Interesting Comparison of World Health Care
Posted by WhiteCoat on May 10, 2008
Reading a blog on Medscape and someone linked to this site where there is a video documentary comparing health care in the United Kingdom, Japan, Germany, Taiwan, and Switzerland.
A written summary is contained here.
So, assuming that our US population will accept it, and assuming that we can restructure the tort system, which parts of each system should be incorporated into the new system in the US once the current system collapses?
Japan was probably the most scary to me. Government (i.e. “single payer”) sets prices. Insurance companies are prohibited from making money. Sewing up a laceration gets paid $4.50 and a hospitalization in a room with 4 other patients is $10/night. MRIs cost a rocking $95. Patients love the system.
Obviously physicians wouldn’t spend $250,000 on a medical school education and even more per year in malpractice insurance to be paid less than minimum wage. You’d have a system that patients love, but that no doctor would practice in.
Where’s the happy medium?
May 10, 2008 at 10:07 am
Good info., thanks for the link! It’s quite helpful for my major, however, what happened to your ‘daily amusings posts?’
May 10, 2008 at 10:09 am
Why do you think “it is scary”? - I am pretty sure in Japan doctors are respected and make their ends meet well above “minimum wage” and there is no shortage of doctors due to that (there is shortage of everybody in japan due to demographics but this is another topic).
Scared in the sense that if we emulate this system, we’d be trying to pound a square peg into a round hole.
I don’t know about how Japanese physicians pay for their education, nor do I know how malpractice cases are treated, nor do I know documentation requirements. The physician in the Japanese system stated that he spent a “couple of minutes” with each patient. With the Medical Marijuana Advocates and other groups issuing directive after directive to “improve” the practice of medicine, two minutes wouldn’t even cover the time needed for the patient to complete all the paperwork.
I do know that if physicians were paid a flat fee for no matter what laceration they sewed, they *might* take the easiest cases, but the more difficult ones would get “turfed” to a specialist because they weren’t worth the hassle or the malpractice risk. If you have a 1 inch cut that could be sewn up in 5 minutes, you’re all set. For the same price, you might never find someone to repair a 3 cm laceration involving the lip and the eyelid. Similar to what would happen if lawyers got paid the same fee to handle any divorce, if plumbers got paid the same fee to handle any toilet problem, or if grocery stores got paid the same fee for any bottle of liquor.
May 10, 2008 at 11:11 am
Whitecoat–
Love your blog, and I have been a frequent visitor for quite some time.
But. I’m wearing thin on the tort comments. Physicians’ blanket and conclusory assessments of the tort system always reach the same conclusion because they fail to realize the complexity of the problem.
“Assuming we can restructure the tort system . .. ”
Come on, Dr. Whitecoat. How do you feel when patients demand specific types of treatment (e.g., antibiotics) because they think they know what is best? There is a reason that medical education is so involved, and there is a reason we respect the opinions of our doctors. The reason is that it takes a long, long time to understand the relationship between all the pieces of patient care. Law is no different. Do you really think that a bunch of doctors and their insurers have solved a legal problem that legions of judges and lawyers and scholars and legislators have been working on for generations? That is exactly as absurd as thinking your average lawyer should be allowed to second guess your assessment of a patient’s symptoms.
Again, I am big fan of your blog, and please don’t take anything I have said personally. But your conclusory treatment of tort issues is just as dishonest as a plaintiffs’ attorney’s conclusory treatment of, say, your assessment and treatment of a mild head injury. It’s sort of a black eye on an otherwise kick-ass blog.
Take care.
Respectfully,
Patrick
May 10, 2008 at 11:57 am
Ohh and btw about “poor doctors ” in japan:
From the interview:
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/interviews/ikegami.html
[Are these lower wages] driving down the number of doctors?
Well, as far as the competition to get into medical school, it’s gone up. …
May 10, 2008 at 2:50 pm
I saw that documentary when it first came out, and I strongly recommend everyone watch it (if you have any interest in this issue).
The one system that they looked at that I thought would do best in the US was Switzerland, where Insurance companies could not deny coverage for, or make a profit on, basic health care, but could provide additional health riders to cover elective care (plastic surgery) and amenities (private rooms).
Doctors can make a living, insurance companies can make a profit, and everyone has coverage that they pay for (not paid through taxes).
May 10, 2008 at 3:41 pm
Patrick,
What leads you to believe that the tort system, where a medically naive jury decides fault, is not telling doctors how to practice medicine?
It seems to almost require doctors to practice law when treating patients.
Pointing out that the tort system has not been good at improving care, seems to worsen care in many cases, is not the same as claiming to “have solved a legal problem that legions of judges and lawyers and scholars and legislators have been working on for generations.”
Recognizing the problem appears to be obvious.
Solving the problem seems to be a growth industry that enjoys increasing the problem, not solving it.
You did not deny that there is a problem and Dr. White Coat only made reference to fixing the problem.
Should doctors have no say in quality of care issues?
Or is a tort not about quality of care, but something else?
May 10, 2008 at 4:14 pm
Solving the problem in this country would have been easier 30 years ago, when most hospitals were non-profit and many people were insured by non-profit BC/BS. NOW, everything is for profit. BC/BS is now for profit. HCA and others own large numbers of for profit hospitals. And for profit means just that - paying CEOs large salaries, paying investors, etc.
30% plus of this system goes to overhead and salaries. That doesn’t happen anywhere else.
What other country generates high profits based on illness, sickness, even death? What other country denies affordable insurance to anyone with a pre-existing condition?
And what other country allows frivolous lawsuits, lawyers keeping 30%++ of awards, and millions for “pain and suffering?”
Getting “profit”, and contingency awards, and “P&S” awards, out of our system, IMHO, will never happen until Big Business says enough, and the people say enough.
May 10, 2008 at 4:45 pm
Rogue Medic,
*sigh*
All I meant to point out was that the simplistic, conclusionary statements I often hear about law in the medical community tend to be based on self-interest and lack of appreciation for the complexity of the problems it faces.
At the same time the simplistic, conclusionary statements about medicine that I hear in the legal community tent to be based on self-interest and lack of appreciation for the complexity of the problems it faces.
(And yes, I am a highly qualified member of both communities.) Neither you nor the august Mr. WhiteCoat are doing any favors by simplifying the conversation. It really, honestly is a mess. But you are not the only victims. Or even the primary ones.
*sigh again*
Okay. Feel free to flame away.
Patrick
May 10, 2008 at 5:17 pm
Patrick,
I disagree with your comparison.
You say that a doctor pointing out what he/she perceives as problems with the civil liability system and making suggestions for improvements to that system, would be like a lawyer second guessing a doctors medical management of a patient.
This is simply a faulty comparison.
A more appropriate comparison would be to say that a doctor making such comments about the civil liability system would be like a lawyer making criticisms and improvement suggestions regarding the health care system.
Guess what? That is happening all the time, and quite frankly there is nothing inappropriate about it.
One does not need specialized medical knowledge to make intelligent comments about the health care delivery system and related issues.
Damn near every major politician is an attorney and it seems to me that they fairly well dominate the stage when it comes to criticisms of the way our health care system performs and with suggestions for it’s improvement.
Similarly, one does not need specialized knowledge about legal theories and strategies etc to comment on the civil liability system in general.
Your image of a lawyer second guessing a doctors medical management of a patient would be more appropriate if doctors were making comments such as “I can’t believe that lawyer didn’t file a motion to dismiss based on the writ of nonsensicus bullshiticus!”
In that scenario, the typical doctor would be getting entirely out of his/her depth and would indeed be second guessing a legal professionals legal management of a legal case.
Non-physicians are frequently unwilling participants in the nation’s health care system any time they or a loved one gets sick, and thus are greatly affected by health care policy in general, and thus are perfectly legitimate when they voice opinions on the system.
Similarly non-attorneys (particularly physicians) are frequently unwilling participants in the nations civil liability system, are greatly affected by legal policy in general, and are perfectly legitimate when they voice opinions on the system.
As you allude, it would be terribly inappropriate and arrogant for the typical physician to second guess an attorney’s management of a particular legal case. Other than physicians feeling their blood boil when they observe attorney’s take advantage of the broken system by filing frivolous suits, etc., you don’t really hear too many docs doing such second guessing.
You don’t really hear doctors saying “She shouldn’t have put him on the stand,” or “My God, I can’t believe he didn’t object to that testimony!”
As rogue medic pointed out already however, our broken civil liability system is a showcase of non-physicians second guessing physician’s medical management of cases in every damn medical liability suit that gets filed.
It’s an endless parade of attorneys telling lay juries “He should have never given that medication” or “My God, I can’t believe he didn’t order a high resolution spiral CT of the chest when this patient first came in to the ER!”
Just as there are many things about our health care system that are terribly broken, there are also many things about our civil liability system that are terribly broken.
Any and all of us who are affected by these failings in both of these systems have not only a right, but a duty to comment on those failings and point out ways we think these systems can be improved.
Your comparison of Whitecoat’s comments about tort reform to non-physicians second guessing doctors medical management of patients is a bad one.
Whitecoat, please keep ranting about these issues! It may wear thin with Patrick, but it doesn’t with me!
May 10, 2008 at 5:44 pm
Those are fair observations, and well taken. I’m happy to rescind my comparison of medical practice with legal policy if that is what you objected to. It’s a trivial point. And, of course, you may not find the corollary to that, which is that interests like HMO’s and insurance companies should have fair say in medical treatment policy any more appetizing.
At any rate, I disagree profoundly what some of what you said (particularly the way you cast the legal industry solely in terms of the very must sensational aspects of what are in fact a tiny fraction of malpractice cases) but I think we have substantially the same point of view. I’m bowing out of the discussion however, because for whatever reason, medical/tort issues seem to be right up there with religion and politics on the scale of incommensurable viewpoints.
My personal observation, and the one I wanted to get across above ( which *I* consider non-biassed, of course,
) is that the medial industry is just is guilty as the legal industry when it comes to manipulating social systems for their own self-interests. Ignoring that, as WhiteCoat (whom I respect) often does, is unfair and just a tad dishonest. That’s all I meant to convey. Have a good weekend.
P
May 11, 2008 at 2:09 am
You are right about the lay out of cash that we have to do here to get through a medical education. I bet though, if it were free or very cheap, people would go into medicine and be happy with a lower wage. Also again assuming our tort system was overhauled!
May 11, 2008 at 2:25 am
Patrick,
I agree with you that there are many problems in medicine caused from within.
I am more often criticize doctors, nurses, and medics, than praise them. It isn’t that there are more bad than good in medicine, but I see the harm from those who are bad as a bigger problem.
One of the biggest problems is the lack of objectivity, even in research to improve medical care. And this is an area that has a formal plan for objectivity - the scientific method. Finding research that is significant is a problem, due to all of the biases introduced into medical research, even if the researchers are trying to be objective.
From this post, I did not see a lack of objectivity in comments about tort reform. “and assuming that we can restructure the tort system,” seems to be a generic statement of the kind that you have stated is not unreasonable. You aren’t suggesting that tort reform doesn’t need restructuring when you write “Neither you nor the august Mr. WhiteCoat are doing any favors by simplifying the conversation. It really, honestly is a mess. But you are not the only victims. Or even the primary ones.”
The primary victims are the patients. When people, who would be good doctors, are discouraged from entering the profession, this does not improve patient care. This is only one example.
When aggressive care is discouraged in favor of following a defensive treatment plan, where will the advances in patient care come from? Yes, defensive from a medical perception of the legal risk, which I believe is often horribly inaccurate. But I have no legal training on which to base that.
An example - One hospital insists that its in-hospital medical response team is not to touch anyone until after the person is registered as a patient. If a visitor collapses, weakness, seizure, cardiac arrest, it doesn’t matter. They have been instructed to behave this way by the legal department. My lay view of the legal situation is that they are just asking for pain. A person is automatically considered to be the responsibility of the hospital if they are on the grounds of the hospital and presenting with a medical complaint. I can’t imagine that this is considered good medical practice, but it does not appear to be uncommon.
EMTALA is a requirement from outside of medicine. Not a horrible one, but one with many flaws. If you have a serious injury, that needs immediate surgical intervention (the whole point of the trauma system) and you drive to a community hospital a mile from the trauma center, oops, the ED physician needs to assess and stabilize you prior to transfer. The most important thing in your survival is the time to surgery. The few things the ED physician can do are unlikely to make a difference if surgery is what is needed. Immediately placing the patient in an ambulance for the few minutes needed to drive quickly to the trauma center is the best treatment available, but it is forbidden.
Doctors do have to deal with these regulations while still trying to protect their incomes. How can self interest not be a part of this.
Our legal system has a bit too much faith in the idea that an adversarial approach is more likely to result in a good outcome, the truth. It seems to have been taken to an extreme, where nobody is interested in the truth, but only in having an edge.
The patient does not seem to have the edge, but neither does the doctor.
May 11, 2008 at 7:13 am
Here’s an interesting article by Dr. Ira Kirschenbaum:
http://blogs.webmd.com/mad-about-medicine/2008/05/amende-honorable.html
Love his blog too. BTW, wonderful post WhiteCoat.
May 11, 2008 at 9:16 pm
First, I don’t take any constructive comments personally. If all I wrote about were non-controversial topics (i.e. the world is flat) then I don’t think as many people would be interested in reading. I expect that people are going to disagree with me and I put the comments out there to get feedback. I’d probably write a lot less if people didn’t comment.
I’m also pretty fortunate in that those who read this blog are both insightful and civil. This is precisely the type of “think tank” where great ideas are hatched. I admit that I have gone a little overboard reality testing ideas or statements that I disagree with, but I’m never going to flame someone for contributing - even if it’s playing the devil’s advocate. I really do learn a lot from all the insightful comments everyone makes.
That being said, my statement “assuming we can restructure the tort system” referred only to the fact that, in my opinion, the medical malpractice system is broken. If you aren’t sure whether the system is broken, give me a chance to show you what I’m talking about. If you believe that the medical malpractice system is fine, then we have to agree to disagree. Don’t bother reading further. Dishonest, though? I don’t I deserved that one.
I linked to an article a few days ago about how Florida has passed several laws contrary to the interest of physicians. Does it make me dishonest for raising the issues presented?
Can you show me any other profession anywhere in the United States - no, anywhere in the WORLD - where if you have paid out due to three allegedly negligent actions you lose your license to practice the trade that you have spent 7 years (medical school plus residency) or even 11 years (add in college tuition) paying to learn? Are you aware of any “three strikes” law for attorneys, pharmacists, or major corporations? Can you imagine any state forcing WalMart out of business if it settled or lost three nuisance lawsuits? The intent of the law was presumably oust bad physicians and the apparent assumption was that “bad” physicians lose lawsuits more often. There is no basis for either. The effect of the law will be to encourage physicians to leave Florida. I am in a position to see the effects and I guarantee that physicians are increasingly choosing not to set up practices in Florida regardless of the statistics you might read or quote.
What other profession even comes close to paying half of its gross income every year for malpractice premiums? One of my best friends is a plaintiff attorney. Neither one of us has been sued, yet his malpractice insurance premiums are 10% of mine. Kindly explain why there should be such a discrepancy. My friend can’t come up with a reason other than to say that the “system sucks.”
On top of the “three strikes” rule, Florida has also set up a system in which a dishonest plaintiff attorney that takes a case with significant damages (i.e. John Edwards with a “bad baby” case) could technically pay an unscrupulous expert to commit outright perjury and lie about the standard of care in order to advance the case. Maybe the jury would balk if the expert testified that “the world is flat.” But how would the jury react if the expert testified that “variable decelerations are always an immediate indication for Caesarian section and the child would not have been born with cerebral palsy had the incompetent physician recognized this.” Would you know who to believe if that statement were made to you? According to the article I linked, Florida law insulates experts from any adverse actions for lying. How is that a search for the “truth” when unscrupulous witnesses have a financial incentive to lie?
Regarding your statement about patients who demand antibiotics, “doctors know best,” and patients respect the opinions of our doctors … in a perfect world, you’re right. Things *should* be that way, but they are not. Patients demand unnecessary testing and most physicians would rather concede to the patient’s wishes rather than to risk a malpractice suit (remember in Florida it’s “three strikes” and you’re out), a complaint to the hospital administration, or an unhappy patient who (justly or unjustly) tells everyone in the community that the physician is a quack.
Yes, some physicians are paid a lot of money, but others aren’t cracking six figures and that’s before expenses. I pay more in malpractice insurance and student loan payments than many people earn in a year, and I don’t have to worry about office expenses and employees. The incentive in the current system is not to provide good care. The incentive is to survive. You survive by making patients happy. Unhappy patients = less patients = less income = no more practice.
Paul’s comment lists some other things that create perverse incentives in the system. How do we change the fundamental mindset of the practice of medicine while still protecting patients from truly bad physicians? That was the whole purpose of this post.
Disenchant yourself with the notion that doctors and insurers are on the same team. Insurers are interested in making money. Doctors are interested first in survival and second in promoting the health of their patients. Even if all doctors were concerned about was the almighty dollar, there would still be a conflict between insurers and physicians. I can’t think of anything that makes money for physicians that does not cost insurers money. Similarly, I can’t think of anything that makes insurers money that is also good for patient care.
I can’t tell you that my statements are completely unbiased. But by reading this blog, you get opinions from someone that is behind the scenes. No one gives a crap what Brett Farve thinks about politics, but when he talks about the Packers, people listen. I don’t discuss politics because I have no interest in politics, nor do I really know that much about politics. I do have a huge interest in seeing a system that is sustainable. Trust me, the current one isn’t. I see a lot of things that patients, attorneys, and even administrators don’t see. I also see the fall out from what our medical system has turned into. If a patient can’t get in to see a physician, they come to see me … and I take care of them. If a patient has a severe head injury, I spend hours finding a neurosurgeon because most have left the area in which I practice. One neurosurgeon left after he was sued and lost a case in which a patient claimed “total disability” yet was shown in surveillance video lifting full filing cabinets after his “botched” surgery.
When the system goes against a physician’s interests and the physician leaves the area, who is hurt? I’ve watched more than a few patients die in front of my eyes because the hospital I was working in didn’t have the specialist care needed to treat them. In a previous post, I made a comment that I am glad I am a physician because I can protect my family. I’ll be able to do so no matter what happens to the medical system. What will those without a physician in the family do?
We have to define the problem with the practice of medicine before we solve it. I’m not smart enough to do either of those tasks alone, but I can throw ideas out to all the people that read this blog so that collectively we can brainstorm and just maybe we’ll come up with something. In my silly little world, I have this dream that some day in the future a lawmaker who is looking for solutions to the health care crisis will come upon this blog or even this entry in a web search. Maybe that person might even adopt one of *our* ideas. And maybe that idea might take hold and really change the world.
Probably will never happen, but wouldn’t that be something amazing to tell my grandkids some day: My dumb little blog helped make the system better for everyone.
Not only that … I had a lot of fun and met some really cool people in the process.
Thanks for reading.
May 11, 2008 at 10:08 pm
I know the world isn’t flat.
That’s why I keep losing my marbles.
I appreciate the ability to learn from your posts. You encourage readers to think about things differently from the way we did before. What could be better than helping people to understand?
Thanks for blogging.
May 13, 2008 at 10:02 am
Vaccines and Autism is once again in Federal Court. These issues highlight the chaotic interface between Law and Medicine. Despite the results of multiple large published series finding no link between vaccines and autism, science is cast aside and the Courts must decide. There used to be a drug called Bendectin. This drug was the only one approved by the FDA for the indication of nausea and vomiting in pregnancy. Despite all the science demonstrating no link between Bendectin and Birth Defects, the manufacturer tired of being dragged into court to defend its drug and pulled it off the market. Despite the courts’ being inequitable, inefficient, and unscientific, it’s uniquely the American way. Rant on, White Coat.