Health care - administrative incompetence

[Tatyana]

What's amazing to me are these posts by Tatyana that so very clearly explain what the criteria are. There is no such accountability in the USA that I've every come across. Most of us have no idea what claims will be accepted, rejected or investigated. Or at least I've never been privy to that information as a consumer.

What's also fascinating is referral to an emergency or other critical care facility. The last criterion reads, "Continuing concern by the professional about the diagnosis." Is there anybody second guessing the GP about this? If so, what happens? Do GPs get money for referring patients to (say) emergency rooms?

NICE (National Institute for Health and Clinical Excellence) is a pretty revolutionary concept, using evidence to practice medicine.

Quite a few governments are considering this model.

I am posting this much as I am not sure how much access those outside the UK have. In the UK, you can look up any of the clinical guidelines.

NHS direct is more accessible to those who don't have a medical background.

Today we are recognised as being a world leader in setting standards for high quality healthcare and are the most prolific producer of clinical guidelines in the world.

We also produce public health recommendations on how to help improve people's health and prevent disease. These are aimed not just at the NHS but at local authorities and all those with a remit for improving people's health in the public, private, community and voluntary sectors.


For instance, many thousands of people have contributed to the development of our guidance. What's more, our Citizens Council is the UK's first advisory body made up entirely of members of the public.

We always use the best available evidence in all our work and we are free from political influence.

Everything we do is underpinned by the need for:

* transparency
* collaboration
* involvement of stakeholders.

The Citizens Council is a board of 30 ordinary members of the public, representing the UK. Members meet twice a year for three days at a time

The current members of the Citizens Council are listed below. It is important to note that the Citizens Council does not officially represent the general public. Its members are selected so that the Council reflects a broad cross-section of the population of England and Wales with regard to age, gender, socioeconomic class, ethnicity, disability and geography.

Jane Sabin, an office manager from the West Midlands

Sally Fitton, a secretary from the West Midlands

Martin Woodward, a warehouse team member from Derbyshire

Annette Lewis, retired, from Nottingham

Elysabeth McCaig Scott, unemployed, from Bath

Ernest Kemp, unemployed, from London

Ian Darracott, a Local Government Officer from Caerphilly

Sarah Monks, unemployed, from Swansea

Jake Newall, an IT consultant from Alperton

Lynn Norman, a Market Research interviewer from York

Oyes Ahmed, a taxi driver from Leicester

Debbie Riddiford, a nurse from Bristol

Martin Maund, retired, from Biddisham

Marian Lord, retired, from Southampton

Philip Steele, retired, from Cardiff

Margaret Hunnam, an interior designer from Ogmore Vale

Beverley Witheridge, a clerical worker from Neath

Steve Durrant, an antiques dealer from East Sussex

Annette James, senior school lunchtime assistant from Bridgend

Betty Barnes, a clerical officer from London

Ivan Gee, retired, from Liverpool

Trevor Betts, unemployed, from Hull

Ray Allen, self employed caricature artist from Hull

Gary Mayall, a self employed builder from Lancashire

Alan Bacon, a carer from Lancashire

Ronald Jobling, retired, from Tyne and Wear

Arlette Fairclough, a shop assistant from Northumberland

Vance Ankrah, a student from Liverpool

Rebecca Adewale, an office manager from London

 

[bookitty]

NICE (National Institute for Health and Clinical Excellence) is a pretty revolutionary concept, using evidence to practice medicine.

Quite a few governments are considering this model.

I am posting this much as I am not sure how much access those outside the UK have. In the UK, you can look up any of the clinical guidelines.

NHS direct is more accessible to those who don't have a medical background.

Whoa. I had no idea. That is such brilliant example of democracy in action. I would love to be a fly on the wall at some of the meetings.

 

[kellyb]

For our rationing, we have insurance companies, and this:

http://www.fiercehealthcare.com/sto...tors-define-medicare-payment-rates/2010-10-27

Does a secret panel of physicians handpicked by medical specialty trade groups wield too much power over Medicare fees?

That's a question the Wall Street Journal has raised in an article on the Relative Value Scale Update Committee (RUC). That's a panel of 29 doctors handpicked by medical specialty trade groups and convened by the American Medical Association. Its main focus is to estimate how much work a physician must do to perform a task.

While the group has no official government standing, CMS usually follows at least 90 percent of its recommendations on how much to pay doctors for their work.

 

[bookitty]

For our rationing, we have insurance companies, and this:

http://www.fiercehealthcare.com/sto...tors-define-medicare-payment-rates/2010-10-27

I can see where it would make sense to have a panel of doctors discussing rates. They know what is involved. But the doctors should represent those that a medicare patient is most likely to see. For example - if 60% of visits are primary care, then the panel should be weighted towards those doctors.

What I would rather see is a panel that was 50% retired doctors who no longer had any financial interest.

 

[xjx388]

Yeah. NICE is nice and all, if your goal is to practice medicine with little robots. But docs in America are taught to use a little thing called "clinical judgement." The medical societies disseminate EBM info but docs are free to use their brains. That's what they went to school for, after all.

 

[kellyb]

I can see where it would make sense to have a panel of doctors discussing rates. They know what is involved. But the doctors should represent those that a medicare patient is most likely to see. For example - if 60% of visits are primary care, then the panel should be weighted towards those doctors.

What I would rather see is a panel that was 50% retired doctors who no longer had any financial interest.

Reimbursement rates are also hugely influential over physician behavior.

In the US, where the third party payers don't openly admit to rationing, controlling doctor behavior via financial incentives is an excellent rationing tool. These people need a LOT of public oversight.
We don't know what these people's politics are, either, but sub-specialist MDs tend to be anti-Medicare conservatives.
And they're paying PCPs so little money that PCPs are having to stop seeing medicare patients just to stay in business.

Hmmm.....

 

[kellyb]

Yeah. NICE is nice and all, if your goal is to practice medicine with little robots. But docs in America are taught to use a little thing called "clinical judgement." The medical societies disseminate EBM info but docs are free to use their brains. That's what they went to school for, after all.

You don't get it. Doctors can and do still recommend what their clinical judgment dictates. If what they recommend isn't covered by the NHS, the patient can pay out of pocket, if they're able to afford it.

Where's the evil there?

 

[Tatyana]

Whoa. I had no idea. That is such brilliant example of democracy in action. I would love to be a fly on the wall at some of the meetings.

Obviously, they also use medical professional, medical ethicists for evaluation of clinical procedures as well as research and development.

The other really transparent aspect of the NHS is the British National Formulary, you can walk into a Waterstone Book Store and buy a copy, register on line for access or get an e-copy.

It lists all the drugs that are available for use in the NHS, some clinical indications, and most interesting, how much they cost the NHS.

http://www.amazon.co.uk/British-National-Formulary-March-2010/dp/0853699291

Everyone who works in the NHS is sent the updates of the latest clinical guidelines from NICE.

I was quite moved when I read:

http://guidance.nice.org.uk/CG110/NICEGuidance/doc/English
Pregnancy and complex social factors
A model for service provision for pregnant women with complex social factors

The guideline applies to all pregnant women with complex social factors and contains a number of recommendations on standards of care for this population as a whole. However, four groups of women were identified as exemplars:
· women who misuse substances (alcohol and/or drugs)
· women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English
· young women aged under 20
. women who experience domestic abuse.

Because there are differences in the barriers to care and particular needs of these four groups, specific recommendations have been made for each group.

The guideline describes how access to care can be improved, how contact with antenatal carers can be maintained, the additional support and consultations that are required and the additional information that should be offered to pregnant women with complex social factors.

It is great, there is no judgment or condemnation, just how can we best help this woman, her partner and/or her family, take the best care of her so that her baby starts life in the best possible manner.

NICE is also actively collecting data, as there really isn't a lot of evidence as to the best way to deal with a pregnant, substance abusing woman.

It is by no means perfect, but is it quite an innovative and bold move to look at the evidence for best practices.

 

[Uncayimmy]

Yeah. NICE is nice and all, if your goal is to practice medicine with little robots. But docs in America are taught to use a little thing called "clinical judgement." The medical societies disseminate EBM info but docs are free to use their brains. That's what they went to school for, after all.

What is wrong with you? Seriously. You continue to demonstrate willful ignorance in this thread. You make wholly unsupported claims, many of which are clearly wrong. Like in this case. Follow the links and do some reading for a change. The NICE guidelines say this:

This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence available. Health professionals are expected to take it fully into account when exercising their clinical judgement. The guidance does not, however, override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

That's what I call excellent medicine. First, they look at all of the available evidence and periodically review it. Next, they deliberate about what the best guidelines should be. Third, they publish the information so that ordinary citizens such as myself can understand what's considered appropriate practice. Finally, they remind the physicians that they are in the best position to decide what is appropriate.

And yet you post the drivel above? Sounds to me more like trolling.

 

[kellyb]

It's the insurance companies that want robots. Paying for "extra" care out of pocket cuts them out of the loop. Robot "medical professionals" also allow them to keep us all fooled into believing that the insurance coverage can provide us with all the healthcare that could ever have even a tiny chance of being useful. Cause, you know, who will openly admit to wanting a for-profit corporation rationing their health care?

 

[Tatyana]

Yeah. NICE is nice and all, if your goal is to practice medicine with little robots. But docs in America are taught to use a little thing called "clinical judgement." The medical societies disseminate EBM info but docs are free to use their brains. That's what they went to school for, after all.

Or doctors are so far behind in the medical literature that they are unaware that most ulcers are caused by Helicobacter pylori , or how to interpret a creatinine?

Is clinical judgment the same thing as intuition or gut reaction?

What if a doctors 'clinical judgment' is counter to all of the evidence?

You do realise that science does damage to what we think of as 'common sense'.

You are a funny fish.

Are you so determined to be right that you can't even see the benefit in having GUIDELINES, read GUIDELINES, not dictatorial mandates.

If you are so blinded by ideology not to realise how difficult it is for clinicians to keep up with best practice, and how quickly medical practice changes, then I think you have more invested in 'being right' than any other factor, happiness, knowledge, or logic.

I also have to ask you, what are you doing on a skeptical site if the practice of using evidence based medicine is so abhorrent to you?

 

[kellyb]

Obviously, they also use medical professional, medical ethicists for evaluation of clinical procedures as well as research and development.

The other really transparent aspect of the NHS is the British National Formulary, you can walk into a Waterstone Book Store and buy a copy, register on line for access or get an e-copy.

It lists all the drugs that are available for use in the NHS, some clinical indications, and most interesting, how much they cost the NHS.

http://www.amazon.co.uk/British-National-Formulary-March-2010/dp/0853699291

Everyone who works in the NHS is sent the updates of the latest clinical guidelines from NICE.

I was quite moved when I read:

http://guidance.nice.org.uk/CG110/NICEGuidance/doc/English
Pregnancy and complex social factors
A model for service provision for pregnant women with complex social factors



It is great, there is no judgment or condemnation, just how can we best help this woman, her partner and/or her family, take the best care of her so that her baby starts life in the best possible manner.

NICE is also actively collecting data, as there really isn't a lot of evidence as to the best way to deal with a pregnant, substance abusing woman.

It is by no means perfect, but is it quite an innovative and bold move to look at the evidence for best practices.

Amazing what people can do when they believe in democracy, huh?

 

[Architect]

I'm still waiting for him to explain why we live longer than people in the US, what with our healthcare system being so bad apparently.

 

[kellyb]

Or doctors are so far behind in the medical literature that they are unaware that most ulcers are caused by Helicobacter pylori , or how to interpret a creatinine?

Is clinical judgment the same thing as intuition or gut reaction?

What if a doctors 'clinical judgment' is counter to all of the evidence?

You do realise that science does damage to what we think of as 'common sense'.

You are a funny fish.

Are you so determined to be right that you can't even see the benefit in having GUIDELINES, read GUIDELINES, not dictatorial mandates.

If you are so blinded by ideology not to realise how difficult it is for clinicians to keep up with best practice, and how quickly medical practice changes, then I think you have more invested in 'being right' than any other factor, happiness, knowledge, or logic.

I also have to ask you, what are you doing on a skeptical site if the practice of using evidence based medicine is so abhorrent to you?

Doesn't NICE also decide what new drugs will and won't be covered by the NHS in some areas?

 

[kellyb]

I'm still waiting for him to explain why we live longer than people in the US, what with our healthcare system being so bad apparently.

The (only close to valid) comeback to that one (and it does have some merit) is that our murder rate in the US is kind of off the charts for a developed nation and might negatively impact our life expectancy.

 

[bookitty]

Obviously, they also use medical professional, medical ethicists for evaluation of clinical procedures as well as research and development.

The other really transparent aspect of the NHS is the British National Formulary, you can walk into a Waterstone Book Store and buy a copy, register on line for access or get an e-copy.

It lists all the drugs that are available for use in the NHS, some clinical indications, and most interesting, how much they cost the NHS.

http://www.amazon.co.uk/British-National-Formulary-March-2010/dp/0853699291

Everyone who works in the NHS is sent the updates of the latest clinical guidelines from NICE.

I was quite moved when I read:

http://guidance.nice.org.uk/CG110/NICEGuidance/doc/English
Pregnancy and complex social factors
A model for service provision for pregnant women with complex social factors



It is great, there is no judgment or condemnation, just how can we best help this woman, her partner and/or her family, take the best care of her so that her baby starts life in the best possible manner.

NICE is also actively collecting data, as there really isn't a lot of evidence as to the best way to deal with a pregnant, substance abusing woman.

It is by no means perfect, but is it quite an innovative and bold move to look at the evidence for best practices.

That's just so civilized and far more practical.

 

[Rolfe]

I was coming to say a thing or two to xjx388, but Tatyana and UncaYimmy seem to have said it, mostly.

NICE issues guidelines. There's no "robot" about it. It is recognised that patients are individuals, and it is up to the doctor to interpret the guidelines in the context of the individual presentation.

"That's what they went to school for." Oh dear. The ignorance that displays is really quite sad, especially after all I've been saying about CME, and the apparent scarcity of it in the USA.

Speaking as someone whose 35th anniversary of graduation is coming up, if I were to practise medicine as I was taught "at school", I'd be a danger to animalkind. Some people would do just that, though, if they were allowed to. It worries me that there are people in America who actually think this is a good idea.

NICE is distilling and codifying best practice in a way that makes it possible for individual doctors to keep up, and not be left behind by the advances in medical science. The USA seems to be stuck in this anachronistic rut of the kindly but desperately ignorant family doctor with his healing hands, making it up as he goes along. It's not like that any more, or at least it shouldn't be.

You don't get it. Doctors can and do still recommend what their clinical judgment dictates. If what they recommend isn't covered by the NHS, the patient can pay out of pocket, if they're able to afford it.

Where's the evil there?

It's not really like that. The chances of an NHS doctor wanting to recommend something that isn't covered by the NHS are extremely small. I'd say zero in general practice. Occasionally in advanced cancer treatment, which is when we see the outraged headlines.

Doctors going off-piste will simply be recommending something else that is also covered by the NHS, because they think it's more suitable for their patient. Like the thing about using T₃ in conjunction with T₄ that someone mentioned earlier.

The spectacle of an NHS patient paying out of pocket for something that isn't covered is something you'll struggle to find, outwith the realms of designer spectacle frames and the flashier sorts of dentistry.

Rolfe.

 

[bookitty]

The (only close to valid) comeback to that one (and it does have some merit) is that our murder rate in the US is kind of off the charts for a developed nation and might negatively impact our life expectancy.

Not exactly a glowing recommendation.

 

[Tatyana]

Doesn't NICE also decide what new drugs will and won't be covered by the NHS in some areas?

Yes, this has been the most controversial area.

NICE and the NHS has a tendency to do their own clinical trials for some of the new drugs.

However, there are avenues of appeal, and NICE has repealed judgments on drugs after further evidence has come forward.

It is quite understandable if you read any of the medical journals.

While the pharmaceutical industry is invaluable at running trials and manufacturing drugs, they have a tendency to withhold adverse events in their clinical trials.

 

[jimbob]

The (only close to valid) comeback to that one (and it does have some merit) is that our murder rate in the US is kind of off the charts for a developed nation and might negatively impact our life expectancy.

Ah: About 25% of this gap can be explained by increased gun deaths:

But not all the US life expectancy differences can be explained by differences in gun ownership...

A significant part can be, but that is not all:

Note that this is quite an old post that I am quoting

I think the point is that the US could be getting far more value for the money it spends, or spend less money and redistribute good-quality care to everyone (while ensuring that people are still free to buy excess care if they want). The only thing holding them back seems to be ideology, and that ideology seems to be based on misunderstanding and misinformation.

Linda

Yup: some further evidence from an earlier thread:

The US state alone spends more of its GDP on healthcare than the UK: for as system that is far form universal.

Here is where I got the 6.6% figure (for 2004)

Medicaid costs a larger percentage of GDP than the NHS does the British taxpayer.
(44.7% of 14.7%=6.6%) was public, as opposed to the UK's (83.4% of 7.7%=6.3%) of GDP Source:

OECD Health Data 2007 - Frequently Requested Data

The death rate is higher in the US too, and not all can be explained by higher gun ownership:

I have found one estimation, in what seems like an appropriate journal.

Thank for for your research.

"The United States thus suffers from a life expectancy gap of 1.7 years."

Now add 1.7 years to your previous stats and tell me were we are.



Keep in mind that this is only one factor to be considered.

"These deaths account for 26.86 percent of the U.S. males' excess mortality when compared to peer nations, and 8.7 percent of the racial gap between black and white males in the United States."

So, yes Jerome, it is significant, but only explains about a quarter of the difference between the US and the other thirty-four other richest countries.


In fact I am surprised at the magnitude of the effect, but it still leaves 74% unexplained by gun-deaths.

In answer to the assertion that the rest of the world is freeloading on the US medical research, which is lowering death rates, a lot of the mortality and morbidity is preventable with better primary healthcare.