Thursday, September 17, 2009

Myths and Lies in Healthcare Debate

The British Medical Journal published a letter to Senator Kerry that was from more than 100 National Health Service (NHS) health service professionals and patients that addresses some of the criticism leveled at the UK's NHS service. Titled "Setting the Record Straight about the NHS" it is worth reading in its entirety. I'm not here to suggest that we need the NHS in the US but having experienced the service as both a provider and consumer I can attest to the high level of service and the feelings of security that arise from a true catch all service that does not require the production of your money for service.

My own personal experience, coming from the fortunate position of having health insurance and good personal health and a family with few medical problems is a fear of approaching any medical facility or health care provider. It remains a mystery, much like the single sock in my dresser that never finds its pair, what the charge will be I end up paying. The idea of health insurance, given the extraordinary amount of money deducted from my pay each month would be that accessing care would cost me little over and above what I already pay in premiums. But this is almost never the case. Following the billing process and managing Explanation of Benefit statements, insurance, medical savings accounts and all the other associated tasks is almost a full time activity and is always a fight. In the tax system you need to reach a minimum outgoing of 7.5% of your Adjusted Gross Income (AGI). That might seem like a lot but each year I am often close and frequently pass this hurdle to be able to deduct anything in excess of the 7.5% of my AGI. This by the way is over and above my insurance premiums. And I consider myself lucky. I wonder how my British friends and colleagues would perceive this state of affairs. At any point in time when I do dig into the details or end up chasing a payment that has not been made I have to organize conference calls to get the insurance agent and the providers billing office on one call to agree what is missing and who needs to fix it. The Providers office does not see it as their problem - hence every time you enter their office they demand you sign a document saying you are responsible for all the costs and as a courtesy they will attempt to bill insurance on your behalf. The insurers for their part fails to deal with the provider except with your forcing the issue and any payments go through their Delay Department that seems designed to make life as difficult for everyone involved as possible. Recently I made a tactical error and agreed to pay the whole cost up front to the provider to get a discount. Suddenly the billing office had no incentive to follow up the billing to get me my insurance payment and the insurance company would not accept any "bill" or claim form me - it had to come from the provider. Heaven forbid I had a serious condition or required extended treatment or clinical visits?

So is this system working for you - I doubt it. But maybe if you started in a system where this was the norm you might not sense that this is an additional unnecessary burden and stress. For all the faults and challenges in the NHS I never feared walking into a physician office for care, treatment or preventative healthcare and screening - never!

Health insurance i nothing more than a commercial operation designed to manage the flow of money with an extra set of mouths to feed adding what some estimates put at 10 - 30% of total cost of healthcare. Is this value for money. While we are at lets crush one misconception here - dental insurance is not insurance. It's does not provide even the most basic of coverage adn the out of pocket expenses are huge even for the most basic of dental care.

With that all said moving the existing healthcare system to a new format is not going to happen. The challenge of "Getting from There to Here" was eloquently detailed by Atul Gawande in his New Yorker piece. The NHS was established on July 5, 1948 but what is lost in the mists of time is the sequence of events to reach that point:
Instead, the N.H.S. was a pragmatic outgrowth of circumstances peculiar to Britain immediately after the Second World War. The single most important moment that determined what Britain’s health-care system would look like was not any policymaker’s meeting in 1945 but the country’s declaration of war on Germany, on September 3, 1939.
The sequence of events and war time necessity created "a national Emergency Medical Service to supplement the local services" which expanded to cover essential services necessary to the population remaining int he country and dispersed by the war time bombing of cities and the returning veterans injured in the line of duty. For many groups providing free care was a necessity of the "war effort" and engaging the private system to supplement the rapidly assembled government system was an obvious step. The system was expected to be temporary but status quo had been destroyed and not least of all because the population, despite the war, had seen an improvement in the health of the population.

The medical and social services had reduced infant and adult mortality rates. Even the dental care was better. By the end of 1944, when the wartime medical service began to demobilize, the country’s citizens did not want to see it go. The private hospitals didn’t, either; they had come to depend on those government payments.
So in 1945 the concept of the NHS was really nothing more than extension of what had been created through necessity of the war.
By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place—with nationally run hospitals, salaried doctors, and free care for everyone. So, while the ideal of universal coverage was spurred by those horror stories, the particular system that emerged in Britain was not the product of socialist ideology or a deliberate policy process in which all the theoretical options were weighed. It was, instead, an almost conservative creation: a program that built on a tested, practical means of providing adequate health care for everyone, while protecting the existing services that people depended upon every day. No other major country has adopted the British system—not because it didn’t work but because other countries came to universalize health care under entirely different circumstances.
So whatever we end up with in the US it won't be an NHS. It might take some of the elements of the NHS and it will be based on our countries experience and system drivers. But within the discussion lets focus on facts rather than anecdotal stories and fears (as seen here in the Scientific American article on "Anecdotal Evidence undermining Scientific Results":
Thinking anecdotally comes naturally. Thinking Scientifically does not
So please start thinking scientifically and base discussion on science and facts and help move this reform forward.

1 comment:

Sandy said...

Winston Churchill, 1948 on his support of creating the NHS.

"The discoveries of healing science must be the inheritance of all. That is clear. Disease must be attacked, whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; it must be attacked just in the same way as the fire brigade will give its full assistance to the humblest cottage as readily as to the most important mansion. Our policy is to create a national health service in order to insure that everybody in the country, irrespective of means, age, sex, or occupation shall have equal opportunity to benefit from the best and most up-to-date medical and allied services available."