PsychMD

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The article may have been freely accessible the day it was published, but now it seems to require a paid subscription to acces (not just a simple registration to the site). I would have liked reading it, but, too bad it's not free anymore...
:(
 
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Miklos

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PsychMD said:
The article may have been freely accessible the day it was published, but now it seems to require a paid subscription to acces (not just a simple registration to the site). I would have liked reading it, but, too bad it's not free anymore...
:(
Yes, I noticed that. Here it is...

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Die in Britain, survive in the US

Which is better — American or British medical care? If a defender of the National Health Service wants to win the argument against a free market alternative, he declares, ‘You wouldn’t want healthcare like they have in America, would you?’

That is the knock-out blow. Everyone knows the American system is horrible. You arrive in hospital, desperately ill, and they ask to see your credit card. If you haven’t got one, they boot you out. It is, surely, a heartless, callous, unthinkable system. American healthcare is unbridled capitalism, red in the blood of the untreated poor.

For goodness’ sake, the American system is so bad that even Americans — plenty of them anyway, if not all — want to give it up. They want something more like the Canadian system or our own National Health Service. That is what Hillary Clinton wanted and there are still plenty of people like her around. Tony Judt, in a recent edition of the New York Review of Books, was damning about American medical care and glowing about European healthcare. Think of all the money that is wasted in America invoicing patients and administering lots of separate, independent hospitals.

At the same time, we can’t help being aware that back here in Britain the NHS is not exactly perfect. The waiting lists have come down, according to the government. They have probably come down somewhat in reality, too. But they still exist and, come to that, there is the worryingly high incidence of hospital infections. So is British healthcare better than American? Or the other way round? And how do you judge?

Let’s try the simple way first. Suppose you come down with one of the big killer illnesses like cancer. Where do you want to be — London or New York? In Lincoln, Nebraska or Lincoln, Lincolnshire? Forget the money — we will come back to that — where do you have the best chance of staying alive?

The answer is clear. If you are a woman with breast cancer in Britain, you have (or at least a few years ago you had, since all medical statistics are a few years old) a 46 per cent chance of dying from it. In America, your chances of dying are far lower — only 25 per cent. Britain has one of the worst survival rates in the advanced world and America has the best.

If you are a man and you are diagnosed as having cancer of the prostate in Britain, you are more likely to die of it than not. You have a 57 per cent chance of departing this life. But in America you are likely to live. Your chances of dying from the disease are only 19 per cent. Once again, Britain is at the bottom of the class and America at the top.

How about colon cancer? In Britain, 40 per cent survive for five years after diagnosis. In America, 60 per cent do. With cancer of the oesophagus, survival rates are low all round the world. In Britain, a mere 7 per cent of patients live for five years after diagnosis. In America, the survival rate is still low, but much better at 12 per cent.

The more one looks at the figures for survival, the more obvious it is that if you have a medical problem your chances are dramatically better in America than in Britain. That is why those who are rich enough often go to America, leaving behind even private British healthcare. One reason is wonderfully simple. In America, you are more likely to be treated. And going back a stage further, you are more likely to get the diagnostic tests which lead to treatment.

Fewer than one third of British patients who have had a heart attack are given beta-blocker drugs, whereas in America 75 per cent of patients are given them. In America, you are far more likely to have your heart condition diagnosed with an angiogram — a somewhat invasive but definitive test. You are far more likely to have your artery widened with life-saving angioplasty. In Britain not very long ago, a mere 1 per cent of heart attack victims had angioplasty. In America you are much more likely to have heart by-pass surgery. In 1996 British surgeons performed 412 heart by-passes for every million people in the population, less than a fifth of the 2,255 by-passes per million performed in the United States. America has many more lithotripsy units for treating kidney stones — 1.5 per million of population compared with 0.2 in Britain.

It is true that in America they overdo the diagnostic tests. In one hospital they did a CT head scan on absolutely everybody who came in complaining of a headache. Even some of the doctors began to think this might be over the top when they realised that only in 2 per cent of cases was anything found. But in Britain the problem is the other way round. Having any diagnostic test beyond an X-ray tends to be regarded as a rare, extravagant event, only to be done in cases of obvious, if not desperate, need.

Peggy, an American radiologist, came to Britain to meet her English boyfriend’s family. A pall fell over the visit when the boyfriend’s father found blood in his urine. He went to the local NHS hospital. Peggy knew that blood in the urine could mean something worryingly serious or could be utterly minor. A few tests could make things clear: a CT scan or cystoscopy for example. That would be routine in the US. But no such tests were done by the NHS hospital in Welwyn Garden City where the father was a patient.
 
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Miklos

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Tests are underperformed in Britain: first, because there is a shortage of equipment and second, because the equipment is underused. Britain has half the CT scanners per million of population that America has (6.5 compared with 13.6). It also has half the MRI scanners (3.9 per million of population versus 8.1). In Britain these machines are generally used during business hours only, regardless of the fact that some are extremely expensive. At the Mayo Clinic in America, by contrast, an MRI scanner is in use around the clock.

And if you do get your X-ray scan in Britain, it may well be done with an old machine. Dr Colin Connolly carried out an audit on behalf of the World Health Organisation and found that over half of British X-ray machines were past their recommended safe time limit. Come to that, he found plenty of other machinery out of date, too. More than half of the anaesthetists’ machines needed replacing. Even the majority of operating tables were over 20 years old — double their safe life span.

Look at any proper measure of the capacity or success of a medical service and one finds, again and again, that America comes out better. In Britain 36 per cent of patients have to wait more than four months for non-emergency surgery. In the US a mere 5 per cent do. While in Britain the government celebrates if the waiting times get a bit lower, in America they don’t do waiting.

There are more American doctors per patient so, not surprisingly, patients have more time with their doctors. American patients also get to see specialists as a matter of routine whereas in Britain 40 per cent of cancer patients, for example, don’t see a cancer consultant. There are shortages of specialists in many areas of medicine in Britain.

The father of Peggy’s boyfriend had asthma that was getting worse. In America he would have been seen by an asthma specialist while in hospital. They would have thought it convenient to do any necessary tests while he was readily available. Not in Britain. The father lay in his hospital bed with breathing difficulties but still did not see a specialist. He was told the wait would be six weeks.

Peggy was surprised at how ‘accepting’ her boyfriend’s family was. She didn’t say too much because she did not want to come across as a pushy, arrogant American but she was thinking that ‘in America we’d go nuts if we were told we would have to wait six weeks to see a specialist. Expectations are so much higher.’ Shortly afterwards, her boyfriend’s father was discharged from hospital. Back home, before his appointment with a consultant came up, he died of an asthma attack.

‘Ah yes,’ comes the knowing response, ‘but what about the poor? The rich might get great care in America, but the good thing about the NHS is that everyone gets treated equally. The care is, in the hallowed phrase, “free at the point of delivery”.’
Before going into any detail, let us remember one thing: all those figures at the start about death rates from various forms of cancer were not just for the rich. They were for the whole population, poor included. That said, yes, it is true that American healthcare is expensive. It is true, too, that the financial burden on people is awesomely unequal; but not in the way you might expect. The seriously poor do not get the worst of it. They get treated for free.

They get Medicaid, the national subsidy for healthcare for the poor. Their treatment is paid for by the state and subsidised by the hospital, or rather its other patients and — if it is a for-profit hospital — the shareholders. The poor might not get showered with as many diagnostic tests as those with full insurance, but they get treated and without the delays that are normal in Britain.

No, the people who get the worst of the cost of the American healthcare system are not the poor. They are not the rich either, of course. Come to that, they are not the old, who are covered by Medicare, another government programme. And they are not the majority of people who are in jobs and have company health insurance.

The ones who face major problems are somewhere between middle-income and poor. They are the ones who are not earning enough to take out an insurance policy, or not one with a high limit on medical expenditure. So if they come down with an illness which requires a long — and therefore ruinously expensive — stay in hospital, their insurance may run out and they may have to sell their homes or even go bankrupt. Those who are temporarily unemployed, between jobs, are similarly vulnerable.

The numbers are not large in relation to the whole population. We are talking about a minority of the American population — figures of 35–45 million are mentioned — which is not insured and which is not covered by Medicare or Medicaid. Of that minority only a small proportion will need fairly long-term hospital treatment. But financial disaster can happen and sometimes does. People lose their homes, their savings, everything. Half the bankruptcies in America are people who had previously been ill. In Britain the system might kill you. In America the system will keep you alive but might bankrupt you.

So there is no doubt that the American system is lousy in certain ways. Actually it is lousy in lots of ways. The insurance policies that cover most people are extremely expensive. They can cost as much as $8,000 a year. Part of the problem is that each state dictates what must be in such policies, thus raising the cost and reducing the competition among providers. A young man can be obliged to pay for a policy which insures him against getting pregnant. State interference means that people cannot easily get the kind of insurance they would really like and which could lead to the most economical healthcare. That could be insurance with a large ‘excess’ — offering coverage against real disasters but not against regular bills for ordinary visits to a doctor.

The tax rules in America are also highly favourable to insurance provided through a company, but offer little of the same advantages to anyone taking out insurance personally. That gives rise to the ‘between jobs’ period of risk of falling ill.

There is much that is wrong with American healthcare. The inflated cost is boosted by restricted entry into the medical profession. It has been pushed up by the courts which have given crippling damages for medical negligence. The doctors have to insure themselves against such damages and so the insurance premiums they pay are huge. Doctors can only pay these by charging high fees. The risk of being sued is also an important reason why American doctors would rather give you too many tests than too few.

Let’s face it, the American system is rotten. It is not even a system. It is a hotch-potch. Most hospital provision is by not-for-profit, private hospitals. But the biggest buyer of medical care is the US government. Through Medicaid (for the poor) and Medicare (for the old) and other schemes, the government pays for 45 per cent of all healthcare. (The British assumption that American healthcare consists of an unfettered free market could not be more wrong.)
Most British people do not realise that the non-private hospitals in America are not run by the federal government. They are local government hospitals. The San Francisco General is run by the City of San Francisco. And another unexpected thing for Brits is that even in such local government hospitals treatment is not free to those who can afford it. (Incidentally, all sorts of American hospitals — especially the not-for-profit ones — receive large sums of cash from charitable benefactors.) And if you think all the above is confusing, that is hardly even the beginning of the bewildering diversity and contradictions of American healthcare. It is a muddle.

The British system was a muddle, too, until Aneurin Bevan came along in 1945. As minister of health, he set about unmuddling it. We, too, used to have local government (‘municipal’) hospitals until he took them over. He took over the charitable hospitals too, like St Mary’s and Moorfields and many other famous ones. He made it not confusing at all. What could be simpler than the central government being in charge of everything? Over time, the government put itself in charge of all the doctors, too. So all was made simple and clear.

But the curious thing is that the new, improved, simple state system of Britain does not work as well as the American muddle. You have a better chance of living to see another day in the American mishmash non-system with its sweet pills of charity, its dose of municipal care and large injection of rampant capitalist supply (even despite the blanket of over-regulation) than in the British system where the state does everything. It is not that America is good at running healthcare. It is just that British state-run healthcare is so amazingly, achingly, miserably and mortally incompetent.
 

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The quoted numbers on cancer survival are somewhat skewed:
- in the US we detect a lot of early stage breast cancer (DCIS) through the mammography screening program. Many people in the cancer community doubt that agressively treating DCIS has an actual effect on breast cancer mortality. Cancer survival is commonly measured in 5 year survival, DCIS won't give rise to invasive cancer for another 10 years, thereby evading the 5 year survival time window. --> we are potentially treating a good number of people who wouldn't have died of their disease within the time window we are looking at.

- in the US, a good number of prostate cancer cases are detected through PSA screening. Prostate ca is a biologically highly variable disease. Detecting prostate ca in a 90 year old is meaningless for his survival. 'Treating it' with testosterone antagonists, and booking the fact that he didn't die of it as a 'treatment success' is going to skew your data.

- Many of the cases of colon cancer we book as treatment successes are actually large adenomas with some foci of invasive ca. Again, it is not clear how the 'treatment' of these affects the 5 year survival.

I am not going to comment on which system is 'better', but here are some points I would like to add.

- In the US, we are testing until 'the cows come home'. It is not unheard of to see 20! CT scans on a patient with kidney stones within a 6month period. Every time they come back to the ED with hematuria, they get another one. Using more testing, doesn't necessarily translate into better treatment.

- The old story of the 'negative wallet biopsy'. While it is true that in a US hospital, you do get asked as to how you are going to pay for the ED visit, turning you away if you don't make a deposit is distinctly illegal and subject to stiff fines for the hospital (EMTALA).

- The coverage problem in US healthcare are the 'working poor'. People who have a job, don't qualify for medicaid but don't work for a company that provides health coverage. There is political consensus across party lines that this has to be fixed somehow, there is however NO consensus how to achieve this.

- The number of people who want a 'system like in canda' is actually diminutive. There is a good number of people who want to have a system that avoids some of the negative aspects of US medicine, but they surely don't want to wait 9 months for their cataract surgery.
 

PsychMD

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Miklos, thanks for having the article handy. I pretty much agree with the author's presentation. I still think it's a shame that there is a relatively significant (and IMHO, GROWING) part of our population who are working (and not necessarily poor, but here we can include even some dilligent and SOLVENT self-employed people) who basically have to go without health-insurance and are just a step away from financial catastrophe, and for whom, like fw said, there just isn't any political will to find a specific solution.

I personally even know several PHYSICIANS, in their PRIME, who do not have any current health insurance at all, and quite a few more who only have catastrophic coverage, but nothing to cover outpatient or less catastrophic occurences.

I know things aren't that peachy in the EU either. It seems everyone is sort of struggling nowadays re. exponentially escalating costs and demand for healthcare. In the end, it is the "regular" sort of middle class people that are ultimately caught between a rock and a hard place everywhere. They bear most of the taxation burdens with very little to show for it. They are the ones supporting the poor, the elderly, the infirm. At the same time, CEO's are earning obscene salaries. Physicians too, increasingly so, are quickly becoming part of this extraordinarily squeezed and overburdened middle class. (Gone are the days of the "upper middle class" fantasies, at least from my vantage point here in the US.) There is a lot of "status anxiety" as well, and in the US it seems just so easy to slide irreversibly into bankruptcy that at times even the most basic sense of mature security feels quite threatened (unfortunately at a higher rate during tougher economic times, such as the ones we are currently navigating).

Although this digression doesn't have much to do with the topic at hand, I also deplore the excessive regulatory and liability burdens that physicians are contending with at this time in the US. It's almost as if the system is set up to really squeeze the very last drop of energy, stamina, wealth building ability, etc. from our healers. It really demands a lot from them and gives increasingly less in return (pretty much across the board for almost all specialties at this time). It is extraordinarily STRESSFUL to be a practicing physician in today's US, and seems to have gotten increasingly stressful on a broader scale in the last decade, at the very least. Maybe we are indeed a generation of "narcissistic whiners", looking for an easier "lifestyle", I don't know. But a lot of currently established mid-career docs are talking quite bluntly nowadays that they would not encourage their kids to go into this profession. This current level of dissatisfaction seems to have grown beyond any original vocational callings or inherent altruism and dedication which are also well recognized hallmarks of our profession. And since physicians are part too of the health-care delivery system...we rant and rave away our current generational anxieties and stresses and extrapolate them at times in a generalized sense.

I agree that if one has a catastrophic acute illness, or cancer (maybe) it is likely that the outcome of care is probably qualitatively superior in the US. I have strong doubts re. chronic patient population (which comprise actually, IMHO, the "bulk" numbers straining the current system). I also deplore certain public health stats, although I am aware how interpretable stats are sometimes. Not too sure about how prevention works either when you have skyrocketing levels of obesity, diabetes, etc. (one could include here maybe some of the psychiatric disorders as well, but I don't have numbers so I'm just speculating).

I'm just observing and ranting away...I don't have any specific solutions either. I think that one has to further parse the problem out re. public health "outcomes" and re. illness/tx. outcomes. I think that often, when we have strong ideological feelings about one system or another, we also, in a human way, might tend to blur a bit the lines and become less specific, to overgeneralize, etc. I'm doing it myself in this very post, although I am merely posting a signal of distress...one of many...rather than any reasoned or substantiated proposed pro- or con- arguments or "solutions". I sure wish that the voices of people who are truly more expert than us "amateur commentators" would be better and stronger heard in these times than the voices of politicians or even journalists.