Sunday, July 16, 2017

More on US Healthcare

NEJM has an article reporting on the Commonwealth report. As we have noted previously, Commonwealth is both a left wing entity promoting single payer systems like the NHS in the UK and that its head was a major player in the ACA development. This player now seems to be decrying the system he was part of creating. But I leave that till later.

The NEJM article notes:

The first challenge the U.S. health care system must confront is lack of access to health care. The high-income countries that are top-ranked according to the most recent Fund report (the United Kingdom, Australia, and the Netherlands) offer universal insurance coverage with minimal out-of-pocket costs for preventive and primary care. Affordable and comprehensive insurance coverage is fundamental. 

As has been noted again and again the socialized NHS has one of the worst records in treating cancers. Why? They delay in seeing a specialist and the delay in obtaining any remedial care. In the US if one wants there is a wealth of immediate care for almost any problem. Take MSKCC in New York. The doors are always open. The problem there however is not access but knowledge of what must be done. We also have a multiplicity of Trials allowing for leading edge access.

The second challenge is the relative underinvestment in primary care in the United States as compared with other countries. Other countries make primary care widely, and more uniformly, available. In contrast to the United States, a higher percentage of these countries’ professional workforce is dedicated to primary care than to specialty care, and they enable delivery of a wider range of services at first contact, even at night and on weekends.

 This is one of those; on the one hand and on the other hand, issues. Primary care should be able to deal with the up front issues that lead to specialty care. For example, obesity, Type 2 Diabetes. Primary care physicians are all too uncomfortable confronting an obese person. They would rather hand out medication and wait for the inevitable heart disease or kidney failure and then hand the disaster of a patient to a specialist. Drug abuse is the same. If we allowed and educated primary care physicians to deal bluntly with the up front problems then perhaps we could reduce the need for some specialists.

The third challenge is the administrative inefficiency of the U.S. health care system. Both patients and professionals in the United States are baffled by the complexity of obtaining care and paying for it. Clinicians and their staff spend countless hours completing documentation to prove that insurance coverage is active, that benefits and services are covered, that services were delivered, and that payment or reimbursement occurred. Coping with the byzantine layers of administration results in high levels of burnout for doctors and other professionals, which can reduce the quality of care. The complexity also affects patients, who receive confusing benefit descriptions, limited information about doctors and hospitals, unintelligible and often unexpected (or “surprise”) bills for services, and unpredictable copayments at labs and pharmacies.

On this I agree. But the problem here strangely is the making in some small way of the efforts of the CEO of Commonwealth while in the previous Administration as well as decades of Government interference. So the solution is more Government? The logic is not only compelling but reeks of insanity!

The fourth challenge is the pervasiveness in the United States of disparities in the delivery of care. People with low incomes, low educational attainment, and other social and economic challenges face greater health risks and worse health in all countries, but especially in the United States, which has a less robust social safety net than other high-income countries. Other countries achieve better population health by spending relatively more on social services than on medical care.

Again the suggestion is to spend more. Frankly the US safety nets have exploded over the last twenty years. The problem is life style that is supported by those safety nets. Obesity is explosive in this population because the "free lunches" supplied are carbohydrate rich and excessive. BMIs have exploded from 20-22 to 30-42! What safety nets are these folks demanding? Is this something where we are to hold the hand of every person, spoon feed them?

Overall the report has in my opinion severe drawbacks. The very questions seem to pose the answer they present. The structure is highly subjective and lacks any substantial set of measurable metrics of value.

But alas, if the more Government we gave in the last eight years did not work, well just add more of that again, until it works.