Scotland's healthcare system doesn't suck!

[Rolfe]

The boards also are full of the "horrors" of the UK's system and how terrible it would be to have that in the States.

Now this is one reason I started this thread. Feel free to link!

Rolfe.

 

[Rolfe]

Generally, life saving medical care is never denied for any reason. Usually, an insured person would be covered in full for such treatment, minus deductibles and copays. An uninsured person would receive it, and go bankrupt.

The biggest problem that would arise after the fact would come in a case where the insurance company claimed that there was a less expensive procedure that would have been good enough, at least according to the insurance company. In such a case, they would refuse to pay. You would have a chance to appeal that decision, providing documentation for why that procedure was necessary under the circumstances, but rest assured that "my doctor said so" will not be considered an adequate response. If they turn down that appeal (and it is the insurance company that judges the appeal), then you can sue, except that in most cases part of your contract is that you can't sue, but you can submit your case to binding arbitration.

Bottom line: If there's a doctor saying that this procedure is necessary to save your life, you will almost certainly get the procedure. Of course, you might not have a house to come to when you are released from the hospital, but those cases are pretty rare for those who have insurance.

I'm still not sure about this. You have an uninsured person, and they have flu, and they're in serious respiratory difficulty. You've done all you can so far as regular treatment goes, but the patient continues to deteriorate. Do you sigh in resignation and let it go, or do you move heaven and earth to get this patient transferred to the central unit that has the facility to carry out this very rare procedure?

I may be wrong, but I have a feeling that the former might just be the more likely approach.

Also, if such a transfer (for an insured patient) is a matter of extreme urgency, maybe in the middle of the night, would the insurance company demand that the patient's life be endangered by waiting for authorisation to go ahead?

Rolfe.

 

[The Mutha]

Now this is one reason I started this thread. Feel free to link!

Rolfe.

I've emailed Helen asking her for specifics and I'll get back to you. She's off today, picking up the Enbrel ($50 co-pay for a month's supply), getting her second son enrolled in high school and her oldest enrolled in college.

ETA (Sister's response):

The first board I found is
http://www.spondylitis.org/patient_resources/main.aspx. The second board is http://www.kickas.org/. I tend to pay attention to the people who can cite research and seem pretty involved in their care and diagnosis but also level-headed about what they're dealing with. There are a lot of people on the first site who spend way too much time wallowing in how awful it all is, and a lot of people on the second site who are convinced that medicine is evil while being willing to take every supplement that comes their way.

This guy's posts are ones that I tend to actually read for instance...

http://www.kickas.org/ubbthreads/showflat.php?Number=355692

 

[Lisa Simpson]

I'm still not sure about this. You have an uninsured person, and they have flu, and they're in serious respiratory difficulty. You've done all you can so far as regular treatment goes, but the patient continues to deteriorate. Do you sigh in resignation and let it go, or do you move heaven and earth to get this patient transferred to the central unit that has the facility to carry out this very rare procedure?

I may be wrong, but I have a feeling that the former might just be the more likely approach.

I doubt any doctor would sigh in resignation and let it go.

Also, if such a transfer (for an insured patient) is a matter of extreme urgency, maybe in the middle of the night, would the insurance company demand that the patient's life be endangered by waiting for authorisation to go ahead?

The doctors would send the patient ahead and then the patient would be forced to cough up the money later. Every insurance I've had (all PPOs, not HMOs) emergency services do not require authorization.

 

[Undesired Walrus]

Any word on the condition of this woman?

 

[Leif Roar]

The doctors would send the patient ahead and then the patient would be forced to cough up the money later. Every insurance I've had (all PPOs, not HMOs) emergency services do not require authorization.

How exactly is emergency services defined? Does it cover all immediate, life-saving treatment?

 

[Lisa Simpson]

How exactly is emergency services defined? Does it cover all immediate, life-saving treatment?

For my insurance (Anthem Blue Cross of California), yes. Obviously, I cannot speak to every insurance company across the country.

 

[Delscottio]

For my insurance (Anthem Blue Cross of California), yes. Obviously, I cannot speak to every insurance company across the country.

Apologies if it seems like you're getting a grilling about your insurance but could the company dispute you needed the treatment / any part of the treatment and refuse to pay?

 

[The Mutha]

Okay, heard back from the sister, don't know if the SI fusing thing is valid in the UK or not...

****************

The difference that I can see is that the US doctors will use it almost prophylacticly (sp), while the UK requires x-rays to show fusion in the SI joints. I think technically, despite having the HLA-B27 gene, noticeable damage to the spine on an MRI, calcifying tendonitis in both shoulders, arthritic damage in the c-spine, swelling in multiple joints, and incredibly high SED and CRP rates, because my sacroiliac joints are painful but not fused, I probably wouldn't get an AS diagnosis in the UK until the joints do visibly fuse on an x-ray.

From talking to my rheumatologist, she's really worried about UHC because right now, she can put the diagnosis in and it's highly unlikely that someone will go rummage through her medical records. Once they're computerized, though, she will lose that ability to make a diagnosis that doesn't meet certain strict criteria. So her thinking is that by treating me proactively she can delay the damage and hopefully reduce my pain now, but once the records are electronic, someone presenting with my same symptoms may have to be treated much less aggressively, and may have a lot more quality of life issues.

***********

My sister is definitely in favor of a UHC plan, for the record.

 

[Rolfe]

Any word on the condition of this woman?

I heard a short update at the end of the news about 45 minutes ago. They gave her name, and where she's from. "Her family said she is getting the best possible care but she is still gravely ill."

Here you are.

Rolfe.

 

[Lisa Simpson]

Apologies if it seems like you're getting a grilling about your insurance but could the company dispute you needed the treatment / any part of the treatment and refuse to pay?

Well, I have a list of procedures that are subject to post-service review. Glancing through it, they do not look like life-saving emergency procedures. However, it does use big medical words that I don't understand.

 

[Agatha]

Okay, heard back from the sister, don't know if the SI fusing thing is valid in the UK or not...

****************

The difference that I can see is that the US doctors will use it almost prophylacticly (sp), while the UK requires x-rays to show fusion in the SI joints. I think technically, despite having the HLA-B27 gene, noticeable damage to the spine on an MRI, calcifying tendonitis in both shoulders, arthritic damage in the c-spine, swelling in multiple joints, and incredibly high SED and CRP rates, because my sacroiliac joints are painful but not fused, I probably wouldn't get an AS diagnosis in the UK until the joints do visibly fuse on an x-ray.

From talking to my rheumatologist, she's really worried about UHC because right now, she can put the diagnosis in and it's highly unlikely that someone will go rummage through her medical records. Once they're computerized, though, she will lose that ability to make a diagnosis that doesn't meet certain strict criteria. So her thinking is that by treating me proactively she can delay the damage and hopefully reduce my pain now, but once the records are electronic, someone presenting with my same symptoms may have to be treated much less aggressively, and may have a lot more quality of life issues.

***********

My sister is definitely in favor of a UHC plan, for the record.

I am aware of people in my Crohn's support group who have been diagnosed with AS prior to having fused joints, so I'm not sure that it is accurate to state that a diagnosis would be so delayed in the UK. Anyone coming to the group with joint or back pain is advised by other members to get their doc to test for HLA-B27.

I have received exemplary care from the NHS, if I had had to pay for it I would have had to declare bankruptcy. Although I used to have a well-paying job I now only work part time (due to my illness) and as a single parent I have to worry about every penny; insurance would be a luxury I probably couldn't afford and with a pre-existing condition, would presumably be very expensive. I don't have to pay the normal £7.20 per item prescription charge due to my low income.

In the last six months alone I have had one inpatient stay of four days, two colonoscopies, one barium meal & follow-through, five consultant appointments, eight nurse-practitioner appointments, seven GP appointments, 26 blood tests, eleven telephone calls to or from my IBD nurse-practitioner, and 37 prescriptions.

 

[Rolfe]

The difference that I can see is that the US doctors will use it almost prophylacticly (sp), while the UK requires x-rays to show fusion in the SI joints. I think technically, despite having the HLA-B27 gene, noticeable damage to the spine on an MRI, calcifying tendonitis in both shoulders, arthritic damage in the c-spine, swelling in multiple joints, and incredibly high SED and CRP rates, because my sacroiliac joints are painful but not fused, I probably wouldn't get an AS diagnosis in the UK until the joints do visibly fuse on an x-ray.

From talking to my rheumatologist, she's really worried about UHC because right now, she can put the diagnosis in and it's highly unlikely that someone will go rummage through her medical records. Once they're computerized, though, she will lose that ability to make a diagnosis that doesn't meet certain strict criteria. So her thinking is that by treating me proactively she can delay the damage and hopefully reduce my pain now, but once the records are electronic, someone presenting with my same symptoms may have to be treated much less aggressively, and may have a lot more quality of life issues.

I don't work in the NHS, I'm a vet not a doctor, so I may be wrong. But to the best of my knowledge there is nothing in the British system for the rheumatologist to get concerned about. So far as I know, the diagnostic criteria for that one are not nearly so prescriptive as that.

I have no idea whether any universal healthcare scheme the US might introduce would try to deny patients early treatment in that way, but I think she's another one who's been frightened by the black propaganda flying around about how terrible universal healthcare is.

Rolfe.

 

[Darat]

I am aware of people in my Crohn's support group who have been diagnosed with AS prior to having fused joints, so I'm not sure that it is accurate to state that a diagnosis would be so delayed in the UK.

...snip...

My AS was diagnosed even before I had a full set of x-rays, diagnosis was based on symptoms, examinations and carrying HLA-B27, and that was was about 30 years ago.

Even back then the aim was to try and prevent joint fusion if at all possible so waiting for fusion before the diagnosis would have been a tad a-about-t.

NHS patient leaflet about AS shows that fusion is not required for a diagnosis: http://www.cks.nhs.uk/patient_information_leaflet/ankylosing_spondylitis

 

[Rolfe]

[....] the UK requires x-rays to show fusion in the SI joints. I think technically, despite having the HLA-B27 gene, noticeable damage to the spine on an MRI, calcifying tendonitis in both shoulders, arthritic damage in the c-spine, swelling in multiple joints, and incredibly high SED and CRP rates, because my sacroiliac joints are painful but not fused, I probably wouldn't get an AS diagnosis in the UK until the joints do visibly fuse on an x-ray.

From talking to my rheumatologist, she's really worried about UHC because [....] someone presenting with my same symptoms may have to be treated much less aggressively, and may have a lot more quality of life issues.

OK, here's the actual facts on this one, and it's as I believed it to be.

My AS was diagnosed even before I had a full set of x-rays, diagnosis was based on symptoms, examinations and carrying HLA-B27, and that was was about 30 years ago.

Even back then the aim was to try and prevent joint fusion if at all possible so waiting for fusion before the diagnosis would have been a tad a-about-t.

NHS patient leaflet about AS shows that fusion is not required for a diagnosis: http://www.cks.nhs.uk/patient_information_leaflet/ankylosing_spondylitis

Once more, we encounter a false account of the restricted care allegedly provided by the NHS. Once again, it's not true. Mutha, where did you get this from? Who is spreading these vicious falsehoods?

Rolfe.

 

[Tsukasa Buddha]

I say it does suck!

Well, from what I understand (which is very little, mind you), the organizations that determine quality of care are not independent from the government, which could lead to politicizing issues best left to evidence-based medicine.

But one anecdote from the States about the bad thing about the lack of a national program is about mental health. At the community health center, patients get diagnosed before entering the program I am in. However, they have to be careful what diagnosis they list on their charts. Different insurance companies have different books that use different codes for disorders, and often the NOS variety is not covered. So then they have to try to figure out what to put down so the person can get their treatment.

 

[Meadmaker]

I'm still not sure about this. You have an uninsured person, and they have flu, and they're in serious respiratory difficulty. You've done all you can so far as regular treatment goes, but the patient continues to deteriorate. Do you sigh in resignation and let it go, or do you move heaven and earth to get this patient transferred to the central unit that has the facility to carry out this very rare procedure?

I may be wrong, but I have a feeling that the former might just be the more likely approach.

Also, if such a transfer (for an insured patient) is a matter of extreme urgency, maybe in the middle of the night, would the insurance company demand that the patient's life be endangered by waiting for authorisation to go ahead?

Rolfe.

Generally, it's as Lisa said. What happens is the doctors say, "Do this, now" and it happens, then the bills get sorted out later. When you present yourself for treatment, they'll ask you for insurance, but if your condition requires immediate attention, they won't worry about it.

Definitely, if it appears that life is in danger, treatment won't be held up waiting for payment.

But then you are left with that "worry" that Leif mentioned. The doctor said do it, and didn't pass it by for review, but perhaps the insurance company will have a different opinion later. There are some conditions you would like treated now, but if the difference is $1,000, you can wait until morning. There's no way for you to know, medically, whether it's safe to wait. If the insurance company decides it wasn't necessary to treat you, they'll stick you with the bill. Meanwhile, there's no way for the doctors to know, and they aren't going to wait around to find out.

 

[Delscottio]

I say it does suck!

Well, from what I understand (which is very little, mind you), the organizations that determine quality of care are not independent from the government, which could lead to politicizing issues best left to evidence-based medicine.

From what I can remember the NHS has a number of Public Service Agreements to meet, in that the government and NHS will meet and agree budgets and what will be delivered for those budgets in the coming year (s). How what is agreed is delivered is pretty much left the the NHS.

A taste of the PSA is here, but they are a lot more in depth
http://www.dh.gov.uk/en/Publication...cationsPolicyAndGuidance/Browsable/DH_5209573

The individual departments who deliver the care are Consultant led - I would take a massive punt these people will follow evidence based procedures.

Obviously political pressure can be applied but its usually only when the people who own (the people who use it..) the service want that change

But one anecdote from the States about the bad thing about the lack of a national program is about mental health. At the community health center, patients get diagnosed before entering the program I am in. However, they have to be careful what diagnosis they list on their charts. Different insurance companies have different books that use different codes for disorders, and often the NOS variety is not covered. So then they have to try to figure out what to put down so the person can get their treatment.

It doesn't seem confined to mental health.

 

[Rolfe]

Well, from what I understand (which is very little, mind you), the organizations that determine quality of care are not independent from the government, which could lead to politicizing issues best left to evidence-based medicine.

If you're talking about the NHS, well, no not really. They're pretty hot on evidence-based medicine apart from a ridiculous blind spot on homoeopathy, that everybody seems to scared of Prince Charles to consign to the dustbin. The politicians don't interfere, and if treatment availability was politicised there would be riots in the streets.

But one anecdote from the States about the bad thing about the lack of a national program is about mental health. At the community health center, patients get diagnosed before entering the program I am in. However, they have to be careful what diagnosis they list on their charts. Different insurance companies have different books that use different codes for disorders, and often the NOS variety is not covered. So then they have to try to figure out what to put down so the person can get their treatment.

Bizarre.

Rolfe.

 

[Camillus]

Last night, the news was full of a healthcare story. A 26-year-old woman, who is pregnant, was taken to hospital with Mexican flu. (The hospital concerned was Architect's local hospital, so he may have more information.) She deteriorated, and was placed on life support. However, things got worse. [newspaper article]

Why did she have to go to Stockholm? This procedure is very rarely required in adults, so although there is a specialist unit in Glasgow which provides the treatment to children, there are only five beds in the whole of Britain for adults. These are located in Leicester, all together for maximum efficiency. Normally, this is entirely sufficient. However, England has flu coming out of its ears, and these five beds were all occupied last night.

The NHS recognises that this is possible during times of unprecedented demand such as a pandemic, and so there are arrangements in place to share these facilities right across Europe. These arrangements were called on last night, a bed was found in Stockholm (which is actually not all that far, as the NHS air ambulance flies), and the patient was transferred. (The arrangements are reciprocal, so a Swedish patient will end up in Leicester if the situation is reversed.)

(ETA: OK, it's a bit further than I originally thought.)

The name of the patient has not been released. We have no idea if she is a single mother on welfare or a well-off upper-middle-class housewife. It doesn't matter. This is the sort of care Scottish (and British) citizens get as of right from the NHS. It's only in the news because she was sent to Sweden - if she'd simply been flown to Leicester, in England, over 300 miles away, it wouldn't even have been remarked on.

Rolfe.

I had a meeting this morning with a consultant from one of the largest intensive care units in the UK. He brought up this case and told me that there were adult ECMO beds available in London but they were not asked to take this patient. Very odd.