Across The Pond (1)…
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My friend Jeff Goldsmith, who runs Health Futures — a health care management consulting firm — also gathers a loose confederation of health care executives four or five times a year to catch up on what’s going on in the industry. His latest clustering brought together a bunch of health care leaders from the US with a bunch of health care leaders from England — including a couple of former members of the Blair Administration. The meeting was fascinating. Here’s the first of three or four offerings on what I learned.
The biggest thing I learned was also the simplest — Britain has issues in managing its health care system and its health care budget. Its issues are different than the ones faced in this country — but they are most definitely — undeniably — there. They do try to cover everyone — and this, more than anything else — gives them a big leg up on our system, and they do it for 9% of GDP while we spend 16%. But they do have problems. First among them is cost. They’ve put a great deal of new money into their health care system over the past few years, and in the minds of many people, don’t appear to have that much to show for it. Waiting times for many specialty procedures are down a bit — but still very much for real — and in some cases, access to primary care — which was supposed to get better with more money — feels to many people as if it’s gotten worse.
This is driven by a number of factors, but one of them is clearly the financial benefit derived by physicians and hospitals if they maintain some degree of waiting time in the more traditional system. Docs and hospitals do get paid — either by private insurance or by their patients — for work they do that “complements” the regular NHS system. This usually has to do with time, queue jumping, and other, “specialized” services. One of the speakers referenced an ad at the airport in London that says something like, “The AXA ‘I’m glad I won’t have to wait months to see a specialist’ Plan — Private Healthcare that complements the NHS”. People do buy private insurance in Britain — which is often available through their employer — and they do use it to enhance their ability to access the system. It not only works for the patient — but it works for the docs and the hospitals, too — since the private pay rates are dramatically above the public pay rates.
It’s not a huge piece of the system — probably less than 10% of the total activity — but the pay differential is much bigger than that — making it a huge issue financially for providers. Take the whole logjam away and eliminate all the private pay business, and the hit to the provider system would be significant. So the big issue for the NHS is how to get docs and hospitals to do things more quickly — to take down the waiting times and move people more efficiently through the system — when it’s not necessarily in their best interest financially to solve this problem.
As a result, they’re experimenting with Fee For Service-type payments for services rendered — paying for the work that’s been done — and away from pure global budgets — because global budgets don’t encourage productivity and throughput. This, of course, is the opposite of the problem we talk about here — where FFS is the primary payment methodology — and most observers agree it leads to over testing and too many procedures.
Wow! Jeff Goldsmith has an incredible background. I find your post very interesting, but not surprising. It doesn’t surprise me that money keeps going into the system with little to show for it. I truly believe that money will create change when it is used as incentive for patient care and existing throughput issues.
The last paragraph tells it all–especially the last sentence. Our candidates and lawmakers in the U.S. should note the message: “most observers agree it leads to over testing and too many procedures” when they reform our present healthcare system. Reform will lead to no improvement unless reimbursement is for health care services only where there is clear cut medical necessity for those services.
http://www.charlesclarknovels.com
There’s an old method to determining your true calling in life that goes something like this: “What would you do every day for the rest of your life if money were not an issue?”
Well, “How would health care in this country be managed and delivered most effectively if money were not an issue?”
This seems less and less to be the starting point in the health care reform discussion, and more and more to be an afterthought. Obviously, money dramatically affects anything, especially a system that has the potential to generate so much of it. If money were not an issue, though, would anyone really be debating the merits of SCHIP? Would taking money out of the equation make it easier to access primary care, or ‘level the playing field’, so to speak? Would there be a need for the sweeping reforms and overhauls we are now faced with, reforms and overhauls whose success and/or failure is inextricably linked to the same financial issues that prompted them in the first place? The answer to these questions is, most likely, no.
I know that this is the utmost in idealism, and I do not advocate a single-payer system, mostly for the very reason that the free market competition (private insurance) referenced above as currently taking place in Britain that pits private insurers directly against the Federal Government (with the patient in the middle) would be inevitable in America. I do support the formation of a national Best Practices Institute and overall national health care reform. Progress seems to be underway in aligning private insurers with state and federal governments, as evidenced by Massachusetts Health Care Reform, similar proposals in California, and Hillary Clinton’s acknowledgement that the need for such a partnership exists. But where is the idealism on the part of our leaders, and from within the collected health care industries?
I know that 16% of the GDP is nothing to shake a stick at, but I think that in order to keep this train from going off the tracks, we need to determine where it is heading.
While we may not wish to replicate a system like England’s, can we take the best of what it has to offer? How about a baseline universal (yes, not the other u word, utopic) system that provides evidence-based preventive as well as urgent / emergent care, supplemented by a private market for most other healthcare services. Such a system could complement existing Medicare and Medicaid programs to ensure that no one goes without basic healthcare that is known to save multiples of cost in the future. Undoubtedly complex in execution, such a system may be no worse administratively than what currently exists.