Richard T. Scholz, M.D.
President
The
current budget debates, proposals and counter proposals bring to the forefront
the question of healthcare coverage and costs in the United States.
Almost
all are in agreement that the current Medicare structure is unsustainable as it
would consume most of the Federal Budget if its growth is left unchecked.
The cost will be one trillion dollars in 2020 and will be 80 percent of
“mandatory” spending. The Paul
Ryan proposal would eventually (for those currently under 55) turn Medicare into
an insurance subsidy for seniors of a fixed amount with increases linked to the
general inflation rate, not the rate of health care inflation.
The Obama administration has proposed an independent body to regulate
Medicare reimbursements. Currently only Congress has the authority to do this?
We
recently heard Dr. John Chessare, CEO of GBMC, speak on Accountable Care
Organizations. At the start of his
talk, he touted a book called The Healing of America which is an excellent summary of health
care systems in developed nations. Some
surprising facts - the health care system in the U.S. that provides care to
veterans is similar to the National Health Service in the United Kingdom (UK) in
that it is wholly government owned and managed.
The physicians are employees of and the facilities are owned by the
Veterans Administration. Medicare is
akin to the Canadian health system with taxes paying for medical care to private
physicians.
One
difference noted is administrative costs between private insurers and government
healthcare programs - Medicare has administrative costs of three percent as does
Canada, while Britain’s system has costs of five percent.
In the U.S., the administrative costs of private insurers is about 20
percent, a huge difference. The
United States is the only industrialized nation that allows for-profit insurance
companies for basic medical services (some allow for-profit policies for
supplemental insurance for non-covered services).
Another
difference is the requirement that all individuals be covered hence spreading
the risk throughout the population. This
“individual mandate” is currently a great bone of contention in the U.S.
It has been heralded as unconstitutional by those opposed to the recently
passed Federal healthcare legislation, but was actually proposed by the
opposition party in 1993 and supported again in 2008 (legislation that did not
pass).
The
criticisms of the national health plans in other countries that one often hears
is that there are waiting lines for care and that there is a lack of choice of
physicians. The UK has attempted to
reduce waiting times in response to public discontent. Canada does have
extremely long waits to see specialists and then additional waiting times for
surgery if a specialist recommends surgery.
This led to a successful lawsuit in one of the provinces.
The plaintiff held that the prohibition on private medical care was
unconstitutional when an individual was in chronic pain and had to wait an
inordinate amount of time for surgical treatment.
This has not led to a relaxation on the prohibition against private
practice but has led to attempts to set maximum permissible waiting times for
certain procedures and greater spending on the health system which was founded
in 1961 and is called… Medicare. Long
waits are still a fact of life in Canada. Britain had to respond to public
outcries over long waits by dedicating more money to reducing waiting times.
These
health care systems seem to enjoy immense public support – Margaret Thatcher
in her quest to privatize government owned industries did not even consider
attempting to privatize health care.
Other
countries such as France, Germany and Japan are discussed.
One underlying theme is that all health systems are faced with increasing
costs and in some cases, physician discontent.
In Germany, escalating costs have led to a type of capitation that has
caused physician protests.
In
response to increasing financial pressure, several things have happened.
The UK has a quality assurance program that pays bonuses for meeting
quality measures, much like the Medicare Physicians Quality Reporting Initiative
(PQRI) in the United States. Bonuses
are paid for administering flu shots as well as other quality measures similar.
As in the United States, physicians pursue non-covered services to earn
extra income.
Physician
incomes are markedly lower than in the United States, but malpractice costs are
minimal and the cost of medical education is either paid for by the state or is
very inexpensive. Practice costs are
minimal, in some cases due to electronic billing and medical records - there is
no need for personnel dedicated to billing and insurance.
In
England, if a physician can demonstrate that he or she was following the quality
guidelines promulgated by the National Institute for Health and Clinical
Excellence (NICE), malpractice actions are dismissed.
Such protections do not work here as illustrated by a case in Baltimore
some years ago where the failure to perform a PSA test on a young healthy man
led to a judgment against a resident and the hospital where he worked.
For
all of us who are invested in the upcoming health care debate, this book is an
excellent summary of healthcare systems in the developed world and the
challenges facing them.