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.

Healthcare perspectives

Although I’m tempted to write a blog post on the current debacle around the Texas legislature’s attempt to remove Women’s choice on abortion, by legislating abortion clinics pretty much out of existence in Texas. I won’t since thats not really healthcare, it’s basic human rights, freedom of choice and freedom of the individual.

I’m heading, this time next week, to my last full distance aka Ironman Triathlon. It’s my last since my right knee is pretty much wrecked, some 36-years after smashing my leg to bits in a motorcycle accident, and some 40-years after having the meniscus removed following a number of soccer injuries. My left knee also shows signs of excessive wear and tear. In 2009 I was referred to Dr Doug Elenz who after looking at x-rays said “a picture is worth a thousand words, I only need six – I don’t know how you run?”. He also said “your right knee needs replacing now, and your left knee soon”. We laughed and joked and I have not seen him since.

So I’ve been considering my options for when I get back. Knee replacement, lot’s of new alternative therapies. A couple of interesting things prompted this blog post though which just show how different things are here in the USA. I checked with a couple of medical insurers websites on type types of treatments available. Here is an example on the Aetna website, it would be nearly impossible to meet these requirements since one or more of the conditions would need to be present in order to make the treatment necessary.

I checked with a friend back in the UK, and yes, provided a Dr referred me to a consultant specialist, and the specialist scheduled the treatment, this would be available free of charge. There may be a waiting list for a hospital bed and surgery.

If I worked for a large multinational, as I did when I was in the UK, I had company provided top-up insurance. Rather than being full health insurance American style, what this did was provide for the things that the UK public healthcare system didn’t. I wouldn’t have had to wait, I would have had a private room. All mostly still at no cost, that’s right, no co-pays none of the other nonsense charges that a US insurance policy mandates.

It wouldn’t be totally free, since the government considered the private insurance a taxable benefit, the value of the insurance was added to my annual income declared by the company to the government tax authorities. So, basic healthcare for everyone, for free. Improved access for those that can afford it or have additional insurance. Both of these come without the panels, expense and charging bureaucracy that are weighing down the US system, the cost and expense mostly actually goes on Heathcare.

The real reason for writing though was an email from a neighbor. He was trying to raise money for his sons’ knee surgery. I’m just left speechless really that average American families have to resort to this sort of thing. Where is the dignity, the respect, the care in a society that allows this to happen?

Everytime I think I understand the American psyche, the societal norms’ something like this comes up and I have to take a step back and accept I just don’t get it.

Some men see things as they are and say, why; I dream things that never were and say, why not. – More at: http://www.youtube.com/watch?v=dvo-7YrMoK0

Senator Edward M. Kennedy quoted these words of Robert Kennedys in his eulogy for his brother in 1968.The New York Times, June 9, 1968, p. 56

Guantánamo Adds Medical Staff Amid Hunger Strike – NYTimes.com

This has been prime news in Europe today and yesterday, that 2/3 of the detainees are now on Hunger Strike, and more than 40 are being force fed. I’m sure this also more than news in many other countries. [BBC; Süddeutsche Zeitung (Germany)]

Whatever you think about the people being held, “terrorists that should rot in hell”, “that should be locked up forever” or “deserve their day in court”, the damage this is doing to the US reputation overseas is immeasurable, and it will be held against us.  Time to end this. The President promised 4-years ago to shutdown Guantanamo,  now is the time for action. While “waterboarding” may not qualify as “cruel and unusual punishment: under the US Constitution, Force Feeding is most definitely clearly a violation of international law.

Interestingly, while this is news outside the US, apart from blog entries, I hadn’t seen or heard it covered on US “News” 24hr or otherwise, TV or Radio, unless you did?

Guantánamo Adds Medical Staff Amid Hunger Strike – NYTimes.com.

Texas, It’s not like anywhere else

austin_bumper_stickerLiving in Austin it’s all to easy to think you are in Texas, but really like it’s often said “Austin is a liberal oasis in Texas“. More often, Austin isn’t in Texas, but you can see it from here!

One of the first things I had to get used to is the Texas Legislator only being in town once every 2-years. That’s right, in what seems a total anomaly  the elected officials of the State of Texas are only in the capital to make/pass law every two years.  I’d guess this stems from the days when they had to ride horses to get to and from their constituents?

So while they work on the bi-annual budget as a key part of their initial work this year, there are a few key things that Texas does differently…

  • The Texas execution machine took a break over the year end, with near-weekly executions scheduled and most carried out. In all, Texas put to death 15 men in 2012. The state will kick off 2013 with the rare execution of a woman, Kimberly McCarthy on January 29th.
  • In all, Governor Rick Perry has presided over 239 execusions, surpassing all modern governors and marking the 478th Texas execution since the reinstatement of capital punishment in 1976.
  • While we await the outcome of Vice President Joe Biden to report back on gun control, Texas and Austin resident Alex Jones demonstrated perfectly why people are right to be concerned about “nut jobs” with easy access to legal guns when he “discussed” it with Piers Morgan on cnn.com.
  • Talking of “nut jobs”, over in Lubbock County Texas, Judge Tom Head claimed on local TV that a proposed tax increase would be needed to put down civil unrest and defend the country from invading UN forces should President Obama be reelected.
  • Down the street from me is a closed restaurant, Jovitas. It’s waiting the return of its owner, Amado Pardo. The restaurant was closed when Pardo was arrested by the FBI with 15-others for allegedly running a longtime heroin-dealing operation out of his eatery. What was really surprising was that Pardo was a twice convicted murderer, even more of a surprise was that Pardo was released on bail today, he has terminal cancer. Where’s the tough on crime, three strikes and you are out, when you need it?
  • Not quite as close to home, across Austin, in the Hot Bodies Mens Club, Victoria Perez, 21, was arrested for aggravated assault with a deadly weapon following a fight among seventeen women in the dressing room. A Male strip club employee was seriously injured when Perez hit him in the face with a spike heeled shoe and may have blinded him. As Alex Jones might have it, should we ban high heeled shoes? Hell no.
  • As a final vote of confidence, Buzz Bissinger, author of the book, Friday Night Lights about an Odessa Texas high school football team, tweeted that “if Dallas slid into a sinkhole, nation’s IQ would raise by 50 points”.

So, much for calm, rational people with legal access to guns. It’s interesting now that Texas has stricter controls over a womans uterus than guns. Texas now prescribes invasive gynecological procedures for Texas women, while at the same time making even harder for many thousands of Texas women to even visit a gynecologist.

And finally, it looks like the governor and the legislator don’t read my blog, otherwise they might have focused on what’s going to happen to all those children that are going to escape an unwanted death in Texas. The Governor continues to make it clear he is diametrically oppossed to any expansion of Medicaid in Texas, that pays for most of these births, and will do everything in his power to undermine national health care in Texas.

@pointaustin, writer and Editor Michael King points out that in Governor Perrys political universe, “Fetal pain” has an expiration date. Once that new Texas citizen takes his or her first breath, they are on their own. Writing in the Chronicle, King says “When the Governor says Suffer the little Children – he really means it.”

Death Panels open in US Health Insurance

Americans were frightened out of a single payer, medical health care system similar to one in operation in many countries using a number of tactics, including by using the term “death panel”. Sarah Palin, who claimed “proposed legislation would create a “death panel” of bureaucrats who would decide whether Americans—such as her elderly parents or child with Down syndrome—were worthy of medical care.”

Palins claim was totally debunked by fact check organizations, and it was named 2009 “Lie of the year” by Politifact.

So a federal or national health care system, or single payer system passed into history and we ended up with whats become known as Obamacare.

As an executive, who is divorced, and has no dependents, I have the best medical plan available through my employer, it comes with an EXPRESS SCRIPTS prescription plan. Recently they started sending out communications on the changes for the 2013 plan. It included a word I’d never before heard “formulary“.

My formulary letter
Express Scripts

In essence, what it is is major aspect of what Sarah Palin referred to as a death panel. Express Scripts tries in its communication to pass it off as an employer choice. They write “Medications not on [insert employer name here] formulary will remain available, but you will pay full price for them.” (highlighting theirs).

This is EXACTLY what happens with the UK NHS Prescriptions. You pay a flat charge of £7.65 approximately, $12. Thats pretty much all drugs, except mostly untested, unapproved ones. Many of the long term sick and unemployed get exemptions from the charge. We though have a copay, no one is exempted from the copay, and it varies from drug to drug.

Express Scripts list though is pretty short in total, the good news is it does include viagra and cialis. So, with none of the real benefits, we’ve got death panels by the back door.

All thats wrong with US Healthcare

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This article in Saturdays Wall Street journal was mostly about healthcare industry stocks, but what blew me away was the chart that was included. I’ve long felt the US Healthcare system aka “industry” was not only too expensive, you can’t have a balanced discussion about it, people immediately get very defensive.

Once you’ve been treated a few times it becomes obvious that insurance is used as a blanket to cover

  • a vast array of unnecessary services, loads of extra tests, samples, examples, scans and xrays. Often because upfront you’ve paid your co-pay, pre-pay etc. so what do you care? The medical facility is paid for what they do, not their results.
  • Excessive administrative costs – for example, during my recent broken collarbone rather than visiting a single hospital and doctor/specialist, I had to visit 2-separate facilities, each duplicating the entire billing, insurance debacle, requiring many pages of documentation and background information. Every medical facility comes with it’s own army of billing and administrative staff to negotiate the insurance rules, claims and reclaims.
  • Inefficiently delivered services – Americans with insurance take great pride in the system as it delivers choice and prompt service and treatment. The reality it doesn’t, it does it through the illusion of choice based on whats available through insurance, and through a long list of appointments which are “first” available, but compared to a single payer system where you can move quickly and efficiently between providers, it isn’t efficient. For those without insurance there is little or no option but to sit in the emergancy room and hope for the best.
  • Prices are too high – because they have to cover an inefficient system and high administration costs.
  • Fraud – of course there is fraud, in any efficient system there are always those that seek to exploit the system; also in a system which excludes many, they look for a way to get what they can.
  • Missed prevention opportunities – and of course any system which generates huge amounts of money to deal with problems isn’t really focussed on prevention. While their are pockets of good practice in prevention, mostly there is a lack of priority in prevention.

Add up the numbers, you could pay for a single payer system with everything except the prevention missed opportunity.