Who Should Pay for Healthcare
A recent twitter on my part to an article by Health Imaging titled: “Americans want healthcare reform, but divided on how to pay for it” raised some comments that are worth exploring. The simplistic 4 word response I got back from one individual:
The Government should pay
Simply passes the responsibility from individuals to a group who receive power, authority and most importantly money from the same individuals . They are then charged with the responsibility of sharing out the limited resources “fairly”. As history has vividly demonstrated the challenge with fairness and charging a smaller group with equal distribution and fairness is problematic. George Orwell’s allegorical novel Animal Farm detailed some of these challenges.
Healthcare remains a central challenge to countries worldwide. Those with more resources do spend more of them on healthcare for their population. But there is no bottomless pit of money to pay for healthcare and unfortunately as the population gains increasing access to better healthcare their reaction is not satiation to the higher levels and increased life expectancy but wanting more. Countries approach this challenge in different ways – the UK healthcare system rationed healthcare with waiting lists and limited availability. In recent years they have attempted to define the rationing standards for healthcare under the banner of the “National Institute for Health and Clinical Excellence (NICE)“. A recent ruling on drug therapy
… it ruled that four drugs for advanced kidney cancer were too expensive for NHS use. The four treatments, NICE acknowledged, ‘have the potential to extend progression-free survival by five to six months, but at a cost of £20,000 to £35,000 per patient per year’.
Their methodology assesses value against “Quality Life Adjusted Years” (QALY’s) that attempt a cost benefit analysis on treatments relative to potential outcome and quality of life. This is a difficult calculation even in the best of circumstances because the assessment of benefit changes dramatically from the perspective of the individual who in most cases assesses the value even if limited in time or effect. In the case of the drugs for kidney cancer drugs NICE’s QALY assessment was”
Translated into QALYs—quality adjusted life years—that works out at between £71 000 and £171 000 a year; well above the rough threshold of £30 000 a year that NICE broadly applies other than in exceptional circumstances.
I commented on the NICE measure before where an individual wanted to pay for the drugs himself but in doing so fell out of the group coverage and was refused access.
There is no such thing as “free healthcare” – free at the point of service removes personal responsibility and encourages abuse. A simple case in point is the nuisance charge or co-payment. The United Kingdom has provided free home visits and free access to their General Practitioner for years. But you only have to spend a night with an on call General Practitioner, especially round any holiday to experience the abuse. Calls at 3am for a headache. And not a new onset headache but one the patient has been suffering from in some cases days, weeks and even months. The introduction of a payment for all visits would discourage some of this and those opposed would suggest that it might discourage patients that should make the call. It might but the underlying issue of value would be solved – if the service is “free” then the value is perceived to be the same.
Providing healthcare to as many people as possible is right but in all cases a line must be drawn that is entirely dependent on the resources available. One can imagine that the availability of healthcare is much diminished in Zimbabwe. There the provision of midwifery delivery services to a preganant mother would require the patient to personally provide $20 Billion Zimbabwean dollars (nearly US $40). But the resources available make this a bridge to far. And so to in all other countries – where we continue to consume every available healthcare resource made available. There is no instance where a country so much makes healthcare available that there is resources left unused, clinics and doctors desperate for patients because they are underutilized.
So what is the answer – personal responsibility and a full understanding of the cost and benefit of healthcare resources available. Attaching value to those resources helps comprehension. Patients can make informed choices in the same way that consumers do – why pay more for the iPod when a Micosoft Zune or SanDisk Sansa does the same job at a lower cost. Some do make the choice for iPod, others do not but they do so based on the available data and a cost benefit analysis. But if all the MP3 player’s were free or the same “cost” to us then the selection is harder and less informed. Free healthcare is a misnomer – everything has a value and attaching a value to healthcare but making it accessible to as many as possible is better strategy than just making it free.
Featured in the March issue of the British Journal of Healthcare Management – Stimulus and Effect: Rationing (full pdf subscription required)
Vitamins Do Not Prevent Cancer or Heart Disease
You just can’t eat your way to a longer life – so says a report in USA Today based on studies released yesterday in the:
Journal of the American Medical Association
- Effects of Selenium and Vitamin C on Prostate Cancerr, and
- Vitamin E & C in Prostate Cancer)
and from previous studies in the
Journal of the National Cancer Institute
- Beta Carotene, C and E in Cancer and
- the editorial on Vitamin Supplements and Randomized Controlled Trials
and from the American Hearts Association meeting in November that featured
Vitamins C and E not preventing heart disease and E causing an increased stroke risk
and B-12 and folic acid not preventing heart disease
So what does it all mean – well the basic premise of eating healthy and in moderation remains the same but the idea that you can encapsulate this ideal into a pill or two just won’t work. Better to work on good balanced diet, reduction in meat and fat consumption and regular exercise.
Taking pills to supplement does not seem to hold a lot of promise based on the recent results released. Overall the best strategy is probably summarised by Peter Gann:
…health-conscious consumers should focus on getting their vitamins from plant foods, such as vegetables and whole grains, which contain precise mixtures of hundreds or even thousands of compounds. Many of these compounds may work better in the combinations selected by nature.
Community Clinics Expanded Providing Essential Care
The NY Times article on President Bush’s health care legacy that has expanded the number of community health care access clinics providing much needed primary care to undeserved areas:
In Mr. Bush’s first year in office, he proposed to open or expand 1,200 clinics over five years (mission accomplished) and to double the number of patients served (the increase has ended up closer to 60 percent). With the health centers now serving more than 16 million patients at 7,354 sites, the expansion has been the largest since the program’s origins in President Lyndon B. Johnson’s war on poverty, federal officials said.
The effort is a great start and while this alone will not solve health care problems it is an imperative to reducing costs and providing ready access to health care everyone. The cost reduction comes in at least two forms, the reduction in costs associated with treating the sequelae of chronic diseases as they manifest from neglect and poor primary care but also the reduction in the unnecessary use of urgent care or Emergency Department visits which have ballooned in the last several years as seen in the McKinsey Report on US Health care Spending featured here
The centers serve 1 in 3 people living below the poverty line and 1 in 8 of those without insurance. It is a relative bargain ($8 billion) against other spending initiatives and the high cost associated with coverage plans and subsidizing insurance coverage. Better yet – if the trade associations are to be believed they save money by reducing unnecessary care and spending in the urgent care system (hospitals, ED’s and other access points)
Unfortunately this needs to be tied to a wider program that links the great care delivered by the front line of medicine – community or general practice to the inpatient, urgent and specialized care that has plenty of facilities but for the most part out of the reach of those unlucky enough to warrant the follow up or additional care for conditions that are outside of the capabilities of the community care health system.
This program should be expanded and be a core component of any future plans to help solve the problems of health care. Primary care is the bed rock of good health care and providing ready cost effective access for everyone will help improve the population’s health as well as controlling and decreasing costs.
Invest in Healthcare Technology
Bill Hersh – the Chair of Informatics at Oregon Health and Science University wrote an oped piece in the Oregonian on investing health care technology
The latest address from President Elect Obama suggest we must invest to prevent errors and save money but as Bill says IT investment does much more than that
The better use of health IT can improve quality, reduce errors, empower
patients and control costs through the use of electronic health
records, decision support systems, telemedicine, and other
technologies.
There is also a lot of job creation and re training that would benefit the economy and help mitigate some of the job losses in other industries. Oregon is poised but so are many other areas and the time is right – lets hope these words turn into actions that will drive the change that the healthcare industry has been crygin out for
Medical Insurance and Medical Bankruptcy
An old report highlighted recently in the British Journal of Healthcare Management in a review of the National Institute for Health (NICE) “Denial of life-saving drugs is not NICE” subscription required for this pdf covered the issue of those wanting to spend their own resources on their medical care. I talked about this issue in another post (Balance between Private and Welfare Medicine) but it was the reference to a 2005 study by Harvard University Researchers: “Illness and Injury as Contributors to Bankruptcy” that reported that nearly half of all bankruptcies in the USA were at least partly the result of medical expenses hat is shocking. Even more so when 75% of those filing for bankruptcy reported having medical insurance at the onset of the illness. Those who did not have it prior to onset would no doubt have fallen foul of “pre-existing condition” clauses.
There’s a crisis if ever I saw one – families descending into debt and bankruptcy as a result of medical bills and the spiraling costs and inability to pay.
In my mind this is because medical insurance is not “insurance” per se
From the Free Dictionary
Coverage by a contract binding a party to indemnify another against specified loss in return for premiums paid.
The periodic premium paid for this coverage.
I like the Wikipedia definition
Insurance is defined as the equitable transfer of the risk of a loss,
from one entity to another, in exchange for a premium, and can be
thought of a guaranteed small loss to prevent a large, possibly
devastating large loss
Somehow this got lost in the provision of medical insurance for these folks? But answers.com features a definition on medical insurance that reveals the gap
Health insurance is insurance that pays for all or part of a person’s health care bills
And there lies the problem – most have part coverage and the part that is uncovered escalates at an alarming rate with serious illnesses, chronic conditions and in the case of diseases with limited treatment options that are often priced far above any typical plan coverage.
When checking your insurance find out what you maximum liability could be in the case of any of these circumstances
iPhone Health Emergency Applications
Of the three mentioned in this post only one is free
PhoneAid – Free
FirstAid – $0.99
1st Response Emergency Kit $2.99
“Free” Healthcare is not the answer
I grew up in a “free” healthcare system and there is much that is right about the NHS but the fundamental point that is forgotten is that it was not free. A Post “Aloha Free Healthcare” addresses one of the challenges when you make something that used to cost money (actual out of pocket cost) and make it free…..it failed and for some simple human nature reasons.
The free coverage was supposed to be for the low income families but those that could afford were dropping their coverage so they could get “free” coverage as well. It reminds me a lot of the challenge to building a business and the desire to sign up customers. There is often a push by the sales team to give away the product to the first few users to get some initial experience, case studies and actual users to talk about. The problem is when you give it away the value perceived by the recipient is often precisely that – zero….
Universal coverage and accessible healthcare for everyone is a good thing – the NHS comes reasonable close to his but is not the only way to achieve this goal. We will find a solution but do not be misled by “free” in any phrase linked to healthcare
Maternity Care Mother and Baby
A recent article in the British Journal of Healthcare Management titled: Safe birth: at last, it’s everyone’s business (subscription required) made for interesting but not surprising reading. The good news was that Maternity Services in the UK are overwhelmingly safe but still not safe as it could/should be. The report from the Kings Fund – Safe births focused on the what can be done to improve the situation
There are many drivers helping to improve things but costs in the UK are currently not one of them despite “50% of all litigation payouts int he NHS being associated with Maternity Care
There are also considerable financial penalties associated with failure. Litigation costs as a result of failure in maternity care make up 50% of all NHS Litigation Authority (NHSLA) payouts. Yet trust boards, because of the pooled approach to payment as a result of the Clinical Negligence Scheme for Trusts (CNST) and NHSLA, have been cocooned from the full financial cost of failure.
But the point that safety is “everyone’s business” is an important one and relevant to everyone – not just the clinical staff.
Childbirth is a natural process and intervention is not always a good choice for mother or baby. The guidelines when picking an obstetrician or midwife should include at least these questions as suggested by the Childbirth Connection group
- How do you feel about epidurals?
How do you feel about labor induction?
How often do you cut episiotomies?
What are my options if labor slows down or stalls?
During labor, can I have my baby monitored with a handheld device or occasional electronic fetal monitoring (EFM) rather than continuous EFM?
What are your rates for Cesarean section, assisted vaginal delivery and episiotomy?
Just in case anyone gets the wrong idea – I am not suggestion no intervention, just the process fo an informed decision that includes an understadning of what the choices are and what they mean to mother and baby.
You can read more about the US experience in my Accelerating the Adoption of IT in healthcare Blog here
