Doctors and Money

The NHS is funded(or should be) to take care of everyone to a level of minimum care. No one(in practice) should have to pay for any medical care.

One question that comes up regularly when discussing how to fix the healthcare system in the USA, is Doctors and Money. While Doctors are far from the only important people in a healthcare service, they are possibly the most visibly important.

It is often asked, or asserted, that if you had a single-payer healthcare system where Doctors were possibly salaried this would act as a disincentive, and over time you’d lose the best doctors to purely private practice. This belies the fact that experienced doctors in the British NHS can make additional money in private practise.

It also completely ignores the fact that while the NHS is a meets minimum, free at the source of treatment health service, there is a thriving private, and private insurance marketplace.

The NHS is funded(or should be) to take care of everyone to a level of minimum care. No one(in practice) should have to pay for any medical care.

However, these days the cost of drugs, the number of highly complex surgical procedures that are “standard” has grown beyond the normal funding of the NHS from say 20-years ago. Cancer care and the drugs for it now consume huge amounts of money, as does the treatment for obesity and the treatment of it, including heart disease.

If you are in a car crash, some form of violent attack, or other urgent care need, the NHS will supply an ambulance, emergency care, surgery, drugs, Dr’s, everything and you’ll never see anything related to billing or cost. Same for almost any minor health care problems, even many elective surgeries, and pregnancy, cancer care, pretty much any medical need.

Elective surgery does tend to get backed up, there are often long waits to see a specialist, as well as to get surgery. This depends though on the problem, the area of the country, and the time of year.

This time of the year the NHS is always stretched to and beyond its limit. It’s damp in the UK, older people tend to have been life long smokers and are very susceptible to respiratory illness. Both my parents died this way after a few weeks of gradually declining health as they were unable to recover from pneumonia. My Dads complicated by heart disease; my Mum a 7-year lung cancer survivor.

Both received 100% free NHS service, they were not rushed or hurried to move out of their hospital beds. The nursing and medical attention was top class. In fact, I’d go as far as to say  much better than here in the USA because there was never a discussion, question or insinuation that insurance might not cover something.

For those that a “meets minimum”, free healthcare service won’t do, you can always pay. Many companies offer private “top-up” insurance, which provides priority appointments, private hospital beds etc. And you can always elect to pay for the treatment you need need.

luton-news-sept-21st-1978I had two major hospital admissions, one on the NHS for a tib/fib fracture in 1978; the 2nd some 16-years later for corrective surgery. The 2nd I was working for IBM with top-up insurance. I saw the same specialist who’d saved my leg 16-years earlier. If I’d wanted to see him on the NHS, there was an 4-week wait; I saw him the next week at a local private hospital.

He recommended corrective surgery. On the NHS he would have done it in 4-6 weeks, depending on lots of things. I was able to schedule a specific day for 10-weeks out that better suited IBM’s schedule, private hospital, private staff, same consultant.

Fast forward to 2013. I’ve done over 100 triathlons and running races, including 6-Ironman races. Despite an initial prognosis in 1979 that I’d never run again. My knees are not so good. I wanted to see the same consultant, he is no longer practicing, wished me luck. I was recommended to the British Olympic Association’s Orthopedic Consultant. Chances of seeing him on the NHS, zero to very little.

I scheduled an appointment with him at Private hospital, flew to the UK, and he came in to see me especially. We spent the whole hour together, what I’d paid 450 UKP for. We discussed options, did measurements, x-rays, looked at different types of replacement knees etc.

He said that when I was ready for surgery to let him know, he would schedule me on his NHS roster and I could fly back. When discussing the same surgery here in the USA, he told me not to bother.

His experience had been that in the USA even dedicated specialist consultants didn’t have nearly the experience as NHS Specialist. In the USA they spend too much time consulting with patients and negotiating over billing. Patients in general take 3x as long to consult with in America because the options, cost and insurance options, and choices are so daunting and often when a preference is stated it has to be negotiated with insurance, co-pays, deductibles etc. all have to be understood by the Doctor and patient. The alternative is you get the Doctor, but little or no choice in replacement technology.

He has 2x 6-hour surgery days per week, they do 6-8 knee replacements per day; he spends 1-day NHS consulting, and 1-day private consulting and has 1-day open for Private surgery or additional consulting.. If he wants he can do private surgeries on Saturdays, vacation days or early mornings before NHS work. Average cost for NHS Surgery $0.

A US Specialist, according to him, does 6-10 operations per month, and my US research was cost around $30,000. In terms of knee replacements, the UK has much better insight, and much less medical device and insurance company influence on the type of replacement, they base their choices on OUTCOMES.

I’ll return to the discussion on healthcare systems shortly, but suffice to say, I’ll be going back to the UK when my time finally comes.

Government US style

It’s clear that many Americans view “Big government” as a bad thing, it seems though that they are OK with lots of branches of small government, that is ineffective, costly and open to misuse, and often technology challenged.

Given the size of the USA, any government is going to be a big government. With over nearly 320-million people, and almost the largest country in geography in the world, most people clearly are clueless about the scale and the challenges of delivering services in what was the worlds most advanced country. Listen to this 10-second clip from NPR’s Morning Edition today, a piece by Frank Morris of KCUR on the FBI and Apple privacy debate.

Seems to be a pretty widely held view. I heard it on the way back from going to trade-in my state of Texas Drivers License for a state of Colorado Drivers License. I had to drive some 12-miles to Longmont CO, wait in line outside for 30-mins until it opened at 8a.m.; go in and explain to a clerk/assistant/helper what I was there to do, exchange my drivers license and trade-in my state of Texas car plates and register my vehicle with the State of Colorado.

I was helpfully told that I was in the wrong office to register my vehicle, and asked for the relevant ID etc. in order  to get my license. I was given a number of told to wait. When I was called, I spoke with a clerk who was helpful and polite, I glanced over at the desks of the other clerks, you could see from the windows on the PC terminals that they were using dated text mode applications. Credit card processing had to be done by hand, typing numbers in. Questions had to be spoken in English and answered in English, there were no touchpad or tablet interactions. I had to say, outloud, with little privacy my social security number, and after checking my eye sight, and paying I was told to go and wait again.

After a short wait, I was shown a printed version of the questions I was asked, the information I had given, and ask to sign “wholly” within a box at the bottom. If the signature wasn’t entirely in the box it would “invalidate” the application as it couldn’t be scanned in. That done, I went through the take a picture exercise, was given my documents back and told the new license would show up in the mail in 7-10 days.

I left some 70-minutes after arriving. Not bad I guess.

Compare that though to many other Western countries, and many emerging economies, and you get a different picture. Change address in the UK? It’s done online and free. Pictures, signatures and details are held securely centrally.

In the clip above, it’s claimed that the government can’t run USPS, healthcare or anything else. Yet, despite being severely constrained in the services it offers, the US Postal Service is actually pretty dam good, reasonably efficient and pretty cheap. Anyone who thinks that private companies, like FedEx, or UPS and some magic form of new state regulated and/or run service would do better simply isn’t thinking about or is clueless when it comes to understand that scale problem, and the investment needed.

The US Government doesn’t run Healthcare, it never has. It it funds the medicare and medicaid programs. Yes, the US dept. of Veterans Affairs does run medical care and benefits for veterans, given the US has been in a constant state of war of one form or another since 1940, and given the physically size and scale, it is again a pretty decent operation. A good friend of mine, Lee, actually is looking forward to the veterans benefits and healthcare  for the rest of his life. Yes, the VA has its’ problems.

But still, most Americans seem to think it’s better to deal with things “locally” even if that does mean inefficiency, a mistake prone system, lack of privacy, time wasting, out of date technology, duplication, cost and more.

Meanwhile, later this week I’ll be heading to Boulder County to office to register my car; right before I start looking for State of Colorado healthcare market place, trying to resolve the naming error on my City waste management account; filling my taxes with the US Revenue Services and the property taxes with a county in Texas…. and yeah, most Americans have the least amount of vacation time, work the longest hours, and get fewest paid benefits, and things like paid maternity leave. So, no problem waiting online then?

Way to go Texas

I’ve been quiet recently for no other reason than I’m mid-move from Austin Texas to Louisville Colorado. I don’t think Texas will miss me, or care if I’m gone, but I can’t help but be glad to turn my back on the what must be some of the most vindictive, small minded, and regressive politicians I’ve ever come across.

11380987_867608403331615_1505800615_n[1]It kind of doesn’t matter where you stand on the abortion issue, I’m pro-choice. However, when you look at the time, effort, money and all the laws, regulations that Texas has pursued in their attempt to de-fund Planned Parenthood, it is nothing less than a scandal. Worse though are the indirect consequences, the way womens health has just become an acceptable casualty in the battle, little more than mere shrapnel.

While the Texas politico’s have gone after Planned Parenthood, what they’ve actually achieved is the large scale closing of family planning clinics around the state. Of the 82 clinics that have closed, only a third were Planned Parenthood. Those clinics didn’t perform abortions, they were not there just to encourage women to have sex outside of marriage, they provided obstetrical care, gynecological care, and Pap smears.

For those that remain open, there are often massive distances to travel, and long waits, less than a quarter of those that should be seen, are being seen for subsidized preventive health care treatment. That would barely meet the World Health Organization requirements for a third-world country. Welcome to Texas.

Wade Goodwyn has a good report on NPR on the state of affairs in Texas, from George W. Bush childhood home of Midland, far west Texas. The most depressing thing Goodwyn says in his report is:

Texas is becoming the model for other conservative states that would like to defund all family planning clinics associated with abortion providers.

http://www.npr.org/player/embed/464728393/464744500

Planned parenthood, arbortion et al

Rarely little more than a bunch of privileged white guys hectoring the President of Planned Parenthood. I watched some of it live, and read a number of reports afterwards, it seems to have achieved nothing, and garnered no new information.

This weeks Congressional hearing on Planned Parenthood was pretty sloppy. Rarely little more than a bunch of privileged old white guys hectoring the President of Planned Parenthood. I watched some of it live, and read a number of reports afterwards, it seems to have achieved nothing, and garnered no new information.

I just saw this clip from Late Night with Seth Myers has the best summary.

Out of control drugs

For-profit hospitals appear to be better players in this price-gouging game,” says Bai, an assistant professor of accounting at Washington & Lee University. “They represent only 30 percent of hospitals in the U.S., but account for 98 percent of the 50 hospitals with highest markups.

Of the many things wrong with the US Medical system, and there are a great many, not least it is the most expensive in the world, are the prices of ancillary parts of the healthcare system.

I’ve just been catching up on my bills, one of which was a visit to a chiropracter. A single visit, with a company provided insurance, my out of pocket cost was $485. Yes, it’s complicated, it involves deductibles, co-pays etc. and of course since it’s my only healthcare visit so far this year, I got essentially nothing from insurance. You then start to question what you got for $485. 10-mins with the specialist; 15-mins electrical stimulation; and about the same ultrasound. Sigh.

I have a mild form of psoriasis which randomly appears(stress?) on my right elbow, left thumb and a couple of other areas. It’s really no big deal, I use maybe two or three small tubes of Fluocinonide per year; in a couple of days and it’s gone. I went to get a replacement tube of cream from CVS recently. It’s a prescription cream, which comes with its own problems. The pharmacist gave me the cream and announced they’d changed providers and the price was now $8. No big deal to me, I can afford it. I paid and left.

Out in the car, I stopped and thought about it. I’d just been stung with 62.5% price hike. Seriously same active ingredient, same size tube; different generic brand. And there you have it, you have no control, no choice, no free market, it’s effectively too difficult to shop around because it’s prescription only. Yet, strangely you can buy it online for pets, it’s about the same price, meaning again, my drug insurance is effectively worthless.

The problem in America is that there is no effective control for the price of drugs. This report by Johns Hopkins Bloomberg School of Public Health report, highlights how this is commonly exploited, let alone specific deliberate abuse.

The 50 hospitals, they found, charged an average of more than 10 times the Medicare-allowed costs. They also found that the typical United States hospital charges were on average 3.4 times the Medicare-allowable cost in 2012. In other words, when the hospital incurs $100 of Medicare-allowable costs, the hospital charges $340. In one of the top 50 hospitals, that means a $1,000 charge.

Of the 50 hospitals with the highest price markups, 49 are for-profit hospitals and 46 are owned by for-profit health systems. One for-profit health system, Community Health Systems Inc., operates 25 of the 50 hospitals. Hospital Corp. of America operates more than one-quarter of them. While they are located in many states, 20 of the hospitals are in Florida.

For-profit hospitals appear to be better players in this price-gouging game,” says Bai, an assistant professor of accounting at Washington & Lee University. “They represent only 30 percent of hospitals in the U.S., but account for 98 percent of the 50 hospitals with highest markups.

We all pay the price for this abuse. It’s nonsense to think that a single payer, public healthcare system would cost anymore. If we had it, there would be drug price control. Those against price control often argue that would stifle innovation and invention of new drugs, they role out the enormous cost of bringing out new drugs and using the profit of successful drugs to underwrite research, and failures during the process.

This is simply invalid. Anyone who thinks that humans won’t become involved because they are prepared to standby and watch their fellow citizens die, is just plain wrong. While medical innovations have progressed dramatically over the previous century, the last 20 years specifically have resulted in monumental advancements that substantially increased medical care standards and improved overall global health, but most of those advances didn’t actually come from the actual drugs(*), but from a better understand about the human body, how diseases spread and much about healthcare. The real ripoff in drug use is both at source, manufacturers, and those that sell the drugs.

Lets hope the next President take drug pricing as a priority.

* Not withstanding massive public health crisis drugs, like HIV, Ebola et al. These serve as exactly as an example of the invention that will still come.

FIFA vs The Government

I heard the BBC reporting the Governor of the Bank of Englands remarks that the “age of irresponsibility” in the City of London is over as the Bank of England promised a crackdown on rogue traders. In a speech on Wednesday evening, the Bank of England Governor said that banks, regulators and individuals had collectively failed to prevent the market rigging that has led to bank fines worth billions of pounds and he recommended tougher rules for the City and longer jail sentences for those who attempt to manipulate markets.

This is a very British approach to a problem, introduce tough penalties, regulations and make things illegal. It made me wonder, how would either the British or the US Governments deal with FIFA, if FIFA was either a UK or US Registered company.

FIFA_Logo[1]The contrast couldn’t be more stark. In the UK they would spend ages trying to bring FIFA to court under numerous, increasing complex and confusing rules. The trial would last years and cost millions, only to collapse at some point for legal reasons.

Meanwhile, the US Government, rather than push ahead with an Untouchables Style prosecution, as it seems to be. They would settle for a financial penalty, and we’d have never heard about the FIFA corruption until the settlement was announced. FIFA currently holds a reserve of $1.52bn, so no problem in paying US Governments fines. Ironically, paying fines is of course a form of legal bribery not to participate in the theater of court, the exact opposite of what FIFA stands accused of, taking money to allow countries to participate in bidding and holding the theater of the World Cup.

Healthcare – Points mean Prizes!

Back on April 6th I wrote a blog called “Healthcare Stupidity“. In a work email today it contained the following:

It may surprise you, but prices for medical services can differ depending on where you go. For example, identical cholesterol tests can run between $10 and $270 and an MRI can range from $300 to $3,000. Need a minor outpatient procedure? Searching in Castlight could save you hundreds. With Castlight, you can compare costs for doctors and medical services before you make an appointment.

Earn more points! Sign up, perform a search and review your medical plan in Castlight by June 30 for a chance to win 10,000 WOWPoints on e-Deals (valued at $100)*! For rules and more details please visit Castlight Rewards Sweepstakes.

Speechless, you can’t make this stuff up. As Bruce Forsyth used to say, Points mean prizes, play your card right!

Watch the video, If you are one of my US Friends… It will dispel any notion you have of the British being intelligent and articulate, much like the US Healthcare system it seems.

Healthcare stupidity

Only in America!

I’m an employed executive, I do OK. I have company provided healthcare insurance. I find the annual waste of time crawling through the policy details and trying to work out which one will pay out for real healthcare and which ones are just superficially attractive frustrating, annoying and the height of absurdity. If you make the wrong selection, you are screwed for the whole year. If you forget to make a selection you are possibly even more screwed as you’ll default into a plan which is totally inappropriate for your needs.

Then there is the whole debacle of co-pays, deductibles, out of network and a whole raft of other ways you can be screwed and charged even more. So, I’m guessing I’m not alone with this and in one of those only in America moments, there apparently is a business model for this.

My company has been promoting and I’ve been getting flyers in the mail, and emails at work in the HR Newsletter for a company called Castlight. The latest email from Corporate HR Said:

Castlight is your one-stop shop for healthcare. With Castlight, you can find a high-quality doctor at an affordable price before making an appointment. Already registered? Start searching today for the best healthcare options for your family. Castlight is provided to [—] team members, spouses or domestic partners enrolled in [—-] PPO 600 and Health Fund medical plans. Register for the Castlight Rewards Sweepstakes for a chance to win 10,000 WOWPoints redeemable at e-Deals@[—-]—a $100 value! For rules and more details please visit Castlight Rewards Sweepstakes

So, lets summarize.

  1. Healthcare providers are charging employees too much, otherwise why does the service exist?
  2. Healthcare Insurance companies are failing to negotiate the best deals.
  3. My employer is paying the company, or is getting a kick-back when employees use the service
  4. Company provided health insurance still isn’t affordable.
  5. None of this is important because you can get rewards and points for being sick and needing a doctor.
  6. If you pay by a cash back credit card, you too can make money, oops I meant save more money.

Yep, only in America would any of this be acceptable because hey, people are making good money out of it.

Abbotts Texas Miracle

This week Attorney General and Republican gubernatorial candidate Greg Abbott continued to demonstrate that the Texas Miracle is based only on smoke and mirrors.

Zap, Pow, Sock it to 'em Abbott
Zap, Pow, Sock it to ’em Abbott

First up, Abbott claimed victory over the evil empire, the Federal Governments’ Environmental Protection Agency. Abbott has time and time again sued the EPA to try to get relief for Texas based businesses, claiming almost everything except the dog ate their homework. The only thing Abbott hasn’t denied is that Texas is the worst state when it comes to air pollution, and given it’s size and position, that pollution is a major contributor to US pollution and to pollution in other states. But, hey, apparently that’s too bad as the regulations would be too costly for Texas businesses to implement.

The truth is that Abbott won a battle to save small businesses from implementing these regulations, but lost the war, the coal plants and other major facilities will have to implement them. The EDF has a different perspective but comes to the same conclusion.

Meanwhile, Abbott(“What I really do for fun is I go into the office, [and] I sue the Obama administration.”) has been explaining the unexplainable, back-peddling on his order to restrict access to the hazardous Chemicals list. As posted last week “The Texas Freedom Illusion“, Abbott confirmed the ban of releasing information to the public as Tier II reports in the 1986 Emergency Planning and Community Right to Know Act (EPCRA).

Well it turns out, he’s explained his position. You, yes, you the people, have not lost your right to know under the EPCRA. If you want to know, apparently all you have to do is visit the plants or write them, and ask. Instead of letting concerned citizens check the state database, where businesses are required to register, the State is pushing handling costs on the business. The Daily KOS has a great piece on this, describing Abbotts remarks as “jaw dropping”. < Zap pow!

It can’t be because it’s more secure that way.because it sure isn’t anymore secure. I’m sure the terrorists would never think of that, after all, they didn’t think of taking private flying lessons pre-9/11… when they couldn’t get trained by the Government.

Meanwhile, Abbott has also been re-confirming that the Texas Miracle doesn’t come with workers compensation insurance, the only state in America to do so. The Texas Tribune this week published a damning report into the cost and effect of this on workers. For as little as $1.38, businesses could provide workers comp. but like that EPA cost, thats too much of a burden. The downside of this, i workers getting hurt, seriously hurt often have no medical coverage, that means you are and I are picking up the tab.

So, lets summarize. Abbott is running for Governor. He is

  • Not prepared to require businesses meet the same emissions standards they are elsewhere in the USA
  • Not prepared to require Workers Comp. insurance
  • Not prepared to provide citizens access to data the State has on dangerous chemical storage
  • Continues to sue the Presidents Administration, costing hundreds of thousands of tax payer dollars, for no real purpose and little result

I’ll be protesting in the morning, Taxation with no representation, I can’t even vote for someone else, let alone against him. Zap Pow – Robin’ the people to pay for business.

Dead Reckoning: The TDI rules don’t quite blind the navigators

1619139_10152188985535915_241142027_nMichael King sums up how I feel about what’s been going on in Texas in relation to Womens Health, the Affordable Care act. I don’t always agree with King, but when I do it’s always the same problem.

For entirely political reasons, Gov. Rick Perry has not only opposed and obstructed the federal health care law at every available opportunity, he has done nothing to offer a usable alternative or even to maintain the entirely inadequate existing state health care programs. It has been more important for Perry and his GOP allies to fight a holy war against Planned Parenthood than to sustain the Women’s Health Program; it has been a higher priority to cut property taxes than to provide local health care districts with state assistance; it has been politically more expedient to deny millions of Texans health care coverage through Medicaid than to accept federal funding for a program that would not only save lives but expand the state economy.

via Point Austin: Dead Reckoning: The TDI rules don’t quite blind the navigators – News – The Austin Chronicle.