Health care - administrative incompetence

[Tatyana]

Our system will change once our citizens wake up and realize that citizens of other nations are getting a much better deal. But standing in the way of that are the people who are getting rich on our current system. Some of these wealthy men have invested millions in a propaganda war. Spreading the idea that in the UK, people have to wait for hours in squalid rooms for even the most basic medical care. That myth is widely believed here in the US.

The government mandated that the turnaround time for AE/ER is four hours. Laboratory results are returned within one hour.

If the patient is under two or three years of age, they are seen within an hour.

All of this is tracked and audited.

This isn't the only parameter that has time restrictions set on it.

Referrals to specialists in the hospital, cancer referrals, time to operations are all mandated and tracked, and methods and systems are developed so that they can be met in a way that is acceptable to patients and staff.

 

[Tatyana]

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.

And the irony of the expensive lab tests is that this is one area where the USA is often 20 years behind other developed countries, lab work.

Not only is this exemplified in the use of odd outdated units, but old, outdated names for tests ie) SGOT for AST, and old, outdated ways of comparing analytes (like Urea:Albumin ratios or some odd thing).

Not only that, but often things like total hormones are measured instead of the free (thyroid function tests come to mind).

We often have to instruct medical and other health care professionals about the outdated methods and techniques still in use in the US so they will not be confused about it if they come across it in articles or textbooks from the US.

As well, there is the tendency to order a ridiculous amount of diagnostic tests for something as simple as a slightly elevated liver enzyme or creatinine level (no modern thing like Cockroft-Gault applied to see if it is relevant to the patient), instead of repeating the test within a month to see if there is a trend.

 

[Tatyana]

The government never denies anyone a service. What care you get is entirely in the hands of your doctor. The closest thing to a "bean counter" such as you envisage is NICE, and it's Scottish and Welsh counterparts. These organisations are committees of (OK, Government-appointed) top consultants who decide whether expensive new drugs are cost-effective. The aim is to avoid throwing money away on Big Pharma's latest money-spinner, not to deny people effective medication.

NICE is also there to determine the best medical practice based on evidence/science based medicine.

The last NICE guidelines I read related to pregnant women who required more support, those who were HIV positive, those who had substance abuse issues and those who were in an abusive relationship.

I am really impressed with the pre-natal, maternity and NICU departments in the NHS.

The NHS doesn't deny any procedures on the grounds of cost, only on clinical need. For example, breast implants wouldn't be done for free for someone who just fancied a bigger pair, but someone who had had a mastectomy will get reconstruction surgery including implants.

Transplant surgery is done on the basis of clinical need and availability of organs. An alcoholic wouldn't be denied a transplant but they have had to have abstained from alcohol for six months (though this can be overriden by doctors) prior to being put on the transplant list. There is no private option for liver transplant surgery.

You can 'go private' for some things, but you don't get better care, you just get it at a time of your choosing (which may not be any quicker), your room may have a carpet, the food will be better and your fellow patients will be richer. You'll usually have the same doctors, though.

I have had surgery both in a private hospital and in the NHS.

The only difference was a private room and slightly better food with a menu.

People can get plastic surgery on the NHS for psychological reasons as well, for example, a woman who is very self-conscious about having small breasts.

Each case is looked at individually, and I am sure NICE will get around to having some general guidelines to help clinicians make the decisions they need to make.

 

[Architect]

From the Mayo Clinic web site (it is one of the most prestigious hospitals in the U.S.), emphasis added:

"Strep throat is a bacterial throat infection that can make your throat feel sore and scratchy. Compared with a viral throat infection, strep throat symptoms are generally more severe. Only a small portion of sore throats are the result of strep throat. It's important to identify strep throat for a number of reasons. If untreated, strep throat can sometimes cause complications such as kidney inflammation and rheumatic fever. Rheumatic fever can lead to painful and inflamed joints, a rash and even damage to heart valves. Strep throat is most common between the ages of 5 and 15, but it affects people of all ages. If you or your child has signs or symptoms of strep throat, see your doctor for prompt treatment."
http://www.mayoclinic.com/health/strep-throat/DS00260

A "sore throat" is not the same as strep throat, and as a matter of fact strep throat can lead to something much more serious, especially in children. That's why everybody needs access to medical care.

I don't doubt the need for access, but the NHS has information on it too - note the different tone:

Streptococcal infections is a general term which is used to refer to any sort of infection caused by a type of bacteria known as streptococcal. Infections that are caused by the streptococcal bacteria can range from being mild, such as a sore throat, to life threatening, such as necrotizing fasciitis (the so called ‘flesh-eating’ bacteria).

And as for the prognosis:

The outlook for non-invasive GAS infections is good. Most cases of throat infection will pass without the need for treatment.

And...

Throat


Non-invasive group A streptococcus (GAS) infections of the throat usually pass without the need for medication.To help relieve symptoms:

• use over-the-counter (OTC) painkillers, such as paracetamol, to help control the symptoms of pain and fever,
• don't have food or drink that is too hot, as they could irritate your throat,
• avoiding smoking and smoky environments, and
• gargle regularly with warm, salty water to help reduce any swelling or pain.

Antibiotics are not recommended

The bolding is taken directly from the NHS website. There is a caveat about small children and those with suppressed immune systems.

 

[Architect]

I have had surgery both in a private hospital and in the NHS.

The only difference was a private room and slightly better food with a menu.

Ditto (PVS of the knee, athroscopic synovectomy), but in all fairness the food was a lot better. Steak and everything.

But same surgeon, same anaesthetist, same treatment as I would have got on the NHS.

 

[Architect]

The government mandated that the turnaround time for AE/ER is four hours. Laboratory results are returned within one hour.

If the patient is under two or three years of age, they are seen within an hour.

This refers, IIRC, to the English NHS rather than the UK as a whole however the other NHS systems have comparable criteria.

Here in Scotland, and in my (alas) experience, triage/assessment in A&E is carried out within 10-15 minutes for walk-in patients, then treatment is prioritised on the basis of the initial appraisal.

 

[Professor Yaffle]

I heard (from my mam who is a nurse) that they are scapping the 4 hour target in England and going back to treatment waits based on clinical need.

ETA
http://www.pulsetoday.co.uk/story.asp?sectioncode=35&storycode=4128087&c=2

 

[Darat]

This refers, IIRC, to the English NHS rather than the UK as a whole however the other NHS systems have comparable criteria.

Here in Scotland, and in my (alas) experience, triage/assessment in A&E is carried out within 10-15 minutes for walk-in patients, then treatment is prioritised on the basis of the initial appraisal.

That's the same in NHS England.

I'm ambivalent about the scrapping of the 4 hour target as I've seen first hand how hospitals move people about to fulfil the letter of the target.

 

[Darat]

This refers, IIRC, to the English NHS rather than the UK as a whole however the other NHS systems have comparable criteria.

Here in Scotland, and in my (alas) experience, triage/assessment in A&E is carried out within 10-15 minutes for walk-in patients, then treatment is prioritised on the basis of the initial appraisal.

That's the same in NHS England.

I'm ambivalent about the scrapping of the 4 hour target as I've seen first hand how hospitals move people about to fulfil the letter of the target but on t'other hand it does seem to have helped speed up treatment.

 

[Tatyana]

There must be enough data now to determine if the four hour turn around time is of any benefit.

I can see that there are certain practices that have been put in place that will help to make the AE more efficient.

I like the shorter time for infants and lab results.

 

[Uncayimmy]

Regarding over-utilization...

There's research showing that utilization varies by type of insurance, and as expected, utilization increases as the patient becomes less financially responsible. That doesn't necessarily mean over-utilization. It's pretty tricky define what over-utilization is anyway, which is not to say that it doesn't exist. I, for one, don't like seeing the doctor only to find out that it's nothing to worry about, but sometimes I just don't know. Education is part of that, and one way to deal with it is through increased education. Our pediatrician gave us an excellent pamphlet (well, small book) about when and when not to call. We consulted it numerous times. They also have a triage nurse to answer questions and decide priority. Nothing like that exists with any GP I've ever had. I just call and ask for an appointment.

One interesting aspect of over-utilization is imaging. MRIs, for example, are very expensive. The costs for the same MRI can vary greatly even within the same city (25% or more). What's disturbing to me is that from the perspective of the imaging lab, an MRI machine has a high fixed cost and, from what I can gather, a relatively low per-use cost. For example, the big MRIs at full power consume about 44 kilowatts per hour. That's a lot compared to a household, but with electricity costing about 15 cents per kilowatt hour, that's less than $7 (the 24/7 bill would be over $4,500/month). There's also the cost of films, but I don't know what that is. Yet prices for MRIs range from $400 to $3,000 (or even more). I'm still puzzled as to why a single breast MRI costs more than both breasts (according to this estimating site). That same site says that an abdominal MRI cost ranges from $1,600 to $6,600 in the USA.

Everything else for an MRI is a fixed cost. You have to pay a technician to be there whether it's used or not. Rent is paid whether it's used or not. If they run MRI shops like other businesses, they work out the fixed costs and per-use costs, then project a utilization rate in order to determine how much to charge to turn a reasonable profit. If doctors refer more patients for MRIs, utilization goes up. The cost to the insurance company goes up (or to the patient). Most likely the profits for the MRI shop increase. Conceivably the shops can compete on price, but considering they are usually under at least yearly contracts (I'd want to sign longer term contracts so that I could better project my utilization rates), the price competition factor is relatively small.

It's really quite complex. Interestingly, auto repair shops have a flat rate and typically don't charge for using machines if needed. They also charge the same hourly rate for replacing a dome light bulb as they do rebuilding a transmission. It seems that medical billing is not so closely tied to time. Perhaps those with experience in billing can chime in on how well correlated the reimbursement rates are to time required.

 

[Bob001]

Just a question here for the professionals: I understand that every medical practice and hospital have to have staff members who basically spend all their time haggling with insurance companies about what's covered for a particular patient's particular case because every policy is different. How would it affect the health care system if insurance was standardized? Insurers would compete on the basis of price and service, but every patient with, say, "Standard Package B with option 3" would have the same clearly defined coverages and exclusions without much room for dispute. This seems to work fairly well for automobile insurance and homeowners insurance. Could it work for health insurance? Or is the field just too complicated?

 

[xjx388]

I appreciate everyone's comments here. I obviously have much to learn about how National Healthcare works. I plan to investigate it more fully.

I did find the comments about Strep Throat interesting. Throat infections caused by the strep bacteria can lead to serious, albeit somewhat rare, consequences. We do a strep test for all sore throats. If positive, antibiotics are given. This is just good medicine because it greatly reduces the possibility that complications will arise. Now, if the NHS doctors routinely do not treat Strep Throat with antibiotics, I think that's a real problem that has its roots in cost savings.

I guess this is my biggest concern with any form of National Health Care: How much is the practice of Medicine compromised in order to save taxpayer money?

Another minor note: Some of the comments seem to suggest that the US health care system is somehow out of date or overly wasteful. I think this is as big a myth as is the "two week wait" myth.

 

[Uncayimmy]

I appreciate everyone's comments here. I obviously have much to learn about how National Healthcare works. I plan to investigate it more fully.

I did find the comments about Strep Throat interesting. Throat infections caused by the strep bacteria can lead to serious, albeit somewhat rare, consequences. We do a strep test for all sore throats. If positive, antibiotics are given. This is just good medicine because it greatly reduces the possibility that complications will arise. Now, if the NHS doctors routinely do not treat Strep Throat with antibiotics, I think that's a real problem that has its roots in cost savings.

I guess this is my biggest concern with any form of National Health Care: How much is the practice of Medicine compromised in order to save taxpayer money?

Another minor note: Some of the comments seem to suggest that the US health care system is somehow out of date or overly wasteful. I think this is as big a myth as is the "two week wait" myth.

You do a strep test for all cases of a sore throat? That seems wasteful to me. The Modified Centor Score says you shouldn't.

 

[jimbob]

I appreciate everyone's comments here. I obviously have much to learn about how National Healthcare works. I plan to investigate it more fully.

I did find the comments about Strep Throat interesting. Throat infections caused by the strep bacteria can lead to serious, albeit somewhat rare, consequences. We do a strep test for all sore throats. If positive, antibiotics are given. This is just good medicine because it greatly reduces the possibility that complications will arise. Now, if the NHS doctors routinely do not treat Strep Throat with antibiotics, I think that's a real problem that has its roots in cost savings.

I guess this is my biggest concern with any form of National Health Care: How much is the practice of Medicine compromised in order to save taxpayer money?

Another minor note: Some of the comments seem to suggest that the US health care system is somehow out of date or overly wasteful. I think this is as big a myth as is the "two week wait" myth.

I think the comments about waste are indisputable. Tatyana's comments were about specific areas of the healthcare system where she has specific knowledge, so I personally defer to her in that.

I have always understood that the reason for not treating strep throat is that it usually isn't effective or necessary, and I also thought it was trying to slow the spread of antibiotic-resistant bacteria.

Saying that, the last time I visited my GP, it was for a sore throat/tonsils, and the doctor took one look and prescribed antibiotics.

 

[xjx388]

How would it affect the health care system if insurance was standardized? Insurers would compete on the basis of price and service, but every patient with, say, "Standard Package B with option 3" would have the same clearly defined coverages and exclusions without much room for dispute. This seems to work fairly well for automobile insurance and homeowners insurance. Could it work for health insurance? Or is the field just too complicated?

I think it could work, but there would have to be a lot of standard plans and a lot of options. The other problem is that the bulk of the administrative hassle comes from trying to get things like MRIs, drugs and surgeries pre-authorized. That's really where the time and resource drain kicks in. Insurance companies do not trust doctors to make the determination as to what is medically necessary and what isn't.

 

[Agatha]

Insurance companies do not trust doctors to make the determination as to what is medically necessary and what isn't.

Is it in evidence that the reason for the different protocol in treating throat infections in the UK is cost-saving?

 

[Professor Yaffle]

Lots of countries with universal health care work on an insurance based system - I'm sure it would be fairly easy to look at how those countries do it.

Eg Germany:

The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population is covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher income workers sometimes choose to pay a tax and opt out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status.

http://en.wikipedia.org/wiki/Universal_health_care#Germany

 

[xjx388]

You do a strep test for all cases of a sore throat? That seems wasteful to me. The Modified Centor Score says you shouldn't.

I'm sure our doctor is well aware of when it is or is not appropriate to test for strep throat. I'm sure there are times when she just looks at a sore throat (along with all the other signs and symptoms) and determines that she should just treat it.

That's why I let her practice the medicine.

 

[Uncayimmy]

I have always understood that the reason for not treating strep throat is that it usually isn't effective or necessary, and I also thought it was trying to slow the spread of antibiotic-resistant bacteria.

In the USA the standard practice is to always prescribe antibiotics when strep throat is diagnosed. It appears that in the UK that's not the standard practice.

Saying that, the last time I visited my GP, it was for a sore throat/tonsils, and the doctor took one look and prescribed antibiotics.

They can make an empirical diagnosis without a lab test for confirmation if most or all the symptoms are there. That's the Centor Score I referenced earlier. I suppose the UK uses the same thing or something similar.