A Brief History…

There was a post on Powerlineyesterday, which attracted a lot of comments, including one of mine that never appeared. Maybe it was too long but I was trying to respond to a question.

This is a better place to respond so I will try here. The questioners seemed to be single payer advocates.

“Brody Halverson · Top Commenter · College for Financial Planning
Where is Michael’s response? I’m eager to learn of your findings after years of studying this.”

I had earlier posted a comment that I had studied medical errors and medical quality for years. The issue was whether the NHS has better outcomes than the US record.

I have had some experience with the NHS going back 15 years. In 1995, I went to northern England as part of a group from Dartmouth to advise primary care doctors on how to cope with the new “Fund Holding” system introduced by the Conservative government. Fund Holding was a way of dealing with a chronic NHS problem. In the NHS, hospitals and hospital-based physicians have almost no contact with the general practitioners. The GPs find it nearly impossible to find out what happens to their patients while hospitalized. Fund holding allowed the GPs to send their patients to hospitals that are not the local district hospital. The payment for treatment followed the patients. The result was a considerable improvement in the relationship between hospital based-specialists and GPs. A lot more information was shared, similar to what happens in the US system.

A personal friend of mine, a surgeon and teacher of anatomy at a London medical school, has told me that he cannot get Muslim female students and nurses and junior doctors, to scrub their forearms before going into surgery. Hospital infections in NHS hospital are high and rising. NHS hospitals are described as “dirty” and there are problems with obvious issues as changing bed linen. This is pretty bad.

Then there is the notorious order from the health ministry to reduce ER waiting times or face fines. The response of NHS hospitals was quite a bit different from those of US hospitals, even public hospitals. In the NHS, the “target waiting time is four hours. Even at that some hospitals have refused to allow ambulances to bring patients to ERs if the wait will exceed the rules. Instead, the ambulance have been forced to wait in the parking lot until the wait time is reduced.

For one thing, patients in the UK have spent 30 million pounds when ambulances were not available or wouldn’t come. THere are stories of patients dying in ambulances during the wait.

Some commenters have described Medicare as “socialized medicine.” This gets into definitions. Fee-for-service medicine is what is at issue here. There are some patients who prefer HMOs, like Kaiser. That is not a problem because they have a choice. The French have the best medical care system in Europe because they have kept most of it fee-for-service. The patient has a choice. Some of them go to community clinics, similar to our HMOs because choice of physician is not important to them.

However, the fact that the French system is largely fee-for-service makes the single payer segment responsive. Those doctors know that their patient volume may drop precipitously if the patients lose confidence in the system.

Canada has had a modified fee-for-service system for years but it has been starved of funding to the point that patients have begun to seek non-government care. The same thing is happening to Medicare here. The changes are still small and not that many people are affected yet. Most of the problem has to do with the elderly. There are severe restrictions on care of the frail elderly, how frequently the doctor can see them, for example. A government official complained recently that surgery on the elderly is useless because ‘most of these people die anyway.’ In fact, that is a distortion of the data. Only those patients who died were included in the study. I have done major surgery on 90 year old people. The key was that they knew the facts and wanted the surgery.

In Canada people are seeking private care. Technically, it is illegal however a recent decision of the Canadian Supreme Court ruled that a government health care system does not mean that care is available. We are seeing an increasing level of private care used by Medicare patients in this country. Expect this trend to increase if Medicare is subjected to increasing cuts, as in the Obamacare plans.

My recommendations for reform follow the pattern of the French system and I have tried to provide some detail on my reasons.

This entry was posted on Thursday, November 10th, 2011 at 7:37 pm and is filed under economics, health reform, medicine. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.