healthcare model

[BabyPsychDoc]

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On the much-debated topic of healthcare...

http://www.msnbc.msn.com/id/29967678/


I have to say, this works in the UK's private healthcare system - and works well. Lumbar laminectomy with fusion costs £5,500 in hospital costs, plus £1,500 surgeon's fee and £500 anaesthesiologist's fee. The hospital fee comes with 30 days "warranty" - ie, all invx, rx, meals and a private room is covered for as long a stay as deemed necessary by the surgeon, and if a re-admission is necessary within 30 days from being discharged from the hospital, the costs of the readmission would be covered, too. There is no dreaded waiting lists, and no MRSA haunting NHS hospitals...For those lacking insurance, the hospital can arrange 0% finance.

 

[HCE]

On the much-debated topic of healthcare...

http://www.msnbc.msn.com/id/29967678/


I have to say, this works in the UK's private healthcare system - and works well. Lumbar laminectomy with fusion costs £5,500 in hospital costs, plus £1,500 surgeon's fee and £500 anaesthesiologist's fee. The hospital fee comes with 30 days "warranty" - ie, all invx, rx, meals and a private room is covered for as long a stay as deemed necessary by the surgeon, and if a re-admission is necessary within 30 days from being discharged from the hospital, the costs of the readmission would be covered, too. There is no dreaded waiting lists, and no MRSA haunting NHS hospitals...For those lacking insurance, the hospital can arrange 0% finance.

Interesting concept. I can see where this would work well in certain instances involving a specific medical problem, with a well-accepted one-time prodedure to resolve the problem. I was just contemplating whether this could ever be used in, for example, the psychiatric field, where I see diagnosing and treating is as much an art as it is a science. I guess I hesitate to use what the article quoted as "cookbook recipes" to diagnose and treat as a general rule, but I would concede this would work in some cases. Does this concept work in the UK for any psychiatric treatment, or for other fields where conditions may not fit nicely into pre-arranged diagnoses? I'm not even sure I'm making any sense, but I'll throw it out there.

 

[OldPsychDoc]

Interesting concept. I can see where this would work well in certain instances involving a specific medical problem, with a well-accepted one-time prodedure to resolve the problem. I was just contemplating whether this could ever be used in, for example, the psychiatric field, where I see diagnosing and treating is as much an art as it is a science. I guess I hesitate to use what the article quoted as "cookbook recipes" to diagnose and treat as a general rule, but I would concede this would work in some cases. Does this concept work in the UK for any psychiatric treatment, or for other fields where conditions may not fit nicely into pre-arranged diagnoses? I'm not even sure I'm making any sense, but I'll throw it out there.

That was my thought exactly--how will this be applied to psych? But I think that we will see more attempts to apply "evidence-based guidelines" in psych--e.g Milliman Care Guidelines, etc. The problem I see is that the "evidence-based" criteria typically rely on research that was done on relatively homogeneous diagnostic groups, and our typical depressed borderline with multiple substance use and questionable psychosis as well as the usual array of psychosocial wreckage just doesn't fit--even when you give allowances for "complexity".

 

[masterofmonkeys]

Shaneyfelt and Centor had a good piece on what really goes into the decision-making process in writing guidelines.

And I realize abramson is a polarizing figure, but his chapters on statins are excellent.

It also leaves little to no room for professional disagreement. Just because I have a different opinion from the 'experts' and their tens of thousands of dollars in honoraria doesn't mean that I'm wrong.

But back to the original topic of bundling. It sort of makes sense in the case of cut and dry procedures like a roid injection, or routine surgeries like lap choles/appys/etc.

But it also doesn't make sense.

If you're a diabetic who doesn't take their meds regularly and thinks candy bars are a staple, is it really the surgeon's/hospital's fault that your wound won't heal/gets infected?

I recently had a volar ganglion cyst removed. Likely caused by the combination of parsonage-turner syndrome and the heavy weightlifting I do to keep it in check. Is it the surgeon's fault if I ignore his admonition not to lift weights for a month, burst the synovial stitch and need a revision because joint fluid is leaking into my forearm?

One of the reasons I am so against government healthcare, low-deductible health insurance and employer coupling is because it shields us from the costs of our own choices and the benefits of husbanding our health.

I don't want to get political here, but to me the problem with bundling (as they're planning on doing here at least for medicare, if it hasn't been enacted already) is that it treats the patient as a passive player in the health role. Bad things only happen when the hospital/doctor screw up. And even when they're not, it's just sheer bad luck. Or something. I don't buy it.

 

[BabyPsychDoc]

Although the same model is difficult to apply in psych, as HCE rightly noted, I was thinking more in terms of overall healthcare savings to be made. One could reasonably argue that psych depts may become indirect beneficiaries of these savings.

Does this concept work in the UK for any psychiatric treatment, or for other fields where conditions may not fit nicely into pre-arranged diagnoses?

It is difficult to make any direct comparisons here, because private psychiatry does not form a very prominent part of the healthcare system in this country. To my knowledge, private practice of a psychiatrist here is mostly "boutique-style" practice, with a significant bias towards psychotherapy (unsurprisingly). Patients are billed per session. The only time I came across anything different was when I was involved in management of a young mother with puerperal psychosis. There is a massive shortage of NHS funded places at mother-and-baby units in the UK, so she had a choice of either a) being admitted on a general adult ward in the local psych hospital (NHS); b) being admitted on mother-and-baby unit in London (also NHS, but about two hours one way commute from here) or c) admitted in a private mother-and-baby unit closer to home. I seem to remember they quoted something in the order of £40,000 for up to 7 weeks inpatient stay (but that was about 2 yrs ago). So, I guess, they may be working using a similar model, but I do not really know many details.

Like OPD said, the cost-limiting tools used in psych here are "EBM" guidelines. I used quotation marks, because these guidelines are produced by committees that can come under significant pressure from the government, and either local or national politics can (does!) has serious impact on their "findings". (And, it is not just my being a cold-hearted cynical person - I have a friend who used to sit on one of these committees, until she got so tired of playing politics instead of discussing medicine that she resigned). I am not inherently against such guidelines in general (actually, I think the ADHD guidelines work reasonably well), but I am inherently suspicious of clinical quidelines produced by committees liable to conflict of interest.

But it also doesn't make sense.

If you're a diabetic who doesn't take their meds regularly and thinks candy bars are a staple, is it really the surgeon's/hospital's fault that your wound won't heal/gets infected?

Well, yes, it does. In the UK, patients liable to develop serious complications (like diabetics or cancer patients) would be most often advised to go NHS route. In the US, the most logical solution would be to build up a multi-tier billing system (a bit like ASA risk classification), based on your pre-existing health conditions.

I don't want to get political here, but to me the problem with bundling (as they're planning on doing here at least for medicare, if it hasn't been enacted already) is that it treats the patient as a passive player in the health role. Bad things only happen when the hospital/doctor screw up. And even when they're not, it's just sheer bad luck. Or something. I don't buy it.

You know, patients do not always bring things upon themselves. And, when they do, the problems frequently could have been prevented or at least alleviated if they had a somewhat better understanding of their health and healthcare (appropriate for their level of intelligence and cultural background).

 

[masterofmonkeys]

Well, yes, it does. In the UK, patients liable to develop serious complications (like diabetics or cancer patients) would be most often advised to go NHS route. In the US, the most logical solution would be to build up a multi-tier billing system (a bit like ASA risk classification), based on your pre-existing health conditions.

My dad has an A1c of six. Is he really 'higher risk' than someone who doesn't have diabetes? Doubtful. Should I really be placed in a 'higher risk' classification because I like to lift weights? *shrug*

Again, I like the idea of bundling in theory. It gets rid of the incentive to do certain things (like escalate the level of anesthesia to GETA for a local procedure...or send the patient to recovery instead of straight back to holding...or use fancier devices for no real benefit).

You know, patients do not always bring things upon themselves. And, when they do, the problems frequently could have been prevented or at least alleviated if they had a somewhat better understanding of their health and healthcare (appropriate for their level of intelligence and cultural background).

didn't say they didn't. And i'm a huge advocate of patient education in MSK health, nutrition, and exercise. I didn't ask to develop a brachioplexopathy post-vaccination, but it does grant me a higher post-surgical risk for poor wound healing (vasoconstriction among other things), and makes the likelihood of successful palliative treatment much lower. It doesn't make much sense to punish me for these things. But at the same time, it would make sense to punish me for, you know, not washing properly, or hitting the weights before I was fully healed, or smoking.

The point remains that, while it may be unfair to punish a patient for things that happen out of their control, it is equally unfair for the patient to force the costs of their actions on the healthcare system and ultimately everyone else. Our health isn't 100% in our control, but even for those of us with illnesses and injuries, a substantial portion ultimately lies at our feet.

Any system which fails to control for this is just as unjust as a system which forces people to pay entirely for the things out of their control.