Health care - administrative incompetence

Architect said:
XJX

One of the debates going on in the UK which your wife you may find of interest, and which has been discussed already in the forum, is the approach to breast screening.

As you are aware, all females in the UK above a certain age are automatically screened. There is, however, a debate as to whether this is necessarily the most effective way of managing the problem and the extent to which it might result in false positives. I'm not sure if it's reached its conclusion yet, but it batters over the press quite regularly. In comparison, the US does not - as I understand - have a wholesale screening process although patients can seek private screeing and some insurers provide coverage.
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I can't speak to the debate in the UK. I wouldn't characterize it as "automatically screened." They are merely invited after age 50 every 3 years. They still have to actually show up at the office.

I know that the US recommendation is to screen women over 40 every year and that is what doctors do for the women they see. Some government task force tried to recommend that women under 50 shouldn't be screened, but their work was widely criticized in the Medical community. I refer you to this blog entry, which echos the thinking of most doctors:
What seems paramount – but ostensibly lacking – in this discussion is an analysis of a physician’s responsibility to individual patients and how those responsibilities are shaped, governed, and guided by policy recommendations. This is especially true when the policy recommendations depend on relative statistics – balancing harms and benefits in different groups. The harms are not greater for 40-49 year old woman than for their older counterparts, they are simply more prevalent, but coupled with the benefit of saving a life with a longer potential life expectancy. Generally, the medical establishment and society at large are willing to ‘go farther’ and take on greater risk and cost to treat, cure, and prevent disease as the potential life expectancy of a successful intervention increases. Breast cancer prevention should be no different. For an individual patient, 1 in 1339 may have the same meaning as 1 in 1904 and they may be willing to undertake the risk of additional follow-up. Where that line should be drawn, or even how to determine where that line should be, is a very personal decision – one that is indeed dependent on a patient’s values, ethics, and views on life – not dictated by a medical organization.
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I put it to you that UHC systems are best placed to address these kind of issues because of their very universality. Well-off groups may well have good survival rates in the private system, but Heaven-help the poor and those on the margins.
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I would respond to that by saying that UHC systems seem to be focused on numbers like QALY, cost benefit analysis, etc. whereas the American way of thinking in Medicine is more focused on saving as many lives as possible even at extra cost for dwindling "benefits."
 
xjx388 said:
You are comparing two different sources using two different kinds of age adjustments. Notice that the UK source says "Age-standardised rate (European)" Not the same thing as the "Age Adjusted" rate in the US source. GLOBOCAN uses the same age adjustments for all countries so that we can compare better. As this little fact sheet shows, in 2008, the USA had a 9.7 mortality rate compared to 13.8 in the UK.
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According to that data, we do seem to be doing very slightly better than Western Europe. Of course, "we" include Canada, there.

I'm struck by the extremely low incidence in Africa and Asia. What do you think is up with that?
 
kellyb said:
According to that data, we do seem to be doing very slightly better than Western Europe. Of course, "we" include Canada, there.

I'm struck by the extremely low incidence in Africa and Asia. What do you think is up with that?
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Probably related to diet, obesity, men dying of other causes before prostate cancer develops and data collection.
 
xjx388 said:
I can't speak to the debate in the UK. I wouldn't characterize it as "automatically screened." They are merely invited after age 50 every 3 years. They still have to actually show up at the office.

I know that the US recommendation is to screen women over 40 every year and that is what doctors do for the women they see. Some government task force tried to recommend that women under 50 shouldn't be screened, but their work was widely criticized in the Medical community. I refer you to this blog entry, which echos the thinking of most doctors:




I would respond to that by saying that UHC systems seem to be focused on numbers like QALY, cost benefit analysis, etc. whereas the American way of thinking in Medicine is more focused on saving as many lives as possible even at extra cost for dwindling "benefits."
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That highlighted part is kind of a straw man, though. I agree with the sentiment, but it's not like under a UHC system women are forbidden from purchasing a non-covered mammogram with their own money if they want to. Doctors are just as free to explain the potential risks and benefits of mammography to women under 50. The whole "gag clause" thing is a uniquely American phenomenon and the invention of profit-driven insurance companies.
 
kellyb said:
According to that data, we do seem to be doing very slightly better than Western Europe. Of course, "we" include Canada, there.

I'm struck by the extremely low incidence in Africa and Asia. What do you think is up with that?
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In Canada, the rate is 11.4. If you scrolll down a bit, there's a big blue map with mortality rates by country.
 
xjx388 said:
In Canada, the rate is 11.4. If you scrolll down a bit, there's a big blue map with mortality rates by country.
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I see that now.

Looks like we're doing slightly better than Canada, but way better than the UK. Do we use different chemo?

It can't be PSA testing. At best, PSA testing reduces mortality by 20%.
 
kellyb said:
I see that now.

Looks like we're doing slightly better than Canada, but way better than the UK. Do we use different chemo?

It can't be PSA testing. At best, PSA testing reduces mortality by 20%.
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Socioeconomic, if life expectancy and infant mortality can be handwaved away.........

In fact all the UK's results should be adjusted upwards considering we're the much poorer country....
 
Darat said:
Because they don't show that the USA has a better system than a very much cheaper & universal system i.e. NHS.
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Well, no, actually. Life expectancy and Infant Mortality are determined only partially by interaction with the healthcare system. There are also socio-economic factors that contribute; diet, lifestyle, accidents, crime, ethnicities etc. So, while they might be OK for very broad comparisons, they aren't very good for specifically judging healthcare in a country.
 
Delscottio said:
Socioeconomic, if life expectancy and infant mortality can be handwaved away.........

In fact all the UK's results should be adjusted upwards considering we're the much poorer country....
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You are poorer in terms of GPD per capita, but since we have such an extreme number of billionaires, it's hard to say who's "on average, really", poorer.

http://monthlyreview.org/images/2010/101001citigroup-plutonomy-report-pt1.pdf
THE UNITED STATES PLUTONOMY - THE GILDED AGE, THE ROARING TWENTIES, AND THE NEW
MANAGERIAL ARISTOCRACY
Let’s dive into some of the details. As Figure 1 shows the top 1% of households in the
U.S., (about 1 million households) accounted for about 20% of overall U.S. income in
2000, slightly smaller than the share of income of the bottom 60% of households put
together. That’s about 1 million households compared with 60 million households, both
with similar slices of the income pie! Clearly, the analysis of the top 1% of U.S.
households is paramount. The usual analysis of the “average” U.S. consumer is flawed
from the start. To continue with the U.S., the top 1% of households also account for
33% of net worth, greater than the bottom 90% of households put together. It gets better
(or worse, depending on your political stripe) - the top 1% of households account for40% of financial net worth, more than the bottom 95% of households put together.
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You guys are a plutonomy, too...

RIDING THE GRAVY TRAIN - WHERE ARE THE PLUTONOMIES?
The U.S., UK, and Canada are world leaders in plutonomy. (While data quality in this
field can be dated in emerging markets, and less than ideal in developed markets, we
have done our best to source information from the most reliable and credible
government and academic sources. There is an extensive bibliography at the end of this
note). Countries and regions that are not plutonomies: Scandinavia, France, Germany,
other continental Europe (except Italy), and Japan.
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But I doubt it's so extreme over there.
 
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kellyb said:
I see that now.

Looks like we're doing slightly better than Canada, but way better than the UK. Do we use different chemo?

It can't be PSA testing. At best, PSA testing reduces mortality by 20%.
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I think that's a valid question: Is it treatment or screening? If it's treatment, then I think that's something the NHS has to answer for. If it's screening that catches malignancies earlier, then there ought to be a more organized screening process in both countries.
 
xjx388 said:
Well, no, actually. Life expectancy and Infant Mortality are determined only partially by interaction with the healthcare system. There are also socio-economic factors that contribute; diet, lifestyle, accidents, crime, ethnicities etc. So, while they might be OK for very broad comparisons, they aren't very good for specifically judging healthcare in a country.
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This is true. I live at ground zero for the worst infant mortality rate known of in the entire developed world, and it's poverty-related stress causing lots of preterm labor to blame.
 
xjx388 said:
I think that's a valid question: Is it treatment or screening? If it's treatment, then I think that's something the NHS has to answer for. If it's screening that catches malignancies earlier, then there ought to be a more organized screening process in both countries.
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Treatment vs screening aren't mutually exclusive, also.
 
UncaYimmy said:
How does more organized screening come about in a free market?
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Well, doctors are mostly all voluntarily accredited by one board or another and members of the corresponding society. For example, the AAFP publishes guidelines for screening and treatment in their journal all the time as does the AAP, ACOG, etc. If they recommended yearly PSAs, then docs would start doing them. Docs also attend a mandatory number of CMEs per year in order to stay board-certified so this would be another avenue of distributing guidelines.

Board-certification is not a government mandate. It's voluntary. Any doctor can graduate from Med School, do a quick internship and get a license to practice. But doctors get certified because patients demand it.
 
Rolfe said:
I can't count the times I heard that in the 1990s from vets who were way behind the times, and demanding sensitivity tests on isolates they should not have been treating. Hearing it from a US human-type doctor in 2011 is seriously scary, and reinforces all I was coming to suspect about the poor state of CME among grass-roots US doctors.

Rolfe.
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Heh.

http://www.businessweek.com/print/magazine/content/08_32/b4095026335160.htm

Teaching Doctors—or Selling to Them?
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At the center of this controversy are medical communications firms paid by pharmaceutical and device companies to produce physician-education courses.
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In June, psychiatrist Daniel Carlat logged on to Medscape, one of the largest providers of online CME. As the Newburyport (Mass.) physician clicked through a series of multiple-choice questions, he says he was surprised to discover that the correct answer to one item about how to treat a patient with schizophrenia and alcoholism was to prescribe paliperidone. Better known by its brand name, Invega, the medication is made by Johnson & Johnson (JNJ) subsidiary Janssen Pharmaceutical. It's a relatively new product intended to replace lost sales from J&J's multibillion-dollar antipsychotic medication Risperdal, which recently lost its patent protection. J&J, it turns out, sponsored the CME course.
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xjx388 said:
Well, doctors are mostly all voluntarily accredited by one board or another and members of the corresponding society. For example, the AAFP publishes guidelines for screening and treatment in their journal all the time as does the AAP, ACOG, etc. If they recommended yearly PSAs, then docs would start doing them. Docs also attend a mandatory number of CMEs per year in order to stay board-certified so this would be another avenue of distributing guidelines.

Board-certification is not a government mandate. It's voluntary. Any doctor can graduate from Med School, do a quick internship and get a license to practice. But doctors get certified because patients demand it.
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You didn't answer the question. How does the free market result in organizing better screening? You're in financial competition with other practitioners, but "organizing" means working together. Take mammographies as an example. Unless your office has the machine, you don't make any money by (say) mailing out notices to those who should get them. If you do have the machine, you said that you limit Medicare patients because they are not profitable enough. Would you spend the money to get them to come in?

By contrast, the NHS schedules appointments automatically and sends notifications to patients. It's an organized effort.
 
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