Health care - administrative incompetence

[Rolfe]

I'm a biochemist/haematologist on the veterinary side, and I'd just like to confirm what Tatyana is saying. The USA is in the dark ages as far as laboratory medicine is concerned. While British medics know this, British vets don't, and it's a constant battle to fight off the tendency to believe that the American Way must be progressive and the best approach. No, if you do it that way it will cost a fortune and provide no benefit to the patient.

And don't get me started on the units thing. More than 20 years ago I had to write a damn textbook for my students because there was nothing that wasn't using bongo-bongo-land mg/100ml nonsense. I never really stopped to think why this is. I'm beginning to catch on though.

Rolfe.

 

[blutoski]

Oh yes, there's plenty of room for improvement in the NHS. however, as far as cost-effectiveness, it is probably about the most efficient in the OECD.

There are a handful of countries that consistently top the list for efficiency and that they usally also rank highest for citizen satisfaction with healthcare.

Realistically, there's a trivial difference between the top contenders and dropping from 1st to 3rd rarely represents a material difference in delivery.

What's relevant is that there's a huge gap between this first-tier performance cluster and the next spread of mediocre countries.



And not that it's an excuse, but Canada has some significant cost challenges to the universality clause: we are obliged to invent a way to provide services to first nations peoples living in the Arctic or on remote islands 1,000km away from a hospital.

I live near VGH and our helicopter pad is constantly bringing in patients from the rest of Fraser and Coastal, which includes the Strait of Georgia and even Haida Gwaii. It looks like this one health district has a larger geographic catchment than the entire UK with only a fraction of the population.

 

[Tatyana]

I'm a biochemist/haematologist on the veterinary side, and I'd just like to confirm what Tatyana is saying. The USA is in the dark ages as far as laboratory medicine is concerned. While British medics know this, British vets don't, and it's a constant battle to fight off the tendency to believe that the American Way must be progressive and the best approach. No, if you do it that way it will cost a fortune and provide no benefit to the patient.

And don't get me started on the units thing. More than 20 years ago I had to write a damn textbook for my students because there was nothing that wasn't using bongo-bongo-land mg/100ml nonsense. I never really stopped to think why this is. I'm beginning to catch on though.

Rolfe.

Ditto.

Everytime I lecture to medics or biomedical scientists, I have to list all of the tests that the Americans still use so that they don't come upon them and think it is something new.

You have to give the Americans credit for trying out new things, however, there just doesn't seem to be the tendency to improve and/or throw out any of the older, established laboratory practices.

Seriously, BUN (blood urea nitrate) instead of urea? Why?

 

[Rolfe]

Oh, I forgot that. It's like dragging nails down a blackboard with me. I have to fight the urge to slap anyone who says it.

Actually, it's units-dependent. Mg of urea and mg of urea nitrogen are different things. Different reference ranges. There is a conversion factor.

Try explaining how it is impossible to measure "BUN" in mmol/l. Except I once saw a paper which purported to do exactly that. The figures were twice the urea results in mmol/l (work it out....). It's completely buging nuts.

Rolfe.

 

[Emet]

[FONT=Tahoma, sans-serif]A PBS special, "Sick Around the World," is an entertaining and informative look at five national health care systems around the world by a former Washington Post reporter who has also written a book about the subject. Some systems are government-run, others are based on private insurance, but all deliver good care efficiently. One key number that sticks in my mind: In the U.S., around 24% of health care money goes directly to administrative costs; in other systems, administration is down to as little as 6%. (This is an hour-long program, divided into five chapters, but it's worth watching when you have the time.)[/FONT]
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/#morelink

[FONT=Tahoma, sans-serif][/FONT] [FONT=Tahoma, sans-serif]
[/FONT]

Thanks for the link, Bob001. I haven't watched the video yet but had a look at the link.

There was another recent documentary about health care around the world: Michael Moore's Sicko. Did you have that film in mind when you set out to make this report?

I thought Michael Moore did a good job in describing the shortcomings of the U.S. system. He didn't pay much attention to our strengths: the best medical education in the world, the most innovative research, the best equipped hospitals. He is an advocate and had a point to make.

link

Aside from other issues already mentioned, the most important issue IMO is the utter unavailability of any care for so many Americans.

You will receive excellent or at least some care if:
1. You are wealthy.
2. You have decent insurance through your employer or purchased through some other means. Of course, there were all of those examples of rescission that where reported on throughout the health care debate. You remember... people who had long standing policies, then were diagnosed with an expensive, serious, life-threatening disease. Despicable, capricious, indefensible, immoral decisions exercised by greedy insurers. link
3. You have public subsidized insurance: Medicare, Medicaid, etc.

But that leaves out tens of millions of Americans without any insurance at all. Like the working poor.

Vital Signs: Health Insurance Coverage and Health Care Utilization --- United States, 2006--2009 and January--March 2010

Results: In the first quarter of 2010, an estimated 59.1 million persons had no health insurance for at least part of the year before their interview, an increase from 58.7 million in 2009 and 56.4 million in 2008. Of the 58.7 million in 2009, 48.6 million (82.8%) were aged 18--64 years. Among persons aged 18--64 years with family incomes two to three times the federal poverty level (approximately $43,000--$65,000 for a family of four in 2009), 9.7 million (32.1%) were uninsured for at least part of the preceding year. Persons aged 18--64 years with no health insurance during the preceding year were seven times as likely (27.6% versus 4.0%) as those continuously insured to forgo needed health care because of cost. Among persons aged 18--64 years with diabetes mellitus, those who had no health insurance during the preceding year were six times as likely (47.5% versus 7.7%) to forgo needed medical care as those who were continuously insured.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm59e1109a1.htm

 

[Uncayimmy]

Everytime I lecture to medics or biomedical scientists, I have to list all of the tests that the Americans still use so that they don't come upon them and think it is something new.

You have to give the Americans credit for trying out new things, however, there just doesn't seem to be the tendency to improve and/or throw out any of the older, established laboratory practices.

Seriously, BUN (blood urea nitrate) instead of urea? Why?

I, for one, would be interested in seeing a thread in the Science forum regarding this subject.

 

[Tatyana]

I, for one, would be interested in seeing a thread in the Science forum regarding this subject.

All we need is someone to post some of their blood results.

I may be able to find some that I have seen on line before.

 

[jimbob]

My point is to apply perspective: these hypothetical concerns are SOP in the US system. And in Canada... we get to vote on whether we like the administrative decisions or not, regardless of income. We're not just customers... we're owners.

That's the big difference between the US and the rest of the OECD.

(Goes off on one about the thread about fundamental rights)_

 

[xjx388]

All we need is someone to post some of their blood results.

I may be able to find some that I have seen on line before.

I'd definitely like to see this. I think it's a pretty extraordinary claim that America is in the "dark ages" when it comes to laboratory tests. Not saying you are wrong but it's definitely a topic worth exploring. Using the BUN vs. Urea example, what makes the use of BUN outdated as opposed to the use of Urea? It seems to me the equivalent of when Americans think Brits are in the Dark Ages when they use words like "Haematology." What the heck is that? Do you mean "Hematology"? I kid! But the point is that maybe it's a cultural/traditional thing more than a utility thing.

 

[Rolfe]

No. The analyte being measured is urea.

Blood (no, we measure it in plasma or serum, not blood).
Urea (yes, that's the stuff).
Nitrogen (once upon a time, measurements were so primitive that what you actually did was measure the amount of nitrogen in the sample that was incorporated into urea molecules - that was a very long time ago, get over it).

The anachronism is the unit thing. mg/100ml, but it's actually mg of urea nitrogen per 100 ml plasma. Not actually mg of urea. This is nuttier than a fruitcake.

In clinical biochemistry, we don't give a monkeys what weight of an analyte is in the sample, we want to know how many molecules there are. So almost everything is measured in mmol/l or µmol/l or nmol/l or maybe even pmol/l. All very logical and simple and everything relates to everything else. All this messing around with mg/100ml is simply insane.

The urea/BUN simply highlights the insanity, because of the insistence on quoting not even the gravimetric result for the actual molecule you're measuring, but the gravimetric result for a couple of the atoms in that molecule. I mean, honestly. Get over it.

The result is a mess of confusion and which conversion factor to use.

BUN (mg/100ml) to urea (mmol/l); 0.36
urea (mg/100ml) to urea (mmol/l); 0.17

To compare the mess of archaism and confusion that is US units to mere differences in spelling conventions is preposterous. It suggests that even understanding of the problem is lacking, which is a bit scary. For goodness sake, couldn't you guys get with the programme and maybe catch up with the 1970s sometime soon?

Rolfe.

 

[Architect]

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.

With respect, nothing that has been posted supports that assumption; the NHS say that, except in certain cases, there is generally not clinical need for the treatment.

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?

There is no evidence of such problems; value for money is a factor in NICE decisions and there are a few well publicised cases of very expensive new drugs with limited benefits not being covered, but basically we can get any treatment required regardless of cost.

Incidentally if a patient disagrees with a NICE decision then can challenge it at judicial review, a very quick process (typically 1-2 weeks) and the State covers the costs for the appellant through legal aid. I can remember 2 cases in the last 5 years or so, and in both cases the NHS then provided the drugs.

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.

Your medical system costs double ours but with broadly similar clinical outcomes. There's certainly waste somewhere, I think you have to agree.

 

[Rolfe]

And I don't know about the rest of it, but in the laboratory medicine field, it's about 30 years out of date.

Rolfe.

 

[Ducky]

No. The analyte being measured is urea.

Blood (no, we measure it in plasma or serum, not blood).
Urea (yes, that's the stuff).
Nitrogen (once upon a time, measurements were so primitive that what you actually did was measure the amount of nitrogen in the sample that was incorporated into urea molecules - that was a very long time ago, get over it).

The anachronism is the unit thing. mg/100ml, but it's actually mg of urea nitrogen per 100 ml plasma. Not actually mg of urea. This is nuttier than a fruitcake.

In clinical biochemistry, we don't give a monkeys what weight of an analyte is in the sample, we want to know how many molecules there are. So almost everything is measured in mmol/l or µmol/l or nmol/l or maybe even pmol/l. All very logical and simple and everything relates to everything else. All this messing around with mg/100ml is simply insane.

The urea/BUN simply highlights the insanity, because of the insistence on quoting not even the gravimetric result for the actual molecule you're measuring, but the gravimetric result for a couple of the atoms in that molecule. I mean, honestly. Get over it.

The result is a mess of confusion and which conversion factor to use.

BUN (mg/100ml) to urea (mmol/l); 0.36
urea (mg/100ml) to urea (mmol/l); 0.17

To compare the mess of archaism and confusion that is US units to mere differences in spelling conventions is preposterous. It suggests that even understanding of the problem is lacking, which is a bit scary. For goodness sake, couldn't you guys get with the programme and maybe catch up with the 1970s sometime soon?

Rolfe.

How many feet in a yard again?

 

[Rolfe]

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all

This is really depressing reading. Never have I been so thankful for the NHS than when reading that. The way the NHS works is that there is no incentive for doctors to over-investigate and over-treat to make more money. Instead, financial incentives are put in place to persuade doctors to do the beneficial things - like extra payments for maximising the number of vaccinations they do, or the number of cervical smears and so on. Committees like NICE look at the evidence for the best way to manage particular conditions, then disseminate that knowledge so that everyone gets the benefit of it.

I've seen behaviour such as is described in that article take root among vets in this country, and it's not pretty. As my now-retired senior partner used to say, there's enough work in the world without inventing it. But then an American corporation came on the scene and started pressurising British vets to invent it - and persuade them that this was the best way, because it was "American".

Meh. It hasn't been good for companion animal medicine. But applying these principles to human medicine - my God, things are becoming clearer by the minute.

Rolfe.

 

[xjx388]

The anachronism is the unit thing. mg/100ml, but it's actually mg of urea nitrogen per 100 ml plasma. Not actually mg of urea. This is nuttier than a fruitcake.

In clinical biochemistry, we don't give a monkeys what weight of an analyte is in the sample, we want to know how many molecules there are. So almost everything is measured in mmol/l or µmol/l or nmol/l or maybe even pmol/l. All very logical and simple and everything relates to everything else. All this messing around with mg/100ml is simply insane.

The urea/BUN simply highlights the insanity, because of the insistence on quoting not even the gravimetric result for the actual molecule you're measuring, but the gravimetric result for a couple of the atoms in that molecule. I mean, honestly. Get over it.

The result is a mess of confusion and which conversion factor to use.

BUN (mg/100ml) to urea (mmol/l); 0.36
urea (mg/100ml) to urea (mmol/l); 0.17

To compare the mess of archaism and confusion that is US units to mere differences in spelling conventions is preposterous. It suggests that even understanding of the problem is lacking, which is a bit scary. For goodness sake, couldn't you guys get with the programme and maybe catch up with the 1970s sometime soon?

Rolfe.

But is there any clinical advantage to using one or the other? I'm not a biochemist, I just run my wife's family practice clinic (or surgery to use an archaic British term ). I don't see any evidence, however, that the British units of measurement are somehow more accurate or, better yet, make diagnosis any better. It's just a different way of doing it and both work equally well. I can understand how it would be a hassle for British doctors to convert units and such, but we Americans aren't in the habit of changing our ways to suit the conventions of other countries. My god, we still use the archaic inches/feet system! So if you are saying we are archaic because we use old units, well you have a very good point! But "old measurement units" does not necessarily translate to "outdated Laboratory Science."

 

[Rolfe]

It does when you're measuring by weight, not moles.

Bear in mind that everybody else changed because the new system is significantly better, not just to annoy those too set in their ways to follow suit.

Rolfe.

 

[xjx388]

[/B]

With respect, nothing that has been posted supports that assumption; the NHS say that, except in certain cases, there is generally not clinical need for the treatment.

Like I said, it's merely my opinion. I could be wrong. But it's possible that the NHS guidelines were drafted in order to save money. I think it's at least a valid question.

There is no evidence of such problems; value for money is a factor in NICE decisions and there are a few well publicised cases of very expensive new drugs with limited benefits not being covered, but basically we can get any treatment required regardless of cost.

Well, the newspaper article I quoted above illustrates the fact that money is a big factor in cutbacks that various NHS Trusts are implementing.

Your medical system costs double ours but with broadly similar clinical outcomes. There's certainly waste somewhere, I think you have to agree.

Oh for sure! I'm not saying our system isn't wasteful, I'm saying it's not necessarily more wasteful than other systems. More spending does not necessarily mean more waste than other countries. My larger point is that there is no perfect system. My opinion, based on nothing more than my own experience, is that the least wasteful system would be the one where patients are more financially responsible for their own medical care. Eliminate the government programs; eliminate the insurance companies. Then, doctors can charge reasonable amounts and competition will keep costs in check.

 

[xjx388]

It does when you're measuring by weight, not moles.

Bear in mind that everybody else changed because the new system is significantly better, not just to annoy those too set in their ways to follow suit.

Rolfe.

But what makes it better?

 

[Architect]

But is there any clinical advantage to using one or the other? I'm not a biochemist, I just run my wife's family practice clinic (or surgery to use an archaic British term ).

A clinic will generally be a larger healthcare facility with different disciplines involved and a wider array of services. So, for example, the one across the road from my office also provides family planning services and (I believe) addresses issues around adiction management.

A surgery can actually be quite large - the one next door to our office (we're in that kind of area, for some reason) has 4 or 5 doctors plus practice nurses. The different is that it will be focussing on what I would call "normal" GP type work.

And all this despite the fact that the hospital - a major facility - is all of a mile and a half along the road (literally).

 

[Architect]

Like I said, it's merely my opinion. I could be wrong. But it's possible that the NHS guidelines were drafted in order to save money. I think it's at least a valid question.

But - and apologies if I appear to be jumping down your throat on this - that's all it is. If we look (and I just have) at French guidance on sore throats, it's broadly the same as the UK. Does that mean it's a conspiracy by the two UHC systems to cost save or, as I would suggest, does it suggest that perhaps the US is over-treating the complaint?

Well, the newspaper article I quoted above illustrates the fact that money is a big factor in cutbacks that various NHS Trusts are implementing.

I think you've misread the article. It talks about low priority work, for example, being put to the bottom of the pile. And the papers were covering this because of the outcry. The NHS Trusts will have to review the position. Find me a health insurer in the US who's open to challenge in this very public way.

Oh for sure! I'm not saying our system isn't wasteful, I'm saying it's not necessarily more wasteful than other systems. More spending does not necessarily mean more waste than other countries.

Logical fallacy, I'm afraid. Your system produces broadly similar clinical outcomes for something approaching double the cost in the UK. Unless you're arguing that health in the US is significantly worse that the UK, then there must be something eating up the money. What is it, if not waste?

My larger point is that there is no perfect system. My opinion, based on nothing more than my own experience, is that the least wasteful system would be the one where patients are more financially responsible for their own medical care. Eliminate the government programs; eliminate the insurance companies. Then, doctors can charge reasonable amounts and competition will keep costs in check.

Same point again. The US system costs more than the government programmes in place in the UK, Canada, and mainland Europe. I would suggest that your problemis not the government but rather private sector involvement and in particular the drive for profit.