National health insurance – beware the externalities

5

Category : General, Medical Rants

Dangerous Delusions Corrode our Medical Services

Please read this article. I will give a few quotes – but the entire article is worth a clickity-click.

Our national flirtation with the illusory benefits of “free” national health insurance corrodes our debate about improving the quality of health care in the United States.

Partly because of the allure of this delusion of free or single-payer national health insurance, we are slowly ceding our medical service system to government mismanagement at patient and taxpayer expense.

The most dangerous delusion of all is that government-paid universal medical services are compassionate because they are supposedly “free” for everyone. This egalitarian theme sounds benevolent in theory, but is callous in practice.

=================

The first myth is well expressed in this quote from the U.S. Physicians’ Working Group for Single-Payer National Health Insurance: “Access to comprehensive health care is a human right. It is the responsibility of society, through its government, to ensure this right.”

The authors point out that the so-called basic human right to health care in countries with national health insurance is “nothing more than the opportunity to get services for free (or at very little cost) as the government decides to make those services available. But government is under no obligation to provide any particular service.”

Government controls costs by imposing global budgets on hospitals and health authorities and limiting supply. As a result, demand exceeds supply for virtually every service and patients are forced to wait months and even years for treatment.

They are sometimes apologetic, however. An electrocardiogram appointment letter from the Moncton Hospital to a New Brunswick, Canada,heart patient said the examination would be in three months. It added: “If the person named on this computer-generated letter is deceased, please accept our sincere apologies.”

=======================

Aneurin Bevan, father of the National Health Service (NHS) established in Britain in 1948, articulated the second myth — equal access to health care for all people. He declared, “the essence of a satisfactory health service is that rich and poor are treated alike, that poverty is not a disability and wealth is not advantaged.”

In spite of this high-minded goal, studies in both Britain and Canada indicate that their socialized systems are far from fulfilling this goal. In an article on the problems of unequal access in Britain, Patrick Butler observed: “Generally speaking, the poorer you are and the more socially deprived your area, the worse your care and access is likely to be.”

=========================

The third myth is related to the above two: that care should be based on medical need rather than ability to pay. But people in countries with a socialized system are increasingly willing to pay outside the system for better and faster treatment. “Free” surgery isn’t worth much if you have to wait until you’re near death to receive it.

Somewhere lurking in all these myths is the delusion that cost is the only limiting factor in obtaining health care. If government provides the medical services to everyone for “free”, then, as the British Medical Journal predicted so hopefully in 1942, a national health system will provide “a 100 percent service for 100 percent of the population.” After sixty years of trying, they haven’t even come close.

Rationing, inefficiencies, and lack of quality are the real fruits of this socialist experiment. And we need less, not more of it.

On the other hand, when patients decide and speak with their own resources, including private insurance and cash, hospitals and doctors pay attention to them — and meet their needs.

Our current health system has many problems, but we must carefully consider the unexpected consequences of any change. As my son reminded me last night – we must consider the externalities of any law.

In economics, the effects that the acts of consumers or producers have on each other. Externalities range from pollution and technological (see technology) inventions to the change in the range of options available to consumers and are differentiated from internalities because current knowledge prevents the former from being included into the formal equations of an analysis. Externalities may also be regarded as the unanticipated side effects of calculated courses of action.

As we think about any change in our health care system beware the externalities!

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A British view of private medicine

22

Category : Medical Rants

The three paradoxes of private medicine

Like many people in Britain I have inherited—and have subsequently nourished—a profound dislike of private medicine. However, it now appears that the reality is much more complicated and disturbing.

We had been told that my daughter would have to wait at least two years to see the consultant as an outpatient, and we felt that this was totally unacceptable. So we made one simple phone call to the private hospital, and she was seen in two weeks.

This much was accomplished without trauma. When we made the appointment it felt like any other—perhaps to see the general practitioner or a school teacher. But the experience began to be qualitatively different when we got there. It began with a feeling of relief that the uncertainty and waiting were over. Then, three things happened that gave me pause for thought.

Instead of the joy of clinical resolution, you are left with a tainted feeling of shameful compromise and guilt

Firstly, the staff were different. They may have had the same job titles and qualifications as staff in the NHS, they may also have had NHS jobs (the consultant certainly did), but they behaved differently. There was a perception of deference to you, the receptionist was caring, they seemed to have more time, the consultation was less pressured (you know that there is no one waiting outside, so you can take as long as you like). So far, so good. But in each of these apples is a worm. Are they only being nice because I’m paying? If so, what do they say behind my back? Do they think I’m as compromised in this Faustian bargain as they are? Is the consultant being pleasant or oleaginous, altruistic or avaricious?

These issues matter because they go to the heart of the encounter: do I respect this person, and therefore do I trust his advice and actions? This is especially important given the manifest perverse incentives, where every additional action means personal income. When he says, “I can see you for the next appointment on the NHS, but it will be a few months,” do I believe him? When he suggests drugs rather than waiting and seeing, could there be ulterior motives? One of the marvels of the NHS is that you can generally trust the motives of the professionals—but here? The result is the first paradox: paying for health care can actually be disempowering.

Acculturation occurs in all societies. Americans generally desire the benefits of private medicine. Most of us read this article with incredulity. I would wonder, I think, as a patient in the NHS whether a decision was being made for financial reasons also. We (the author and I) each distrust the financial motives – he of the private physician, and I of the NHS.

How do we provide the best medical care for the most people? Are we better served by a government bureaucracy or by the profit motive? (As an aside, while certainly some physicians think about profits, I truly believe that most physicians do not consider their income during individual patient encounters.) The profit motive certainly decreases wait times. The bureaucracy may do better in preventive care (although I know of no data).

An editorial runs in the same issue of the BMJ – Why Britons should be grateful for the NHS

If you read Britain’s tabloid newspapers, you would think that Britain’s National Health Service was a disgrace. In this week’s media review, for example, Peter Wilson quotes some of their headlines on MRSA (methicillin resistant Staphylococcus aureus). “Our squalid hospitals: no wonder the MRSA superbug is so rife,” is typical, but the subject can be anything, from stupid managers to uncaring nurses. Moreover, newspapers don’t let the facts stand in the way of a good story. As Wilson says, in their eagerness to paint a picture of MRSA some papers “even include cases of methicillin sensitive S aureus (MSSA), particularly if it happens to involve a minor celebrity.”

But most of the millions of encounters that go on in the NHS each day are not like that: the NHS is not a disgrace. I’ve always marvelled that this complicated organisation—which deals daily with extremes of human emotion, high uncertainty, and technical complexity against a background of politicisation—manages to function as well as it does. In recent encounters I’ve been hugely impressed not only at the standard of care that the NHS provides, and the care that people take, but also at its basic equitableness and decency. Britons should be grateful for it.

So (in my opinion) the BMJ has run two articles to support the NHS. I would argue that these articles are far from objective.

I often rant about the deficiencies in our system. We could certainly use our resources more efficiently. But our system trumps the NHS regularly. Regardless of payor status, if you are truly sick, our system responds. We could do a better job supporting primary care – but even here we trump the NHS (where physicians get around 8 minutes per patient).

So the BMJ’s apologies aside, I will disagree. I am delighted that we have private medicine in this country. We should continue to improve it. We need to better link payment to service, so that patients understand costs. But our system remains the one that I prefer.

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The British NHS

1

Category : Medical Rants

Many physicians still clamor for universal health care in the US. We must look at international models to better guess what such a system would do to our health care. Perhaps we would still have an active private medical care system. Great Britain does. Private health: bigger than NHS!

This week, BBC Radio 4 asked me to do an interview on the origins and growth of the non-state healthcare market. Boning up for it, I was reminded just how significant the independent sector is. It provides 85 percent of the UK’s residential care beds, for example, and 20% of all acute elective surgery – that’s the stuff like hip replacements that isn’t exactly life-threatening, but which you want to get done fast anyway.

Indeed, the independent sector has more beds than the NHS and local-authority care homes put together!

It employs almost as many people – roughly 750,000 of them – and it accounts for a quarter of UK health and social care spending. In addition to the 15,000 nursing and residential care homes that the sector provides, private agencies care for more than 200,000 people in their own homes.

Another thing which people don’t realize is the huge contribution of the private sector in mental health and dealing with drug abuse. Indeed, around half of Britain’s medium-secure mental healthcare places are provided privately, in more than 200 private hospitals and units. The sector accounts for 80 percent of all rehabilitative brain-injury beds. Nearly all (96 percent) of NHS-funded in-patient child and adolescent mental health services are provided privately.

On the funding side, almost 7 million people have private medical insurance, while 6 million are members of health cash benefit plans – schemes which pay you cash when you are in hospital. Around 3.5 million trade union members (that’s more than half the total membership) have some kind of private health cover.

Thanks to the blog author for the “heads up”.

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Healthier Food

3

Category : Medical Rants

I want to compare and contrast the current truth and the truth as proposed by my daughter. The current truth – Gov’t Won’t Force Cos. on Healthier Food

The Bush administration says the government can’t force food companies to produce and promote more nutritious products in an effort to reduce obesity, although it is trying to encourage them.

Health and Human Services Secretary Tommy Thompson said Thursday that the industry has the resources to help Americans make healthier eating choices.

But he argued that lawsuits against restaurant chains or requirements that product labels include health information will prove less effective.

Food companies “have got the advertising dollars to do it,” Thompson said at a conference on obesity sponsored by the Consumer Federation of America. “That’s much better than passing legislation.”

He promised that manufacturers that invest in promoting healthy eating and fitness will get recognition for their efforts. “I’m going to start giving more awards and singling out those that have done it.”

At least Thompson is using the bully pulpit. This represents a good start. Perhaps he should read this paper that my daughter wrote for a public publicy course. This assignment is written in the form of a memo to a senator. She advances an interesting proposal.

The problem of obesity in the United States has grown to epidemic proportions, making it impossible to ignore. As you may know, the National Health and Nutrition Examination Survey (NHANES) recently reported the results of their 1999-2000 study which investigated the prevalence of overweight and obesity in our country. Since 1994, the prevalence of overweight, that is, persons who have a Body Mass Index (BMI) greater than 25, has increased from 55.9% to 64.5%.1 Simply put, two-thirds of the population can be classified as overweight based on their BMI. In addition, since 1994, the prevalence of obesity, defined as persons who have a BMI over 30, has increased from 22.9% to 30.5%.1 Nearly one-third of the United States population can be classified as obese. These statistics, especially when viewed in light of the negative health effects associated with overweight and obesity such as heart disease, diabetes, and cancer, are startling. Not only is the health of our country at risk, the amount of money that will need to be spent on healthcare must be considered now as this problem continues to worsen.

Interestingly, the prevalence of overweight and obesity has increased dramatically over the past ten years despite the growth of the commercial diet industry. For this reason, we can no longer afford to wait for the private sector to find a reasonable solution to fix this ever-growing problem. The government must protect the common welfare of its citizens as it has become apparent that the mixed messages coming from the diet industry are not working. To that end, I would like for you to consider drafting legislation aimed at correcting this problem. This legislation would implement a tax on foods that compose the main sources of saturated fat in one?s diet, such as whole milk, butter, cheese, and high fat meats.2 The other part of this legislation would include language for a subsidy for some foods that are low in saturated fat and/or high in fiber, such as fruits, vegetables, whole grains, and lean meats.

The problem of overweight and obesity is unequally distributed among socioeconomic groups. Less wealthy individuals are disproportionately overweight and obese as compared to the population as a whole.3 One main contributor to this is that higher fat foods offer a large amount of energy (calories) for a low price. “Super-sizing” food has become appealing because it is quick and cheap. When a family’s food budget accounts for a high percentage of their total living budget, buying cheap, high-calorie foods appears to be a logical and economically sound choice. Unfortunately, these seemingly logical choices are being made at the expense of one?s health and the health of their family. Since poor people spend proportionally more of their income on food than rich people,2 it is easy to see how the prevalence of overweight and obesity differs between socioeconomic groups.

Before you consider drafting this legislation, I imagine you need a few questions answered. Namely, would a tax on these high fat foods make a difference in consumption patterns? Would lowering the prices of healthy foods increase the likelihood that they would be consumed? A group of researchers at the University of Minnesota investigated these questions.4 In their experiment, they used vending machine purchasing patterns as a means of looking at consumption patterns. During the intervention period of the study, the researchers lowered the prices of low-fat items in the vending machines by 50%. Sales of low-fat snacks increased 150%. Once the prices were returned to pre-intervention amounts, the sales of low-fat snacks resumed to baseline levels. This study suggests that with an economic incentive, it is possible that consumers will change their consumption patterns by purchasing low-fat foods as opposed to high-fat foods. The taste of the high-fat foods may not be the only motivator when it comes to consumption.

Currently, 18 states have special taxes on soft drinks, candy, chewing gum, and snack foods.5 These special taxes equal an extra $1 billion per year in revenue. This money could be used to subsidize healthier, lower fat, more nutritious foods. These “snack taxes” have been more politically amenable because they are aimed at foods with virtually no nutritional value. Although these taxes are useful, it would be more meaningful to impose taxes on foods that contain large amounts of saturated fat in an effort to decrease the rates of heart disease, our nation’s #1 killer.6 Like the “snack tax,” this “fat tax” would still bring in revenue to be used for healthy food subsidies. Additionally, this tax could potentially detract people from consuming foods that have been linked to heart disease. I recommend the Department of Agriculture, specifically the Food and Drug Administration, work to implement this tax by determining which foods should be taxed and which foods should be subsidized.

A “selling point” for this legislation is that the taxes would only be levied on those people who choose to buy the high-fat foods that are taxed. If people do not wish to pay these taxes, they need not buy these foods that have been found to be major contributors to the obesity epidemic. Hopefully, the high-fat foods may seem less appealing when their costs are raised. Another advantage to this legislation is that the revenues gained from these taxes would subsidize the prices of lower-fat, higher-fiber foods, allowing more individuals and families to purchase these traditionally more expensive foods. This legislation could help to lessen the divide between the rich and the poor when it comes to eating a healthy diet and assist in closing in on the gap in overweight and obesity between socioeconomic groups.

As mentioned above, the rate of overweight and obesity has grown to epidemic proportions. The costs to society, both in terms of dollars and shortened-lives, are immense. Therefore, I recommend you introduce legislation now to implement a “fat tax” that will discourage people from eating unhealthy foods and subsidize foods that contribute to a healthy diet. This tax is a small step towards addressing obesity in the United States, but it is an important step we must take now.

References

1. Flegal et al. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002; 288: 1723-1727.

2. Marshall. Exploring a fiscal food policy: the case of diet and ischaemic heart disease. 2000; 320: 301-304.

3. Philip et al. Socioeconomic determinants of health: The contribution of nutrition to inequalities in health. British Medical Journal. 1997; 314: 1545-1549.

4. French et al. A pricing strategy to promote low-fat snack choices through vending machines. American Journal of Public Health. 1997; 87: 849-851.

5. Jacobson et al. Small taxes on soft drinks and snack foods to promote health. American Journal of Public Health. 2000; 90: 854-857.

6. Anderson. Deaths: Leading Causes for 1999. National Vital Statistics Report. 2001; 49 (11).

Congress has often used taxes as a policy tool. While I have not thought carefully through the policy implications of this concept, her reasoning looks sound. If I am missing unintended consequences please let us know. Needless to affirm, I am very proud of my daughter’s reasoning and scholarship. Having this blog allows me to share her work with the blogosphere! (Disclaimer: she has given explicit permission for me to share this paper with you the reader)

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MRSA in Great Britain

3

Category : Medical Rants

British Hospitals Struggle to Limit ‘Superbug’ Infections

Britain has one of the worst rates of hospital-acquired M.R.S.A. bloodstream infections in Europe, second only to Greece, and the problem is getting worse. The National Audit Office, a government watchdog organization, announced this month that there had been an 8 percent increase in the number of all staphylococcus aureus, or staph, infections in the bloodstream, to 19,311 in 2004 from 17,933 in 2001. Of those, 40 percent were resistant to the antibiotic methicillin.

But that reveals only a slice of the problem because the Department of Health, which began to keep figures on the infections in 2001, does not track the existence of staph infections outside the bloodstream, in wounds or in the urinary tract.

One in 10 patients contracts a staph infection while staying in England’s hospitals, which rank among the oldest and most crowded in Western Europe. Because superbugs multiply easily in unhygienic surroundings, dirty hospital wards and unclean hands contribute to their spread from patient to patient.

While estimates remain sketchy, mostly because the cause of death is seldom narrowed to hospital-acquired infections, the National Audit Office stood by its assertion, first made in 2000, that the infections result in at least 5,000 deaths a year.

===============================

Some hospitals do a better job than others. The problem is rare among England’s handful of private hospitals, although those facilities seldom see the most vulnerable patients.

And while most Britons rely on government-financed National Health Service hospitals, a growing number, like Mrs. Rayner, are choosing to spend their own money on private care.

“It sounds awful complaining like this because in lots of way they were good,” Mrs. Rayner said. “But I’ve stopped using the N.H.S. Our hospitals are going downhill.”

Alison Langley, a spokeswoman for the Department of Health, said the agency was determined to do more to combat the infections. In the meantime, there is no need to panic, she said.

“I’m not sure how to reassure people,” Ms. Langley said. “But M.R.S.A. is not a death sentence.”

I always like bureaucratic “spin.” The NHS has a very serious problem, which relates to funding. Infection control costs money. It requires hand cleaning between patients, and space between patients. The article does a nice job of defining the problem.

Solutions require investments. Saying that there is no need to panic fails to pass the logic test. I would avoid hospitalization in a hospital with insufficient beds and precautions.

Health care costs keep rising. To insure our highest quality care, we may need to spend more money. Few politicians will make that argument. The simple sound bite demands that we control health care costs. I argue that we should spend our health care dollars wisely, but spend the right amount. Perhaps Great Britain should follow that line of reasoning.

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