Data, anyone?

[From Rick Marken (940901.0830)]

Bill Leach (940831.21:12 EST) --

"Economy of scale" (of a single payer system) has been seriously
challenged.

How? Since it works well wherever it has been tried, what's the challenge?
Doesn't anyone care for data anymore? It works wherever I've heard of it
being implemented -- Canada, England, Denmark -- and virtually everyone likes
it. It's simple and efficient. I have yet to hear anyone say what is good
about the US health care system. What is so good about it? The only thing I
can think of is that we seem to be good at keeping corpses alive long
after they are clinically and/or spiritually dead.

My experience with the health care system in this country is that it is
absolutely appalling. When my kids were little I remember having to fill out
reams of forms (proving that I had health insurance coverage) before they
would start sewing up a cut or taking a temperature on one of my babies. This
was while I had health insurance with one of those great, efficient, private
enterprise insurers. Why all the red tape and regulations? I thought that was
just supposed to be the job of the "government". What crap. A friend of mine
is married to a Dane; when she was over there getting married she got sick;
a doctor was at her bedside (BEDSIDE) immediately and there were no papers or
forms to fill out; the govenment took care of the whole thing; if there was
any beaurocracy, it occurred in the background. Indeed, my friend (who is a
professor in the US) believes that there is a good chance she would have died
of the same illness in the US -- it was some kind of acute gastrointestinal
thing and she had visions of being made to fill out all the proof of
insurance forms and whatnot; she was amazed at how easy it was in Denmark
(and she's not even a citizen; she was covered automatically, as a visitor,
on her mother-in-law's insurance, no questions asked); even if she hadn't
died in the US, she sure would have suffered unnecessarily for a LOT longer.
Oh, and the cost of the Danish govenment health care beaurocracy? I recall
seeing that the cost per capita is almost half of what health insurance costs
us in the US.

What in the world do you LIKE about the US health care system, Bill? The only
people who could possibly be happy with it are the doctors (making a fotune,
thank you) and insurance companies (making a, possibly smaller, fortune,
thank you).

I realize that my statements do not provide any proof that a single
unified health care system will be any worse than "privately run" but at
the moment I don't see where there will be any improvement of problems
that I see facing the health care industry

What about the DATA?? Why does single payer health care seem to work in so
many countries? It works (as far as I know) in terms of less cost/person,
more effective heath care (longer average life span, much lower infant
mortality rate than we have in our country) and public acceptance (I doubt
that a significant percentage of Danes or Canadians would be willing to give
up their single payer system; and I would bet that none would want to go to
the US "best of all possible health care systems").

I only have to look to the "impressive" efficiency of anything else that the
federal government administers to conclude that overall costs have to go up.

But that's just your imagination; try the data. Medicare is run extremely
efficiently; more efficiently than any for-profit health care system. Ok,
the post office probably could be improved. It seems to me that the problem
is figuring out what the govenment should be doing and how to set things up
so that it does it the best. Private business obviously has it's place -- but
clearly it's not in the health care field.

Oh, and I agree that there is much too much suing of doctors going on, and
that this brings up the cost of health care (though surprisingly little,
relative to other costs). But how do you limit spurious medical lawsuits
except by passing laws placing limits on these suits -- ie. by government
regulation.

This anti (or pro) govenment ideology has really gotten in the way of just
solving problems, it seems to me. I feel bad for all those insurance people
who won't be able to make money pushing around paper anymore -- but
eventually the public will see past this "govenment can't do it" hooey and
implement a single payer system like that in all other developed countries.
If they can do it soon enough, then maybe my kids won't have to go through
the beurocracy that I had to go through when they were covered by private
insurers. When my grandchild-to-be cuts her foot, my daughter could just
bring her in to the nearest hospital and have her sewn right up -- without
waiting hours filling out forms.

Maybe Clinton can make it happen; all he has to do is ask the American public
what I'm asking Bill Leach: What in the world is so good about the current
US health care system? The complexity? The red tape? The egregiously high
cost, high infant mortality rate? Why in the world do you imagine that a
single payer system (like those implemented in every developed country
except the US and that we know works BETTER THAN OUR PRIVATE HEALTH CARE
SYSTEM) wouldn't work here?

Clinton should just present the data. Then maybe the insurance companies and
doctors would be forced to show some data (that they are obviously hiding)
that makes private health care look good. Maybe people can be persuaded by
the DATA, for a change, rather than by catch phrases ("govenment
beaurocracy", "socialized medicine").

Best

Rick

[Martin Taylor 940901 17:00]

Rick Marken (940901.0830)

A friend of mine
is married to a Dane; when she was over there getting married she got sick;
a doctor was at her bedside (BEDSIDE) immediately and there were no papers or
forms to fill out; the govenment took care of the whole thing; if there was
any beaurocracy, it occurred in the background.
...she was amazed at how easy it was in Denmark
(and she's not even a citizen; she was covered automatically, as a visitor,
on her mother-in-law's insurance, no questions asked);

More anecdotal data.

I fell ill in Dusseldorf, Germany, while in a shop. An ambulance came
and took me to hospital. I had a medical examination, including X-rays
and a doctor's consultation. He decided it was not serious, and some
humungous aspirins fixed it for long enough to get me to the plane next
day. The time in the hospital emergency department before they decided
I was well enough to go was about 6 hours. The cost? Zero, apart from a
fare for the ambulance, which the Ontario Health Plan paid back after I
got home.

Why zero? I offered my provincial health card (which would have covered
the cost), but the doctor said that it was his call whether to charge me,
and he wouldn't because I was Canadian. The cost of the paperwork to pay
would be paid by his or my government, and the cost of the treatment
would be paid by mine, and he assumed that if he fell sick in Canada,
much the same would happen. If I had been a US citizen, he said he would
have charged the full shot.

(I doubt
that a significant percentage of Danes or Canadians would be willing to give
up their single payer system; and I would bet that none would want to go to
the US "best of all possible health care systems").

Oh, you'd be surprised how affected we are up here by the negative US
advertizing. There are lots of people quite happy to point out all the
wonderful machines that you in the US can have used by your doctors (if
you have a million dollars, which such people don't seem to notice). I
feel that our health system is definitely threatened by the proximity of
your unhealth system, whose main purpose seems to be to extract money
from people on pain of augmenting their sickness if they can't or don't pay.

ยทยทยท

==========

Oh, and I agree that there is much too much suing of doctors going on,

Yes, and I think legal services ought to be paid in the same way as medical
services (by government), so that the rich cannot beat the poor by paying
more for lawyers.

Blah--not PCT, for sure. Sorry about that.

Martin

<[Bill Leach 940901.20:49 EST(EDT)]

[Rick Marken (940901.0830)]

How? Since it works well wherever it has been tried, ...

Speaking of data...

Rick, I admit that I don't have the data available and will further admit
that even the data I have seen is questionable.

As for anecdotal 'support', I can cite many "counter-examples". Indeed,
a very dear friend died in Canada just a couple of years ago and medical
authorities cited "inability to provide adequate care" on the part of the
Canadian medical people as the reason for his death. While on several
trips into Florida over the last several years, I met dozens of people
that were in the United States only because it was necessary for them to
be able to obtain required medical care.

I have read several sets of statistics indicating that complex medical
procedures are routinely available in the US but have "waiting lists" in
most other (all cited) countries. Waiting times that usually mean that
the person waiting will die prior to the performance of the procedure.

In addition, there are other factors that I am quite sure that none of us
knows the correct information. For example, how much (if any) does the
US contribute to the maintainance of the medical system (or economy) in
these countries?

Will the medical community continue to discover, invent, and develop
improved medical procedures in a centralized system? Will a more closely
regulated medical profession attract more or less competent, motivated
people?

I don't know of course and I realize that I am strongly influenced by my
own experience and circumstances. In the first place, I am "one of the
statistics" (or was). Until just a few months ago, I have not had any
medical insurance (since 1977), most of the time I just could not afford
the cost. I am not sure that I can now and in particular, I am not sure
how long into next year I will be able to afford insurance. Even with
insurance, I know that a major medical problem "would wipe me out". I am
a bit annoyed that in my perception, a significant portion of my income
has gone to not just provide medical care that I can not afford for
myself for others but that in so doing, I have helped to increase my own
medical costs.

Another thought that crosses my mind however, is that there are two times
in my life when I was really miserable. The first was while in the armed
services and the second was when I worked a "union job"! Seems to me
that maybe both "extremes" are about equally bad and for the same basic
reason (though I am admittedly just now picking up on the reason).

-bill

[Paul George 940902 10:30]

Sorry about the un-annotated response to the Intro post by Dag. I intended
direct email

I should know better than to jump into this, but I can't resist. Much of my
family is in the medical profession, and so I have a degree of familiarity.

[Bill Leach 940901.20:49 EST(EDT)]

responding to [Rick Marken (940901.0830)]

...I met dozens of people
that were in the United States only because it was necessary for them to
be able to obtain required medical care.

I have read several sets of statistics indicating that complex medical
procedures are routinely available in the US but have "waiting lists" in
most other (all cited) countries.

You two are talking about two different health care systems. One is for care of
routine trauma and illness, along with preventitive medicine. These things are
normally provided by GP's and nurse practitioners and have a large economic and
quality of life payback. The other is critical care which (in the US) is
provided by specialists and expensive equipment

In the latter case people have a strong desire to live, regardless of cost or
suffering. While life may be priceless, that merely means it is worth nothing
in monetary terms, not infinite. The callous (me) might suggest that these
highly expensive procedures are not cost effective. They have poor prognoses
and eat up the recipient's and their families' substance. A heart transplant
_may_ extend someone's life, but I would argue the money would be better spent
on basic medical care for others. It might even be used for their children's or
grandchildren's education or support. Sometimes dignity and a sense of
responsibility dictate that you should accept the inevitable. Given finite
resources, some kind of triage is needed.

Waiting times that usually mean that
the person waiting will die prior to the performance of the procedure.

According to most accounts I have heard,and I work with several Canadians, this
is a most unusual outcome. 'Watchfull waiting' is becoming an more accepted
treatment technique in this country. There is some indication that US patients
demand action and US doctors are much too eager to 'do something, anything', in
the latter case partially for financial reasons.

Will the medical community continue to discover, invent, and develop
improved medical procedures in a centralized system?

Yes, for the same reasons that PCT'rs perform research without rich financial
rewards. Many are academics who are (at least partially) motivated by a desire
for fame and recognition. Only recently has the money making potential of
medical equipment been a major motivator (drug companies are arguably a special
case). I also do not observe that medical progress in absent in the rest of the
world. Note that prior to the Guild status of the AMA, medicine was considered
more of a vocation than a profession. It was also not generally very well
paying, though respected, kind of like a minister.

Will a more closely regulated medical profession attract more or less
competent, motivated people?

At the moment it attracts (or more accurately passes) those who are motivated
by money. One must go through long years of training and abuse in the guild to
get a licence to practice. One will have incurred very large bills for the
privilidge. Indeed one could alledge that the extreme competition for admission
to and within medical school, and the very long hours required for internship
and residency would tend to weed out most of those motivated by compassion or a
desire to heal. We are perhaps selecting for doctors with the motivational
structures of lawyers. Perhaps lower incomes and educational costs (due to less
restraint of trade) would provide more talented and motivated people for health
care.

I might also add that the explosion in medical costs only ocurred after
insurance was sufficiently common that ability to pay for procedures ceased to
be a consideration. Dozen's of middle men could then charge what the market
would bear (anything 'reasonable and customary' ;-}). Profit margens for
equipment, tests, and supplies are generous, as costs could be passed on.
The other factor was the conversion of hospitals (and medical practices) from
charitable or educational institutions to profit making ventures headed my MBA
types. "Thar's gold in them thar bills". I might add that the cost of an
abortion has remained at about $200 since the 70's, as it is generally not
covered and so must be paid for out of pocket.

Enough

Paul George

[Bill Leach 940901.20:49 EST(EDT)] writes:

I have read several sets of statistics indicating that complex medical
procedures are routinely available in the US but have "waiting lists" in
most other (all cited) countries. Waiting times that usually mean that
the person waiting will die prior to the performance of the procedure.

If the subject of this thread has to do with the importance of accurate
data (or information) then some of the discussion has certainly lost its
way.

The above statement illustrates the point.

As a recently retired Canadian/Ontario physician I can tell you that the
fact that someone is on a "waiting list" means that he/she has at least
become someone's administrative/political responsibility - with the
accountability that entails. This differs from jurisdictions where, far
from procedures being routinely available, there are many millions of
people do not make it into the health care system at all and those who do
run risk of being impoverished.

Urgent cases are placed on a special waiting list if indeed they don't
bypass any waiting list at all. All hospitals, and indeed all physicians as
far as I know, give their first and earliest attention to emergencies, then
to the most urgent cases, i.e. they set priorities. Waiting lists are
priorized and kept updated. This includes patients waiting for cardian
surgery. If and when a patient's condition deteriorates he/she will be
moved up to the urgent/emergency category.

As we know, if a patient dies, suppositions of perceived dereliction may
hit the fan - i.e. papers and TV. So there are these (and other) potent
accountability factors - anticipatory feedback and control - built in which
influence physicians and politicians.

Of course people continue to die, but to automatically blame the health
care system, on the grounds of what is clearly inadequate information, is
not to be serious. What are more serious are the questions with regard to
standards of evidence that are implied by the arguments offered.

Cheers!

Bruce B.

<[Bill Leach 940903.13:51 EST(EDT)]

[Paul George 940902 10:30]

I am sure that we all hope that "she controls well" but this is one area
where that seems to be the case much more often than not! :slight_smile:

-bill

<[Bill Leach 940903.13:59 EST(EDT)]

[Rick Marken (940829.1840)]

I am sorry...

Thank you. I have fortunately had rather limited experience with the
death of people close to me. Mike's death was and still is a really
disturbing thing for me. "Life goes on" of course and his wife has even
remarried recently though I am concerned that a couple of their children
are still having trouble coping. Mike was one of the finest examples of
a person that both means and does "good will toward others" that I have
ever known. Everyone that I knew, that knew Mike (especially his
children) appeared to "just plain want to be around him".

I am not trying to be "contrary" here and am genuine in the question that
I raise...

You say:

tries to control costs. Also, if the government has an "agenda" by
trying to regulate med school attendance then so does the current
private health care industry -- notably the AMA. I don't see the AMA

How does creating yet another government power structure "fix" this
problem? Does it not only move the problem? Is not the problem rather
that "private industry" is coercively controlling others? Is not
government the "unwitting" or otherwise instrument of this existing
control? Does not the AMA's control derive from laws passed regulating
the health care industry?

As far as I understand it, the existing laws governing health care were
created to "protect us" (the common citizen) from "quacks" and
"charlatans". Problem with this is, as usual, who decides who is a
charlatan and who is not? Does not giving a group the authority to make
such decisions set up the potential for greater mistakes much less
subversion of the original intent than no regulation at all?

Please, understand me in that I do believe that anarchy is also not an
acceptable solution but abuse of people by other people is really not a
function of the existance of "organizations to prevent abuse". Whether a
person is the "head" of the AMA, Monsanto, UAW, EPA or just a small
businessman does not affect much the nature of their treatment of others
(or abuse of relationships) but only the magnitude. The converse is of
course also true in that the greater the power the greater the potential
that someone helping others may have.

I think that the issue is not how much authority someone or some group is
granted by the "collective" but rather, if such power is granted, what
sort of system is necessary to ensure that the references that follow
from the objectives are indeed the references for the members of the
controlling organization.

I realize that I may yet be "off on another of my tangents" but it seems
to me that ultimately all of these sorts of questions come back to the
same point. If a (large portion of a even 99.9%) group of people agree
to some standard or limit that is to be applicable to each and every one
of the whole group, what means exists to insure that the political or
economic system that is put into place to enforce these limits is doing
just that?

-bill

[Martin Taylor 940904 17:00]

There was a request for data on the cost and effectiveness of health care
systems in different nations. Here are some.

These data come from the World Factbook 1993, put out by the CIA (I think;
at least it is a US Government publication). I selected data for all
Western European countries down to the size of Liechtenstein, plus
Austria, Australia, Hong Kong, Japan, and New Zealand, which seems to
cover more or less what we used to call "the First World."
There are 26 countries in the data set (including Turkey, which I included
because it is a NATO member, though not strictly Western Europe.
The same goes for Greece.

I took three items: infant mortality, male life span, and female life span.
On these three items, the US ranks 21st of 26, 22nd, and equal 20th.
This is not the performance to be expected of the country with the
"most efficient economic system in the world". Canada ranks 13th, 7th
and 3rd on the three indices (Japan and Hong Kong are the best, with
rankings 1, 3, 2, and 2, 1, 1 respectively).

The World Factbook does not mention expenditures on health care, but
there was a recent newspaper article which I cannot now find, which said
that the US has the highest per capita spending on health in the world,
approximately 1.6 times Canada, which I think was second (I may be wrong
on the cost ranking for Canada).

It seems that US dollars are not spent efficiently on health care.

Martin

<[Bill Leach 940905.08:11 EST(EDT)]

[Martin Taylor 940904 17:00]

Let me continue "playing the devil's advocate" here for a bit and just in
case you missed it let me state again that I do not believe that the
American Health care system is as good as it should be and have believed
for a long time that it was becoming worse. Where I differ is in what I
believed caused the problem and what changes would likely be a solution.

Overall the numbers that you cite are interesting not only for their
possible relationship to "quality of health care" but also to how health
care may or may not be related to life span.

Many health care people have been asserting for quite some time now
(though it is only now "popular in the media") that the major factors
influencing illness and life span in the US are poor "life style" choices
rather than failure of the medical system. Naturally, there is clearly a
"vested interest" in such a perception but there are a few "fringe"
doctors that support the claim with "case" evidence produced by employing
unique treatment techniques as well as the results from some rather
limited medical research in the same area.

I suspect that I will always have a problem with "snap shot" figures in
that I don't accept that such comparisons imply causality. Indeed,
though probably beyond the amount of research effort than any of us would
be willing to undertake, a history of the changes in these factors and
the change in cost per person as a percentage of income (real cost) would
be instructive. The problem again though is that, as far as I know, we
have no way to even determine the nature of "other factors" much less
estimate their effects.

Of course just showing a high cost per person with less than "excellent"
results is a pretty clear indication that something is wrong even if not
necessarily an indication of what it might be...

-bill