Health care - administrative incompetence

[Rolfe]

Actually, if we got hard-core about emulating the NHS, our costs would go down by about 50%. You'd pay the same as you do right now for Medicare/Medicaid, except you'd be able to actually have it pay all (or 99%) of your medical expenses, too.

Your continuing efforts to personalize this argument are ridiculous. Stick to the facts.

Sacrifice = putting your immediate wants aside in the near-term to achieve a more rewarding want in the far-term. Personal responsibility = finding your own way through life without using the crutch of "welfare." Two concepts many Americans have forgotten about . . .

Evasion noted.

Rolfe.

 

[Tatyana]

There's a number in there that is telling. The NHS recommends mammography once every three years?!? Now come on, people! Surely you can intuit that the only possible reason for this is cost-savings.

We screen every year and have better survival and mortality rates. Further evidence that the NHS crafts their guidelines to save money at the expense of people's lives.

I just noticed that.

Intuit? Seriously?

On a skeptical site, you are referring to intuition?

How about we use science based medicine?

As well, please provide some links.

Ta.

 

[Uncayimmy]

Don't see this advised in the UK . . . I wonder . . . could it be . . .

COST-SAVINGS?

That's what you have to prove. Just because one country recommends something different than the AMA doesn't mean it's about saving money. I could just as easily argue that the USA is trying to jack up costs. After all, the AMA is made up of for-profit physicians.

 

[kellyb]

That's what you have to prove. Just because one country recommends something different than the AMA doesn't mean it's about saving money. I could just as easily argue that the USA is trying to jack up costs. After all, the AMA is made up of for-profit physicians.

Since I'm the resident conspiracy theorist, I should use this opportunity to point out that the mammography machine makers are huge funders of the American Cancer Society.

Just sayin'.

 

[Tatyana]

There's a number in there that is telling. The NHS recommends mammography once every three years?!? Now come on, people! Surely you can intuit that the only possible reason for this is cost-savings.

We screen every year and have better survival and mortality rates. Further evidence that the NHS crafts their guidelines to save money at the expense of people's lives.

Just in case the message didn't get through:



Ooooooooooooh, look SCIENCE!!!!

A large research trial in 2002 concluded that the NHS Breast Screening Programme has got the interval between screening and invitations about right at three years, compared with more frequent screening. The trial was organised through the United Kingdom Coordinating Committee on Cancer Research (UKCCCR) and was supported by the Medical Research Council, Cancer Research UK and the Department of Health.

Here are the results from the UKCCCR Randomised Trial (PDF-186Kb) from the European Journal of Cancer, 2002.

http://www.cancerscreening.nhs.uk/breastscreen/EJC.38.11.pdf


The frequency of breast cancer screening: results from the
UKCCCR Randomised Trial
The Breast Screening Frequency Trial Group*,1
Received 23 October 2001; accepted 23 October 2001


Abstract
The optimal frequency of breast cancer screening has been a subject of debate since the inception of the UK National Breast


Screening Programme (NHSBSP). This paper reports on the only randomised trial directly comparing different screening intervals.


99 389 women aged 50–62 years who had been invited to a prevalent screen were randomly allocated after the scheduled prevalent
screen date to the study arm (invited to three further annual screens),or to the control arm (invited to the standard single screen 3
years later). 37 530 women in the study arm and 38 492 in the control arm had attended the prevalent screen. The endpoint was
predicted breast cancer deaths. The prediction was based on both the Nottingham Prognostic Index (NPI) and a similar method
derived from survival data from a series of tumours in the Swedish Two-County screening trial (2CS). Both indices were based on
the size,lymph node status and histological grade of the invasive tumours diagnosed in the two arms of the trial. The pathology of
the cases diagnosed was subject to review by two pathologists using standard criteria. The tumours diagnosed in the study arm were
significantly smaller than those diagnosed in the control arm (P=0.05). The relative risk of death from breast cancer for the annual
compared with the 3-yearly group was 0.95 (95% Confidence Interval (CI): 0.83–1.07, P=0.4) using the NPI and 0.89 (95% CI:
0.77–1.03, P=0.09) using the 2CS. Shortening of the screening interval in this age group is predicted to have a relatively small effect
on breast cancer mortality. Improvements to the screening programme would be targeted more productively on areas other than the
screening interval,such as improving the screening quality.

# 2002 Published by Elsevier Science Ltd.
Keywords: Mammography; Breast screening; Screening interval

 

[FattyCatty]

That's the operative phrase here. They craft their guidelines putting costs ahead of care as evidenced by the three year recommendation for breast cancer screening.

I consider your statement about the UK's health system extraordinary. Please provide extraordinary evidence that it it true (I don't mean anecdotes or news articles about a single patient or your specious claim that 3-year breast cancer screenings are proof).

And do you seriously think U.S. health care providers aren't putting cost ahead of care? Look at the profits they make. As a consumer, how do I know that the guidelines for yearly mammograms are not motivated by the pursuit of profit also? Someone has to pay for all those x-ray machines, after all.

And not everyone agrees with having a yearly mammogram:

In 2009, the U.S. Preventive Services Task Force (USPSTF) — a group of health experts that reviews published research and makes recommendations about preventive health care — issued revised mammogram guidelines. Those guidelines include the following:

• Screening mammograms should be done every two years beginning at age 50 for women at average risk of breast cancer.
• Screening mammograms before age 50 should not be done routinely and should be based on a woman's values regarding the risks and benefits of mammography.
• Doctors should not teach women to do breast self-exams.
• There is insufficient evidence that mammogram screening is effective for women age 75 and older, so specific recommendations for this age group were not included.

These guidelines differ from those of the American Cancer Society (ACS). The ACS mammogram guidelines call for yearly mammogram screening beginning at age 40 for women at average risk of breast cancer. Meantime, the ACS says the breast self-exam is optional in breast cancer screening.

I don't want to cling to anything. I want a change. You say health care is a right, but you aren't willing to cough up the millions it takes to truly give it to people who need it?

I think you are confusing Rolfe with someone else. Health care is a right in the UK and they "cough up the millions it takes" through their taxes. It's in the U.S. that people aren't willing to give health care to all people who need it. You are an example of that. Apparently the only change you want in health care is for everyone to save for their own care; if they can't save enough before they need care, tough noogies. If I've misunderstood your system, please clarify it.

Oh and so you pop over to the dermatologist whenever you feel like it and they just give you Accutane with no trouble? I hardly think so. According to this document, they must be referred to a dermatologist but only under certain conditions and after having tried other treatments. Anecdotally, it took a friend of ours in the UK two years to get her GP to refer her. Here in the US, your GP (Family Medicine) can take care of the whole thing. If your severe cystic acne doesn't respond to first-line treatment, you can get Accutane within a few months. I have not heard of any issues with covering it, although it is at a higher "copay."

If your GP is taking care of the whole thing on his own, it is not legal. There are legal requirements for its use. Accutane was not intended to be the first treatment used, rather it was to be used when other treatments failed. And there are legitimate concerns over any use of Accutane (which won't be sold in the U.S. anymore under that name):

On June 29, 2009, Roche Pharmaceuticals, the original creator and distributor of isotretinoin, officially discontinued both the manufacture and distribution of their Accutane brand in the United States due to what the company described as business reasons related to low market share (below 5%) coupled with the high cost of defending personal-injury lawsuits brought by some patients prescribed the drug.
<snip>
Since 1 March 2006, the dispensing of isotretinoin in the United States has been controlled by an FDA-mandated website called iPLEDGE – dermatologists are required to register their patients before prescribing and pharmacists are required to check the website before dispensing the drug. The prescription may not be dispensed until both parties have complied. A physician may not prescribe more than a 30-day supply. A new prescription may not be written for at least 30 days. Pharmacies are also under similar restriction. There is also a 7-day window between the time the prescription is written and the time the medication must be picked up at the pharmacy. If the original prescription is lost, or pick-up window is missed, the patient must re-qualify to have another prescription written. Doctors and pharmacists must also verify written prescriptions in an online system before patients may fill the prescription. Women must be on two forms of birth control if they take isotretinoin because of its teratogenic effects.

Define ordinary standard care. Cite sources of when such has been routinely denied, then we can talk. Until then all you've got is ranting and insults such as that last little bit there.

Why don't you do the same for the U.S. "health care system" of which you are such a proponent? Tell us when emergency rooms stabilize then release sick indigent patients with nowhere else to go. Tell us about how they actually turn ambulances away. Tell us about all the children and elderly who don't get health care (except emergency visits to the ER) under your wonderful "free market" system. Define ordinary standard care. Define denial for pre-existing conditions. Define cap on coverage amount. Define "we don't cover that medicine." Cite sources that say the system in the U.S. is superior to any other systems (if I recall correctly Iran and Iraq beat us in some areas). Until you do, all you've got is ideological dogmatism and personal prejudice against poor or uninsured people.

 

[banquetbear]

¡Ai-yi-yi! . . .
In the UK (Your own source by the way)



In the US



So not only yearly mammograms in the US but MRIs for some rare women. Don't see this advised in the UK . . . I wonder . . . could it be . . .

COST-SAVINGS?

...hold on.

According to your cites: the UK provides screening every three years: free at point of delivery.

According to you, the American Cancer Society recommends yearly mammograms from 40.

To make a fair comparison to the UK system, can you show me that the US government provides screening every year free at the point of delivery?

 

[Rolfe]

That's the operative phrase here. They craft their guidelines putting costs ahead of care as evidenced by the three year recommendation for breast cancer screening.

Bad example. I don't particularly want to be dosed with more ionising radiation than need be. Your mileage may vary.

Get back to me when the USA is screening every woman who can be arsed to turn up for her automatically-generated appointment (as happens here), at no cost to her, and we can talk about who's putting cost ahead of care, and whose outcomes are superior.

I don't want to cling to anything. I want a change. You say health care is a right, but you aren't willing to cough up the millions it takes to truly give it to people who need it?

There goes that lack of comprehension thing again. Healthcare to the standard the NHS provides is a right in this country. If you think the NHS's standards should be even higher, like extra irradiation to women, or providing experimental drugs that aren't likely to do any significant good, then fine. But come back and argue that moral high ground when your own country allows all its citizens access to affordable healthcare of as high a quality as the NHS.

Define ordinary standard care. Cite sources of when such has been routinely denied, then we can talk. Until then all you've got is ranting and insults such as that last little bit there.

You are the one who is ranting with no citations. You repeatedly say alcoholics will be denied a liver transplant on the NHS when this isn't even necessarily true, but then we find they aren't eligible for transplants in the USA either.

And whatever the hell drug it was your little poster child got, that may or may not have been responsible for her outlier survival time, where are your links to show that it's routinely available for American women?

Come on, tell us the truth about what the NHS "denies" on cost grounds that is routinely available no-quibble to US patients.

Rolfe.

 

[Rolfe]

¡Ai-yi-yi! . . .

My, is this a football match or something? When a poster who started out saying he wanted to learn ends up yippeeing when he finds a cherrypicked point he falsely thinks will shore up a collapsing argument, you know you have a zealot on your hands.

In the UK (Your own source by the way)

In the US

So not only yearly mammograms in the US but MRIs for some rare women. Don't see this advised in the UK . . . I wonder . . . could it be . . .

COST-SAVINGS?

No, evidence-based medicine. You've been told this a dozen times.

Rolfe.

 

[Tatyana]

While we are focusing on the whole breast cancer screening issue:

BMJ 2000; 320 : 1635 doi: 10.1136/bmj.320.7250.1635 (Published 17 June 2000)

http://www.bmj.com/content/320/7250/1635.full?sid=afc00762-9208-42cf-b39a-16b0e64d1d89

US women's attitudes to false positive mammography results and detection of ductal carcinoma in situ: cross sectional survey

Conclusions: Women are aware of false positives and seem to view them as an acceptable consequence of screening mammography. In contrast, most women are unaware that screening can detect cancers that may never progress but feel that such information would be relevant. Education should perhaps focus less on false positives and more on the less familiar outcome of detection of ductal carcinoma in situ.







http://www.journal-surgery.net/article/S1743-9191(05)00090-7/abstract

Volume 3, Issue 3, Pages 179-187 (2005)



Does surgery induce angiogenesis in breast cancer? Indirect evidence from relapse pattern and mammography paradox

Michael RetskyaCorresponding Author Informationemail address, Romano Demichelibemail address, William J.M. Hrusheskycemail address

Abstract

A significant bimodal relapse hazard pattern has been observed in two independent databases for patients untreated with adjuvant chemotherapy.

This implies there is more than one mode of relapse. The earliest and most closely grouped relapses occur 8–10 months after surgery for young women with node-positive disease.

Analysis of these data using computer simulation suggested that surgery probably instigated angiogenesis in dormant distant disease in approximately 20% of cases for premenopausal node-positive patients. We explore if this could explain the mammography paradox for women aged 40–49: an unexplained temporary excess in mortality for the screened population compared to controls. Calculations based on our data predict surgery-induced angiogenesis would accelerate disease by a median of two years and produce 0.11 early deaths per 1000 screened young women in the third year of screening. The predicted timing as well as the magnitude of excess mortality agree with trial data.

Surgery-induced angiogenesis could account for the mammography paradox for women aged 40–49 and the bimodal relapse hazard pattern. According to the proposed biology, removing tumors could remove the source of inhibitors of angiogenesis or growth factors could appear in response to surgical wounding. While this needs confirmation, this could be considered when designing treatment protocols particularly for young women with positive nodes. It reinforces the need for close coordination between surgical resection and ensuing medical intervention. Women need to be advised of risk of accelerated tumor growth and early relapse before giving informed consent for mammography.

Keywords: Angiogenesis, Breast cancer, Mammography paradox, Surgery, Dormancy, Early detection

 

[Ampulla of Vater]

I think there is something you need to know.

The amount of tax paid by British citizens to fund the NHS is slightly lass than the amount of tax paid by US citizens to fund state-provided healthcare in the USA. This is true whether you compute it on a per-head basis, or as a percentage of GDP.

The only difference is that while most US citizens cannot access the state-provided healthcare in their country, and so have to make other arrangements paid for out of their taxed income, British citizens can all access the NHS and so need not make any additional arrangements unless they choose to do so.

It's very hard to compute exactly what anyone is paying in tax, because there's income tax, national insurance (supposedly to pay for pensions), VAT, council tax, petrol tax, tobacco tax, alcohol taxes, the list goes on and on. All I know is, I seem to have enough left to do what I want!

I think, overall, British citizens do pay more tax than US citizens. But whatever we are getting for that money (better pensions or Trident missile systems, who knows), it's not healthcare. Because, as I said, you're already as things stand paying out more in tax for state-provided healthcare than we are.

Bear in mind also that we are completely free to buy additional insurance over and above that, if we're suddenly terrified by the thought that the NHS might deny us something (or more likely if we want a single room in hospital and no chance of mixing with the Great Unwashed while we have our sinuses done). It's just that most people don't, because simple observation shows that the NHS comes up with the goods when required.

If the NHS was falling short, no doubt there would be a growth in the private insurance business. The option is there, if it was needed. But there's no real sign of that happening. Private healthcare is more a snob thing than anything else.

Rolfe.

So start easy: What is your income tax percentage, what is your VAT percentage and at what rate is your national insurance tax?

You having "enough left to do what you want" is not specific enough in a discussion of the advantages and disadvantages of NHC.

Perhaps it is purposely confusing because if you really knew how much you were actually paying you'd move to the U.S.

Do you know of any stats regarding how many people have the additional private insurance?

 

[kellyb]

My, is this a football match or something? When a poster who started out saying he wanted to learn ends up yippeeing when he finds a cherrypicked point he falsely thinks will shore up a collapsing argument, you know you have a zealot on your hands.




No, evidence-based medicine. You've been told this a dozen times.

Rolfe.

The ironic thing about that is that he's accusing the NHS of "covertly" rationing care in the case of mammograms, which is very unlikely for a few reasons. The first is that even the Cochrane Collaboration says that mammography in general might do more harm than good based on the issue of false positives alone. The second is that the NHS has no motive to "covertly" ration at all since it does, from time to time, OPENLY "ration" in the cases of mega-expensive drugs unlikely to extend life for more than a couple of weeks.

The really ironic part is that the third party payers in the US absolutely DO covertly ration our health care, via exclusion from the system, recission, denials of approval, etc.

 

[kellyb]

Perhaps it is purposely confusing because if you really knew how much you were actually paying you'd move to the U.S.

Do you know of any stats regarding how many people have the additional private insurance?

Look at page 20, chart II-7 here:

http://www.commonwealthfund.org/~/m...mparisonshltsysdata2006_chartbook_972 pdf.pdf

 

[Ampulla of Vater]

Quoted for truth.

There is no limit on the care anyone can receive on the NHS so long as that care is evidence-based and has a reasonable probability of being effective.

And we do all this for half of what the USA spends on healthcare, in fact for about the same amount (per person) as the USA spends on government-provided healthcare to cover only a fraction of the population.

Rolfe.

This is simply not true. NICE decides the amount that cannot be exceeded to extend a person's life beyond a year.

Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year.

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?pagewanted=1&_r=1

 

[Rolfe]

So start easy: What is your income tax percentage, what is your VAT percentage and at what rate is your national insurance tax?

Someone else posted the income tax rates, which are on a sliding scale.
VAT is 17.5% at the moment but is going up to 20%.

You having "enough left to do what you want" is not specific enough in a discussion of the advantages and disadvantages of NHC.

As I said, what I do know is that the USA spends slightly more than Britain on state-provided healthcare, both per capita and as a percentage of GDP. Thus, even if we do pay more in tax, it's not about healthcare provision.

Perhaps it is purposely confusing because if you really knew how much you were actually paying you'd move to the U.S.

Not on a bet! Nice place for a short visit, lovely people. I'd never move away from the NHS or a similar universal healthcare system. If you're doing a true comparison, then you have to factor in both the costs of the taxation and the benefits we receive from it.

The benefit of full and free access to the NHS is quite clearly worth a small fortune in US terms, when I read what US citizens are having to pay for health insurance coverage.

Do you know of any stats regarding how many people have the additional private insurance?

No. It's not a priority for most people, if anyone. I had it as part of my job, initiated back in the early 1990s when the NHS wasn't performing as well as it is now. It got me a sinus operation a couple of months earlier and in a swankier hospital than if I'd had it on the NHS, but the same surgeon.

I've looked into continuing it, now I've changed jobs, but even though the premiums are quite cheap I can't see it as being worth it at all. It's little more than snobbery.

Rolfe.

 

[Rolfe]

This is simply not true. NICE decides the amount that cannot be exceeded to extend a person's life beyond a year.

Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year.

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?pagewanted=1&_r=1

Evidence-based, remember.

And finally someone other than me has brought up the subject of the QALY. I referred to this implicitly in a lot of posts, and explicitly in one which was ignored.

Paying large amounts of money to prolong the dying process is problematic. How would you like to approach the issue?

Rolfe.

 

[Delscottio]

So start easy: What is your income tax percentage, what is your VAT percentage and at what rate is your national insurance tax?

You having "enough left to do what you want" is not specific enough in a discussion of the advantages and disadvantages of NHC.

Perhaps it is purposely confusing because if you really knew how much you were actually paying you'd move to the U.S.

Do you know of any stats regarding how many people have the additional private insurance?

The tax stuff was done upthread but it easier if you go to a takehome calculator and do yourself.

Private is around ten percent as per wiki which sounds about right- mostly linked with jobs

 

[Tatyana]

So start easy: What is your income tax percentage, what is your VAT percentage and at what rate is your national insurance tax?

You having "enough left to do what you want" is not specific enough in a discussion of the advantages and disadvantages of NHC.

Perhaps it is purposely confusing because if you really knew how much you were actually paying you'd move to the U.S.

Do you know of any stats regarding how many people have the additional private insurance?

No, I wouldn't move to the US, and I probably could.

VAT is 20%

I think my income tax averages at around 33%.

I have spent a lot of time in the US, and there are so many hidden and sneaky taxes, I would assert that most Americans are paying more tax than they are aware of.

You can look for stats, I don't think you will find many.


It isn't as if we need insurance to access private health care, you can just pay for it at the time.

For example, when the swine flu news was first breaking over a year ago, I was flying through the two places where there had been cases and deaths, LA and Auckland.

I asked my GP for Tamiflu. I couldn't get it on the NHS as I was asymptomatic (I would have been able to get it if I had flu symptoms), so I got a private prescription from my NHS GP.

It cost me £ 22, which is less than $ 40.

It typically costs around $ 100 in the US.

I also see my NHS physiotherapist privately on occasion (I often have a really heavy training routine and I only typically need one session and I can see him within the week, instead of three).

He charges £ 35/hour.

It doesn't make any sense for me to pay monthly for private insurance.

 

[banquetbear]

This is simply not true. NICE decides the amount that cannot be exceeded to extend a person's life beyond a year.

Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year.

http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?pagewanted=1&_r=1

...why are you citing the NY Times and not NICE?

And you are aware that Sutent has been approved for use?

 

[bookitty]

My mom-in-law had two abnormal pap smears that the doctor didn't tell her about. He waved away her symptoms by telling her that they were related to menopause and put her on hormone replacement therapy. Then she gets a new job, new insurance and therefore a new doctor. The new doctor finds stage IV cervical cancer.

The new insurance company gets a hold of the old doctors records, calls her cancer a pre-existing condition. Months of phone calls, arguing, etc. They will consider covering her if she can get the first doctor to say he didn't give her the pap smear results. Maybe. Doctor bulks at this. More paperwork, more phone calls. The insurance company drops her. More paperwork, more phone calls, medicaid covers some of the cost.

Here's the fun part - Sister-in-law is infuriated. She calls every news station in California with this shocking story. They turn her down. Insurance company not paying? Nope, no story. This sort of thing is too common, it's not news. Maybe when they do a "High cost of insurance" special they'll call her. They never do.

Mom-in-law dies two years later. If she had lived, she would have been $300,000 in debt.

MIL worked for 35 years. She and her employees paid for health insurance during that entire time. She also paid taxes. When she got sick, she was on her own. Had she paid the same amount of money into the British model, she would have been helped. She may still have died but at least she wouldn't have wasted months on useless phone calls and paperwork.