Tag: International

INTERNATIONAL: Canada cuts waiting list by using management techniques

The good news about being a wishy-washy centrist like me is that unlike Napoleon I never have to worry about whether my left flank is covered, as Don McCanne does it for me. Today he found this letter in an Alberta newspaper which shows that using new organizational techniques the waiting time for hip replacement in Alberta was cut from 47 weeks to 4.7. It’s worth reading the letter that details this, as it also shows that numerous lies continue to be told about health care in Canada by the ideologues up there and down here.

But the key point is that public as well as private sector organizations can make the organizational changes necessary to improve productivity — in this case each surgeon has apparently doubled the number of operations they perform. While the details about how it happened are limited, as are hints on the extra money it cost, it is clear that there was no increase in the amount of most expensive resource — the surgeon. After all it takes a few decades to get a new one out of the shoot and the Canadians sensibly limit the number that they produce. Something Americans don’t see the need to bother with, despite the havoc it wreaks.

Of course whatever your system of payment or the organizational form of your providers, you are going to be able to make improvements in  the way care is delivered.  But that’s not the case if your insurance system is as screwed up as ours is, and the real innovation comes in how to avoid insuring anyone under-65 who needs the care, or how to “persuade” the government to make sure that its over-65 insurees get all the care they need — and much, much more.

POLICY/INTERNATIONAL/PHYSICIANS: It’s not just here that doctors fees are an issue

And from the THCB Japan bureau (well actually the Yomiuri Shimbun)….

It’s worth noting that the Japanese, who have one medical fee schedule for all of their multi-payers (and also a complex system of cross-subsidization between those payers), are about to cut fees and reallocate them. In Japan private doctors make lots and lots more money than hospital-based ones, and the government is slowly trying to move the incentives away from what’s traditionally been a system with a high-volume of office visits and prescriptions of dubious benefit.

We’re about to do the same here, calling it pay for performance. Like there it’s going to turn into a fight. Joe Paduda notes today that the AMA is having some success in its attempt to stop the 4% cut that’s scheduled to come into effect for Medicare at the end of the year. And is directly linking it with a demand to stop pay for performance.

The advantage that the Japanese have got is that there’s only one fee schedule to argue about. Here we have gazillions and no one really knows what they are

INTERNATIONAL/QUALITY: U.S., Canada heart-failure mortality compared

This one’s from last week, but well worth a quick look. A study in the Archives of Internal Medicine compared heart-failure mortality in the U.S. and Canada

Two findings emerged from a recent Archives of Internal Medicine report on heart-failure mortality rates. One affirms the notion that the U.S. is a leader in acute care, but the other finding offers evidence that there’s room for improvement in the management of chronic conditions.The report, which was released Nov. 28, compared 30-day and one-year mortality rates of American and Canadian heart-failure patients measured between 1998 and 2001. The findings: after risk standardization, the 28,521 U.S. Medicare beneficiaries studied had a lower 30-day mortality rate than the 8,180 similarly aged patients at hospitals in Ontario, Canada (8.9% vs. 10.7%), but one-year adjusted mortality rates were essentially the same (32.2% in the U.S. vs. 32.3% in Canada).

So in other words we spend a lot more here and there some short-term benefits, but soon enough the differences disappear (but of course the money is still gone!).  I was struck by this particularly because Vic Fuchs did a study back in the 1980s at Stanford hospital comparing the outcomes of patients admitted to the same hospital by the faculty versus community doctors. Compared to the community doctors the faculty doctors supplied more services and spend more money on patients with similar acuity (i.e. similarly sick patients). And in the short term their patients had better  results, but after several months outcomes were the same. When Fuchs talked to them with the results, both sets of physicians thought that their type of care (i.e. more intensive versus less intensive) was better for the patients.

The health economists, though, amongst us tend to believe that there’s precious little point paying a lot more money to keep very sick people alive slightly longer, when within a year they’re going to be as dead as the rest of them. And that appears to be the way it works in Canada too. Anyone really surprised?  Of course with the Dartmouth data we also know that the same variation is exactly the case between different parts of the US.

POLICY/INTERNATIONAL: Obvious, but public and private taxes still cost money

Via Ezra, Krugman, and  Bradford Plumer there are some interesting numbers showing that the private welfare state (i.e. pensions, health benefits, etc provided by corporations) in the US added to the public welfare state which exists here but is more extensive in Europe, is roughly the same size as its counterparts in Europe. Krugman’s point, which I’ve reflected many times, is that if you let the corporate welfare system fall apart (i.e. replace GM as largest employer with Wal-Mart) then you are going to have a collapse in the coverage of welfare which will be to the wide detriment of society, particularly to the middle-classes. The fall in employer-based health insurance is the most obvious example of this collapse, and it will continue to get worse until there’s a political solution some years down the road. (Although in Joe Paduda’s view the time-table for this solution is moving up).

What I’ve been saying for years is that whether you call them “premiums” or “taxes”, society (i.e. people) still needs to pay for the underlying expenses, and when your underlying expenses are up to two times greater than those of other countries, you will have to pay more for them. So, there is a cost for having health care at 15% of GDP, and we are going to have to pay it somehow. And that’s one reason why other countries make serious efforts to contain those costs, with all the unpleasant consequences that may entail, as I discussed yesterday.

POLICY/INTERNATIONAL: A European conservative complains, but groks the problem

This is pretty interesting. Paul Belien, a Belgian conservative is complaining about governments in Europe cutting spending on health care, with the results that more expensive technologies are withheld from the elderly (like his 90 year old uncle).  He thinks the answer is to move towards building reserves for the future, and he’s probably is in the individual HSA crowd (although theoretically these could be pooled reserves). But that’s not the interesting thing.

The interesting thing is that he understands the equation. If we spend more on health care, we spend less on other things, and that there’s a choice between these positions. Given that, he has what he considers to be a solutions. Here’s his conclusion.

At the root of these decisions is the understandable desire of governments to control health-care costs. But rationing is clearly not the answer. What many governments in Western Europe have overlooked is that there is nothing wrong with a society devoting more of its resources to health care. This even appears to be an indication of prosperity. The higher and the more developed a society becomes, the more its citizens are willing to spend on keeping healthy. Modern technology makes everything cheaper except the highest quality of medical care, which is constantly improving. To try to limit access to this technology in the name of “cost-control” is irresponsible.

Meanwhile, the larger and more fundamental problem of how to finance the health-care systems is not adressed. Instead of funding the provisions of today’s sick with taxes from today’s healthy and young, people should be building up reserves for their own future liabilities. What Europe needs is to replace its pay-as-you-go systems by privatized and capitalized health-care systems. This, however, would imply that the governments relinquish control over the system, which is the very last thing they are willing to do.

Now I disagree with him about who should ultimately control health care, because I think it’s more of a public good than he does, but at least we are starting on the same page—one that I went over at length in my “Health care = Communism + Frappuchinos” article, which is well worth another read. The issue is that some care is basic and some care is a luxury good bought on the margins. You’ll note that he never says directly that people should be forced to pay for all their own health care with no cross-subsidiaztion. Of course that is where the US has been heading, and why our poor and unisured are literally dying (albeit not) in the streets.

Would it that we could have this rational argument with most conservatives (and even several liberals) in this country. Instead we get the Cato guys missing the point by trying to get us to worry about the almost incidental spending on the healthy, and Ron being Ron. No one wants to talk about whether or not we should be paying for the more expensive stuff for the 90 year old uncle, and that’s the real debate.

PHARMA/POLICY/INTERNATIONAL: Not all the wingnuts are in the US

Australia had some great news yesterday as the national team qualified for the soccer world cup, even though it’s only the 4th most popular team sport with the word "football" in the title in the country. But there was also some more bad news. The way that the national broadcaster ABC presented it as Australia’s rural doctors disappointed by Abbott’s abortion pill decision.

Abbott is not the drug company, it’s Tony Abbott the health minister. Because I randomly know his sister and parents, I can tell you that what’s not in the article is that Abbott is a devout Catholic who nearly became a priest. Meanwhile he’s been kicked around in the Australian press for kow-towing to the pharmacist lobby on pricing, and also for not forcing promised cuts in generic prices. He was also at the center of some more complex wrangling over drugs in the free trade pact that many on the left in Australia are very suspicious about, but where I felt they walked a tight-rope fairly well in getting the free-trade deal done.

But the reason given for the ban on RU-486 is that rural doctors wouldn’t be able to treat women using it. Well as evidenced from the statements by rural doctors managed just fine to treat women who spontaneously abort, that’s pure bunk.  Which leads us to the conclusion that yet again religion and ideology have trumped science at the highest levels of national decisions about drugs.

INTERNATIONAL/POLICY: Sick patients in six countries

No reader of THCB will be surprised that the cross-national series which the Commonwealth Fund has sponsored for several years now (and for which my old colleague and friend at Harris, Kinga Zapert has been running the surveys) continues to find that sick people here have it worse than sick people in other countries. Their latest work was published in Health Affairs yesterday and it’s called Taking The Pulse Of Health Care Systems: Experiences Of Patients With Health Problems In Six Countries. Here’s the press release if you don’t want to read the whole thing.

The headlines have been taken by the finding that patients in the US were more likely to say that they’d experienced a medical error (34% here versus between 30% and 22% elsewhere). But no one really has got the medical error situation under control, and it’s likely that patient reporting isn’t such a great measure of medical errors in reality. After all, Brent James has shown us that clinician reporting is a lousy guide to whether mistakes have been made. And in general all countries need to do better on care management of sick people, including treatment planning and clinician co-ordination.

But of course the study continues to find the the US is a real outlier when it comes to the financial impact on patients of being sick.

• Half of U.S. adults reported that they had gone without care because of costs in the past year• In contrast, just thirteen percent of U.K. adults reported not getting needed care because of cost• One-third of U.S. patients reported out-of-pocket expenses greater than $1,000 in the past year• U.K. patients were the most protected from high cost burdens, with two-thirds having no out-of-pocket expenses. The variations were notable given the study’s design focus on sicker adults with recent intensive use of medical care. (My emphasis)

And while we continue to hear reams of rubbish about the terrible impacts of waiting lists in Canada, none of the America-first crowd in Health Care seem too bothered by the confirmation that speedy access to primary care is none too good here, and ends up increasing emergency room use.

Access—including after-hours access—and waiting times to see a doctor when sick differed markedly across the countries:• Canadian and U.S. adults who needed medical care were the least likely to report fast access (same day) to doctors (30 percent or fewer of U.S. or Canadian patients) (My emphasis)• In contrast, majorities of patients in New Zealand (58 percent) and Germany (56 percent) reported that they were able to get same-day appointments, as did nearly half of patients in Australia (49 percent) and the United Kingdom (45 percent)• Majorities of patients in Germany (72 percent), New Zealand (70 percent), and the United Kingdom (57 percent) also reported easy after-hours (nights, weekends, or holidays) access to a doctor• In contrast, majorities of patients in the United States (60 percent), Australia (58 percent), and Canada (53 percent) said that it was very or somewhat difficult to get after-hours care• The four countries with comparatively more rapid access to physicians—Australia, Germany, New Zealand, and the United Kingdom—also had lower rates of emergency room use, with Germany having the lowest rates• One-fifth of Canadians and one-fourth of U.S. patients who reported going to the ER said that it was for a condition that could have been treated by their regular doctor if available. (My emphasis)

I know this is just piling on, but for the gazillionth time let me remind you that the biggest difference between the US and the rest of these countries is that they cover their entire populations and do it for remarkably less per head than we do. And in virtually no other country are people financially destroyed just because they are sick.

There’s an awful lot wrong with health care everywhere, but my guess is that if there’s one reason that foreigners are saying Vive La Difference, it’s that one.

The authors, though, find a few other ways to put the boot in:

In past patient surveys among the five English-speaking countries, the United States has stood out for having relatively short waiting times for specialized care. Based on patients’ reports in this study, Germany also provides rapid access to such care. Understanding how Germany has achieved access to physicians, after-hours care, and specialized care while spending much less than the United States spends as a percentage of national income could help inform U.S. policy.Symptoms of inadequate insurance coverage and more fragmented care in the United States emerged throughout the survey. The United States outspends the other countries, spending 14.6 percent of national income compared with Germany’s 10.9 percent, Canada’s 9.6 percent, Australia’s 9.1 percent, New Zealand’s 8.5 percent, and the United Kingdom’s 7.7 percent.Yet the United States often ranks last or tied for last for safety, efficiency, and access. With one-third of U.S. patients reporting medical, medication, or lab errors and a similar share citing duplicate tests or medical record delays, our findings indicate widespread performance deficiencies that put patients at risk and undermine care. Moreover, a recent study finds that the United States is not systematically a leader in clinical outcomes.Confirming spending data from the Organization for Economic Cooperation and Development (OECD), the United States also stands out for its patient cost burdens, with consequences for access.U.S. physician visit rates are already low by OECD standards.To the extent that U.S. insurance continues to move toward higher front-end patient deductibles, these rates could go up, as increasing numbers of insured patients become “underinsured,” lacking access or adequate financial protection.Contrasts between the United States and Germany, in particular, indicate that it is possible to organize care and insurance to achieve timely access without queues, while ensuring that care is affordable at the point of service. There are clear opportunities for the United States to learn from other countries’ insurance systems.

INTERNATIONAL: Monday morning world view

If you thought America was strange consider the plight of my birthplace and its former Empire. For a start the Royal Family is so broke it’s having to send its first-born son out to work for a Hong Kong bank, no less. Meanwhile, at least one junior doctor (resident to you Yanks) thinks that doctors in the UK get paid too much. Finally a great soccer player, George Weah, (who starred for AC Milan in their hey day in the 1990s and played briefly for Chelsea and Manchester City) has decided to go back to his home country of Liberia and take over as President

On a less light note, the earthquake in Pakistan and India is very, very serious, as are the mudslides in Guatemala. Here is a link to a page with several charities working in relief.

UPDATE: I got Liberia and Cameroon mixed up. Liberia was of course founded by free African-American slaves.

INTERNATIONAL: Medpundit in another foolish attack on the NHS

It’s been a while since I took at look at what Syd has been saying over at Medpundit, but I picked up a couple of gems recently.  One gave Syd the chance to attack those damn socialists in the UK who apparently don’t do preventative screening the way she thinks they ought to. She manages to extract from an article in the Times which broadly agrees with the BMA’s criticism of whole-body scanning and other "excessive" screening, that the UK is not doing screening for diabetes and high cholesterol, (although she thinks that it must be somehow) and pretty soon that gets lumped into some random reader’s comment about having to wait 2 months in Canada for a diabetes test.

I know that these are just the random thoughts of a conservative doctor who hates socialized medicine, but Jeez, Syd–can you give it a rest for a second?

First, the really comprehensive study of primary care in five English speaking nations done last year did indeed show that the US did slightly better in preventative screening than the other nations, but it didn’t do that much better and on an absolute basis we’re not doing that well–(here’s the detailed chart). But overall we did pretty damn poorly in comparison to a bunch of health systems that spend a whole lot less money, including by the way in such measures as waiting times for primary care, coordination of care between doctors, and of course having the poorer among us to avoid necessary care because of the cost.  So taking one measure in isolation to bash the UK’s NHS and then to take one anecdote to extend that to Canada is just sloppy.

Secondly, there’s more to primary care than preventative screening–there’s treatment of the chronically ill. UK GPs are now actively compensated on the rates of their patients who get recommended treatments. We know from Beth McGlynn’s RAND study that only about half of American patients get the recommended treatment, so I’m prepared to bet that that number is now higher in the UK.

Thirdly I visited two GP practices in the UK early last year. Both were very typical and both did something that I suspect almost no American clinic can do. The first was able to tell me immediately how many of its patients were on certain drugs and be able to break that down by those patients’ demographic groups and health status. The second has a Wednesday each month when one afternoon was devoted to eye and feet exams for all its diabetic patients, who are called into the office when a nurse team checks them out. And because they had a functioning EMR, they knew who all the diabetics were. In the US we have a whole mini-industry that mines claims to try to find out who the diabetics in a health plan are, and I can assure that they can’t just call the doctor’s office up to find out–because no doctors office using a paper chart can possibly know.

Now to her credit, Syd has been putting in an EMR and she probably soon will be able to answer those types of questions, but she shouldn’t be quite so hasty in slagging off those Brits who’ve been showing us how it’s done just because she has an irrational fear of the socialized medicine bogey-man.


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