Health care - administrative incompetence

[Agatha]

I just have a few questions about socialized medicine. Do you have medical group-type offices or individual practices? Is there any out of pocket costs, at all, when you go to a doctor? Is the price of prescription drugs controlled or do you pay similar prices to the US on medicine?

In England (I'm sure Rolfe will explain the situation in Scotland), GP practices are all under the auspices of the NHS. Most people register at one of their local practices, but if you move to a new area, or for some reason you wish to change your GP, you can register at a different practice. You can choose not to be registered anywhere, but you cannot be left without a GP if you want to be registered, as the local primary care trust will put you on a GP's register if you can't find one. If you are in another area temporarily, then you can just go and see a local GP as a "temporary resident".

Some GP practices are small, with one or two GPs, perhaps plus a nurse and midwife; some are large practices with several GPs, some of whom will have specialties in addition to being a GP. They may have the facilities and skills to do minor operations, they may have counsellors and other healthcare professionals attached to the practice.

There is no charge for seeing an NHS doctor or other healthcare professional, in any part of the system. There is similarly no charge for a flu jab, or for childhood immunisations. GPs are entitled to charge for some travel vaccinations.

Prescription prices are controlled, those people who have to pay prescription charges (and a good many people are exempt on the grounds of chronic conditions or on income grounds), each item costs a fixed fee of £7.20 (in England only). This fee bears no relation to the cost of the drug (or wig, or gluten-free food, or whatever).

In an emergency, you can call out your GP for a home visit, or call an ambulance, or present at any A&E department at any hospital. There are no charges for any of these. You will be asked whether you are entitled to NHS treatment, but emergency treatment wouldn't be withheld from someone who is not (they'll get a bill later).

There is no charge for hospital inpatient or outpatient treatment.

If I haven't covered anything you might be wondering about, you can look at http://www.nhs.uk/NHSEngland/Pages/NHSEngland.aspx

I use the NHS a great deal more than I'd like to, given my illnesses and disabilities, and contrary to the implication above, I'm getting 2010 care, not 2000, 1990 or even 1970 care. Hospitals are clean and modern - yes there is always room for improvement; waiting times are, in general, short; consultants are up-to-date in prescribing the most effective drugs and care.


I understand prescription-only drugs are advertised to the general public in the US. Does this mean that the pressure to prescribe one drug rather than another comes from the patient, rather than the doctor using clinical knowledge to choose the one which is the most effective treatment?

 

[Kestrel]

I understand prescription-only drugs are advertised to the general public in the US. Does this mean that the pressure to prescribe one drug rather than another comes from the patient, rather than the doctor using clinical knowledge to choose the one which is the most effective treatment?

Yes, prescription drugs are advertised directly to the public. And patients do pressure doctors to prescribe the drugs they hear advertised. The net result is that expensive drugs are prescribed even when low cost alternatives are just as safe and effective.

 

[ZirconBlue]

I understand prescription-only drugs are advertised to the general public in the US. Does this mean that the pressure to prescribe one drug rather than another comes from the patient, rather than the doctor using clinical knowledge to choose the one which is the most effective treatment?

To some extent, yes. Of course the doctors are also being courted by the pharmaceutical company reps to try to encourage them to prescribe the newest, bestest drugs.

 

[blutoski]

I just have a few questions about socialized medicine. Do you have medical group-type offices or individual practices? Is there any out of pocket costs, at all, when you go to a doctor? Is the price of prescription drugs controlled or do you pay similar prices to the US on medicine?

The answer will vary by country, and often within regions in a country.

In BC:

• both medical group-type offices or individual practices - doctors are independent businesses that operate as they choose - billing is sent to the medical services plan (MSP) instead of to the patient
• there is no out-of-pocket cost for items covered by the MSP (defined in the Act as anything 'medically necessary'), but doctors can offer services not covered by MSP and patients will pay for that however they choose (a good example is cosmetic surgery - I paid for my LASIK)
• prescription drug prices are not 'controlled', but prices are lower in Canada than in the US for a mix of reasons, mostly because of the already-mentioned fact that there is no direct-to-consumer advertising here; patients can get private health insurance (called extended health) for prescriptions and equipment like needles or glucosometers, many through an employer (I'm with SunLife); the province runs an extended health plan called MSA and citizens with low income can get their premiums waived

 

[Emet]

I understand prescription-only drugs are advertised to the general public in the US. Does this mean that the pressure to prescribe one drug rather than another comes from the patient, rather than the doctor using clinical knowledge to choose the one which is the most effective treatment?

I can only hazard a guess, but in some cases, I suspect the answer may be a limited yes. IOW, patients may request a drug based on ads, and the MD may Rx it, even though s/he may have been ready to Rx another drug. I don't think s/he would Rx something that is far less effective based on the patient's preference without a discussion.

But I also believe that MDs in the US may be more influenced by the pharmaceutical companies. I've experienced MDs Rxing the latest, greatest new drug that is on patent, expensive, and really no different than older, less expensive drugs that are either still under patent protection, or may have generic equivalents.

IANAD, only a sometimes patient. For others in the US, YMMV.

 

[sgtbaker]

Thank you for the answers, now I am truly disgusted.

 

[jimbob]

Rolfe, neither you, nor Cuba, nor Europe, nor the US for that matter, can give out free health care unless somebody invents it first. Insofar as socialized medicine (as with warlords or anarchy or dictatorships) contributes to a generally business-unfriendly environment, scientific development rates suffer.

And the scientific rate of development of treatments and cures outweighs over the decades, like compounding interest, everything else. I'd rather have costly 2010 care than "free" 1990 care. Or 2000 for that matter. Much less 1970.

How many decades behind is the world because, say, Europe has a much more unfriendly environment than the US? How much faster will development go as China gets into the act?

You're like Groundhog Day, you know that? No matter how often and in how many ways that rubbish you spout about scientific advances is shredded, you just pop right up again with the same delusional nonsense.

The US is wasting about 8% of GDP on gadzillions of clerks, plush HQ buildings, private jets and gold-plated cutlery, not investing it in medical research.

And you know perfectly well how the NHS is funded, and so do we, and we're absolutely fine about it. Particularly as we're paying a bit less for it per skull than you're paying for the "socialised" healthcare you can't access. So you have to pay all over again. And we've already sent you plenty of links to medical research going on in Britain, made better by the comprehensive patient access the NHS can provide.

So by one way of looking at it, we're getting it for nothing compared you your situation. And I wouldn't trade places on a bet.

Rolfe.

As Rolfe alluded to, here is my sig, which reiterates her points:

And we are talking about healthcare that is free at the point of use, not utterly costless.

OECD healthcare statistics

http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html
2007 Data (latest available)
UK 8.4% of GDP of which 81.7% is state expenditure = 6.86% of GDP from taxes
US 16% of GDP of which 45.4% is state expenditure = 7.264% of GDP from taxes

 

[Rolfe]

Beerina seems to think that the huge expense of US healthcare means all that money is being used for medical research, when it's nothing of the sort.

He also seems to think that medical research in every country with universal healthcare is controlled by the government, when again nothing could be further from the truth.

Be careful what you put into Beerina's head, because you will never get it out again.

Rolfe.

 

[blutoski]

Beerina seems to think that the huge expense of US healthcare means all that money is being used for medical research, when it's nothing of the sort.

I got that impression, too. Ironically, a country that wastes healthcare dollars at the provisioning end has less available to invest in technology and will fall behind.

My impression is that this is one reason US medical research has been declining - waste in the provisioning end is crowding out investment in research. Didn't the US used to get lots of nobel prizes back in the old days?

He also seems to think that medical research in every country with universal healthcare is controlled by the government, when again nothing could be further from the truth.

Well, a good portion of medical research probably will be government funded and therefore partly under public control (is that a bad thing?), but that's the same as in the US.

The point is that we're talking about healthcare delivery, not research. HMOs are the last businesses to spend spend a nickel on research.

 

[blutoski]

As Rolfe alluded to, here is my sig, which reiterates her points:

And we are talking about healthcare that is free at the point of use, not utterly costless.

Yes, those statistics are the sad part. Americans pay more in taxes for their blended healthcare than Canadians do for their entire public healthcare... and then on top of that Americans pay more again out of pocket. And they get less value based on the metrics. The only defense of such as situation is ideological. There's no pragmatic argument.

 

[jimbob]

I can only hazard a guess, but in some cases, I suspect the answer may be a limited yes. IOW, patients may request a drug based on ads, and the MD may Rx it, even though s/he may have been ready to Rx another drug. I don't think s/he would Rx something that is far less effective based on the patient's preference without a discussion.

But I also believe that MDs in the US may be more influenced by the pharmaceutical companies. I've experienced MDs Rxing the latest, greatest new drug that is on patent, expensive, and really no different than older, less expensive drugs that are either still under patent protection, or may have generic equivalents.

IANAD, only a sometimes patient. For others in the US, YMMV.

Ben Goldacre's blog has category devoted to this:

http://www.badscience.net/category/medicalisation/

 

[Agatha]

I meant to explain in my post above that all drugs, needles, dressings etc that are used during hospital inpatient and outpatient treatment are free to the patient; the only exception to this is if a hospital outpatient is given a prescription for medication or appliances to be used away from the hospital, in which case it's £7.20 (only in England), the same as a GP prescription.

I have been reminded of this today as a friend of mine has just had a mastectomy, and will be starting chemotherapy almost immediately.

 

[Emet]

I meant to explain in my post above that all drugs, needles, dressings etc that are used during hospital inpatient and outpatient treatment are free to the patient; the only exception to this is if a hospital outpatient is given a prescription for medication or appliances to be used away from the hospital, in which case it's £7.20 (only in England), the same as a GP prescription.

I have been reminded of this today as a friend of mine has just had a mastectomy, and will be starting chemotherapy almost immediately.

Nothing is free in the US.

1. When I had day surgery, and was getting ready to leave, the nurse told me to take the crappy, disposable pillows (not the linens) and plastic drinking cup, as I was being charged for them.

2. A friend was in an ER for her child; she had an infant in tow who was fussing. A kindly RN asked her if she would like a pacifier for the baby. She said sure, thanks. It was a $20 pacifier.

3. I had some blood work done. The charges were $800. My health insurance discounted it twice--they used a secondary insurer so that the final cost was $150-- of which they paid 80% (I had not reached my out-of-pocket). Had I not had insurance, I would have owed the lab $800.

 

[blutoski]

3. I had some blood work done. The charges were $800. My health insurance discounted it twice--they used a secondary insurer so that the final cost was $150-- of which they paid 80% (I had not reached my out-of-pocket). Had I not had insurance, I would have owed the lab $800.

My impression is that the market price of a service is very elastic, and billing will start high and reprice down to the maximum obtainable from the customer.

Unfortunate story: my friend's relative was visiting the US and was in a car collision (passenger). Hit-and-run, unfortunately. Minor head injury and some broken bones by the sound of it. Ambulance, minor surgery. Hospital for a few days. Her bill upon returning to Calgary was $350,000.

The unfortunate part is that the province won't cover full cost for charges outside the US, and she did not have the foresight to obtain travel insurance. She has no idea what's going to happen. At this point, she's shopping around for legal advice.

 

[Rolfe]

Oh, crikey! I'm a bit lackadaisical about insurance when I holiday in Europe, especially as I have a European Healthcare entitlement card. But the one thing I insist on having before I put a toe on US soil, is platinum-plated insurance covering any healthcare needs. It's not that expensive for a basically healthy person visiting for a couple of weeks, especially as the insurers know that anyone having a serious accident/incident can almost certainly be repatriated quite quickly at which point the expenditure stops. I wouldn't go without it.

I heard about an English woman who had a heart attack in America while on holiday, and was having to sell her house to pay the bill. Other US posters said, more fool her, nobody in the USA pays these bills, but I don't understand how you can avoid it. If you go bankrupt you'll still lose your house, in Britain anyway.

Rolfe.

 

[TragicMonkey]

Unfortunate story: my friend's relative was visiting the US and was in a car collision (passenger). Hit-and-run, unfortunately. Minor head injury and some broken bones by the sound of it. Ambulance, minor surgery. Hospital for a few days. Her bill upon returning to Calgary was $350,000.

The unfortunate part is that the province won't cover full cost for charges outside the US, and she did not have the foresight to obtain travel insurance. She has no idea what's going to happen. At this point, she's shopping around for legal advice.

She may be covered under the auto policy of the owner of the car she was in when hit. The specific coverage is the "uninsured/underinsured liability". Provided that the car's owner has that coverage, and then the company has to agree that an unidentified driver = an uninsured driver (some companies try to fight that, reputable ones do not), and then subject to the coverage limits...but worth looking into. No sense paying for coverage if it's not used when needed.

(Public service announcement: a lot of people opt out of that coverage because they don't understand what it is--they see "uninsured" and think they're paying for the other guy. They're not. The coverage exists to cover you when they don't have insurance at all, because otherwise if they're at fault you'd have to sue them to recover your damages. It's usually very cheap coverage. Get it, and set the limits to the same as your regular liability. It's worth it because there are a lot of idiots out there!)

 

[xjx388]

Don't know about any of the other issues you raise, but are you sure about this part? I really don't know how to find statistics on this but anecdotally most people I know here really do not go to the doctor very often. It is more common for people to express a wish not to bother the doctor, and this is because we know they are busy and that minor stuff gets better by itself or with over the counter stuff. I don't think the decision to visit a doctor is much influenced by the lack of direct cost here.

You may be right but it is honestly not my impression: though the culture may well produce different results in the two countries, for all I know.

I can tell you from running a family practice clinic in the US (and consulting for many others) that overutilization is huge. People with Medicaid (state-provided insurance that provides free healthcare) come in every time their kid gets the sniffles or they have a headache. People with private insurance come in much less frequently because they don't want to pay the copay. Self-pay patients come in only when something is really wrong.

Maybe in the UK or other places with Socialized Medicine it's too much of a hassle to get an appointment with the doctor for minor things so people just skip it. Don't you have to wait a few weeks to actually get in to see a doctor? At our clinic, we will see a patient the day they call in most cases; we also accept walk-ins. So, for Medicaid and Medicare patients there is almost no barrier to access. Hell, even if they don't have a car, the government will pay for a van to bring them to their appointment!

The point remains that making people responsible for their own healthcare is the surest way to reduce utilization and therefore begin decrease costs.

 

[Agatha]

Maybe in the UK or other places with Socialized Medicine it's too much of a hassle to get an appointment with the doctor for minor things so people just skip it. Don't you have to wait a few weeks to actually get in to see a doctor? At our clinic, we will see a patient the day they call in most cases; we also accept walk-ins. So, for Medicaid and Medicare patients there is almost no barrier to access. Hell, even if they don't have a car, the government will pay for a van to bring them to their appointment!

The point remains that making people responsible for their own healthcare is the surest way to reduce utilization and therefore begin decrease costs.

It's like whack-a-mole, dealing with this myth! No, we don't have to wait weeks in the UK. At the GP practice I attend, if I don't mind which GP I see, I'll usually be offered a same day appointment and certainly within 48 hours. If I want to see a particular GP then I might have to wait a little longer, but there are usually cancellations so I'll get offered an earlier one than booked. A lot of GP practices have open surgeries at least one day a week where no appointment is necessary. There are also walk-in clinics in most major towns and cities, anyone can go without an appointment at any time. We can also access an NHS symptom checker on the internet, and there's a low-cost number to ring for health advice 24 hours a day http://www.nhsdirect.nhs.uk/ We can also ask a pharmacist for advice at any dispensing chemist.

Maybe it's a cultural difference? Most people I know don't go to the doctor with mild self-limiting stuff, though I am sure there are some people who abuse the system and see their GP or go to A&E when it isn't warranted.

 

[xjx388]

It's like whack-a-mole, dealing with this myth! No, we don't have to wait weeks in the UK. <snip>

Hmmm... thanks for that. I only know what I hear about and you know how that goes. I'm thinking that it's definitely more cultural. My experience in the US is that the less a person is responsible for the cost of their healthcare, the more they utilize healthcare.

I can see that there might be a lot of benefits to going to a completely socialized medicine model. But it can't be a hybrid. It has to be equal access for all. Somehow, however, I doubt this is the case in actual practice in the UK and other places with socialized medicine. For example, is it possible to pay for a service yourself if the government denies the service? If so, then the rich still have better access to care and the poor are still denied services that might extend/better their lives, even if a government bean counter doesn't think it's worth it. So the system may cost less for the government to run, but can you really say it's gives all citizens equal access to medical care?

For example, a poor man who is alcoholic needs a new liver, but the government denies it because it isn't cost effective to give an alcoholic a new liver. He dies 6 months later. A rich man will also be denied the transplant, but he can simply pay for it out of his own pocket. He gets to live another 10 years or more. Even if it isn't allowed by law, he can still travel to another country where it is allowed.

Honestly, I don't know enough about the systems in other countries because I'm too focused on making the one in my country work better for my clinic. I'm open to hearing more about how socialized medicine actually works.

 

[Rolfe]

There's actually a legal requirement for patients in Britain to be seen within 48 hours of requesting an appointment (or is it same day? - I can't remember). For sure, if you need to see a doctor today, you will see one. If you want the doctor to make a house call, you will have to make a damn good case for it, but they'll come. ("No, my mother is 94 years old, I am not bringing her to the surgery" works every time in my experience.)

In 1989, when I had just moved house and hadn't registered with the local GP yet, I fell suddenly ill with a very high temperature. I telephoned the local practice, agreed they'd never heard of me before, but indicated that I was really sick. I knew where my NHS medical card was, which helped, as I was able to give them some sort of number.

I made the phone call at about 9am. The doctor was on my doorstep by 10.30am. She called twice more to see me over the following few days, and five days later, when I wasn't improving in spite of the antibiotics she had prescribed, she called the hospital and had an ambulance come for me. I was hospitalised for a week, and diagnosed with pneumonia. They kept me in an isolation room with my own en-suite facilities and a television. I had several x-rays and more antibiotics and stuff.

I got better, as you can see.

Total charge for that? I think it was about £3.50, which was the prescription tax at the time.

Rolfe.