ subsidized medical benefits offered to their employees.
The public sector is not subject to the financial discipline of the private sector. Confronted with increased billings and bureaucratic bloat it has relied for a long time on increasing the taxes on companies and on a shrinking minority of the public.
This still does not explain the difference between the US's 18% fraction of its GDP and what other welfare nations devote to healthcare. At this point, we can only conjecture that the US is, or was, more affluent than other welfare nations so that it could afford giving 6% of the workforce 'meaningful' work in 'medical administration'. Whether this conjecture holds water or not, reducing administrative overhead is yet another major opportunity to fix US healthcare.
However, half a century later we witness the consequences of unconditional entitlements: the need for assistance has increased to a majority of the population due to the implicit 'right' to procreate at the expense of the society.
The longer we postpone addressing these side effects, the more difficult it will be dealing with the consequences.
[Brook] Brook, Y., The Right Vision Of Health Care, http://www.forbes.com/business/2008/01/08/health-republican-plans-oped-cx_ybr_0108health.html
[CPB] Ageing and the Sustainability of Dutch Public Finances, 2006 March, http://www.cpb.nl/nl/pub/cpbreeksen/bijzonder/61/bijz61.pdf
[Dawkins] Dawkins, R., "The Selfish Gene", Oxford University Press, 1976 & 1989 & 2005.
[Gore] Gore, A., "An Inconvenient Truth", Rodale, 2006.
[Heritage] Lips, D., Heritage Foundation, 2006 http://www.heritage.org/Research/Education/EdNotes42.cfm
[Lawrence] Lawrence, D.G., "From Chaos to Care: The Promise of Team-Based Medicine", ISBN 0-7382-0859-0, 2002.
[Meadows] Meadows, D, "The Limits to Growth", Universe Books, NY, 1972.
[Meadows2] Meadows, D., J. Randers & D. Meadows, "Limits to Growth, The 30-Year Update", Chelsea Green Publishing Company, 2004.
[Medi-Cal] http://www.chcf.org/documents/policy/MediCalFactsAndFigures2007.pdf
[Medicare1964] http://www.medicarerights.org/maincontenthistory.html
[Medicare1965] http://www.cato.org/pubs/journal/cj16n3-3.html
[NYT] http://www.nytimes.com/2009/11/29/us/29foodstamps.html?hp
[Pinker] Pinker S., "The Blank Slate, The Modern Denial of Human Nature", Penguin Books, 2002.
[Seidman] Seidman, S.W., "Inevitable Incompetence, Soaring Medical Costs", Dangerous Medical Care, Universal Publishers, 2007.
[Tax] DISTRIBUTION OF CERTAIN FEDERAL TAX LIABILITIES BY INCOME CLASS FOR CALENDAR YEAR 2000, http://www.house.gov/jct/x-45-00.pdf
[Witschi] Witschi, H., "A Short History of Lung Cancer", http://toxsci.oxfordjournals.org/cgi/content/full/64/1/4
Grandma: Octuplets mom obsessed with having kidsBack to index
By RAQUEL MARIA DILLON LOS ANGELES (AP) - The woman who gave birth to octuplets this week conceived all 14 of her children through in vitro fertilization, is not married and has been obsessed with having children since she was a teenager, her mother said. Angela Suleman told The Associated Press she was not supportive when her daughter, Nadya Suleman, decided to have more embryos implanted last year. "It can't go on any longer," she said in a phone interview Friday. "She's got six children and no husband. I was brought up the traditional way. I firmly believe in marriage. But she didn't want to get married." Nadya Suleman, 33, gave birth Monday in nearby Bellflower. She was expected to remain in the hospital for at least a few more days, and her newborns for at least a month. A spokeswoman at Kaiser Permanente Bellflower Medical Center said the babies were doing well and seven were breathing unassisted. While her daughter recovers, Angela Suleman is taking care of the other six children, ages 2 through 7, at the family home in Whittier, about 15 miles east of downtown Los Angeles. She said she warned her daughter that when she gets home from the hospital, "I'm going to be gone." Angela Suleman said her daughter always had trouble conceiving and underwent in vitro fertilization treatments because her fallopian tubes are "plugged up." There were frozen embryos left over after her previous pregnancies and her daughter didn't want them destroyed, so she decided to have more children. Her mother and doctors have said the woman was told she had the option to abort some of the embryos and, later, the fetuses. She refused. Her mother said she does not believe her daughter will have any more children. "She doesn't have any more (frozen embryos), so it's over now," she said. "It has to be." Nadya Suleman wanted to have children since she was a teenager, "but luckily she couldn't," her mother said. "Instead of becoming a kindergarten teacher or something, she started having them, but not the normal way," her mother said. Her daughter's obsession with children caused Angela Suleman considerable stress, so she sought help from a psychologist, who told her to order her daughter out of the house. "Maybe she wouldn't have had so many kids then, but she is a grown woman," Angela Suleman said. "I feel responsible and I didn't want to throw her out." Yolanda Garcia, 49, of Whittier, said she helped care for Nadya Suleman's autistic son three years ago. "From what I could tell back then, she was pretty happy with herself, saying she liked having kids and she wanted 12 kids in all," Garcia told the Long Beach Press-Telegram. "She told me that all of her kids were through in vitro, and I said 'Gosh, how can you afford that and go to school at the same time?"' she added. "And she said it's because she got paid for it." Garcia said she did not ask for details. Nadya Suleman holds a 2006 degree in child and adolescent development from California State University, Fullerton, and as late as last spring she was studying for a master's degree in counseling, college spokeswoman Paula Selleck told the Press-Telegram. Her fertility doctor has not been identified. Her mother told the Los Angeles Times all the children came from the same sperm donor but she declined to identify him. Birth certificates reviewed by The Associated Press identify a David Solomon as the father for the four oldest children. Certificates for the other children were not immediately available. The news that the octuplets' mother already had six children sparked an ethical debate. Some medical experts were disturbed to hear that she was offered fertility treatment, and troubled by the possibility that she was implanted with so many embryos. Others worried that she would be overwhelmed trying to raise so many children and would end up relying on public support. The eight babies - six boys and two girls - were delivered by Cesarean section weighing between 1 pound, 8 ounces and 3 pounds, 4 ounces. Forty-six physicians and staff assisted in the deliveries.