Sunday, October 01, 2006

Spending on health

This graph is referred to by my son's new 'work' blog. I find the figures quite surprising. In the UK in 1997 Tony Blair's warning was 90 days to save the NHS. It is certainly true that there has been a marked increase in spending on health, but after nearly 10 years the UK is still bottom of the heap as far as health spending is concerned.

Everybody has had to increase spending to keep up with what can be done.

A recent feature on BBC TV looked at the best public services in the world. For public transport they chose Portland, Oregon, but for health they chose Cuba. Astonishing! Cuba has no access to modern drugs and its health workers are paid a pittance. Nevertheless, life expectancy in Cuba is higher than in the US. Life expectancy in the US is an anomaly, probably the result of inadequate public health services for the poor. A high infant mortality impacts more significantly on life expectancy than excellent care for the elderly; an individual loses 70+ years rather than 3-4 years. So when the indigenous poor have next to no ante-natal care and when there are areas where the commonest cause of maternal death is gunshot wound, these impact far more heavily on the statistics than all the rituximab in the world.

All health care systems want to get the best value for money, but how you collect the statistics affects the result. Suppose the figures were collected not from cradle to grave but from conception to grave. What price Roe v Wade then?

Public health measures give you more bangs per buck than any other health intervention. Edward Jenner and John Snow had more impact than Harvey Cushing and William Osler. Of course, America has clean water and smallpox has been eliminated, but without full vaccination for children and good housing and nutrition for the poor, the acute health care system gets overrun by preventable disease.

I believe I saw somewhere that America spends more on Medicare and Medicaid and front-line free-care in the ERs of County Hospitals per head of population, than the UK spends on the whole NHS. What I am getting around to saying is that despite spending a far smaller proportion of the GDP on health, Britain spends it more efficiently than America. This is not done by impoverishing the physicians; British doctors are the second highest paid on the planet.

What I complain about in the NHS is the lack of freedom to individual clinicians. The bureaucrats have tried to turn medicine into painting by numbers. I once chaired an NHS committee that was trying to turn hematology into a protocol driven service that could be costed. They had done it for cholecystectomy, hernia repair and mastectomy. After 2 years of committee meetings I believe I had convinced them that it was impossible; patients were just too different. At least I convinced them that it was impossible with me as chairman, because the committee was disbanded, and I was never asked to chair another committee for the government.

The Conservative Party is holding its annual conference in Bournemouth this week. Their big new idea on health is 'Leave it to the professionals'.



Jim McVey said...

The following points I consider are counter productive to good Healthcare in USA.
The size of the country.
The spread of population is not uniform.
The 40+ million uninsured.
The employer supplied health insurance system.
The variations of care between States.
Medicare is a Government run Insurance where Seniors pay to join
when they are living on Pensions, Social Security and Savings.
The statement that the Government will not negotiate with Pharma.
Companies on behalf of Seniors paying for drugs. When they did
negotiate during the Anthrax scare for Cipro.
The lack of uniformity in doctor training.
Employers do not have to supply healthcare benefits if employees are hired to work less than 40 hrs/week.
The lack of Government supplied clinics.
The 2 party system that splits the country 50:50 The Government goes from crisis to crisis with some created politically.

These are my observations as a new American of 15 years standing.
I am biased as I lived most of my life in UK. There is a lot of good
in USA but a lot of waste too. I also feel that the past affluence of
USA is now catching up, now that it is not so affluent, the
Government will have to pay more attention to the Nation’s Healthcare
I see it as a Human Right in this great country.
Hospitals have to treat the sick whether they can afford to pay or not but the Healthcare they get is Emergency care only. This must impact hospital efficiency and finances detrimentally. There must be many more than the 40 million uninsured contributing to the detriment of hospitals nationwide.
This standard of care is not good for the patient and probably creates
the need for more care in their future.

Steve Madden said...

As my sister in law (who as an academic has researched health systems for decades) keeps telling me "Money is not the answer". The more money we throw at health the more it will absorb and the higher costs will rise.

Governments are as bad at running health as is private enterprise. A mix of the two may provide the answer.

The best "bang for your buck" is in education programs, assistance to quit smoking, advice on healthy eating, reduction of obesity etc. In other words help people to "live healthy".

Jim McVey said...

I just listened to Mark McClellan the Administrator of Medicare and Medicade on C-Span he outlined a Medicare I didn't know.
He talked about the large staff he had to help the patient. I tried to find out why I had not managed to get a particular medication, I tried to find out through local affiliates who talked to Medicare, however I couldn't get to first base because I didn't know the code describing the medication.
He spoke mainly about improving Healthcare and keeping down costs. He never once mentioned Quality Of Life for the patient.

With patients becoming more aware of their disease through the internet, there should be a forum capable of answering questions. I would like to know who decides the procedures or the best practices for my disease. Perhaps then I could get answers and they could get the patient's point of view.

The present method if one wants to know if a medication is available under Medicare, one asks the supplier of the drug to get an answer. This does not happen with tests the testing company can't or won't answer. One has to resort to the above tactics if the doctor or their biller doesn't know.

The only other method is to ask one's Senator to advise on a question. I have done that, but by the time I got an answer the question had become moot.

I thought I had better post this comment in case my previous comment gave the wrong impressions.

The C-Span Medicare was not known by me and I am a concerned recipient.
It could be my syntax that is at fault, I don't have the necessary language skills, I jest, but many times I am not understood.

Jim McVey said...

I also watched Tony Blair give his last speech to the New Labour Party.
That was shown on C-Span also.

It was a great speech he will be missed. I only hope Gordon Brown can follow in his footsteps.

I wonder what Tony Blair's next move will be. Maybe he could emigrate and give some advice over here.

vance esler said...

Managed care was supposed to lower costs. All it has done is shift the money from the pockets of those who take care of patients to those who run and invest in insurance companies.

Managed care -- which includes Medicare and other government programs here in the U.S. -- is so inefficient. There have been many, many times I have tried to save the insurance company or government some money by prescribing a certain plan of attack. Instead, we are increasingly forced into pathways that wind up duplicating effort or wasting resources on things that could have been skipped.

It's maddening. This has been coming for years. I went into oncology because I thought it would be one of the last fields to be "cookbooked." But even now the molds are being formed. Soon, you won't need a doctor. All you'll need is someone who can read a flow diagram...

A cynical view, but not that far off base, I bet...

Anonymous said...

I find it interesting that report after report shows all government-paid health care is inferior to the best HMOs in America.

I used to belong to Kaiser, and I loved it. I got excellent care, no paperwork, same-day appointments, good surgery (I had a basal cell cancer removed, and you can't really see the scar).

I only left because I know I wanted to get into a clinical trial or go to a different institution than be limited. Otherwise, I'd still be in.

My girlfriend belongs to Kaiser, and I'd rate her care as excellent.

The point is that the Kaiser model has ranked much higher than the British NHS, the Canadian mess, Australia, New Zealand, etc.

Those countries save money by dragging their feet in approving drugs such as Ritxuan.

There is no incentive for excellence in the British NHS, and in Canada it is ILLEGAL to seek private care outside of the system.

It's also a little known fact that generic drugs are cheaper in the US than in Canada.

Ruin the US system after I'm dead, OK? The ones pushing the idiocy of national health are those who can afford to pay for their own treatment.

Mortality rates in the US are misleading because we have so many illegal aliens (10% of Mexico is already here). That's why we are, on average, fatter, shorter, darker, and live shorter lives than if you take the white population by itself.

Anonymous said...

I recommend the following report on the American system versus the inferior Canadian and British sytems.

It's compelling reading. Bottom line, there is no incentive for innovation in publicly-paid medicine, the Brits and Canucks control costs by limiting services, the denial of care, indifference to patient's needs, and so on.

Only an very strange person (or a liberal) would want worse health care. Care to wait 17 weeks for an appointment with an oncologist after a referral from a family doc?

Exiled in mainstream said...

Well, as a student of the American health care system all these comments have value to me. Thanks for posting.

Jim, thanks for some insightful comments, particularly around medicare. I'd be interested on your views about the weakness of an employer as a purchaser of health insurance - please feel free to respond to my blog. (PS I suspect that our Tone will be heading your way on the $30k an hour after dinner circuit pretty soon, he has to fund that mortgage somehow).

Steve, I agree with nearly everything you say, although I view that there is a point below which money is the answer, but above that you do get diminishing returns (and I suspect that the recent UK experience is good evidence of this).

Thanks for your critique of managed care, Vance. However, my reading of the literature is that the relative flattening of health expenditure as % of GDP in the 1990s reflected the growth of capitation model HMOs, and the increase since reflects their rejection, particularly in favour of fee for service PPOs. I do however, recognise the frustration you express around the protocolisation of medicine.

Anonymous (1). Kaiser certainly has a good reputation internationally. Perhaps I may take issue with you on two points First, your comment that there is no incentive for excellence in the NHS presupposes that market-based incentives in increasing profit and income are the only effective ones inside health systems. My reading of the evidence, and indeed my experience of working inside health systems and my burgeoning knowledge of how US healthcare works suggests that in fact the power of profit motive - especially on doctors - may be less than non-financial incentives such as organisational and professional kudos and preservation of autonomy. As such a marketised health system may not be best-placed to use these incentives. You may wish to read the insightful work of Martin Marshall on this subject - inspired by his own Harkness Fellowship in California about five years ago. Secondly, the international view of Kaiser is perhaps not quite what it was. You may wish to consult Jennifer Dixon's later and more detailed review. (apols for cross posting)

Finally. Anonymous (2) thank you for your post which is explains many things, not all health related.

Steve Madden said...

A personal perspective on the Australian Health System.

My case is different because I am on a disability pension (fun at 51).

I pay nothing to see my GP (primary care physician). I pay $4.60 per prescription medicine (I get a $5 per fortnight allowance paid into my bank.

My rhuematologist - who is in private practice charges me $75 per visit ($68 refunded in cash by Medicare).

My clinical heamatologist charges the same - he also works in a private practice.

If I chose to see a "public" doc this would be free. (And I do mean free, I no longer pay any tax).

All diagnostic test are free, I have had many many blood draws, CAT scans, nuclear medicine bone scans etc etc all free.

If I need rituxan I can get it for $4.60, in fact if I needed Herceptin I could get it for $4.60. The only drug I cannot get that is available in The US and UK is RU-486. I doubt if I will need it :)

The biggest problem in Australia is not money ($30 billion budget SURPLUS in the past two years, and surpluses every year for 10 years)it is trained staff.

But that is OK we are pinching them from the UK by the thousands.

Terry Hamblin said...

It is easy to set up straw men, Anonymous#2, but in fact in the British NHS,an oncologist must see a cancer patient (or a suspected cancer patient) within 14 days of referral from a GP.

Anonymous said...

From a different Anon-
According to the WHO, Americans spend 15 cents on the dollar for administrative expenses. Some domestic estimates are as high as 30 - 50 cents per. Administrative costs include everything from paperwork to padded executive salaries. This is precisely why we spend the most money per capita on healthcare and still have 45 million people uninsured.

Medicare's overhead is 4 cents on the dollar. But there are problems with servicing the customers in this system.

We need an American-style healthcare system that is universal in scope (not short-sighted - working for the few who dont care about the rest) and customer-oriented. A system that covered everyone would cost about $7700 annually per family. We spend on average right now $5500 per person annually. That is $22,000 for a family of four (for those lousy at math.) If we eliminate the waste in the system, we could cover everyone and SAVE money.

Personally, I would gladly pay $150 a week flat rate knowing that my family is covered and a medical emergency wont soon see us living under a bridge. But it wouldnt be necessary with the taxes that are already collected from us. The occupation of Iraq for instance has already cost the US the estimated equivalent of 10 years of universal healthcare (in a little more than 2 years).

The money is there - the priority of our elected leaders is somewhere else (that's another topic).

Anonymous said...

The last post cited Iraq. All we need now is a reference to Halliburton.

Halliburton! is the answer to any problem at all. Flat tire? Halliburton! Poor love life? Halliurtion.

I recommend all liberals just keep using this. It is almost as effective of a charge as 'racist!!!'

Anonymous said...

The last post said what the last post said.

Grow up and join the world of adults dealing in reality.