Just a link to OECD data so I can get back to it easily…
Category: US/World Health Care Comparisons
Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries — American College of Physicians, — Annals of Internal Medicine
“This position paper concerns improving health care in the United States. Unlike previous highly focused policy papers by the American College of Physicians, this article takes a comprehensive approach to improving access, quality, and efficiency of care. The first part describes health care in the United States. The second compares it with health care in other countries. The concluding section proposes lessons that the United States can learn from these countries and recommendations for achieving a high-performance health care system in the United States. The articles are based on a position paper developed by the American College of Physicians’ Health and Public Policy Committee. This policy paper (not included in this article) also provides a detailed analysis of health care systems in 12 other industrialized countries.
Although we can learn much from other health systems, the College recognizes that our political and social culture, demographics, and form of government will shape any solution for the United States. This caution notwithstanding, we have identified several approaches that have worked well for countries like ours and could probably be adapted to the unique circumstances in the United States.”
AMA It’s not just about us
Some excerpts from the address of AMA President Nancy Nielsen:
“We need fundamental change in our health care system for ourselves, for our patients, for our nation. Right now annual health care costs exceed $2 trillion. That’s 16 percent of our nation’s GDP. Costs are estimated to reach $4 trillion and 20 percent of GDP in 10 years.
Right now, annual health care costs are the number one reason for bankruptcy. Right now, Americans get about half the preventive services that are recommended. Right now, we rank 19th among 19 developed countries in mortality that could be helped by health care. That means deaths that might have been prevented by health care. Nineteenth out of 19.
Forty-six million Americans have no health insurance, and another 29 million are underinsured. Those 75 million Americans are delaying or failing to obtain preventive care.
In our nation’s sick economy, job losses mean the loss of health insurance. Just yesterday, the government reported that employers cut 240,000 jobs in October alone. And so far in 2008, some 1.2 million jobs have been lost.
We as a nation have to do some serious soul searching. We are the most innovative, resilient, determined, self-reliant and creative nation in the world. Our health care system ought to be the best in the world but currently it is not.
Today we pay twice what other countries with better health outcomes pay. But we rank last or next to last in many health indices. And, that’s compared with Australia, Canada, Germany, New Zealand and the United Kingdom.
Now, we can try to protect the status quo. But the status quo is not serving patients well, and doctors are angry and unhappy. It is high time we do something about it and I’m not talking about single-payer. I am, however, talking about comprehensive change. I’m talking about responsible change that builds on the strengths of the current system. Isn’t it time to build a bridge to a new and better health system? A system where patients are better served and physicians are happier and more fulfilled in their work?”
…
“Do you remember this pivotal question during one of the presidential debates? “Is health care a right, a privilege or a responsibility?” Whatever our personal convictions on the answer to this question, the broader population seems to be moving fairly rapidly to the view that health care is a right.
But who will pay for this right, if that’s the country’s decision? Who will define the parameters of this right to health care? Because everyone cannot have everything, and society should not have to provide everything, nor can it afford to do so.
Take education as an example of setting parameters. Our society has decided that K-12 education is a right, but post-secondary education is a privilege and a responsibility.
Defining parameters for health care “rights” and “responsibilities” will require society’s honest deliberation and some difficult decisions. For sure we have to define the expectations of personal responsibility. What is fair to expect the individual to do? What should be up to the individual, and what should be society’s concerns?”
…
“As we participate with the rest of society in this debate, we cannot allow the discussion to descend into ideology and inflammatory labels. If we do, if we allow reason to be trumped by rhetoric, then we will have lost our chance to shape the change, to build the bridge to a better health system.
So I ask you, are we prepared to participate in that societal debate? Because the debate is going to happen. This is not just about doctors. It is not just about us. But physicians and patients will have to live with the outcomes. That’s why we have a central role to play.
We all use the commons and that is why we all have to do our part to protect it. Make no mistake, I am not in favor of a single-payer system. I am in favor of a health care system that works better for all of us, patients and physicians.
We’re in a time when our country is demanding change. We need change. Let’s harness that energy for our patients and ourselves. For sure, this is for us – we have to remove the sand from our shoes. But it is for so much more than us.”
…
“In many countries, when people are scared, they turn to government for protection. Even though many do not trust Washington politics, they may see it as their only option. There is great concern in our country. We need to help calm those fears. We need to embrace our role as healers in a time of need. We need to help craft a solution that is based on our professional ethics–one that is equitable and just, one that builds on the strengths of our system, addresses current weaknesses, and allows us to regain the joy and simple dignity of caring for our patients. “
Please go check out the whole thing. Credit where credit is due. It is a remarkable statement from the the AMA President.
I am concerned by the last paragraph I quoted, however. My goal is to turn to my government for fairness, and it is not our of fear, it is out of anger at the mismanagement of our system and at the giant sucking sound, to quote Ross Perot, that emanates from our insurers, Pharma, and ourselves that makes our system so inefficient. So, I hope this is not the line in the sand that the AMA is drawing, that a solution based upon strong government regulation is off the table.
Ohio.com – Health-care matchup finds Ohio falls short
Ohio.com – Health-care matchup finds Ohio falls short
From the article, which is a nice overview of US (Ohio) vs. Canadian (Ontario)
To explore how Ohio compares to the nation and the world, the Beacon Journal looked 60 miles across Lake Erie to the Canadian province of Ontario.
How does Ohio measure up to its neighbor?
Not very well:
• A 65-year-old Ontario resident can look forward to living about 20 more years — three years more than an Ohioan the same age can expect. At birth, the difference in life expectancy is greater — 76.4 years for Ohioans, compared to 80.7 years in Ontario.
• In Ohio, nearly eight of 1,000 newborns die each year — significantly higher than the U.S. rate of 6.8 deaths. In Ontario, the infant mortality rate is 5.5
• Ontario also has lower death rates for each of the top six causes: heart disease, cancer, stroke, emphysema and other chronic lower respiratory diseases, diabetes and accidents.
Overall, the gap in these key health-care yardsticks was wider between Ohio and Ontario than between the two nations as a whole in all but two categories: strokes and accidents.
That difference was striking because the state and the province are so similar demographically.
While the 300 million people in the United States are nine times more than Canada’s head count, Ohio and Ontario are close in population, overall economic size and demographic measures such as median age, average household and family size, and education.
Ohio and Ontario also have similar economies, with almost the same percentage of both work forces employed in manufacturing and retail and wholesale trade — the two largest industry categories. Wages and salaries also are comparable.
While the U.S. Spends Heavily on Health Care, a Study Faults the Quality – NYTimes.com
While the U.S. Spends Heavily on Health Care, a Study Faults the Quality – NYTimes.com:
“In some cases, the nation’s progress was overshadowed by improvements in other industrialized countries, which typically have more centralized health systems, which makes it easier to put changes in place.
The United States, for example, has reduced the number of preventable deaths for people under the age of 75 to 110 deaths for every 100,000 people, compared with 115 deaths five years earlier, but other countries have made greater strides. As a result, the United States now ranks last in preventable mortality, just below Ireland and Portugal, according to the Commonwealth Fund’s analysis of World Health Organization data. The leader by that measure is France, followed by Japan and Australia.
Other countries worked hard to improve, according to the Commonwealth Fund researchers. Britain, for example, focused on steps like improving the performance of individual hospitals that had been the least successful in treating heart disease. The success is related to “really making a government priority to get top-quality care,” Ms. Davis said.”
The Commonwealtth Fund’s Report is here:
Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008July 17, 2008 Volume 97
The Commonwealth Fund Commission on a High Performance Health System
Interview with Dr. Calloc’h, of France’s Chambre du Medicine
Interview with Dr. Louis-Jean Calloc’h, Auditeur au Conseil National de l’Ordre des Médecins and Secrétaire-Génèral de l’Association Médicale Française and Director of International Affairs for the Chamber of Medicine of France
In France, “a ‘G-P Specialist’ is a G-P who practices and has a quite exclusive and verified good and permanent practice in general medicine. Not an other not referenced opposed verified practices: homeopathie, acupuncture, psycological-consultations. The others are simply G-P.”
Economic pressure is forcing physicians to become specialists. In the past in France you were able to go to any physician but there became restrictions on access to cost restrictions. The GP is still the gatekeeper. A patient is not allowed to go directly to a cardiologist or other specialist without using the gatekeeper function. This is a recent change.
Training is changing. In the past, it required approximately 8 or nine years of training to become a GP. It took two or three years after that to become a specialist. But now GPs are becoming specialists: I think he’s saying here that a GP can get additional training at the University to get further qualifications. It’s not clear to me the difference between GPs with a traditional training versus true specialists. It sounds like it might be that one becomes a GP specialist in cardiology and therefore sees more patience with party logic problems but they are still not true cardiologist specialists. And they still perform a gatekeeper role before the patients get to the true specialist. It sounds like the GP and the GP specialist both are in charge of handling the ministerial and medical record-keeping work in the system. Keeping the dossier, as Dr. Calloc’h says.
Dr. Calloc’h notes that patients can be put on the list, for example, of diabetics who require more advanced care. These patients can then go see an endocrinologist directly several times a year. There are limits to how many erect visits the patient can get. The idea is apparently to make the primary interface with a primary care physician can not a specialist. He specifically said that specialists such as cardiologist and endocrinologists do not perform primary care functions.
The GP is the person who interfaces with the single-payer entity. The GP also develops a care plan. This plan may specify a number of visits to a specialist. If the patient exceeds the number of visits they then have to pay out of pocket. There is a list of from 20 to 22 diseases that are specifically supposed to be managed with a plan by the GP. He gave several examples including hypertension and diabetes obesity and some others that I didn’t catch. It sounds like these patients that also signed a contract with some details of their management plan including specialist visits. Now here Dr. Calloc’h indicates that a specialists may actually act as a GP for some of these patients. He called it the “Reseau,” which is a kind of managed care contract. The réseau is a contract that the GP or specialist also signed with the single-payer and agrees to manage the patient. The Medical Society, Chambre Du Medicine, seems to be advocating for this approach, but the trade unions do not. The chamber also would rather see multiple players for more competition. It’s not clear to me what the competition would center around.
Dr. Calloc’h: “The “Assurance Maladie or CNAM” is so powerfull in France that, today, there is quite no economique competition with other public or prived medical care insurance. Only one entity to negociate with.”
Trade unions. It took a little while for me to figure this out, but the physicians have trade unions. So, when he was talking about trade unions, he was asked a talking about the physician trade unions who sound to me to be the advocates for the physicians on economic matters. As opposed to the chamber of medicine, whom he represented, who were more the professional watchdogs and ethical watchdogs. For the trade unions, the single-payer is a big problem because there is only one entity to negotiate with. This seems to be why they would like to see multiple payers.
Generally people pay the physician. Poor people get a card to excuse them from payment. If the patient is without means and has complicated multiple illnesses, apparently one has to appeal to the single-payer for credit on the card for more frequent visits etc. For the people who do pay, currently the fee is €22 but this will be rising this coming year. Interestingly, it sounds like the complexity or time of the visit is immaterial. He said a 4 or 5 minute visit gets the same fee is a more complicated visit. However the more you do, such as EKGs or blood work, the fees accumulate. He said something in here about the patient’s then getting reimbursed by the single-payer, but only about €17 for a visit. So this functionally works out to a five euro co-pay. Some patients buy supplementary insurance so that even that small co-pay is taken care of.
He makes the point that GPs are expected to be able to do everything except the most dangerous of procedures. He feels that this is asking too much and that some physicians make the mistake of being too proud and believing that they can do anything. And this is something that the chamber of medicine handles, and it’s role as what we would call a state Board of medicine. France has civil sanctions, administrative sanctions and penal [criminal?] sanctions. The Chamber of Medicine is responsible for the professional sanctioning. It is akin to a state Board of Medicine however it is run from within the profession and not from the state or national government. Complaints can come from patient to patient organizations or from other doctors. Apparently the complainants and lawyer decide whether something can be handled through sanctions or through civil law, which sounds like medical liability action. He says that he feels this is having a chilling effect particularly on young physicians who are now more worried about liability. He also indicates that this is slowing the activity of the Chamber of Medicine because of concerns with the civil liability aspect of the case. So where they might act quickly in the past they now are more circumspect and take more time to make a decision. Dr. Calloc’h feels the France is about 15 years behind where the US is regarding medical liability. He indicates that France now has lawyers who specialize in finding medical liability cases much as we have here in the US.
[Dr. Calloc’h has updated me that he thinks they have nearly caught up due to their new lawyers.]
Half of physicians in France are GPs. There are limited number of specialists. This is due to specific decisions made by the single-payer, apparently. The decision was made that too many specialist made care too costly and that this had to be stopped. Apparently the thinking was that too many doctors led to many prescriptions and too many prescriptions increased the cost of care. “So stupidly, they decided 15 years ago to make the big selection(?)”– not sure if he meant here about cutting training or something else.
And what of the most pressing concerns of physicians under the French system? The pressure of lawyers and prescription restriction. The first is obvious, the second simply refers to pressure to prescribe generics and formulary restrictions on expensive medications. And the patients are specifically asking for the newer, better medication. The single-payer keeps statistics on each physician and they know when you prescribe to many antibiotics for example. They will then send someone out to talk to you. If this keeps happening you can get an administrative sanction. This can then turn into an economic sanction where they single-payer will refuse to reimburse patients for their visits to you. Obviously this is fairly severe. It sounds like much of this takes place in the context of your position neighborhood and what others in your area are prescribing or not.
The Chamber of Medicine is apparently not allowed to advocate politically. Political advocacy therefore takes place either through the universities or the trade unions (and maybe the specialty societies?). There are trade unions for GPs and for specialists also. It sounds like you typically belong to your specialty’s trade union and its academic society.
I will keep updating this as I receive clarifications from Dr. Calloc’h.
Sunday Forum: Medicare for all (“Australian Rules”)
Sunday Forum: Medicare for all:
“Some Americans believe that countries like Australia, Canada and nearly all of Europe have ‘socialized medicine.’ For many, it’s a vague concept that often conjures images of uncaring doctors, dirty government clinics, cracked plaster, crowded waiting rooms and really old magazines. And if you don’t like it — well, you can’t fight city hall.
But that’s just a dark fantasy. Australia has attractive offices and hospitals, great doctors, state-of-the-art care and, most importantly, quick and easy access to high-quality emergency care.
It’s not socialized medicine, it’s Medicare for all. You are born with it, you die with it and you get all the care you need in-between. Everyone has insurance, all the time.”
Dr. Flanders is a psychiatrist in Pittsburgh and does a nice job of contrasting healthcare in the US and Australia. I’ve written for the Sunday P-G, so I know they really limit the length of your column. I hope this means we can hear more from her in the future.
Frontline: Sick Around the World
Frontline: Sick Around the World
Lots to digest, and I’ve only begun to explore the web extras, so I post now for convenience’ sake. Overall, though, TR Reid did a terrific job all around.
From the physicians’ perspective, I, of course would have liked more but they only chose to do an hour. Frankly, this would have been another good use of an extended format Frontline, as they did with “Bush’s War.”
Most Republicans Think the U.S. Health Care System is the Best in the World. Democrats Disagree. – March 20, 2008 -2008 Releases – Press Releases – Harvard School of Public Health
“A recent survey by the Harvard School of Public Health (HSPH) and Harris Interactive, as part of their ongoing series, Debating Health: Election 2008, finds that Americans are generally split on the issue of whether the United States has the best health care system in the world (45% believe the U.S. has the best system; 39% believe other countries have better systems; 15% don’t know or refused to answer) and that there is a significant divide along party lines. Nearly seven-in-ten Republicans (68%) believe the U.S. health care system is the best in the world, compared to just three in ten (32%) Democrats and four in ten (40%) Independents who feel the same way.”
The survey results are here.
Single Payer Debate at Duquesne U, 3/10/08
SEPP Organization – SEPP Events
(The link above takes you to the details of the event.)
I attended the debate last night among Dr. Scott Tyson and Gariel Silverman, arguing the single payer case, and Sue Blevins and Nameed Esmail, arguing against at Duquesne University last night. First, props to Duquesne: Great venue in the Power Center, easy parking, nice facility all around. And props to both groups for getting attendance to a surprisingly high level (over 200, I’d guess). Pro-single payer were in the majority, I’d guess, by a significant amount.
I’ll cut to the chase: Jerry Bowyer, moderator, at the end of the evening, asked if the discussion had changed anyone from their pro or anti single payer or undecided camps, and only a handful of hands went up. Sigh. But, not, of course, unexpected.
To those of us who are familiar with the issues and arguments for and against single payer, and familiar with the players (esp. Mr. Esmail’s Fraser Institute), there were not many surprises. My most pleasant surprise was Dr. Tyson’s excellent performance. Powerful, personal and passionate, Dr. Tyson did a very good job of making the moral, practical and economic case.
As my bias is obvious, I won’t pretend to disguise it. I found the same old arguments from the status quo/free market/every man for himself side very tiresome indeed. I’ll just toss out a few “highlights.”
Single Payer advocates see Canada as a Panacea solution for America’s woes. I don’t know of any, but it somehow forces single payer advocates into the silly position of defending Canada’s system, even though it is not the one we would emulate. From now on, we should respond to the Canada graphics with ones comparing us to Germany, France, Belgium, Japan, or almost anyone, and leave Fraser to shit on their own country as they seem wont to do. Heaven forbid they offer constructive solutions. And by this, I mean ones that at least 30 or 40% of the Canadian population would at least consider.
Showing a spending chart showing Canada at the high end of spending on healthcare compared to the rest of the world, and omitting the US, cause we’re so off the charts as to make the chart look laughable.
Arguing that taxation sufficient to pay for healthcare would strangle economic growth. This is just too brain-dead to answer, especially sitting in a country that spends 16.5% of its GDP on healthcare. And especially from an economist who said, specifically, that there is no “government money” only our money in government’s hands.
Waiting times in Canada are intolerable and/or deadly. Please click here.
$32 Billion in Medicare fraud annually is an outrage and a scandal. I don’t know the source or veracity of this figure, but the 2006 Medicare expenditures were $408 billion, meaning 92% of the money gets where it’s supposed to, which needs work, but isn’t awful. And the suggestion that I think Ms. Blevins made was that she preferred private insurer’s solution: deny care first, and then sort out who was trying to scam you, rather than covering claims in good faith and then going after the perps. I’m all for getting the perps, but not until I’ve made sure the patients are taken care of first. Silly me.
Patients in Canada often have to wait 10 or 12 hours to get a hospital bed when admitted through the ER. Imagine our shock. (He did know Pittsburgh was in America, right?)
Veterans Administration hospitals are horrible places. Dr. Tyson did try to set Ms. Blevins right on this one, though I think she didn’t believe him.
You cannot pay for treatment in Pennsylvania outside of your contract with your health insurer.
This one got my attention. I hope somebody will post a comment for me about it, because I’d never heard this before, and it seems exceedingly odd.
The usual “anecdote-off,” for which I’ll just refer you to our special section.
I was pleased to see Mr. Esmail’s praise of other systems, particularly those of Switzerland, Japan, France, Sweden, Germany and some others. He rightly pointed out that the old PNHP proposal, from 1993, was fairly beholden to the Canadian model, but there are newer proposals from PNHP, and besides, they are not the only proposals out there. As has been often pointed out by our side, and always ignored by theirs, we need a uniquely American system, pulling from the best of all other extant systems. Though Mr. Esmail did seem gratified to sear Dr. Tyson say this, I doubt it was the first time he heard it. (You don’t suppose he didn’t watch Sicko, even as an academic exercise?) Oh, and Esmail even admitted we were rubbish for Mental Health care, too.
Oh, and a personal shout out to Scott Tyson for his wonderfully dismissive treatment of HSAs. Made me chuckle and even snort a bit!
OK, folks, that’s all I can remember at this late hour, but please add your comments to remind me of things I forgot to mention….
Cheers,