Comments on: Across The Pond (2)…

By: Charlie Baker

Charlie Baker — Mon, 22 Oct 2007 18:49:19 +0000

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.

By: MT57

MT57 — Fri, 19 Oct 2007 20:08:59 +0000

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?

By: Gordon Moore

Gordon Moore — Wed, 17 Oct 2007 16:41:42 +0000

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.

By: Susan L

Susan L — Wed, 17 Oct 2007 11:39:58 +0000

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.