Across The Pond (2)…
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Who runs the biggest HMO in the world? Kaiser Permanente? Wellpoint? United HealthCare? Nope, nope, and guess again. The answer is — the National Health Service in Britain. This is one of the big “ah-ha’s” I picked up during my time with the folks from England. There’s only one route to a specialist in England — what they call a “consultant” — and it requires a referral from a “GP” — or General Practitioner. Now maybe I misunderstood what I was hearing, but I asked several times if there were other routes to self-refer to a specialist, and the answer I got was an unqualified “no.” Everything — even the privately insured business and the self-pay stuff — had to have a GP referral. Under the current model, a GP refers you to a specialist/consultant, and the consultant sends you a letter that you’ve been approved for a specialist visit — and it will take place on such-and-such a date at such-and-such a time!
Now the time you wait can vary, depending on the nature of your coverage and your options (see Across the Pond (1)…), but you need a referral from a GP to see a specialist. No exceptions.
As a result, the GP has a lot of standing — and a far more influential role — in the British health care system than a GP has in the US system. And therefore, there are more GPs than there are specialists (I think the numbers were something like 60/40 GPs to Consultants) — which is just the opposite of the US — where we have 30 GPs for every 70 specialists.
I asked several speakers if giving people direct access to specialists — as they have in this country — would make a difference. They all said “hugely.” They believe the PCP/GP referral model is an important piece of managing total cost and work flow throughout the system.
Pretty interesting, no?
The capacity of American GPs, especially inexperienced GPs, to overuse resources and misdiagnose–are you perhaps underestimating that? (Example: the GP who decided that the knee-pain of the diabetic was due to diabetic neuropathy. But it turned out to be a broken knee-cap.)
A GP lacking inexperience with a particular condition may also be more anxious to make use of the Big Guns, such as CAT scans, than a specialist who had seen many such cases before.
Of course the specialist has three leading characterisitics: better specialized knowledge, a higher price, and a greater desire to undertake expensive procedures. The big issue is, how to get the knowledge without much extra expense?
One advantage of the UK is that they make better use than we do of nurse practitioners and nurses, who can be a good source of specialized knowledge and experience.
Then there are diagnostic algorithms, real-time use of them, and so forth.
Right on, Charlie! The NHS is one of the world’s most successful “primary care led” systems and their extensive network of GPs is often cited as a reason that they can spend half of what we do and still achieve universal coverage. Their other big innovation, and relevant to your
“Who runs the biggest HMO” question, is their progressive movement towards a purchaser-provider model that was first suggested to them in the mid-80s by the economic guru of managed care, Alain Enthoven. This model’s direct heritage is the HMOs that Enthoven used as his model. So, no wonder they are looking more and more like a very large, and very successful HMO. Too bad that most Americans disparage the English system by the term “socialized medicine.” For anyone willing to take a look at the modern NHS, there is a lot to admire and much we could learn from.
The difference between that and a US HMO is there is no profit incentive, which cuts both ways: there is no incentive to do well by the patient community, because they can’t cut off the provider’s income by going elsewhere, but the HMO’s managers have no direct financial incentive to deny coverage either; they’re all just bureacuracts on fixed salaries. However there is an incentive to deny coverage — it’s just elsewhere in the system. The providers, like most bureaucrats, optimize their livelihood by providing the minimal level of service that maintains continued employment and then pursue additional income through other channels or pursue leisure. So I wonder what incentives the government puts in place to offset that - fees for service? Fees for patients seen? Hmm - sounds like ,,, umm, the US HMO approach?
MT57 - Your last point, was, for me anyway, one of the ironies of these conversations. The American system used to have a lot more capitation, but people worried about the incentive it created to do “less” than what was required. FFS creates just the opposite problem - no financial reward unless you do “something.” The NHS was, historically, a budget based system built on the “less” model, but they’ve worried about the impact that’s had on productivity and efficiency, and have now installed a series of procedure based incentives that look a lot like FFS. It appears to be very hard to figure out the right model.