Scotland's healthcare system doesn't suck!

[kellyb]

I don't really know where you're coming from with that, but it looks as though you are saying [2] is really no worse than [1], and that the possibility of severe financial penalty at some point in the future does not impair patient experience (is not a social bad). Were that a correct interpretation I consider it utterly delusional.

I don't think you mean that . . .

It is delusional.
Ideology can be powerful stuff.

 

[The Mutha]

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




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.

In my sister's case, her Doctor.

 

[Rolfe]

OK, I probably phrased that wrong. Who is originating these vicious falsehoods?

I've no doubt your sister's doctor believes what she says to be true. However, it is not true. We constantly encounter a drip, drip, drip of erroneous statements that this or that or the other is not available under a universal healthcare system, so Americans should not support such a system, because it will result in their care being restricted.

Where are these lies coming from? Who is feeding them to peole like Mutha's sister's doctor? In fact, the chances of care being restricted in the USA are far higher than the chances of it being restricted in the NHS - either because of sheer inability to pay (the uninsured or those having difficulty affording co-payments), or because of insurance company bureaucrats who stand between you and your doctors.

People, you are being lied to, systematically, comprehensively and maliciously. And I think we only have to look at the "Dirty tricks" thread to see what's behind it.

Rolfe.

 

[kellyb]

OK, I probably phrased that wrong. Who is originating these vicious falsehoods?

I've no doubt your sister's doctor believes what she says to be true. However, it is not true. We constantly encounter a drip, drip, drip of erroneous statements that this or that or the other is not available under a universal healthcare system, so Americans should not support such a system, because it will result in their care being restricted.

Where are these lies coming from? Who is feeding them to peole like Mutha's sister's doctor? In fact, the chances of care being restricted in the USA are far higher than the chances of it being restricted in the NHS - either because of sheer inability to pay (the uninsured or those having difficulty affording co-payments), or because of insurance company bureaucrats who stand between you and your doctors.

People, you are being lied to, systematically, comprehensively and maliciously. And I think we only have to look at the "Dirty tricks" thread to see what's behind it.

Rolfe.

I think it's mostly some grotesque mutant form of confirmation bias? And it's running at epidemic levels in "American thought"?

Here's the real physician response to the AMA's endorsement of Obamacare. (from the biggest "US MD-only" forum on the web. You have to be an MD to even view it. They published this thread to prove that the AMA is not speaking on their behalf with the endorsement.)

(I'm starting my selective quoting about halfway through. It starts with the worst of the worst, because that was what motivated me to open up a word document. But I really, really encourage everyone to at leat skim the thread for themselves.)

http://www.sermo.com/ui/blog/comments/physicians_respond_to_ama_endorsement_of_hc_bill.html


First, a psycho:

I have no interest in meeting the needs of the population as a whole and absolutely no interest in providing health care for all citizens. I think it is time that (some) of us doctors make our "ugly" feelings known;

"Those that cannot afford health care need not receive it"

Yes, I am absolutely fine with people dying and (ideally not) suffering if they cannot purchase our services.
Now, call me a monster!

ps: I'm all for reducing costs by eliminating malpratice lawyers, CPT codes, and insurance companies. They do no good for patient nor physician.

Now, it's the patient's fault the costs are so high:

All of the comments are very valid. But, I agree with mm1484...in that No HealthCare Reform will work until patients Reform their lazy American Lifestyles. Any plan will bankrupt our country unless patients change their bad choices...and you don't hear this sober fact in any of the healthcare reform discussions. 85% of all healthcare dollars are due to lifestyle choices...so why aren't Reformers starting with education and 'mandates' to change individual behaviors? All healthcare reform is a complete joke and will be a complete disaster until this is addressed

Now, a reasonable respone:

Tort Reform is A MUST. without that no doctor will stop practising defensive medicine. Argument that malpractice pressure maintains good medical care and less mistakes ( obviously by our friendly trial lawyers, as it appeared in last Sunday's NY Times ) is a hogwash. Physicians are by and large caring human beings and that is precisely why they are in this noble profession.
Without Tort Reform there is no chance of significant reduction in healthcare expense.
I am dismayed that Mr. Obama is missing this vital point.

Now, a run of the mill jerk:

Physicians need to have the courage to say, "Nobody has a 'right' to my medical care." I have the right to my life first, and nobody has a right to any part of my life. Our forefathers did not risk their lives to cast off a dictator King George III, just so we could have another dictator rule over us. I will not work under the conditions the government is attempting to foist upon us. If Physicians have the guts to say this and stand by it, they can trot out whatever plan they want but it will go nowhere without us. If we acquiesce, we deserve what we get. For me, I will never work under a government plan, period. I will choose freedom, even if I have to give up medicine.

Blame the sick, again:

yes, raising taxes on some and lowering provider reimbursement will NOT lower healthcare costs....but only continue to subsidize bad patient lifestyle choices. Healthcare Reform was started because of escalating costs.... Then start by addressing what is causing those escalating costs! Reward those that make good or maintain good lifestyle choices and punish those who don't....is the ONLY way people will change their behavior (I.e. Car insurance). Free healthcare is fine....but then those paying for it should be able to dictate your lifestyle choices.

Another reasonable response:

I am against the bill proposed, although I am strongly "for" major changes in the current medical system. What galled me most was the absence of malpractice reform. I have spoken to many physicians from countries with socialized medicine such as France- they NEVER have to worry about lawsuits! It is considered ridiculous! Especially if the government limits access to testing (or does not fund it, which is exactly the same), I do not want to be on the receiving end of a lawsuit when a migraine patient's asymptomatic 1 cm meningioma is discovered 10 years later.
I recently attended a health care conference sponsored by the medical school where I am employed. In discussing costs, the "experts" invited to speak on the issue entirely excluded and discounted the cost that practicing defensive medicine adds to the system, suggesting instead that physicians should make less money. I subsequently discovered that they did so because they were not sure how to measure the cost of defensive medicine, not because they could prove that it is unimportant. I pointed out that not only does defensive medicine cost money, but that depending on the tort system to punish and exclude "bad" doctors is highly ineffective.

And another reasonable response:

Family Medicine
Posted Jul 18, 2009 at 3:08 PM
Some thoughts/responses to the community:

I realize I'm swimming against a strong current, but I think it's critical for other voices to be heard.
I enjoyed the Peter Singer article in the New York Time, 7/15/09: Why We Must Ration Health Care—thanks for the recommendation, drapp1952. Trijcpg—you may want to take a look, as it challenges the basic premise of the WSJ article from 7/9/09 (the WSJ article argues against rationing).

Many argue against NP/physician extenders having the same value as physicians and some including suvarov worry about the enormous med school tuition. I agree, when medical school costs well over $200K, and you pay PCPs ½ to ¼ of their physician "colleagues," there should be no surprise when med. students opt against primary care. The solution? Government subsidized medical school, residency, and fellowships and leveling the salary playing field between types of physicians. As auburngal points out though, not all docs are created equal, and we should be able to discern who are "the best." So, within fields there has to be a way to reward quality, and I believe different specialty organizations should make recs on this, be it polyp detection rate for GI, percent of DM patients having A1C's done within a certain time frame and BP control for primary care, mammo/pap percentages, complications among surgeons, etc.

JA1930 points out that outpatient primary care docs don't get paid enough, which I agree with, but he believes that their salaries should not be increased at the expense of specialists. I disagree. Primary care physicians aren't starving and neither are specialists. But, we can't afford to pay everyone specialist salaries and so the playing field needs to be leveled. Discrepancies in reimbursements are basically arbitrary anyway, and favor procedure and surgery driven fields, negotiated unfairly against PCPs, in the 1960s. I'm willing to bet that if you were to let the public in on medicines dirty little secret, that many specialist make $300-500K while many primary care docs make 1/3 of that, they would have very little sympathy for this argument. JA1930 fears that if we lower specialist salaries, no one will match in GI, cards, and ortho. Yeah. I lay awake at night with the same fear. The fear should be that most primary care will be done by NPs and PAs, who have less training and expertise (this is what really worries me) and FMGs, who lack cultural awareness, which is not insignificant, but otherwise do good jobs from my experience. I also have to disagree with JA1930 about the UK, Canada, and many other industrialized nations. They do have equal or better outcomes for all of their citizens, and their citizens are happier than ours in terms of their health systems (75% v 50%--see NY Times, Peter Singer article, 7/15/09). And, most importantly, they don't kick a quarter of their citizens to the side of the road.

sailingdad made many good points about the demise of primary care. Also, he pointed out that the medical community does not speak with one voice, which is clearly true. I hope his diagnosis of the "terminal" condition of primary care is wrong and that we do get together with one voice to speak out against the enormous profits of insurance companies and Pharma, that come at the expense of health care for all..

tnkaiser believes that if we embrace a single payer system, our entire economy would embrace socialism. Single payer systems cost half as much and cover all citizens, with better health outcomes. It's not a single payer national system that will break our economy, but the current free-for-all money grab that is costing 18% of the economy and growing and which causes more individual bankruptcies than any other cause not to mention a huge burden on our nations small and large businesses, who try to give their employees insurance, but are hampered by the unreasonable expense.

Drdawgfan says that "single payer systems work for the young and the healthy, they never have to use the services." Actually this statement applies better to the current insurance systems, with their prior authorizations and rejection of those with pre-existing conditions.

xrayangiodoc --wow, a specialist and a radiologist at that who supports a single payer system! Glad to have you on board.

merthin said, "If you think dealing with multiple insurance companies is a hassle, wait until you only have to deal with the government." As a primary care doc, I would welcome a single payer system which is electronic and streamlined, covers everyone, would have one type of paperwork and I would know exactly what I have to do to get reimbursed. This system would place more emphasis on prevention than on procedures, and would thus level the playing field among physicians. Optimally it would include tort reform as well. It would not be without its problems, but beats the monstrous, untenable system we have now.

And to this next one, .

I wonder how many of the folks who post onto this blog giving opinions that are so sharply opposed to what the majority of us here think are "plants" from the AMA or Representative Waxman or are Obama's personal MD, or the like.

Justin Matrisciano MD

A response:

Family Medicine
Posted Jul 18, 2009 at 7:08 PM
To JA1930, congratulations on a fantastic specialty that manages to do minimally invasive procedures and get reimbursed top-notch. Most here would commend you on great choice and even I can see the wisdom. However, many of us, esp. PMDs working in clinics, have an ever harder time turning a blind eye to a pathetic system that doesn't provide basic care to most of our poorest and most vulnerable citizens. In addition, I must point out that you are mistaken in your data, where you say that 70% of Americans are happy with the health care system in the U.S. (it's 56%). Actually, it's the Brits and Canadians who are much happier (73%). You are also incorrect in your belief that there is no need for rationing. Unbeknownst to you, and apparently this is a big surprise, but rationing already does occur in the U.S. Please click on the NY Times, 7/15/09 for Peter Singer's article:
Sermo Doc
It also seems clear how little you value primary care but I would remind you that we should all be a team and that investing in primary prevention leads to more savings than curing a problem after it has developed. In any system where one group is paid so much less than another, which is mainly an artifact of a backwards payment system, you will get disrespect and dissatisfaction from those on the bottom. I haven't yet figured out why there's so much dissatisfaction from the top dogs though.
In response to the extra years of training to become a specialist, I've already mentioned the need to subsidize the few extra years of GI training for example v primary care, but in the big picture, it will take a specialist 3-4 years to make up the lost money from not working earlier, and after that, the next 25 years are all gravy, probably to the tune of millions of dollars more or income, assuming $100K/y higher salary. This is the reason why people choose single organ doctoring, no more no less. You've confused how much they pay you with how much you're worth. If we do start to pay less for procedures, the main result will be less procedures—see the Dartmouth study:
Sermo Doc
If the result is less specialists that would be a good thing. Currently, 70-80% of U.S. Physicians are specialists, a figure that is probably at least 30% too high, considering the needs of the population. Again though, I don't hate specialists and I certainly see the need for them, we just need to level the playing field with the neglected field of primary care.
To louermd: That orthopod only makes $400K b/c of an artificial reimbursement plan. Are you saying if we dec. reimburesments for orthopedic procedures by 25%, esp. the huge number of unnecessary arthroscopies, to decrease the average ortho's salary from $300k to $225/y, the field would collapse? It's preposterous. If orthopedists. actually had to collect real fee-for-service, most wouldn't survive. The only reason they can actually garner such high incomes is because of the artificially high reimburesements for procedures and surgeries. I think that this is the real reason most specialists are against change.
In response to Jmatrisciano, I find your suggestion that the physicians who don't tow the interests of specialists to be "plants" from the AMA etc." to be bizarre. I would venture that the average citizen, were he/she to peruse these comments, would be disturbed by what he finds and would take away the message that couldn't be clearer. Specialist physicians want to protect their salaries first and patient care comes a distant second. I am not a member of the AMA, though they continue to send me their journal, I imagine to pad their membership. I believe the AMA does not hold the interests of patients first. The groups I belong to, as I've mentioned, are PNHP and NPA.

And I left out all the ones just complaining about socialism and restricting the free market.

 

[Francesca R]

I've no doubt your sister's doctor believes what she says to be true. However, it is not true. [ . . . ] Who is feeding them to peole like Mutha's sister's doctor?

Your question implies that doctors could not manufacture and propagate the lies themselves. They can of course, being human rather than paragons of unerring virtue, and having vested interests (even misguided ones) in protecting their status quo.

 

[Rolfe]

Your question implies that doctors could not manufacture and propagate the lies themselves. They can of course, being human rather than paragons of unerring virtue, and having vested interests (even misguided ones) in protecting their status quo.

No, I don't imagine doctors couldn't manufacture the lies themselves. However, the particular story Mutha told didn't seem insincere. It had more the feeling of someone passing on something she'd been told.

Rolfe.

 

[Darat]

Your question implies that doctors could not manufacture and propagate the lies themselves. They can of course, being human rather than paragons of unerring virtue, and having vested interests (even misguided ones) in protecting their status quo.

I was thinking about this just before you posted and it may well be the case in this instance that there is more than just ignorance at play.

If the doctor in The Mutha's sisters case is actually a specialist/consultant rheumatologist then I would find it very strange that they would believe that fusion was somehow required by government bureaucrats in the NHS before a rheumatologist was allowed to diagnose someone with AS. Then again given the sheer scale of the fabrications and ignorance shown by many folk in the USA in regards to the NHS, perhaps it is not so strange.

 

[Rolfe]

Oh, I wouldn't be at all surprised at a consultant being wrong about something like this. Especially if the misinformation she encountered fed into her existing prejudices.

Rolfe.

 

[gtc]

Somewhere in the bowels of this thread I asked what treatments were available in the USA (for 75% of the citizens) but not available to someone living in the UK via the NHS.

I've been trying to answer my own question and apart from experimental and clinical trials I've come across nothing so far but I thought one of the reports I did come across may be of interest to folks reading this thread: http://www.independent.co.uk/life-s...e-treatment-was-available-on-nhs-1301570.html

Was that the usual sort of bungle we expect from such organisations or is it an attempt to rein in costs by not informing doctors of the options?

This is where my understanding of organisations like the NHS falls down. No government has an unlimited budget so how do they limit expenditure while offering a more-or-less 'whatever it takes' approach to health care.

Is a British doctor less likely to decide that a particularly expensive treatment is needed than an American doctor (with a wealthy enough patient)? Are waiting queues longer?

 

[ponderingturtle]

That's another problem. I bet many of those people will end up in nursing homes (which they might not need) paid for by Medicare, yet Medicare won't pay for assisted living facilities even though the cost per paitent is much less than a nursing home.

No medicare has a certain limit on how many days it will pay for a nursing home. Medicaid is the one that keeps most people in nursing homes. Of course that means that they must have gone through most of their assets.

I am not sure if medicaid will pay for assisted living.

 

[Darat]

Was that the usual sort of bungle we expect from such organisations or is it an attempt to rein in costs by not informing doctors of the options?

...snip...

I'd say SNAFU.

This is where my understanding of organisations like the NHS falls down. No government has an unlimited budget so how do they limit expenditure while offering a more-or-less 'whatever it takes' approach to health care.

Is a British doctor less likely to decide that a particularly expensive treatment is needed than an American doctor (with a wealthy enough patient)? Are waiting queues longer?

We do have "rationing" and sometimes it is based on cost, but generally when cost is a considertion it is based on "cost effectiveness. So we have "NICE" that produces guidelines for NHS England & Wales (NHS Scotland has a similar body).

As for waiting times - well I don't know if there are any comparable figures for NHS UK v USA, because in the USA some people just don't get access to the treatment no matter how long they wait.

Certainly for elective and minor procedures I would be surprised if a well-insured person in the USA wasn't treated in a shorter period of time compared to a non-insured Brit. But otherwise the time waited is usually a function of clinical need, and the NHS will (when there simply aren't the resources in the UK to provide the treatment quick enough) even pay for patients to receive medical care in other countries.

 

[Rolfe]

Is a British doctor less likely to decide that a particularly expensive treatment is needed than an American doctor (with a wealthy enough patient)? Are waiting queues longer?

The answer to the first question is simple. Within the NHS, no doctor cares how wealthy the patient is or isn't, if he even knows. If an NHS patient needs a procedure that is covered by the NHS, they get it. And if there is a wait (for elective procedures only, obviously, let's not fantasise about people with appendicitis going on a waiting list) the patients are prioritised by clinical urgency, not by their bank balance.

The difference you're searching for is that a wealthy patient in Britain may choose not to exercise his right to NHS treatment. He may purchase private insurance, or he may simply pay for the procedure privately. This gets him in a swanky private clinic away from these uncouth poor folk, and if there is a wait in the NHS for the procedure he needs, it will circumvent that.

Actually, you don't have to be all that wealthy to do that. The option is open to everyone who has a little bit of spare cash. You choose - go with the NHS, get your treatment free, but maybe wait a bit longer, or ask to be treated as a private patient and get faster service. My mother, a clergyman's widow on a pension, did this when she needed cataract surgery. She had the cash (about £3,500 for both eyes). But if she hadn't, she would still have got exactly the same operation, just a few months later.

Does this answer your question?

This is where my understanding of organisations like the NHS falls down. No government has an unlimited budget so how do they limit expenditure while offering a more-or-less 'whatever it takes' approach to health care.

By setting the limits very high. Very expensive treatments which offer only limited benefits are not approved by the system, often to the fury of the few people caught in that net. Google "QALY" for more information. A cancer treatment costing £100,000 which offers a 1 in 1000 chance of extending the patient's life by a couple of weeks is not going to be approved, even if the drug has a product licence. If you want that, you will have to go private. However, most things with a reasonable prospect of benefit are approved. You can get an awful lot for 8% of GDP if you try to budget wisely (and maybe some day we'll get that last bit licked....)

I'll post these two examples again. They made the news because there was something unusual about them, but it wasn't the quality of care. In the first case, the artificial heart in question had never been used for a patient with that condition before (so it was experimental, so would almost certailny have been denied by US insurance companies). In the second case, the air ambulance flight went all the way to the Karolinska Institute in Stockholm, maybe about 1,000 miles (guessing) instead of just to Leicester (maybe 300 miles), which is why it was news.

Abigail's new heart
Flu patient gets a free trip to Sweden

These two reports are standard of care in the NHS, where the clinical need exists. And note that the only wait involved (in the former case) was for a donor heart to become available, and that nobody in the system was even thinking about how the procedures were going to be paid for. These procedures are offered by the NHS, here we have a British resident who needs them, so the system springs into action. The wealth of the patient is irrelevant.

Rolfe.

 

[Darat]

...snip... This gets him in a swanky private clinic away from these uncouth poor folk,

...snip...

Bad news - when there is a resource issue sometimes the NHS forks out the money for an oink to be treated in one of those swanky hospitals... No getting away from the great unwashed in socialist Britain!

 

[Rolfe]

Oh, I'm sure they only select the better class of oiks to be sent to the private clinics...
[/Hyacinth Bucket}

Rolfe.

 

[Toke]

My favorite:
We had to eat with the crew [/Onslow] (after his 1. class cruise on queen mary)

 

[Francesca R]

oink

oinks

Oik

Sort it out--I'm not even British (well, wasn't)

 

[Darat]

I'm squealing like a pig in embarrassment.

 

[Ducky]

A cancer treatment costing £100,000 which offers a 1 in 1000 chance of extending the patient's life by a couple of weeks is not going to be approved, even if the drug has a product licence.

This would likely not be approved for coverage by a private system in the US either.

 

[Lothian]

I'm squealing like a pig in embarrassment.

Ham acting at its wurst.

 

[Rolfe]

This would likely not be approved for coverage by a private system in the US either.

OK, I was exaggerating for effect. The point is that there are some treatments so outrageously expensive for minimal benefit that only a crazed egomaniac would expect them to be covered. And there are treatments with such clear benefits that they go through on the nod.

The devil is in exactly where you draw the line. That's where the QALY comes in. It allows as objective as possible an assessment to be made of the cost-benefit equation from any particular procedure. And inevitably there are procedures which fall just outside the parameters. And inevitably there are two or three people whose doctors would like them to get that procedure. And inevitably they make a Great Big Fuss about it, which is entirely within their rights.

And inevitably, the tabloid press sees a sob story, and prints something about brave cancer patients being denied care by the evil NHS bean-counters. So then some right-wing US campaigner finds this article, and uses it to rant about the evil rationing in the NHS, where you can't get cancer drugs because some "bureaucrat" has denied them.

What is usually missing from these stories is the whole QALY assessment, and the fact that no "bureaucrats" are involved at all - these decisions are taken by a committee of top consultants, who try to take the pain off their colleagues by making the decisions unclouded by concern for their own particular patients. Oh yes, and the fact that US citizens are far more likely to be dumped by their health insurer than a UK citizen is to find themselves on the wrong side of a decision by NICE or its equivalents.

Rolfe.