Tag: International

INTERNATIONAL/PHYSICIANS: Canadian doctors going home means the US sucks, n’est-ce pas?

This one I find hilarious and gives me great deal of personal satisfaction. The pro-American health care system, "it’s the finest on earth crowd" goes on and on about how terrible the Canadian system is and how all the doctors are leaving. In fact it was that sentiment especially from the wonderful, but confused, Sydney Smith over at Medpundit that inspired my "Oh Canada" tome.  (Actually I re-read "Oh Canada" the other day and it’s a pretty damn good piece of analysis if I say so myself).

Syd was basically saying that all the doctors were leaving cos they hated the clinical restrictions of the single payer system and wanted to move to the glorious homeland of free-choice medical practice and CABGs for 97 year olds. I showed pretty conclusively using actual real life data that a) very few doctors were leaving Canada for the US, and that b) if they were leaving it wasn’t that surprising as they get paid about twice as much by sneaking below the 49th parallel.

Well now we have more actual statistics and real data that shows that more Canadian doctors are heading back to Canada than are leaving — and this was in 2004 when hockey was on strike so there was no real reason to go to Canada! The numbers are:

Canada has seen more doctors returning than leaving for the first time in 30 years, a report by the Canadian Institute for Health Information (CIHI) shows. The report, released Wednesday, says that between 2000 and 2004,the number of physicians leaving Canada declined by 38 percent. In 2004, 317 physicians returned to Canada and 262 left. That was a drop from 2000, when 420 doctors left the country and a significant decrease from the peak of 771 physicians who moved abroad in 1994.

I’m looking forward to the barrage of articles from the know-it all alleged "free-market" crowd who get spoon-fed rubbish by Frasier, PRI, Manhattan et al offering their apologies to the Canadians and admitting that their system is better than the one down here.  After all the alleged rush of Canadian doctors to the US was absolute proof in their mind that the reverse was true.

I’m waiting, I’m waiting….

POLICY/INTERNATIONAL: The Weekly Standard on moron support

In an article called Socialized Medicine on Life Support, there is just yet more rubbish from a libertarian doctor form a libertarian "think-tank" writing in a conservative weekly. For chrisssakes, Canada doesn’t even have "Socialized Medicine" — defined as the physicians providing the care working for the state.  That would be Cuba, Sweden or even the UK.  Canada has single payer….In American terms Medicare is single payer, the VA is socialized medicine…

It’s not even worth refuting the rubbish they write, but just once it would be nice if the sources they quote actually had done some, say, real research.

And as for the hackneyed old arguments; "Canadians flooding the US looking for care". Rubbish. "Opinion polls show Canadians think their health care is in crisis" — not compared to the US (read down to "System Satisfaction"), and "long waits for care everywhere but the US" — again just BS.

But the point is that these guys don’t need to deal with the truth or even fake real research.  Spreading FUD about anything that’s not the US status quo is all that’s needed.

POLICY/INTERNATIONAL: More rubbish being talked about single payer and Canada by major newspaper columnist

I had hoped that when the Boston Globe gave Jeff Jacoby a chance to rant about Canada and single payer, and THCB was able to call bullshit, that I wouldn’t have to repeat myself quite so soon. But to no avail. The Chicago Tribune gives a columnist called Steve Chapman, who incredibly enough worked for the liberal  New Republic (although aside of that has a long list of writing for libertarian and conservative newspapers), a chance to spread way more disinformation.

It’s good to know that a serious newspaper can allow a leading columnist to write about Canadian health care using numbers about the length of Canadian waiting lists from hopelessly biased organizations like Fraser and Cato, but ignore the official statistics which indicate that Fraser is wrong on waiting lists by a factor of 4. And for that matter the average waiting lists quoted by Fraser of around 4 months for elective surgery aren’t that bad–yet somehow Chapman starts talking about two year waiting list because one orthopedic surgeon said so.

Chapman then goes on to cherry-pick different outcomes on cancer to show that American care is better. Of course he doesn’t bother looking at overall care in different countries. This article in Health Affairs did just that (and is one in a series). The result, as again commented on in THCB, is that overall there is no real advantage to being in America. We do worse on somethings and better on others, but the suggestion by the Canada bashers that we get what we pay for is well off-base. And we clearly pay a lot more than anyone else and the share of those costs borne directly by poorer Americans is much, much greater than that borne by poor Canadians (or poorer people in other nations).

And if you look at the Health Affairs study a little more carefully you come to the authors’ conclusions.  Remember this is a real academic peer reviewed study, not some rubbish that Fraser Institute made up to suit its political agenda.  Here are the conclusions:

Across multiple dimensions of care, the United States stands out for its relatively poor performance. With the exception of preventive measures, the U.S. primary care system ranked either last or significantly lower than the leaders on almost all dimensions of patient-centered care: access, coordination, and physician-patient experiences. These findings stand in stark contrast to U.S. spending rates that outstrip those of the rest of the world. The performance in other countries indicates that it is possible to do better.

There’s plenty wrong with Canadian health care–something I looked at in depth in my "Oh Canada" piece. I’m also pretty sure that it’s not a good model for America, whereas Germany, Holland, France or Japan might well be.  But I really wish that if right-wing know-nothing columnists are going to write about this subject, that they’d either learn something about it themselves, or try to abstain from feeding at the research trough of totally biased organizations like Cato and Fraser. I suspect though that I’ll be wishing in vain for a while, but shouldn’t the Chicago Tribune hold itself to a higher standard?

INTERNATIONAL: The Future of Europe, Seen from a Sickbed

Timothy Garton Ash is a veteran British journalist, sort of from the Blairite "Third Way" school. He has lectured Bush on foreign policy and has been an influential writer about the collapse of communism in Eastern Europe. So his thoughts about how the health service in the UK is a microcosm of the future of Europe, which is called The Future of Europe, Seen from a Sickbed, is a great read.

It’s also very relevant in the US, where an aging white population is going to have proportionately more Hispanic youngsters looking after it in the coming decades.

INTERNATIONAL/QUALITY: The Brits are in court over “how much is enough?”

Well I was up late late last night working on some client stuff and am about to head back to that meat grinder, but for now consider this….

You may (unfortunately) remember the Terri Schiavo incident.  The Brits are playing this rather differently.  Here we’re keeping people alive who want to die (or at least we’re keeping some people who want to die alive). In the UK the issue of the NHS continuing to treat people who are going to die but who want all the stops pulled out anyway is ending up in court. Traditionally this process played out in the UK in a "stiff upper lip" way, mostly controlled by the medical profession.  Now the government is being explicit that it feels some medical care is a waste of resources. Pretty interesting stuff, because of course they are right, and the same thing is going in here but no one has the cojones to point it out.  But with the baby boomers about to hit Medicare and the Federal budget in the pocketbook, and way too much excessive care of the nearly dead going on in America’s ICUs,  the day when this discussion starts here will come.

INTERNATIONAL: The UK plans for a group practice future

Showing again that innovation isn’t dead in single-payer (and for that matter socialized) systems, the Brits are serious about creating the environment for pay for performance.  In an article called Super-surgery plan signals end for the family doctor, the Times reports that the British government is planning on coalescing its traditional onesy-twosey GP practices into bigger units.

While the article is full of fears about the end of Dr Finlay (the UK’s TV version of Marcus Welby), and also ridiculous claims that it’s being pushed because mass murdering GP Harold Shipman got away with his crimes because he had no partner looking over his shoulder, the real issue is that the Brits now believe that group practice in primary care will create better quality care.

They have already instituted a pay-for-performance model for primary care that rewards physician practices for hitting a number of process targets.  And over the last decade, they have spent the money and the necessary political capital to computerize practices.  Now they are going to force the GPs into the organizational form that has been shown in the states to create the environment for continuous care quality improvement, and of course have the shared resources to put in the systems that can monitor those processes.

Obviously there are lots of problems with the British system, and the connectivity both in terms of IT and in terms of communication between the primary care and the specialty care parts of the system is still an issue, and will be even when the huge IT project gets done — and that has its own problems.  But the fact remains that, despite all the knocks on the UK system, because it is government controlled it’s able to push the providers into a format that–according to the tenets of the best health services research–has been shown to produce the most effective medical care.

Of course, while there is a good game talked about that by Brailer and McClellan, they must be very envious of the relative power of their British equivalents.

INTERNATIONAL: US primary care looks poor in comparison to other nations

Not two weeks ago Bush yet again trotted his dad’s old line about the American health care system being the best in the world. A little earlier this fall Robert Centor at DB’s Medical Rants said that primary care in the US “trumped that in the UK”. I posted my objections to both Bush and to Dr Bob on TCHB before, but I didn’t have a lot of proof in terms of hard data.

Well I do now.

Health Affairs has published the latest Commonwealth Fund report, (survey research was conducted by my ex-colleague Kinga Zapert and her group at Harris Interactive), on primary care in 5 English speaking countries. Here’s the Press Release and here’s the whole article. Essentially on every measure, apart from peventative screening, on an absolute basis American primary care performed as badly as anywhere else and usually worse than everyone else. And of course it costs a whole lot more, both absolutely and in terms of out of pocket costs.

For example only 37% of Americans had a more than 5-year relationship with their primary care doctor, and 20% had no primary care doctor. Everywhere else more than 50% have a five year-plus relationship.

Here’s a look at timely access to care:

The majority of adults in New Zealand and Australia said that they received appointments the same day the last time they were sick and needed medical attention. In contrast, only one-third or less of Canadian or U.S. adults reported such rapid access. Canadian and U.S. adults also reported long waits, with 20-25 percent waiting at least six days to get an appointment when sick, a waiting time rare in Australia or New Zealand.

Telephone help lines provide a potential source for primary care access after hours. In the United Kingdom, NHS Direct operates a twenty-four-hour telephone nurse advice and information service. When respondents were asked about any use of such assistance in the past two years, help lines were used most frequently in Canada and the United Kingdom, followed by the United States.

And then again costs really impact use of care, especially for the poor:

U.S. adults were the most likely to say that they did not see a doctor when sick, did not get recommended tests or follow-up care, or went without prescription medications because of costs in the past year. New Zealand rates of not seeing a doctor rivaled U.S. rates and were significantly higher than rates in the other three countries. The United Kingdom and Canada stand out for having negligible cost-related access problems. Australia stands midway between the country extremes. Lower-income adults’ access to care was particularly sensitive to costs, with problems again the most acute in the United States.

And American primary care looks pretty bad regarding test results and patient communication — a result I suspect of poor care coordination here:

8-15 percent of patients said that they were given incorrect test results or had experienced delays in being notified about abnormal results. Test error rates were highest in Canada, New Zealand, and the United States…..The study reveals missed opportunities to identify patients’ preferences or concerns, to communicate well, or to engage patients in care decisions. On each of these measures, U.S. adults were significantly less likely to score their doctors highly and the most likely among the five countries to report concerns.

The US did better than other nations on some preventative screening measures like pap smears and checking for high blood pressure, which the study attributes to the pressure brought on providers via the NCQA’s HEDIS measures. But otherwise there’s a really clear question. What are we getting for all the extra money that we’re spending? In fact the authors come straight out with it in the discussion phase when they write:

Across multiple dimensions of care, the United States stands out for its relatively poor performance. With the exception of preventive measures, the U.S. primary care system ranked either last or significantly lower than the leaders on almost all dimensions of patient-centered care: access, coordination, and physician-patient experiences. These findings stand in stark contrast to U.S. spending rates that outstrip those of the rest of the world. The performance in other countries indicates that it is possible to do better. However, moving to a higher-performing health care system is likely to require system redesign and innovative policies.

It’s of course no secret where the extra money goes in the US system, where we lead the league in excessive care of the virtually dead, or as THCB contributor Dave Moskowitz said yesterday “For 70% of healthcare dollars to be spent in the last 12 month’s of a patient’s life means that it is spent on surgery and ICU care that is futile but expensive”. And of course the recent Dartmouth studies showed that the variation in ICU and end of life care and costs both between states and between leading hospitals in different parts of the US varies by a factor of 3! Not to mention Uwe Reinhardt’s point that we pay higher prices for the same amount of medical services delivered here.

In other words, buyers here(and by that I mean the big employers and the Federal government) have got to start changing the way they regulate the system and how they pay for care. It makes no sense for us to continually defend the way we’ve been doing things when the indicators are that everyone else can essentially do better spending less money. And saying it can’t be done, or Bush denying that there is anything wrong, reminds me of American auto execs in the 1970s poo-poohing the threat from Toyata. The alternative, of course is more of the same and the rest of the economy picking up the tab, at considerable social cost.

Meanwhile, the foreigners are trying to get further ahead. Here’s a webcast from Kiasernetwork of the study’s lead author Cathy Schoen ripping the US system, and a somewhat smug–and every right to be–UK health minister explaining how the government there is working to add improvements to the system (and no that doesn’t mean introducing more cost-sharing, which seems to be our only idea here).

Finally, the study also used the three part Harris question that you’ve seen me reference before. The question asks people to put their views on the whole system into three buckets which are in favor of a) minor tinkering, b) fundamental reform, and c) complete rebuilding. Most people end up in the middle bucket, of course, but the number of Americans looking for complete rebuilding is way higher than anyone else’s, and is now back up to 33%. In fact another Blendon study conducted more recently found that it was at 36%. Immediately before the 1992 election that number was at 42%. My forecast is that as cost shifting continues and as the uninsured rate rises, that number will climb here back to near the 40% mark, and a big debate will ensue.

INTERNATIONAL/PHYSICIANS: American doctors running off — to the UK!?

So I spent most of last week at two different conferences. One in Vegas was sponsored by a subsidiary of SAS Institute, Better Management, and was mostly about the application of data analysis to health care process redesign. The other was the American College of Emergency Physicians meeting (ACEP), where I spent my time checking out the state of IT use among Emergency Room docs. More on both those meetings later this week.

Meanwhile, the most surprising conversation that I had the whole week was in a booth for the NHS at the ACEP meeting — yup that NHS, as in the UK’s National Health Service. As I’ve reported from time to time in THCB, having not basically spent much money on its health service from 1945 to 1997, the UK in the second Tony Blair government has decided that it should spend a bit more. Some of this is going on IT, (much more on that here), and some of it is going on improving the overall quality of care in the system. But most of it is going to decrease the waiting times for elective surgery, including paying for people to go have surgery done in France and even elsewhere in Europe.

One major stumbling block is a lack of staff, as you can’t just turn on the pipe and get more British doctors. There are significant shortages in several specialties, hence the NHS has been recruiting abroad, paying relocation and housing for doctors prepared to take 2 year contract. So far they have recruited about 300 doctors, mostly Indian psychiatrists (as apparently that’s a very easy transition). However there are about another 1,200 doctors who have agreed to move to the UK, but haven’t got there yet. What blew me away was the fact that 300 of these are Americans. Note that these are American doctors moving to the UK to work at UK salaries, which are about less than half the average US level.

Now I know not having to pay for housing bumps up the pay level somewhat, but that’s still pretty flabbergasting. Apparently the type of doctor signing up is either one who’s hit a glass ceiling or one at the end of their career looking for a new adventure. American docs just out of residency struggling to pay off those loans will not find this too attractive.

Meanwhile the only special thing the immigrant doctors have to do to qualify for the program is to pass an English language test. Apparently male American doctors have been having trouble with the listening and comprehension part of the test, which (I was told) was something that didn’t surprise the female American doctors (who all passed that part of the test just fine, thankyou) at all!

Given the back and forth last year between me and Sydney at Medpundit about Canadian docs moving to America, I wonder what she’ll make of all this?

INTERNATIONAL: Canada’s Liberal Party Loses Majority

So after all the fuss about Canada possibly changing political horses, the election result shows that the Liberal Party got much more of the vote (37%) than the conservatives (29%). Due to the way Canada’s parliamentary system works (and because of the gains by the Quebec nationalists), PM Martin will have to form a coalition government. But the impact on the health care system will likely be neglible, as both sides more or less want to keep it as it is and both have promised to spend more money on it.

INTERNATIONAL: Tight elections and the Canada/US comparison

Up north they are having an election in the land where they no longer ever win the Stanley Cup, (although it should be noted that like the “Swiss” who won the Americas Cup over the New Zealanders mostly because the Swiss had a Kiwi crew, most “American” hockey teams are stuffed with Canucks). And the election is going to be very close. Go to this chart and follow the polls along from 2000 to today — interesting stuff and a potted history of Canadian politics in the last 4 years.

So what does this have to do with health care in the US. Well you’ve guessed it, the old chestnut of health care systems comparisons has reared its ugly head in THCB. As I mentioned a couple of weeks back, the Canadians are not planning on moving to an American system. That includes the newly resurgent Conservatives. Even if they win (and its about even in the polls now) both they and the governing Liberals are promising more cash for the current system, rather than changing course. In fact at the bottom of this news story in which (Liberal PM) Martin is trying damn hard to paint the Conservatives a shade of Republican–with references to gays and abortion–the health care issue is made clear:

    Harper (Conservative Leader, BTW) said on Friday he would inject C$10.4 billion ($7.7 billion) to C$15.2 billion into the ailing health-care system over the next five years. He pledged C$600 million to $800 million to cover drug costs over C$5,000 a year, and C$2 billion to C$3 billion a year for general health costs.

    On Thursday, Martin pledged C$26 billion to C$28 billion in new spending — including plans for a national day-care program and an expanded military — which he said could be done without driving the federal budget into the red. He too has pledged to inject more money into the public health-care system.

So basically they are outdoing each other for who will spend more on health care. And don’t forget that the Liberal government under Chretien in the 1990s actually cut healthcare costs and reduced healthcare as a share of GDP–not something that Americans have ever seen happen here!

So given that the Canadians are not heading our way, why bring this up? Well funnily enough a new report from both Federal Governments is out comparing the two countries’ health care systems. And what were the findings? Well no surprises. Insured Americans had a slightly better time in the system than all Canadians, while uninsured Americans had a worse experience. Cost was a big issue for Americans, while not one for Canadians, while waiting times were an issue for a large minority of Canucks.

    Americans were more likely to report that the quality of their health care services in general was excellent compared with Canadians (42 percent compared to 39 percent.) Among uninsured American respondents, 28 percent said the quality of the health care services they received was “excellent,” 44 percent “good,” and 28 percent “fair” or “poor.” When asked about their satisfaction with health care services in general, 53 percent of Americans and 44 percent of Canadians said they were “very satisfied,” while 37 percent of Americans and 43 percent of Canadians said they were “somewhat satisfied.” Among uninsured Americans, 39 percent were “very satisfied” with the services they received, and 40 percent were “somewhat satisfied.”

    Unmet medical needs during the past 12 months were reported by 13 percent of Americans and 11 percent of Canadians. Among those with an unmet need, Americans were more likely to identify cost as the primary barrier to health care (53 percent of unmet needs cases), while Canadians cited waiting for care as the primary barrier (32 percent of cases). Among the 11 percent of American respondents who were uninsured, four out of every ten reported an unmet medical need. Likewise, only 43 percent of the uninsured respondents said they had a regular medical doctor, compared with 80 percent of total American respondents and 85 percent of Canadian respondents.

So the message is fairly clear. With 40% of the uninsured with an unmet medical need, and less than half having access to a regular doctor, if you’re going to be uninsured in the US, move up north! Alternatively, maybe you should vote down here?


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