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| Reforming the Healthcare Mess: Can it be done? |
THE UNITED STATES IS THE only remaining industrialized country without some form of universal access to medical services, in part because policy debates are driven by false, self defeating beliefs. One such belief is that the United States cannot afford to cover the uninsured, when in fact a coordinated financing system is the key tool for holding costs down, and there are affordable ways to do it. Even the largest employers are unable to hold major cost drivers in check.
A second belief, held by the medical profession, is that they would lose still more power than they have already under corporate managed care. Yet universal health care systems elsewhere give the profession greater institutional powers.
Third, many believe that the only alternative to voluntary, market-based health insurance is a single-payer system financed by tax revenues, when there are a number of options.
Fourth, many believe that the United States is so large and diverse that any lessons one might learn from smaller and less diverse countries do not apply here, so why bother with possible lessons from anywhere else?
Finally, conservative policymakers and providers imagine that a universal health care system would mean low salaries, rundown facilities, poor quality, and endless waits to see a doctor, as with the British National Health Service (NHS). In US policy debates, the NHS serves as a dreary image of everything we want to avoid and might get if we actually developed a universal system that was equitable and efficient. American journalists almost never describe its remarkable achievements or its innovative and instructive reforms.
As one who’s lived in Britain I can attest to the functionality of the system, but also be the first to admit that it has its problems. Which system doesn’t? Most of Britains NHS’s dreary features—the rundown hospitals, the chronic shortages of specialists in every field, the long waiting lists—stem from chronic underfunding and undersupply of personnel and equipment. Many universal health care systems avoid these problems.
How well a system is designed must always be distinguished from how well it is funded; the NHS is quite well designed but under provisioned. By contrast, the US health care system is richly funded but designed so that it maximizes waste, inefficiency, and inequity. This makes people working in it feel it is inadequately funded as well as badly designed. A large health services research industry has arisen to try to figure out how to reduce these inefficiencies but without discussing how the basic design of US health care—risk-selecting insurers, self-enriching fiefdoms, and profit-seeking vendors—impedes that goal. Learning about other, better-designed systems provides a needed comparative perspective.
Can Hilary make a difference? It is important to understand, given the dominance of conservative views in US politics, that the NHS and related systems may be characterized by some as “socialist” but may actually support conservative values: to maximize the ability to exercise individual freedom and responsibility by enabling people to take care of themselves and be productive. Indeed, conservatives in every other industrialized country believe their values support universal access to health care.
How did the British Do it?
Excerpts from Articles from American Journal of Public Health are provided here courtesy of American Public Health Association
The British have made a number of good decisions that are transferable to other systems. Some of these are mentioned in the text and others come from a more comprehensive list.
1. Health care should be “free at the point of service,” a founding principle of the NHS. Although this is precisely opposite the principle of American employers and politicians as they increase co-payments, the evidence from the United States and abroad supports the British position. Co-payments create inequities, raise barriers to access, and usually do not achieve their goals. They are not very effective in containing costs, because patients have discretion over just a small percentage of ambulatory and elective choices. Most “cost containment” efforts focus on minor, front-end costs rather than addressing major, back-end costs.Moreover, co-payments undermine the goals of appropriate and effective care and discriminate against the working and lower classes. Such evidence seems ignored by advocates of co-payments in Congress and the business community.
2. Fund health care from income taxes. Whenever the British have reviewed the option of using health insurance instead of income tax financing, they have found evidence that an insurance-based health care system costs more to operate, is more inequitable, controls costs less effectively, and provides no basis for population-oriented prevention or public health gains. By sharp contrast, US employers are moving the other way, from large group insurance toward individuals buying their own policies on a voluntary basis, long known as the most costly and inequitable way to structure health insurance, with few means to contain costs, raise quality, or improve the health status of the population.
3. Establish a strong primary care base for a health care system. Every UK resident chooses a personal physician or practice. The system provides incentives to practice in underserved areas and prevents new GPs from setting up in saturated, affluent areas. The primary care base of the NHS is widely celebrated 31 and has been consistently strengthened over the decades. For example, as recruitment into general practice and morale waned and sub-specialty medicine grew in the postwar years, the British raised GP lifetime incomes to equal those of subspecialists. Other changes were made to strengthen primary care by providing more practice staff and nurses in order to encourage solo practitioners to come together into teams. More recently, these teams have been further enlarged by bringing together geographic clusters of GP practices into large Primary Care Trusts that include all community health care services and many social services as well.
4. Pay GPs extra for treating patients with deprivations and from deprived areas. Almost 20 years ago, Brian Jarman developed a deprivation scale based on factors that affect clinical care, so that living alone is a factor as well as low income. The British have long paid GPs considerably more for taking care of patients who are more likely to have more problems and whose care is more demanding. American health policy researchers are still debating whether it can be done.
5. Reduce inequalities in historic funding that usually favor the affluent. Regional inequities in the United Kingdom are much smaller now than 20 to 30 years ago, and all major budgets are risk adjusted, in sharp contrast to the United States. Reductions have been achieved through national planning, building up hospitals and resources in underserved areas, and giving disproportionately more new funds to less well-funded areas.
6. Devise a set of bonuses for GP practices that reach population-based targets for prevention. Starting in 1990, the government added a new element to the GP contract—lump sums or bonuses for carrying out preventive measures on a high percentage of the patient panel (enrollees). For example, a practice could receive about $1250 if it completed the childhood immunization series for 70% to 89% of all eligible children registered and $3700 if it completed the series for 90% or more. The result has been high levels of immunizations and other preventive measures. Another incentive rewards GPs for using generic drugs for 70% of their prescriptions. Why don’t US health plans follow suit?
7. Pay all subspecialists on the same salary scale. This policy conveys the sense that psychiatry is as important and complicated as cardiology and pediatrics as challenging as orthopedics. On what defensible grounds should one specialty (cardiology) be paid more than another (psychiatry)? Equal pay signals to young doctors that they should specialize in what they do best and enjoy. Yet in many systems pay differs greatly by specialty. This decision has many cultural, organizational, and clinical benefits, even though some subspecialties have more opportunities to supplement their incomes than others.
8. Control prescription drug prices while rewarding basic research for breakthrough drugs. Like most other countries, the British have a national board that negotiates with the industry. Pharmaceutical companies like to portray this approach, which is nearly universal outside the United States, as “price controls” that can “never work.” In fact, nationally negotiated price schedules have worked well for years and saved billions. The British approach goes further, by rewarding breakthrough research and discouraging “me too” research or patent manipulation. It regulates profits, not prices, by having companies submit financial records and by determining set proportions for expenditures (e.g., a limit of 7% of sales for spending on marketing) on in-patent branded drugs.If prices result in higher profits than allowed, the excess profits are paid back. The British approach both ensures and limits profits. Meanwhile, providers are given drug budgets within which they have to live. Any other nation or large buyer can learn from this system.
Note: GP means General Practitoner or otherwise known as PCP - Primary care physician
The evidence it clear - IT CAN BE DONE! Let's hold our politicians accountable with our votes.
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Posted by Passion09 on 2008-02-08 12:31:04 | Rating: | Views: 187
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