Sunday, July 9, 2017

What Europe has to Teach America About Health Care

NPR ran a story about two of its reporters who live in Europe and what they experience in getting their health care in Spain and Britain respectively.

The woman who lives in Spain said she could be seen the next day for an urgent problem, but for a less urgent visit to the dermatologist, or for other specialties, it took a month. 
She noted there were no cash registers or credit card machines in doctors' offices or hospitals. Prescriptions were generally about $2.  
Hospital wards might not feature single rooms. 
Quality of care was high, as far as she could tell--Spain does more organ transplants than any country in the world, which she used as an indicator of how high tech their medicine is.
British hospital ward

From the point of view of the doctors, a cardiologist makes about $2100 a month, in a country where $1800 monthly is the median. Her friend, a cardiologist, does Botox injections on the side to supplement her income.

The British reporter said that pretty well described British health care, except if you had private insurance to supplement the National Health Service, you could go to the private systems which functions alongside the no frills government service; you could go to a swanky upscale hospital with high thread count bed linens. 
The medical care is the same quality in both private and public and in fact, the doctors are often the same. It is more or less like flying first or business class as opposed to economy class: It is more comfortable for the rich in the private British system, but you are landing in the same place, at the end of the flight.

Upscale American hospital room for the 1%

From the point of view of British doctors, in a country where the median income is about $35,000, a specialist can make $140,000 in the public health system, although most of the GP's (general practitioners) who have only an MB (Batchelor of Medicine), the wage is closer to $40,000. British GP's go to medical school straight out of high school and skip college. They are upper middle class. Competition to become specialists is intense and the rewards get you to the upper 10% in income in the country.

Both reporters said the fundamental difference in Europe is Europeans think health care is too important to be corrupted by the profit motive, where most Americans think health care is too important to be trusted to government.

Americans simply do not trust government, nor any authority. Some wag once said medical care is simply too important to be left in the hands of doctors. What the Right believes, and what they've convinced Americans to believe, is the profit motive and private enterprise are always superior to cooperative group efforts. 

In Britain, about 7% of public spending is on health care. In the United States, if you put together spending on Medicare, Medicare, CHIP and other public health care spending is closer to 17%.  If you are challenged by numbers, that means we spend, from government more than twice as much as our European friends, in the name of keeping our health care system out of the hands of government.

This is no secret and no surprise: Medicare has for decades had an administrative cost of around 3% where the private sector it's said to be over 20%. If those numbers don't mean much to you, think of your doctor's office: How many people are working in the billing and front office vs the number of nurses and doctors you see in the rooms. And those are just the people you see.

Think of those huge health insurance company buildings you see scattered around, filled with people processing bills, fighting with doctors' offices over bills, sending you bills. To pick a number more or less out of the air, somewhere in the neighborhood of 3 million people make a living as employees of the health insurance in this country. (The number of people employed in doctors' offices to deal with the insurance companies could bring the number of people working on health care billing as high as 20 million.)

Those jobs are unnecessary here and do not exist in Europe. 
There are roughly 13 million jobs in actually delivering health care in this country, although who knows what the number really reflects. Is the guy who sweeps the hospital room included in that number, or the woman who works in the hospital cafeteria or the hospital plumber?

Swedish hospital room 

By many measures, American health care is inferior to European health care. In terms of public health, we are clearly inferior, because the upper 10% get excellent care but the rest do not. Infant and maternal mortality and morbidly are better in a dozen European nations and life expectancy stagnant in the US is improving in Europe and beyond ours. There are many other technical measures which all suggest the Europeans enjoy a better health care system and the government runs the show in European health care, even if there are private options swirling around that. 

I can give the worm's eye view, from our annual national medical conferences, where new science is presented:  the Europeans are as good or better than we are when it comes to the medical science they do.

What may be lost in all this is a more difficult, more intangible thing:  If we went to the Spanish system, where doctors' pay puts them into the upper middle class, rather than the British system, where doctors beyond the GP level are in the upper 10% of earners, we would see an entirely different sort of person in the white coat. Like it or not, when you look at 500,000 people making decisions about whether to go down a career track in medicine, you will not find more than 50,000, I would wager, who will choose medicine for the love of the science, the calling of service, even though they could make more money elsewhere. 

On the other hand, even with our profit motivated system, I cannot prove it, but it's my sense based on worm's eye view observations, that that shift has already taken place.  The quality of worker among doctors is not what it once was.  "Good" people, i.e., smart, intelligent, driven people do tend to follow the money. 

What we mean by "good" in doctors would require a dozen blog postings. The qualities you are looking for across that very broad spectrum which constitutes medicine are diverse. What you want in a surgeon is very different from the qualities which make for a good psychiatrist. And even if you could choose the perfect medical school class, the person you get at age 26 will not be the same person 30 years later. 

Look around at your own community. Do the physicians you see look like the top students you went to high school with? Put another way, do you feel comfortable trusting the health of your family to the doctors you see? 

This is not to say the doctors out there in the community are inadequate to the task. You don't need to be Warren Buffet or Zuckerberg or Steve Jobs to practice pediatrics and you don't need to be Einstein or Jonas Salk to practice endocrinology, but overall, the more money you pay doctors, the more you will see competition for those doctor jobs rise. Whether a driven, Type A doctor is going to give you better care is an open question, but it is a question.
But to say, "You get what you pay for" in medicine has proven to be a canard--we have been getting considerably less than we paid for in medical care in this country for decades.

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