Saturday, February 17, 2007

Two Tiers Part III

It is interesting to observe, from this sequestered shore, the seemingly perennial debate over the growth and evolution of further two-tiered systems akin to that found downunder.

In particular, the heated debates arising amongst and between the principle sources of health bloggers : the UK and the US.

Although at present they appear at extremes in their philosophy of healthcare delivery - and funding thereof - they appear, from afar, to be gravitating towards each other.

Dr Dork knows little of fiscal matters, but it seems that in the UK, in essence, there is fairly heavy taxation with the resultant expectation of (amongst other public services) quality, accessible public healthcare. In the US, there is perhaps less taxation, certainly less public funding for healthcare, and more of a “user-pays” or privatised system.

In Australia, we have been under the sway of a rightward leaning government for a decade, and whilst for many years prior healthcare has been an admixture of public and private, the pendulum has swung increasingly moreso towards the latter.

In theory, we have public hospitals and a fully government funded Medicare system to provide inpatient and outpatient care to all.

Australians, for the most part it seems, still subscribe to the ideology of providing healthcare to all – irrespective of income, employment status, or ability to pay.

Dr Dork disagrees profoundly with the viewpoint that access to basic healthcare is not a right, as some have suggested. Healthcare is a fundamental right common to all humanity. It is inhumane to deny treatment to those who cannot pay – directly or indirectly – just as it is inhumane to deny the starving food and water.

For many reasons healthcare costs will only continue to grow. As science advances, we live longer, and consume more health resources. We expect not just greater longevity, but greater quality of life.

What we gain in mortality, we lose in morbidity.

Our public healthcare system in Australia is increasingly struggling to keep up. The cracks are perhaps not as wide as in parts of the NHS, but one supposes this has much to do with such being papered over by a parallel private system which is inexorably growing. Many doctors choose to practice only within the private system. They are not necessarily better skilled or qualified than those remaining largely in the public sector, but it is almost inevitable that the overall standard of care is often better in the ‘private’ system.

Like 40% of Australians, Dr Dork has chosen to pay for private health cover. It is silly not to, with our current system, if one can afford it.

If one can afford it.


jmb said...

Very interesting post. Here in Canada we are barely clinging to universal healthcare, with chinks in the system appearing regularly. Advocates of a two-tier system are vociferous, especially when they site the waiting lists for some types of elective surgery.
I recognize the problems we have but am adamant about the system remaining universal. Everyone demands the governments (federal and provincial are both involved)spend more money on healthcare. But 20 yrs in the hospital industry made me super aware of the waste, especially not in patient care areas but in administration.
One example: In the period of a few weeks, two hospital administrators of large local hospitals were fired with golden hand shakes of $500,000 (two years salary). One was replaced by a hospital administrater from another province, also fired, also with a half a million golden handshake. The other two immediately found positions in the industry elsewhere. Total spent from the healthcare budget $1,500,000, on three individuals, judged to be failing in their jobs.
How about the logo of our hospital being changed for who knows what reason( a consulting firm was paid $250,000 to advise) with the resulting cost of all the signs being changed plus all the stationery being chucked and replaced. A big hospital too, with three different sites.
More money, forget it. Spend the budget as if the money were coming out of your pocket, which it is in the long run.
Sorry, Dr Dork. Didn't mean to hijack the comment section.
How come you're watching from the shore when you live under a rock in the desert? On vacation?
jmb, the Zero Slasher

scalpel said...

HEalthcare simply isn't a right, no matter how many times (or different ways) you say it. Nobody has a right to someone else's labor.

If I'm on a liferaft with a dozen people and only six of us brought provisions, the other six don't have a right to our food. We might offer them some to be charitable, but they don't have a right to it.

Dr Dork said...

Hi jmb,
This is what appears to be the biggest problem in the struggling NHS, and with our public system as well - bureaucratic and administrative inefficiency and short-term political motivations taking precedence over longterm healthcare planning.

And you're welcome to "hijack" the comment section ! If I wasn't interested in what others think I would turn off the comments. I'm only putting forward my opinion, and if you've taken the trouble to read my two cents it's only fair you should be able to add your own if you choose - whether for or against my viewpoint.

Hi Scalpel....Ha! I thought you might bite on this one. I think it being enshrined in the UN charter, as per the link, is pretty strong support. If it is not a right, why do prisoners receive healthcare?

No-one has a right to your individual labour, I guess, but everyone has a right that their taxes pay for basic healthcare, especially urgent. In my opinion. It's one of the conditions of being a doc, swearing the Hippocratic oath and all that - we'd all help if the call came out on a plane, a boat, in a theater, driving past a crash...I've done so myself several times...this is technically 'unpaid labour', but we would all help in such scenarios.

In Oz, emergency physicians are salaried. They are paid the same whoever (and however many) come through the doors. I get the impression - correct me if I'm wrong - that in the US each patient gets "billed" individually after an ER visit and that is how you are remunerated ? I can imagine how frustrating, as out of all specialties you would be getting screwed in terms of not being paid for much of your day to day work in a user-pays I'm sure even a private hospital there can't turn an emergency away.

You wouldn't share your provisions amongst all, scalpel, in the liferaft analogy ? Seriously ?? I think you would.

Kind regards

View from the Trekant said...

I think the answer lies somewhere between "an absolute right" and "an absolute commodity."

There has to be safety net of some sort.

We don't want children, the mentally handicapped, the extremely elderly and the transiently disadvantaged (think unemployed here) having no resource when something serious is happening to their health.

However, people should be rewarded for their different levels of motivation and contribution on some level.

I have patients who have an RV,3 cars, a 4-bedroom home, and 5 t.v.s who chose not to purchase health insurance because it is "too expensive." I don't have alot of pity when they turn up needing care and bitching about the cost of their medications and doctor visits.

On the other hand, there are those who simply are caught at a bad moment or who have conditions that will probably forever keep them from getting private insurance.

Our community decided to be pro-active about our deserving uninsured. We have a project into which most physician groups and all the local hospitals have invested. We agree to see selected deserving uninsured patients free of charge. They get certain absolutely necessary procedures from the hospitals free of charge. The patients also have a limited formulary provided from a combination of donations from industry and local businesses.

Bottom line: we are going to see these folks anyway, so we may as well see them before the MI or stroke or septic shock, when things get really expensive.

Of course a huge challenge to us in the U.S. is the massive amount of illegal immigration. I don't have a good answer about that one. And our project doesn't address all of the uninsured in our community - let alone those who really abuse the system (i.e. drug seekers in the ER).

How's that for hijacking your thread?

Bo... said...

You "don't have pity" view-from- the-trekant? Did I hear you correctly? Let me tell you something: for every family with all those RV's, bedrooms, and tv's who don't purchase health insurance, there are people like me, a hardworking road nurse who works 5, 6 or 7 days a week (plus some nights on-call) who do not have the luxury of employer-provided health insurance, lives in a tiny apartment, can't get any insurance privately because of "prior conditions", is not able to qualify for Medicaid, lives in a rural location with NO county/charity medical services, and has a hard time paying for doctor/dental/Rx bills out of my own pocket. And yes, I do "bitch" about the high cost of medical care---not because I think the doctor/hospital "owes" it to me, but because there's NOT MUCH ELSE I can do besides bitch, ya know? (Sorry for the rant, Dr. Dork...)

Calavera said...

What a fascinating post - I really didn't know what the healthcare system was like in Australia.

It's obvious that as people expect more and more from the NHS, the system will soon implode.

Somehow, we need to get more people to contribute to it.

There was a debate in my school once, about whether the NHS should only be available to those who have contributed to the system through paying taxes.

But then that doesn't make it free for all on the point of entry, does it?


Alison said...

It's a right.

essaybee said...

Regardless of whether or not we call healthcare a right, the fact is that we (US, Canada, Australia) can afford to provide healthcare to all, and we should. It is immoral not to.

The only question is how it should be managed and funded. Do we really want the government managing healthcare? Layers of bureaucracy will just add to the costs and hassles. And how do we avoid the moral hazard (economic term, not a moral judgment term) that is always encountered when anything is offered free?

Prediction: the US system will be radically changed in the next 15 years, it will be an utter failure, and people will belatedly realize that it wasn't really broken in the first place.

Dr Dork said...

Echodoc, Boheme...feel free to hijack, rant, call me a banana-brained nincompoop...I don't mind.

I wonder how things work in some of the Nordic countries that seem to do so well on international rankings of health indices ?

We all pay via our taxes, of course. Thus those of us who earn more, pay more - in an absolute but not proportional sense - , just as we do towards roads, public education, police etc etc. I think this is fair.

Alison, Sheila, personally I agree. But this is my particular moral and political bias, one could argue.

What seems a common problem amongst the few systems I have any familiarity with is bureacratic and managerial inefficiency. Can't be perfect, but certainly could be a lot better.

Kind regards

Godwhacker said...

Great post DD. This is one of the most important issues of our day. It is complex and there are no easy answers that I can see.

The U.S. does a pretty good job taking care of those at the bottom with Medicaid. Those at the top have cushy private plans. It is those in the middle that get the shot end of the stick here.

As we move forward with this issue, lets do so with compassion and error on the side of grace.

Nutty said...

I live in the UK and rely on the NHS. There are those that want privatised health care, but there is nothing to prevent those that want it from paying for private treatment if they want it. They don't have to use the NHS if they don't like it, but it's there for all that want it and need it.

The problem with private insurance is it has gaps. Let us suppose you have a well-paid steady job and choose to take out health insurance. All well and good. Then you lose your job for health reasons and either you can't afford to keep up your cover, or it runs out for the condition you're off sick with after, say, three or five years. Then you need NHS cover.

But supposing then you go back to work. Surely then you can go back to private cover? Well, it's not going to be so easy, is it, with a pre-existing medical condition. And the older you are when you re-enter the job market, the more pre-existing conditions you're likely to have.

I support the NHS because at present when I'm out of work I am grateful for the safety net and because I know that when I was in work, I was medically uninsureable. I've heard of countries with mixed health systems that provide cover for those on low incomes, but I've yet to hear of those that provide cover for those that simply can't get an insurer to cover them.

(And yes, I've tried.)

View from the Trekant said...

Bohemian Road Nurse -

I think it is a very valid point that there are notch group patients - working class folks - who have inadequate access to care. And point well taken about rural care. Many of my patients drive 2-5 hours to see me - there is no subspecialty care at home and primary care is tough to come by in some communities.

My comment about 'not a lot of pity' was about those who chose not to purchase health insurance, clearly show every evidence that they could afford it and have no back up plan. Believe me there are plenty of those folks out there. I know that because I see them transition to buying into insurance plans - so know that option was there to begin with. Amazing how those priorities change when they meet the reality of health care costs.

Our system oddly sometimes does the best taking care of the folks at the top and at the bottom, but it is the working class who can really get squeezed. Echo Doc

scalpel said...

"Regardless of whether or not we call healthcare a right, the fact is that we (US, Canada, Australia) can afford to provide healthcare to all, and we should."

I mostly agree with this comment. I think my disagreement is over the semantics of the issue being discussed. I think society should support a level of basic medical care for all, and everyone should get emergency medical care. We aren't necessarily going to pay for liver transplants or heart transplants for all who might potentially benefit from them, however. Everyone is not entitled to receive the most expensive treatments available simply because they are breathing and have a heartbeat. They aren't entitled to see the best specialists or get treated in the best hospitals simply because they happen to be fellow human beings.

If someone wants (and is able to) pay for more complicated/expensive/expedited treatments, they should be able to do so.

If a physician chooses to pursue extended training to become the best in his field, he should be amply rewarded for his work. His right to earn a living and achieve excellence (capitalism) supercedes anyone else's socialistic "right" to receive his services for free (or for some government-approved reduced-value payment for his services).

That's why I can't call healthcare a "right."

essaybee said...

Nutty, here in California people who are uninsurable can get insurance. You have to send in three rejection letters from insurers, then you qualify for a program that offers med insurance to the "uninsurable." If insurers want to do business in California they have to participate in the program. I'm not sure how much it costs; it's probably not cheap.

scalpel, I generally agree with you. I'd particularly like to see some preventive care be available to low income folks who make just a little too much to qualify for medicaid. I think Calif already has a lot of this available (vaccines, prenatal care).

scalpel said...

The trouble with any "insurance plan" is that the motivation of the payer is to pay as little as possible. If a patient happens to be sicker than most and therefore uses up more resources than he is paying into the system, the payer (whether government/socialized or private) is better off if that patient dies.

That's why they delay expensive treatments in NHS-like plans, simple as that, and that's why there is typically an extended review process before expensive treatments are approved by private payers.

The other problem with socialized plans is that there is going to be a budget, and that budget will be kept. So waiting times for procedures increase, again, in the hope that some patients will die or give up before getting them.

There are no easy answers.

Dr Dork said...

Thanks all for your feedback and perspectives. Some interesting views. No easy answers, as scalpel summises.

Disingenuous government bureaucracy vs predatory corporate exploitation. Pros and cons of each.

Once we can all download our entire consciousness into Google / CyberDyne we won't have to worry about such things anyway...

Kind regards

Cathy said...

Dr. Dork, I agree with you completely on this. I am so sick of people who say that there is healthcare for Americans who can't afford it when many times there is not. Maybe in a particular county in a particular state there may be, but it is not wide spread and it is not available to all. There are not FREE health clinics across this country.

The working poor in this country get the worse deal. Some will say "Oh, they can just go apply for medicaid" No, they absolutely cannot! If they own a car (to get back and forth to work) right there they are shut out of medicaid. No need to even discuss all the other loop holes there are for them to jump through.

I think I am most worried about all the Doc's who I hear say they are (or will begin) to fire non-compliant patients. This would cover all those who have medical conditions and who don't take their medications regularly regardless of their ability to pay for those medications.

This says some really horrible things about American morals and ethics. There seems to be so many healthcare professionals who believe that the majority of Americans CAN pay for medical care and just refuse to for whatever reason. This is almost beyond comprehension for many people. Most people do not have tens or hundreds of thousands of dollars available to them for a healthcare emergency. It is driving a wedge between professionals and the public in general.

When I hear healthcare being bandied about and compared to buying automotive parts, or whatever, it makes me ill. It makes me doubly ill that it is the physicians who care so little about life as to compare it to an object.

Greg P said...

Whether or not healthcare is a right isn't a yes or no type of question. Even for those who say no I would say most probably treat patients without the funds to pay the bill.
If you say yes, then it becomes a question of how much, and of what quality. All health care systems in the world set limits on what can be obtained, and it seems that "free" healthcare has the greatest restrictions, the greatest delays of getting your healthcare.

Anonymous said...

"I think I am most worried about all the Doc's who I hear say they are (or will begin) to fire non-compliant patients. This would cover all those who have medical conditions and who don't take their medications regularly regardless of their ability to pay for those medications."

Aside from the fact that this is somewhat tangential, I'd like you to show an example of a doctor who has said they will "fire" people for being unable to afford medications because I have never heard of any such thing.

Furthermore, your ire at this should be targeted towards the government and insurance companies, who want "quality measurements" of things like patient compliance. Failure to have adequate "quality" measurements means either loss of a bonus or (increasingly) a financial penalty. Naturally as this increases so will the incentive to dump patients who are hurting your "quality scores". Most of my colleagues and I would still keep most of these people, but there is a strong temptation to say "screw it" for patients who have a wanton disregard for both their health and your efforts, and as the incentive to drop these people grows so will the frequency with which it happens.

And re: health care as a right, the very idea to me is absurd. If I am suddenly the only physician in the US, am I the property of the masses? Does the "right to healthcare" make me a slave? What if I want to go be a violinist, am I violating their rights to health care? The idea of a "right" which demands someone else serve you is just ridiculous to me.

Dr Dork said...

Hi Cathy,
This is close to my view I think. A functioniong society doesn't kick anyone to the curb, in my opinion. The strong support the weak, not vice versa.

Hi there Greg,
I think it is more straightforward than that. It is a right. And one could argue, better delayed care for non-urgent than no care for non-emergent. But I agree, there aren't any easy answrs, and all systems have much room for improvement, from those of us in the trenches.

I think you make an important point - the problem isn't so much patients or physicians at much is lost to poor govt. administration or private profiteering.

And yes, noncompliant patients are always psychologically challenging to all medicos, and financially challenging in your scenario as well, it seems.

I don't agree that by virtue of something being a right it automatically makes workers in that field "slaves". Basic education is a right. Teachers are not slaves.

If you were the only physician left I think you'd probably have other things to worry about more...

Kind regards, and I appreciate all the considered responses. And no-one's even called me a wishy-washy poopyhead once !


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