Tuesday, December 26, 2006

Two Tiers (Part the Second of n)

"In a country well governed poverty is something to be ashamed of. In a country badly governed wealth is something to be ashamed of."


"And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me."

Matthew 25:40

"The degree of civilization in a society can be judged by entering its prisons."

Feodor Dostoyevsky

"The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped."

Hubert Humphrey

Dr Dork notes a quintessential contrast in what he perceives of the US and UK systems, and of those exponents and critics of their approaches to healthcare.

The NHS is disparaged as “socialised medicine”, as if that is a failing unto itself. Of course, private companies driven by shareholder profits would not exactly be more compassionate, one thinks, in attempting to distribute a limited resource unable to keep pace with demand.

The US provides well, but at great direct financial cost to its users. Dr Crippen, of interest, pointed out the frighteningly high correlation between medical costs and personal bankruptcies in the US. Yet, as far as Dr Dork can infer from his US colleagues, the system is underpinned by a “socialist” Medicaid network.

Australia is a mixture of these two approaches. Here in Oz, we have traditionally operated primarily as a public healthcare system for the most part. In recent years, there has also been increasing growth in a separate private healthcare system. Rather than funding by largely employer sponsored insurance, as in the US, ‘private’ healthcare is funded generally by paying insurance premiums oneself. The exception to this rule is occupational health problems, wherein the cost of treatment (whether via the public or private system) is funded by the employers insurance.

This system is inherently possessed of two tiers of care level – in many areas, but not all. The public system struggles to meet demand in many areas. Emergency departments get overcrowded. Waiting lists for elective surgery are sometimes ridiculously long, and numbers are politically obfuscated. Only in the private system can you choose your doctor, choose your hospital, and not spend several months on firstly a waiting to be seen list, then a waiting to be treated list.

However, for acute, devastating injuries and illnesses, public hospitals are, arguably, much better equipped. Larger and better staffed ICUs, for example. Medium level staff always onsite.

One important annotation to the ‘private’ system is that health insurers in Oz are not-for-profit. There is no CEO earning $30 million in bonuses. There are no shareholders demanding cuts in coverage to boost their stock portfolio.

As mentioned in his previous post, Dr Dork is cogitating out loud on the two-tiered system in which he operates. This is further groundwork.

There is more to the story than this précis. Arguments for and against each approach. Dr Dork would love to hear from others experienced in multiple healthcare systems, as health provider or patient.

To echo the sentiments of Dr Crippen, in large part, Dr Dork is open in his bias: he believes healthcare is a right, and not a privilege, in any civilised society. Tax-based support of the public system in Oz is positively biased to place costs moreso on the wealthy who do not self-insure than the poor (the Medicare Levy).

It becomes, one could say, essentially an argument of efficiency and management, of finite resources confronted with ballooning demand, as our knowledge of the health sciences grows, and our populations age demographically, and live longer lives. Neither approach seems sustainable in the long term.

More on this at a later date. Your opinion is welcomed.


scalpel said...

I cannot consider healthcare a right because the provision of healthcare requires the work of others. Rights are basic principles. I have the right to be safe in my own home or to walk freely down the street, for example. In a civilized society, the presence of policemen (law enforcement) help me to exercise those rights. Is police protection a right in itself? Not at all. the legal and law enforcement systems are nice constructions of an advanced society, but they are hardly "rights." They are established in order to protect my rights.

When it comes down to it, I am ultimately responsible for my own safety and my own health.

And yet, the EMTALA law proclaims that emergency healthcare is indeed a "right" in our country. But it requires emergency physicians like myself to provide a service that is uncompensated. What about my right to receive payment for the service that I perform? It seems to me that one of my individual rights is being usurped when the government imposes this demand upon me that I must perform an uncompensated service to another member of society.

If I'm hungry, do I have the "right" to receive a free steak dinner from a restaurant? Or even a stale leftover dinner roll? Not at all. Why should healthcare be any different?

The MSILF said...

From my interest in public health, one of the things that always comes up is why the British NHS and Canadian system have so many complaints and seem to be having trouble functioning. The answer always seems to come down to the fact that government is not a very good service provider. In the NHS model system, the government is the employer of health workers and the provider of the service.

There is another system, the one in effect in lots of Europe and other places, called the Bismarckian system. In this, part of your taxes go mandatorily to healthcare/social security.

The providers are HMO-like entities and providers who contract as free agents to them (these can be anything from a solo practice doc to an entire hospital). The HMO provides the services and is reimbursed by the government from the health tax, based partly on services and partly on capitation for number and age and some other demographics of members.

These "sick funds" as they are often called, are competitive with one another - so they try to keep costs reasonable so that they can turn a profit a little bit and expand and attract more customers, but they also compete for customers (people usually can choose which one they go to), so they have to provide decent service or people will leave. Usually various competing funds compete for different market shares - some focus only on the young, healthy population; others more toward an older population. One fund that, for example, targeted a young population would probably offer less services under their own umbrella. They would have to pay for these services (to whoever is providing them - usually a hospital under the auspices of a fund or a non-profit hospital). A fund that treats older, sicker patients would probably develop its own nursing and home care setup - and maybe allow another fund to pay them to use it for their few young patients who need it.

In the systems I'm familiar with (and I've never been in an NHS-like one), this system is most friendly for patients and doctors (who can also go work for whoever they want).

If you google or pubmed search for Bismarckian healthcare, plenty of data about cost and quality come up, as well as details about how exactly it works. The biggest hurdle to it in the US, I think, is the socialism of it all - everyone pays a certain percent of their income in. Although that's what they already do with social security/medicare.

essaybee said...

A few notes on the US system:

-o- It is illegal for an emergency room to turn away patients. Everyone, regardless of ability to pay, receives the same treatment.

As the poster above notes, the system for paying the providers is very flawed. This needs to be remedied. Some US states are experimenting with various ways of reforming the healthcare funding system. Sort of like Laboratories of economics. Successful systems will spread, failed ones will wither. Slowly we will find a solution that works for us. It may take a long time, but no one can KNOW what is going to work. Just because something sounds like it makes sense doesn't mean that it's going to work in the real world.

-o- Our safety net, Medicaid, is paid for by the gov't, but not administered by the gov't.

When Americans object to socialized medicine, it is because we know that any large bureaucracy multiplies inefficiency and corruption. Our taxes already pay for healthcare for many people, but we just don't want the gov't running the show. Dr. Crippen should be mandatory reading for anyone who favors letting the gov't take over healthcare.

In the US many counties have public hospitals, but these are run by the individual counties, not by the US federal gov't.

-o- In my opinion a major flaw of the US system is that tons of money goes to paper pushers at insurance companies and billing depts. Anybody got a link to a study that has the numbers on how much $ is spent on this? There is one private system here, Kaiser Permanente, that is a non-profit and tries to function without billing. All the providers are on salary, and members pay a monthly fee plus per-visit copays for all their care. There are no maximums, and you never get a bill.


-o- The system is pretty fast when necessary. I know two people who had to have their gallbladders out this year. Both were medically indigent (no insurance and no ability to pay), and both had their surgeries within 48 hours of going to an ER. On the other hand, I had a hip replacement last year, paid for by my private insurance (which is paid for by my employer) and the wait was 6 weeks, which is scheduling and prep time. If I had needed the surgery urgently, I could have had it right away.
The bottom line is: nobody knows the best way to fund healthcare. I don't see any existing system that fairly pays providers, gets people the care they need in a timely manner, doesn't de-skill medical professions, and doesn't bankrupt patients or payors. Nobody knows how to do that. It's going to take lots of experimenting and patience to find the solution.

Zoe Brain said...

It's a bummer when you need a procedure not actually performed in Australia. Not only is the cost not covered by insurance, but it's not tax-deductible either.

And I still get to pay medicare levy. I've stopped the private insurance because with the medical expenses, I can't afford it.

All in all, the Australian system works pretty well for most people.
But there are anomalies, and my life savings are now gone, despite me taking every insurance provision I could.

Even more of a bummer that I need another $40k worth for full functionality (with no way of saving it), but at least I'm out of danger now. I can live with it.

Oh yes, and Dr Dork?
Thanks. How you guys can do so well considering how much we don't know is a tribute to your knowledge, memory, logic and especially intuition.

Dr Dork said...

Hi Scalpel,

I've mentioned my bias, but I'd still argue healthcare, just like police protection and education is a right in a civilised society. I am aware that this necessitates funding by all, myself included, and am happy to see my tax dollars go to these areas. I don't think there is any suggestion you should be unompensated for providing emergency services, same as for police, teachers, sanitation workers...I happily pay 0.001 % of their salaries, or whatever, as do all. No-one forces you to go to work and get paid ;-) In terms of helping someone injured on the street, I'd say that is implicit in our Hippocratic oath and I'm happy to do that (and have) if the situation demands it.

Thanks for bringing up this Bismarckian system - I was not aware of that, it sounds similar in many ways to Oz, or at least the NZ system which is quite revolutionary in aspects of medical tort as well.

Sheila, I agree very much! Neither approach is without major flaws. One problem with public administration of health here and in the UK is that those responsible for administering these frighteningly complex systems are, relative to what they can earn in the private sector, underpaid. I believe we should pay our leaders better - to attract the best, to reduce the potential for corruption, this goes for healthcare management as well. Rather than adding layers of bureaucracy, pay well but make it performance dependent. If you pay peanuts...

Hi Zoe,
Sorry of your own circumstances - there are certainly gaps in the Oz system. When I was younger, it was a better fiscal option to self-insure for health, and instead insure my income.

ps - the first thing I know, of course, is how little I know...

Kind regards

scalpel said...

"In terms of helping someone injured on the street, I'd say that is implicit in our Hippocratic oath and I'm happy to do that (and have) if the situation demands it."

Helping an injured person on the street is quite different than treating an injured or ill person in the ER. I'm not sure what you are trying to say with that comment.

Surgeon in my dreams said...

I have been a patient, or had a child or spouse as a patient, in an emergency room no more than 5 times in my 46 years.

Two were for my dear son who grew faster than his coordination could keep up and either had broken bones or gashes that needed suturing and could not wait until the next morning.

Two were for me. One I was in labor and the other was having a drug reaction.

The 5th, my daughter broke her wrist sledding...unfortunately after 5:00 PM. At that time, there were no "doc-in-a-box" in our area.

I don't pretend to know the answers. Heck I don't even know some of the words you use without consulting Websters, but I know what it is like to be on this end of things.

Now that my husband is so ill, if something doesn't change soon, we may be one of those families most doctors detest who use the ER like a family physician.

His insurance (COBRA) runs out in March. His job so far refuses to consider him full time (hence no benefits) even though he is working 40 hours every week since they hired him 3 months ago.

Through no fault of his own, he lost a good paying job with good benefits this past April. He is on over $1400 a month in medications. He has several chronic illness' and was in good health until one after another they struck him down over the last 9 years of his life.

He worked full time throughout high school and college, paying off his parents home as his dad was disabled by 44 and dead by 49.

I guess you could blame it on us somehow - I you stretched it. Maybe he could have gotten his degree in an area that was termination proof. Maybe he could have married a woman who was better educated and better equipped to pay these medical bills.

Like I said, I don't know the answers, but I also don't know what we will resort to when his COBRA expires and our small savings is depleted.

Use an ER as a family doctor? Maybe divorce (on paper) so he will qualify for all the freebies out there he would qualify for were it not for my paycheck?

Next time some of you docs snarl and moan about someone using your ER as a doctor office, look yourself in the mirror and remind yourself that it could have been you walking through that door.

Not everyone who finds themselves in this situation are there because they are lazy or dumb or not willing to try or any of the other names you can pin on them.

Thanks for the opportunity to vent Dr Dork.

scalpel said...

You will get charged a lot less from a family doctor's visit than from an ER visit. The only difference is that the family doctor will make you pay up front before receiving treatment, while the ER cannot.

The ER visits you mentioned above SIMD were all emergencies and therefore appropriate use of the ED. I'm not certain what type of visit you are contemplating needing the ED for, but we are always happy to evaluate anyone for the presence of a possible emergency and treat them to the best of our ability.

I don't think anyone has said anything different in this thread.

Surgeon in my dreams said...

scalpel said... You will get charged a lot less from a family doctor's visit than from an ER visit. The only difference is that the family doctor will make you pay up front before receiving treatment, while the ER cannot.

EXACTLY, and then in the mean time, I will be able to continue to keep a roof over our heads, pay our power bill and our taxes, thus preventing us from being a further drain on society by winding up homeless.

I'm not certain what type of visit you are contemplating needing the ED for.

"Any and all" types if it gets down to that scenario. Some people would not understand if it were explained to them a million times. I guess it is one of those "you would have had to have been there" situations.

I was commenting in general to all of the complaining I read from physicians concerning this matter - not particularly this post. I don't think Dr Dork minded this post being used as a catalyst.

Normally, I would not respond to a comment made towards my comment. I just typically refuse to get into those "urinating matches". I was just hoping the "look in the mirror thing" might have opened a mind or two to even slight consideration of why some people resort to doing some of the things they do.

scalpel said...

Many people do in fact come to the ER with unrealistic expectations. We can't do anything about anyone's financial situation, their living situation, their job situation, the arguments they are having with their family members or the stress it is causing them, etc.

We can't check someone's cholesterol or make their acne go away in time for their Christmas picture. We can't fix their chronic back pain, and we probably won't even give them enough pain medication to last until their next doctor's visit, much less the one to three month supply that would certainly be more convenient for them.

But anyone can come in and seek our opinion. Just don't gripe about the wait or yell at us for not being able to fix chronic problems that are out of our realm. It's either an emergency or it's not.

We can only do what we can do.

Dr Dork said...

Helping an injured person on the street is quite different than treating an injured or ill person in the ER. I'm not sure what you are trying to say with that comment.

Hmm - not suggesting yuo wouldn't, scalpel ! I understand how frustrating it must be as an ED physician when so many of the faults in the system (whichever system that may be) end up in your lap. Or at least I think I do - I might be wrong. What I was unclear on was how access to and provision of services are separable...to me one implies the other. What I meant was that once we someone needs treatment, we provide, I guess, in the street, in a clinic, wherever. If a patient has an AMI in a psychiatrists office, the psychiatrist will still innitiate treatment.

Kind regards

scalpel said...

Helping an injured person in the street is simple. You can't really do much, honestly, and it costs you nothing but a little time.

If I didn't have all the facilities, equipment, and personnel of an ED behind me, I couldn't do much more for them there either. My desire to help someone would be the same, but my ability to help them would be minimal without the support of the ED infrastructure and staff.

The difference is that it is not MY money or MY time that I am spending by using the ED equipment and personnel to help people. I think there is a bit more responsibility required when you are spending the resources of society. Helping one person is easy....helping thousands not so much. So in forums like this I like to step back and look at the issues a little differently, with a bit more detachment and a little less emotional involvement.

It's just triage, when it comes down to it.

scalpel said...

I'm enjoying this discussion immensely, btw. Thanks for initiating it.

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