Y'all didn't expect me to lurk forever in a discussion of US health
care, did you? :-))
Health systems worldwide are born of the societies in which they exist,
reflect the social contracts underlying those societies and don't seem
to transplant well unless there are changes in the system or the social
contract of the recipient country. Arguments for health care reform in
all countries seem to be a mixture of validated (and specious) research,
myth and ideology, too often with the ideology driving the research.
The problem, however, is universal: demographics, expanding technology
and rising expectations arrayed against finite resources and the whole
mess mediated by two referees who are often at odds - allocative
efficiency or utilitarianism and egalitarian liberalism or rights-based
concerns.
The differences in health care systems arise in the way in which
countries attack this problem. Beveridge style systems of tax-paid
universal coverage (e.g. UK, Nordic countries, Spain, Portugal) compete
with Bismarkian systems (Germany, Austria, France, Switzerland) of
mandatory employer-based social insurance 'almost-universal' coverage
in Europe while the US evolves a public plus regulated free market
system based on aspects of both of the above plus our fabled 'individual
responsibility'.
The CIS/CEE countries - purported to be Beveridge style - in actuality
often involved large co-payments (bribes) to achieve any coverage at
all. Most are currently attempting to move to Bismarkian employer-based
social insurance systems - with varying degrees of success.
Each and every system is currently faced with the problems Ahmad has so
eloquently listed, to a greater or lesser extent. But since no system
has yet evolved that seems to have the proper combination of allocative
efficiency and health care of a quality and quantity that satisfies the
patient, the payor(s) and the physician, we keep experimenting. Thus the
current alphabet soup in the US (HMO, PPO, POS, PSO, PHO) and the UK
(PCGs and God knows what other acronyms).
The pedantic bit being said, I'd like to address a few of the specific
points made earlier in the thread about US medicine, which, BTW and
IMVHO, does have enough problems to write volumes on - probably why so
much has been written.
Andrew writes:
Regarding US-style health care, it would be great for us doctors, 'cos
we
would make a mint, which is why all medics in the US support the system
to
the hilt. It definitely delivers a terrific standard of medicine to
those
who can afford it. The prob in the US, is the proportion of GDP health
consumes, and the very high proportion of consumers who do not have
access
to high standard health care, because they cannot afford insurance. This
would deliver the type of two-tierism that we are always so afraid of
here.
The interesting thing about the difference between the US and the UK
systems
is that there is no statistical way of proving a difference between the
health of the two populations.
Phil replies:
1) The mean income of GPs in the US in 1996 was USD 131,200 or about UKP
82,000.
Not bad, but hardly enough to properly outfit one with, quoting Toby "
new Porsches, yachts, aeroplanes…and trophy wives". BTW, if you are a
rural GP, you will work more hours, see more patients and earn 10-15%
less than your urban colleagues. Consultants do considerably better -
obscenely so in some cases IMHO. I think this is true in the UK as well.
2) There are reasons other than 'making a mint' to support a
decentralized free-market approach to medicine - clinical freedom and
patient advocacy amongst them. Most of us are not in HMOs - and
sometimes we *run* them to try to keep ahead of the guys in the green
eyeshades.
3) Only about half of the 14% of GDP spent in the US on health comes
from the public purse, which means that government spending on H/C in
the US is only slightly more than in the UK. 14% is high, but
sustainable (if we can keep it there).
4) The 12-15% of the population with no insurance coverage encompasses
those who want but can't afford it (the problematic part), those who are
wealthy enough to self-insure, those who are changing jobs and
temporarily lack employee coverage and those who can afford it but are
young, healthy, invulnerable and prefer the money to the insurance. (Not
a really good gamble, IMHO). Even in the problematic group lack of
insurance does not often equate to lack of care. This is where patient
advocacy on the part of a GP who knows the resources available can take
care of his patients. Are there those who can't bother? Of course; we
have inadequate docs here as well.
That said, would I like to see everyone covered for health care? Of
course. There is just the small problem of defining the limits of
"health care" - and deciding how it is to be financed. I am not yet
convinced that a centralized Beveridge-style system is most workable in
our society.
5) As to "two-tierism", I've made rounds on the "Nightingale wards" at
the Royal Victoria in Belfast and the Middlesex in London - also at the
Harley Street Clinic and a couple of surgeries on Harley Street. I'd
never seen an 8 foot diameter crystal chandelier in a surgery
before.:-) And it is not just amenities. When I was in NI (1992) the
medical community was anxiously awaiting the delivery of the first MRI
to this population of 1.7 million (and this with a 25% greater NHS
budget than any other HA in the UK).
6) As to international comparisons, a good point. Unfortunately, it is
attempted anyway all the time by those trying to bolster a particular
point of view. Take the oft quoted Infant Mortality Rates (IMR). Along
with the varying statistical reporting quirks country to country there
are large differences in basic definitions used in a country's
statistical reporting. "Live birth" is defined in the US as one
postpartum respiratory effort or one postpartum heartbeat. In France it
is not a "live birth" until it is registered at the appropriate
municipal office - during regular office hours - or rather, French
office hours. A birth Friday evening which does not survive till Monday
is a "delayed stillbirth" which the WHO lumps in with 'stillbirth' in
their stats for France, but under 'live birth' in the US. Many
international comparisons are so plagued.
Declan wrote:
Have a look on Medsig (sorry, it is on Compuserve but there must be an
equivalent website or usenet) and see what people there say about HMOs.
Then think about the first people to fly the flag for HMO-style medicine
in the UK---like Michael Goldsmith who set up the Harrow private thing
and ran it until it was bankrupt. Then consider things like litigation
costs and malpractice insurance costs in the USA. Consider also the %
of medical costs spent on billing. Or the higher % of GDP spent on
disease care in the USA but no better national disease etc figures. Or
the fact that until recently they could not run a decent family doctor
service.
I think I'll stop there.
Declan
Phil replies:
When you go to activist sources where ideological points are being
pressed, it is not hard to find horror stories since horrible cases
occur in all systems. Would you believe we actually trade NHS horror
stories over here :-)). The interesting question is whether one of our
several types of HMOs or competing acronyms does better than the others
- and whether the incidence of - not horror stories - but documented
bad care is lower amongst one system compared to another. I don't think
this has been done yet on much more than the horror story level.
Blaming the US H/C system for high litigation and malpractice costs is a
bit like blaming the rape victim instead of the rapist (good analogy,
that!). Now the lawyer (ooops, rapist) can say 'Well, she was just
asking for it with that short skirt and all" and indeed, some docs do
'ask for it' with poor practice, but having by far the highest number of
lawyers/population in the world and the contingency fee system plays a
major part.
If by 'billing costs' you mean the administrative costs of running a
practice, which includes the submission of too many reports to too many
entities on too many subjects, including bills to too many different
payors, I very much agree. Look out for the figures, though, for reasons
given above. I have seen between 11% and 26% depending on who is
counting for what reason.
Do I envy you who have so few worries about paperwork and administrative
hassles! Has anyone ever costed out *total *administrative costs in the
NHS? Including your time? J
As to the higher % GDP outlay with no better disease stats, the above
comments on stats applies. Mortality stats are a crude tool and do not
reflect that 'quality of life' component many are willing to pay for.
Unfortunately, even "satisfaction" can't be compared in a meaningful way
because expectations are so different in different cultures. I do know
that the importation of 18 month waiting lists for, i.e., hip
replacement (Vs 1 month) or MRI (Vs 2-3 days here for elective stuff)
would cause the locals here in Boston to start heaving physicians into
the bay instead of chests of tea. But this is changing: wait till your
culture comes to expect the level of medical miracles expected here!
Latest argument - is it ethical to withhold state funded Viagra from
nursing home patients just because they are old? ("ageism"). (We've
already allowed it for the young poor on Medicaid - why not the old as
well?) The ancillary questions of how many erections per week should be
supported in an 85 y/o and upon whom these should be utilized have yet
to be settled. Penetrating legal issues (and lawsuits) will be raised,
and barriers erected, depend on it.
As for the "decent family doctor service", I haven't the foggiest; we
don't have any, so far as I know. (Unless you mean family docs in the US
are finally learning some medicine? :-).)
Toby writes:
Mmm. Food for thought. In that case why don't we go over to the US
system and have new Porsches, yachts, aeroplanes, houses with swimming
pools and trophy wives with expensive plastic surgery?
Phil replies:
So far I'm 0 for 5. What a miserable failure! Only yachts I get on are
by invites from consultants. (Well, trophy wife for 26 years, but no
plastic surgery).
Ahmad writes (and writes and writes… :-))
7. Move towards USA style health care through HMOs, managed care and
hyper-surgeries
Phil - Please remember that the three alternatives here constitute only
a part (sadly, growing) of US medicine.
- family doctors set up shop in areas where their services are needed
- their surgeries often become the focal point of the community
- you know you can always go to your doctor's and that the door will
be open
Phil - Yes, this is the rural medical household I was raised in and
tried to continue.
Yes, it is becoming more rare, especially in the cities.
- this is because your family doctor is on your side and does not have
to worry too much about questions of profit and loss
- your doctor just does what is best for you
Phil - Odd, but these are two of the myth/arguments we use against the
NHS style system of capitated payment vs. fee-for-service, where we are
accused of doing too much for patients to reap higher fees.
- lumping doctors together in large unwieldy organisations has many
benefits for the accountants and managers
- this because the hyper surgery can be run more efficiently
- how many times did you hear that before!
Phil - the song is familiar - like fingernails on a chalkboard.
- you will just have to go where that hyper surgery happens to be and
not only that you won't be able to see your own family doctor, you may
not even get to see a doctor at all!
- this is because some bureaucrat would have decided to put your case
to 'the team'!
- that team will include doctors and nurses, yes, but it will also
include social workers and other people you have never dreamt of giving
information about your health to
- this large bureaucratic organisation will have too many masters to
please
- it will always be worried about expensive things and will look to
buy things on the cheap or it might even cut corners when it comes to
serving you!
Phil - I would have thought these problems were already characteristic
of the NHS. I certainly sat in on enough 'team approach' conferences in
GP surgeries where the docs were outnumbered.
- the whole idea of lumping family doctors together whether they like
it or not is to be able to control and manage them
Phil - plus ca change….
- in America, family doctors are always under pressure not to spend
too much. They even get penalised if they do and rewarded when they
don't!
Phil - No, Ahmad - this is true for those who work in some types of
HMOs. - still, happily - the minority. Most GPs here are still accused
of having a perverse incentive to spend too much on patients under the
fee-for-service system. One of the proposed solutions to this perceived
overgenerous FFS system is to make GPs risk bearing by capitation, (a la
the NHS), making a physician's income dependent on spending fewer
resources (time and money) on the patient.
- would you like your family doctor to be under the same pressure?
Phil - NO.
Cheers,
Phil
--
Philip G. Dunlap, D.O., M.P.H., Ph.D.
4 Bailey Hill Road
Natick, MA, 01760, USA
[log in to unmask]
(508) 650-9097 - voice
(508) 650-9152 - fax
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