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Monday, August 5, 2013

Health care in Eastern Europe, Singapore and the US: How could pre-paid and concierge medicine help us be great?

American healthcare is expensive. We pay lots of money for it and we have outcomes that we aren't proud of. We gnash our teeth at how terrible we are and look to other countries with lower costs for ideas on how to improve. I have been combining personal and second hand experience of countries that spend very little on healthcare with what I know about medicine in the US, and we really aren't entirely bad. In some ways we are outstanding.

Singapore is a city-state comprised of 20 islands, near Malaysia, which began its modern prosperity when it was reinvented as a port by the British empire. It spends a tiny proportion of its GDP for healthcare, on the other hand, and ranks in the top 20 countries in the world in both life expectancy (15th) and infant mortality (1).

So how do they do it? There are many factors that might enter into the overall health of the population of Singapore. One very striking thing about Singapore is how strict their laws are and how rigidly enforced. There are high taxes on both alcohol and cigarettes. Trial is by judge, not by jury and trafficking drugs is punishable by death, as is possession of large quantities of drugs of abuse. Trafficking in arms is a capital offense as is using a gun in the commission of most crimes. Cigarettes and alcohol are heavily taxed, and cigarette use is prohibited in most public areas, transgression punishable by rather high fines. Singapore provides universal healthcare by a combination of health savings accounts funded by salary deductions along with partially government funded health insurance for catastrophic costs and a government fund to pay for the care of patients who are unable to afford medical care or for those whose resources are inadequate. There are also private health insurance companies to pay for medical services not provided for by the government programs, which many people of means purchase. Actual medical services are subject to market forces since the majority of care is out of health savings accounts which are controlled by the individual patient. Medical care is very good, but is quite limited for those entirely dependent on government programs. Expensive care is not necessarily available, and the basic level of healthcare available to all citizens is not what most Americans would consider adequate, at least according to my experienced ex-pat source.

Eastern European countries spend only a small proportion of their GDP on healthcare and they have poor outcomes, with rising rates of various preventable diseases and deaths. When the Soviet Union collapsed, the universal government funded health programs were suddenly unfunded and, although patients could choose their own doctors, those doctors didn't necessarily get paid and the technology they needed to function well gradually became unavailable. There is no good assurance of quality of care or of practitioners, and they make less than the national average salary. They depend on illegal payments and bribes to survive, and routinely receive money or gifts which are not acknowledged but are a vital part of the survival of healthcare providers. The quality of care is spotty and terrible, or so say my informants. Extremely brief doctor visits with next to no information imparted and no assurance of quality or accuracy is the way things roll.

In the US we are very picky about who gets to be licensed to work as a doctor and there are many assurances of adequate education and skill as part of the process of becoming one. Doctors who practice medicine poorly or do things which can be considered unethical frequently lose their permission to practice medicine. Even though we sometimes get shoddy or inattentive care we expect more, which is not true in Eastern Europe. Doctors actually talk about how to delivery higher quality compassionate care and they  feel bad when their patients are dissatisfied. There is some terrible inconsiderate and stupid doctoring going on, especially in situations where doctors are overworked and burned out, but this is certainly not the rule and it is not an expected part of our culture. We sometimes become greedy and mercenary, but we have the decency, usually, to feel bad about it.

So, what I'm saying is that I don't think we should trade our system in for Singapore's, even though they do get more healthcare for their money, or Eastern Europe's, even though there are more than enough doctors there to go around.

We, here, have the luxury of a healthcare system that is lushly supported and heavily replete with technology and infrastructure. We have high standards which we sometimes live up to. We also do crazy things like spend lots of money on high end intensive care medicine for people who put no energy or resources into taking care of their bodies and who subsequently become disabled and despondent and live short miserable lives. We conversely spend no money on the basic healthcare that could keep the average poorly or uninsured middle class people from becoming very ill, and we have treatment routines that are poorly thought out in terms of value for the patient, leading to medical debt related bankruptcy. Still, every day I work I see miracles of effective, well thought out care delivered with respect and consideration. This sort of thing is not the exception, but more often the rule.

I also see too many doctors losing their joy of practicing because they are encouraged to see too many patients and follow too many guidelines and spend scarce energy on the demands of the many third party payers.

Just a few days ago I read an article about doctors who are moving to "cash only" practices, in which they are paid monthly by patients to be their primary doctor, sometimes with better access than patients whose medical care is paid by insurance. Even though a doctor who is paid by an insurance company is really working for his or her patient, a significant portion of the energy put into an encounter goes toward the insurance company, and the insurance company, be it Blue Cross or Medicare or Medicaid, always defines in some way what care we deliver. Not so in a "cash only" practice where there is no third party payer to please. Because there is no third party payer, the physician can afford to treat less patients, providing at least theoretically better care to each one. Critics argue that only the rich can afford this kind of care and that it will lead to primary care doctors being less productive in a time when primary care doctors are scarce. Since cash-only practice cuts out the very complex insurance billing piece, it is actually a less expensive way of delivering medicine, and there are many affordable cash-only practices, which are way cheaper than paying for health insurance. Someone with zero money can't afford this sort of thing, so it is not of help to patients receiving state funded healthcare. Still, it is affordable to middle class folks who often can't afford to pay health insurance premiums.

Cash-only practices preserve the intimacy of the client-provider relationship, since it is that relationship only that determines what kind of medical care happens. To build a practice, physicians in this kind of a payment scheme have to deliver care that is valued by the patient.

Combining a cash-only (also called "concierge" medicine, especially at the high end of cost and service) primary care model with a catastrophic type insurance coverage for hospital, procedure and emergency care could  help hold on to what is good in American medicine at the same time we tighten our belts and try to start delivering more cost efficient care. Primary care coverage, in the pre-paid, cash-only model, could be paid for out of health savings accounts, much like in Singapore, which could be compulsory and tax free. This would help control costs and improve quality as I've heard it does in Singapore. Most people who get good primary care rarely need expensive hospital based care so a catastrophic policy just for the expensive stuff still need not cost much. If there was some cost sharing for tests and procedures and hospitalization, there would be even more motivation to use primary care and healthy lifestyle based preventive strategies to keep from needing high tech and high end care.

Since cash-only physicians get all of the payment associated with their care, rather than paying for an insurance industry which in turn sucks up their energy, they can survive with fewer patients on their panels. The patients they see can conceivable actually use less time since there is no need to spend time and energy on dealing with insurance. Dealing with insurance companies is, actually, a big energy and overhead sink. These doctors usually treat fewer patients because this practice model hasn't entirely caught on, so it's really kind of hard to have a large panel of patients. Since, however, treating more patients means making more money, I believe our quite human greed will make us as busy as we need to be. If cash-only practices really started to make an impact on medical care and clearly were a better way to practice medicine, government programs such as medicaid might give patients the opportunity to use their benefits to pay for care.

After two years of looking at all kinds of permutations of medical communities I am more impressed with how desirable our medical system is, in terms of quality, though not affordability or access. Ideally we would not get rid of what we have that is excellent, but instead make it more available to everybody. We have such creative people in the field of healthcare and they have thought of so many ways to make their doctoring rewarding to all of us, as doctors and as patients. We should embrace some of these ideas when they are obviously good.


Anonymous said...

So, we do a pretty good job, from an American physician practicing in a conservative State, who refers to two anonymous sources, and we should pay our MDs in cash? Seems legit.

"An average of 195,000 people in the USA died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002, according to a new study of 37 million patient records that was released today by HealthGrades, the healthcare quality company."

In 2010, heart disease killed 597,689 Americans, and cancer killed 574,743 Americans, according to the CDC. Next on the list is chronic lower respiratory death at 138,080.

Hurray, we're only accidentally killing 1/3rd of the people cancer and heart disease do in our hospitals! We have high standards!

Facts are fun kids. Check them. I learned about medically unnecessary deaths being a leading cause of death in my first year of biology in pre-medical school. Either Miss Janice Boughton missed that day, or she has a different definition of high medical standards than I do.

Janice Boughton said...

Hi anonymous. Do dip into a few other posts to see that I don't let us off easy. Medical errors are a bad thing that happens because we do too many complex things to people that have no actual value to them, and everything we do has a set of potential bad outcomes. The point of this article is to open our eyes to how some other countries provide healthcare and see where they fall down, so we don't make the same mistakes when we inevitably reform ourselves.

Anonymous said...

Yes, many of those deaths are caused by unnecessary medical procedures, drug side-effects, surgery for profit, lack of quality control in procedure checking, etc. My point is: your assessment of countries to potentially model our health care system on is staggeringly narrow, short-sighted, and uncited. You can't take a topic as complex as the economics of socializing health care and write up thirteen paragraphs on it basely almost entirely on anecdotal reports while appealing to the authority of your job title and personal experience. It's academically disingenuous at best.

The top 10 most effective health care countries are:
1. Hong Kong
2. Singapore
3. Japan
4. Israel
5. Spain
6. Italy
7. Australia
8. South Korea
9. Switzerland
10. Sweden

You wrote about the pros and cons of Singapore quoting anonymous anecdotes while ignoring how radically different the systems in the other top 10 countries are to that particular one. Do they casually execute people for drug crimes or exceedingly tax alcohol and tobacco in Japan, Israel, Spain, Italy, Switzerland, and Sweden? And then to vaguely refer to the whole of the former Soviet Union and their many systems, while ignoring the other countries with poor healthcare systems like most African nations, some South American, and many Asian countries is again both too narrow and uncited.

You've also ignored that Americans have far less federal regulation and funding in their healthy safety sector than Japan, Europe, and Australia do. We have an ineffective and underfunded FDA and EPA and we allow pharmaceutical corporations to run for-profit models where the population of the country isn't used as a negotiating tool to lower drug costs, while they are simultaneously allowed to advertise aggressively and bribe officials and doctors. I have to assume all of those factors contribute to higher prevalence of disease here in the US.

You've done essentially what the popular new agencies do: you've taken a very a robust and complex topic and narrowed it down to a sound bite for the easy digestion of people too lazy or stupid to check your facts.

Most physicians in the US do not want socialized medicine here. They make more money here. Not all physicians are rich, but I personally know some with multiple houses and several cars. When I talk to foreign physicians who come from countries with those better medical systems where no physician makes such embarrassingly high wages (yet still earn very livable upper level incomes), they tell me that physicians are hostile to their idea that America should have socialized medicine too. So, you'll hafta excuse me if I'm more than slightly suspicious of a physician from a conservative State suggesting paying physicians in cash is the solution.

Janice Boughton said...

One of the problems with writing a blog is that people won't read long blog posts, and I certainly understand that, but it does necessarily reduce my ability to address complex issues. Also, over the course of the years I have written, I have addressed many of the subjects that you bring up, which are all quite relevant. Doctors, at least many of us, make too much money. We are rated as one of the top 5 best compensated professions, and yet doctors somehow feel financially insecure and undercompensated. Some of this is due to huge debt burden after medical school and the fact that at least primary care physicians often have trouble making enough money to cover overhead, but there is also a tendency to deny the fact that we are often overpaid for what we do.

Regarding the comment that I address too few of the truly efficient countries, yes, I don't have any relevant personal information on them. I like to write about what I actually personally experience, because New York Times and Bloomberg do an excellent job of collating data from diverse sources, but they don't have my perspective, which is what I can best write about.

Again, I think you mistake the point of this particular post. I don't think the US is doing a great job of healthcare. I think we have far to go.

Regarding the paying in cash vs third party vs socialized medicine, all have pros and cons. Friends of mine who get their healthcare in the UK and Canada are generally happy about their care, but have specific issues with timeliness of treatment, which we do quite well in my community. It would serve us well to be open minded about possibilities for payment systems that have ways built in to them to reduce cost and improve quality. I would prefer to see community based cooperative payments which would do this, but movement in that direction is super slow, and cash-only practices have some of the same economic incentives to improve quality and reduce costs.

You do keep harping on the idea that I am from a conservative state. It appears that you think that being from Idaho means I vote republican and favor the tea party. That is a silly and wrong assumption. But regardless of my political leanings, it is important for all of us to realize that there are sizable numbers of intelligent people who have different ideas than we do and that some of those ideas, though they may be outside of our chosen party platform, may be good ones.