Tag: International

INTL/POLICY/POLITICS: American governor crosses border for healthcare

BredesenbloodIn the first public (non-academic) health care talk I ever gave to a Rotary club (in I think 1993) I was laying into the US health care system when some guy stood up and said “when he was sick the Prime Minister of Ontario came to the US for treatment.” Apparently that meant that the entire Canadian health care system was rubbish and the American one was a-ok. Given that the small business people in that room have spent the last two decades paying through the nose for their political representatives’ determination to keep the government out of health care (or something), you’d think that that meme would have less of an impact. And my Canadian friends (with help from Yankee Steve Katz) blew up that “Canadians coming south in droves” myth in their Phantoms in the Snow paper in Health Affairs a few years back.

But no matter, according to Cato et al, the Canadians are dying to become just like us. And really what’s not to love about dragging in the “market forces” which have served our system to become so cheap, consumer friendly and deliver such great outcomes for the money! (Especially if you’re a poor underpaid Canadian doctor).

So I began thinking that those of us on the other side of the spectrum need our own meme. And I think I’ve found it.

Before I tell you what it is, a little bit of background. In 1992 Ian Morrison at IFTF wrote a great piece comparing three Scandinavian health care systems. The three Scandinavian “countries” were Sweden, Denmark and Minnesota—which on all kind of ethnic and social measures, as well as in health care practice, looks far more like Scandinavia than it does the rest of the US. So in my view we can call Minnesota, in health care terms, a foreign country.

Here’s where it gets good. Tennessee has a Democratic Governor, Phil Bredesen, who is a multi-millionaire former HMO executive and the one who managed to basically throw a good chunk of his state’s population off Medicaid. So he’s representative of the prevailing wisdom about American health care. So when Phil got sick, what did he do?

He high-tailed it for Minnesota! American health care wasn’t good enough for him!

I think that’s it. American health care—not good enough for the best and brightest amongst us!

Feel free to add your own slogan

INTERNATIONAL: Maybe privatization in the UK will not be quite so swift

Strike one for the little guy. A pensioner (that’s a “senior” to us Yanks) has won a court battle to stop a US healthcare giant from taking over a GP practice. The giant in question is United HealthGroup which apparently has also got a few other problems.

Perhaps doctors and hospitals in Arizona, St Louis and the outer boroughs of New York City should be flying in 67 year old Ms Pam Smith, 67, a former hosiery worker and Labour councillor from the huge metropolis of Langwith, Derbyshire, to advise them on how to “work” with United?

POLICY/INTERNATIONAL: Canadians somewhat grumpy about waiting, but not waiting that long

How bad are those terrible waiting lists in Canada? Well if you hang with the loonies at Fraser and PRI they average 10 months for a typical pregnancy and care for everyone else is delivered only by morticians. On the other hand, StatCanada (the official government body, and this one I believe is an independent bunch of civil servants rather than the US variety who’s reports are re-written by 23 yr old Republican staffers) is out with some real data.

What’s the conclusion? Canadians have to wait a little bit, and they’re pissed off, but only a little bit

Results for 2005 indicate that waiting for care remains the number one barrier for those having difficulties accessing care. Median waiting times for all specialized services have remained relatively stable between 2003 and 2005 at 3 to 4 weeks, depending on the type of care. There were some differences noted in selected provinces. Most individuals continue to report that they received care within 3 months.

Similarly, patients’ views about waiting for care have remained  fairly stable between 2003 and 2005. While 70 to 80 percent indicated that their waiting time was acceptable – there continues to be a proportion of Canadians who feel they are waiting an unacceptably long time for care.

And how bad did that wait make them feel? Well most didn’t seem to worry at all but some were pissed off.

The proportion of patients who felt that their waiting time was unacceptable was highest among those who waited for specialist visits (29%) and diagnostic tests (21%) and lowest among those who waited for non-emergency surgery (16%) (Chart 2 ; Table 9) even though individuals are more likely to wait longer (i.e. > 3 months) for non-emergency surgical care compared with other specialized services (Table 7).

And for some the wait involved real inconvenience and pain. But that was less than 20%.

Approximately 18% of individuals who visited a specialist indicated that waiting for the visit affected their life compared with 11% and 12% for non-emergency surgery and diagnostic tests respectively. (Table 10)

And most of that was stress related rather than actual pain, although there was some of that too with about half experiencing pain. (These are proportions of those who experienced adverse effects from waiting)

Most of those who were affected reported that they experienced worry, stress and anxiety during the waiting period: ranging from 49% among those whose lives were affected by waiting for non-emergency surgery to 71% among those affected by waiting for a diagnostic test. (Table 11) Between 38% and 51% of individuals waiting for specialist services experienced pain and close to 36% of those who were affected by waiting for non-emergency surgery indicated that they experienced difficulties with activities of daily living. Approximately 28% of those who were affected by waiting for a diagnostic test indicated that it resulted in worry, stress and anxiety for their friends and family.

But of course what this doesn’t tell you and what the myopic Canada bashers like Gratzer, the PRI crowd and the AMA guy all fail to point out is the other half of the equation.

Even if every single American never had to wait for any care, there is considerable the impact because of our system on the financial health of poorer Americans, and there is also consequent impact on those poorer Americans’ access to care services. Below is a chart from the 2004 Health Affairs report which shows that on a raft of issues, like not getting care from a doctor, skipping recommended care, and not filing prescriptions, the direct cost of care here impacts people just as much, if not more so. And of course some substantial number of Americans (whichever side of that argument you believe) are going bankrupt because of it.


Yes there are problems with the Canadian system. Yes there’s room for honest debate about it.

But take the veil of ignorance test John Tierney uses in his columns in the NY Times. If you didn’t know you were going to be born or become rich, which system would you rather be in given the realistic chance that you might end up poor? The one that will get to you if you’re prepared to wait a few months, or the one that you won’t ever get to because you can’t afford to, and that might bankrupt you if you really need it? I bet you nearly half Americans would change places if they knew.

INTERNATIONAL/CONSUMERS: Consumerism meets single payer

So do the tappings of consumerism in health care need American-style CDHC? Apparently not, as in the UK the latest is that doctors are to be graded for quality of service

Every doctors’ surgery (surgery = office in Brit talk, not what it means in Yank-sih) is to be inspected and awarded Michelin-style stars so that patients can tell the quality of care offered by their GP at a glance, The Times has learnt. Expert panels will give family doctors one of three gradings in a move backed by ministers desperate to show that patients are getting value for money from huge GP pay rises. The scheme, being drawn up by the Royal College of General Practitioners, will run alongside government plans to publish detailed patient surveys of each surgery’s performance.

Of course the huge pay rises for GPs were as part of a pay-for-performance scheme…something their American colleagues might be a little envious about!

TECH/INTERNATIONAL: Health care globally (mostly about the NHS)

Quick session notes from one on Global care, amusingly chaired by Humphrey Taylor my old boss from Harris

Pfizer thinks that integrated care looking at all the costs and benefits should  be counted. Prevention and DM does work.

Dr Reddy CEO Apollo Hospitals 

His hospitals can do heart surgery as well for 1/10th the US price, and wants to become a global HC destination. Not only do they give the same level of care, but they also have all kinds of eastern therapy that helps recovery. He calls this global access to health care.

Richard Granger, Director IT, NHS UK

He wanted to take the opportunity to “purvey some facts” to those of us who read newspapers. He thinks its fascinating that in the US most primary care is delivered in paper. 200K users of NHS system; mass roll-out has commenced. He finds that the supply chain is immature, and most IP is on a jurisdictional basis, with little ability to transfer. That works on a country by country basis, unlike any other software market. Some of the risks are put on suppliers, and you’ve seen the result (he forecast that some would get in trouble 2 years ago and said he would hold them to their contracts).

Now putting risk to patients, and he thinks that consumer pressure will overcome provider resistance. In addition there’s a grey market across jurisdiction (similar to Amazon) and that will happen in pharmaceuticals in Europe and globally. Many professionals in healthcare have been careful to constrain information “liquidity”

No more than 80m emails sent in last year—messages that weren’t sent before. Now information will start to move and question will be how to accredit that information.

PACS-over 50% adoption in southern region is digital Xray, now available everywhere in the system. Digitizing a hospital a week — he thinks that as a consequence of this there’ll be much more remote reporting eliminating the barriers for craft guilds. Money from NHS will therefore start moving to the expertise and leaving it in India.

Connectivity—NHS will have biggest VPN in world next year.

99% of PCP records exist digitally but only just started having that information move around the country. That will save costs and breakdown the providers guild mentality.

INTERNATIONAL: Exactly what care does a pregnant woman need? with UPDATE

Lynn Payer wrote a great book a while back called Medicine and Culture. I remember that Americans were put on medication if their blood pressure was too high, and Germans were put on medication if their blood pressure was too low. Here’s an amazing example of differences in medical treatment between the UK and Germany for the same “condition” — normal pregnancy. Be sure to read the comments!

NHS Blog Doctor: Vaginal examinations in pregnancy

 I asked a leading UK ObGyn with whom I’ve had a life long relationship what he thought. Here are my dad’s comments:

I agree entirely with Dr Crippen, vaginal examinations in pregnancy require a proper indication. apart from that there is no indication for performing vaginal ultrasound after about 13 weeks as abdominal u/s gives more information. About the only indications for v/e in pregnancy are to give an assessment of pelvic size in late pregnancy if the head does not engage in a primigravida (prior to xray pelvimetry if elective c/s for disproportion is contemplated) or to assess the state of the cervix if labour (in your language, labor!) is to be induced. In early pregnancy the only indication I would accept is in the investigation of vaginal infection (discharge). If there is any doubt as to the progress of early pregnancy, either diagnosis or possible missed abortion then vaginal u/s is indicated.

POLICY/INTERNATIONAL: South Africa, the future of the US?

I know most of you don’t have access to the WSJ, so I’m reprinting liberally from its story about the CDHP in South Africa. You know what I think by now on the subject, but it’s worth noting that the proponents of high deductible plans are viewing this as a success. Read these snippets:

Whatever Discovery’s advantages, they are available only to a small sliver of South Africans. About seven million people in this nation of 47 million have private insurance, entitling them to use a system of private doctors and hospitals that is considered on a par with Western nations in quality. The rest — including most of the estimated five million people infected with the AIDS virus — are stuck with the public system of hospitals and clinics, which are mostly underfunded and overwhelmed.


Discovery has a 26% share of the private-insurance market in South Africa, at least twice that of its nearest competitor. The majority of insured South Africans have high-deductible plans and have put aside some of their income in a savings account with tax advantages to spend on medical care. That is the combination President Bush is promoting in the U.S.

Most of Discovery’s rivals in South Africa have tried to copy its points program, and the idea is making some headway in the U.S., too.


Discovery says preliminary studies of its South African members suggest its incentives are having an impact. The most striking result: People age 50 to 54 who were actively chasing wellness points saw their health spending decrease even as they aged. However, the data cover only a few years and haven’t been published in a medical journal.


Skeptics in South Africa, including officials at the nation’s health-insurance regulator, say Discovery’s rewards program isn’t the win-win situation the company claims. They believe the real goal of the program is to attract a vigorous, health-conscious clientele and discourage older and sicker people from signing up for Discovery’s insurance plans.

"You discount things that younger and healthier people tend to like," says Alex van den Heever, a senior technical adviser at the regulator, which is called the Council for Medical Schemes.


And now it gets interesting, because like the Singaporeans the South Africans are going to do something about the destruction which underwriting and self-selection wreaks on the risk pool.

The problem of cream-skimming by insurers is a familiar one to health economists, and recently South Africa has taken steps to prevent it. Starting in about a year, companies whose insured populations are disproportionately filled with the young and healthy will have to pay a penalty. Discovery says its customer base is close to average now, and it doesn’t believe its success is the result of cherry-picking healthy people.

Discovery Holdings, the parent of Discovery Health, saw net profit jump 40% in the year ended June 30, 2005, to $97.4 million. The company is majority-owned by FirstRand Ltd., a South African financial-services company, but trades separately on South Africa’s main stock exchange. Its stock price has more than doubled since the beginning of 2004.


Another measure of the Vitality program’s value is how members’ health-care costs change over time. The insurer measures this using the "loss ratio," which is the cost of paying a member’s annual health claims divided by the annual premium. If the insurer receives $5,000 in premiums and pays out $2,500 to cover claims, the loss ratio is 50%.

Discovery examined 1,467 insured people age 50 to 54. From 2000 through 2003, those with elite status in Vitality saw their loss ratio fall to 70% from 73%, while the loss ratio for nonelite members rose to 80% from 72%. In the 30-34 age bracket, members in both the elite and nonelite categories saw loss ratios rise but the ratio rose faster for nonelite members.

Discovery says the study excluded those with family coverage and focused on individual members so that it could be sure the person racking up the points was the same one filing the health claims.

The bottom line seems to suggest some health benefit for eager point-getters, but Discovery’s own actuary, Mark Litow of Milliman Inc., acknowledges "we’d have to follow it much longer" to prove anything. Also, separating cause and effect is difficult: It is possible that the elite Vitality members would have pursued a healthy lifestyle even if they didn’t get rewards for it.

Alex van den Heever, the senior adviser at the government regulator, says: "I do not trust any commercial entity that has a big financial incentive to produce research." Discovery’s Mr. Gore says the government is welcome to examine the raw data. So far the company hasn’t submitted the data to a peer-reviewed medical journal. It says it might at some point.

Meanwhile, Discovery has brought its Vitality rewards program to the U.S., where it has a subsidiary called Destiny Health. Destiny’s South Africa-style plans, which combine a high deductible, a medical-savings account and reward points, are available in Illinois, Maryland, Massachusetts, Texas, Virginia, Washington, D.C., and Wisconsin.

And they don’t have to contend with any of that messy risk adjustment here. On the other hand, if there was a level playing field we might find out if any of this CDHP stuff worked (backing out for health and income). It’s just that the way the US is regulated we won’t because any insurer is by definition better off avoiding sick people. The rest is just window-dressing.

Pity, because there are certainly some interesting approaches in the CDHP morass.

POLICY/INTERNATIONAL: High co-payments prevent needed care, and not in the US this time

So charging at the point of care, another Zombie of health care policy, isn’t just a problem for the poor here—although it’s going to get a whole lot worse. It’s also a big issue in that place that the US loony right thinks will be where they ascend to heaven (or at least I think that’s what they think about it…who can tell with that bunch of nuts?).

Read up about the problems of paying for care in Israel.

Meanwhile if you want to know more about health care Zombies, read this great speech from Morris Barer


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