US and Scandinavian Healthcare System: A Comparison

The article puts it in very simple terms that Scandinavian countries’ healthcare system is for social good, and that of US is like a business (Bradley & Taylor, 2013).  Both the authors are quite accomplished.  Elizabeth Bradley is is a professor of public health at Yale University and the director of the Yale Global Health Leadership Institute.  Lauren Taylor is a Presidential Scholar at Harvard Divinity School where she teaches Health Ethics.  Together they have co-authored The American Healthcare Paradox, on which this essay is based. 

It is a know fact that United States spends most per capital on healthcare.  Against this backdrop, the authors have tried to analyze the reasons why it resists switching to publicly funded/delivered healthcare system.  It is something that has increased efficiency and coverage in other countries. 

It states that the United States in its belief to be different from other countries has consistently ignored their outcomes.  There is clear evidence that the “Scandinavian model”, when compared to US’s, outperforms in delivering better outcomes at reduced costs.  These countries spend a little more that half of what US spends on healthcare, cover 100% of their citizen, and have more physicians and acute care beds the latter.  This bring into front what we can learn from their model.  That is not to discount that they too must be having problems of their own.  Their research involving in-depth interviews and surveys with policy makers and practitioners found that both countries shared a common values, which is personal freedom.  To be more specific people of both countries value their personal freedom and their ability to control theirs as something paramount.  Also, one needs to take into account that the need for freedom and love for competition does not mean that quality and efficient care cannot be provided to the population.  Also, it does not hold true that the need for scientific innovation cannot find common ground with the belief in having humanistic approach to healthcare. 

The big question then is why is the there so much resistance to change? This is where the differences start.  Americans are less amenable to taxing the rich so as to cross-subsidize services to the poor.  This has to do with their psyche that social assistance in any form is likely to weaken the resolve of the people to exert and excel.  In contrast, the Scandinavians consider dependence on government as an assurance against their own insecurities.  These differences are prominently reflected across their respective healthcare system. 

The take away form this article is that its not the narrow comparison between the system of both the countries, but a broader view how these system evolved in the first place that is the key.  Further, it needs to be determined what is to be done in light of how the Americans view their system.  Up till now the debate on healthcare has always been restricted to ways to cut costs, increase access and improve outcomes.  And most would agree that the reforms so far have not been sufficient enough to curtail long-term costs or attain universal access.  In light of the prevailing view in US regarding government’s involvement in their daily life, a boarder debate on this required before any substantial progress can be made on healthcare.  It is only then that any comparison with Scandinavian model can have meaningful impact. 

The article is well structured, as sets the tone with usual WHO/OECD data.  Then builds upon a bit by describing the Scandinavian model.  It then tries to find a common ground between the US and Scandinavian values.  Then it moves on to more of analytical side by describing its survey and interview, which tries to go deeper into the problem.  Against this background, it tries to evaluate the reasons behind the difference in the system.  It concludes logically by bringing to front the psyche of people of respective countries, especially how they perceive the role of government in their daily lives.  Finally, how that reflects in their respective healthcare system.

After going through this article, I believe, before any further debate on healthcare, it is essential of have a broader debate about the role of government in the lives of average Americans.  It will be even tougher debate, and individual steps would be even harder to push.  Without broadening too much, they should limit the debate to health and social issues.  They should bring into forefront the need to take care of have-nots.  They should also consider promoting institutions, such as those that are typically people focused. 

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Bradley, E. & Taylor, L. (2013). US Health Care Reform Is Only Getting Started. [online] Retrieved from: http://yaleglobal.yale.edu/content/us-heath-care-reform-only-getting-started [Accessed: 11 Dec 2013].

Leadership Skills for Healthcare Reforms

Was reading Tom Dolan’s article in Healthcare Executive Sept/Oct 2010 edition, about changes PPACA and the changes it will bring.  He talks about five broad points.  Even without the new legislation, these points do hold ground.

1. Mastery of change management and change leadership:  No matter how big a change, there are are few things that healthcare executives will always need.  They are change change management and change leadership.  Change management is the technical component of strategy and to be able to oversee their implementation.  This would include how the methodology is being applied to various initiatives, and whether staff are trained in it.  Change leadership is the human component of it, which is the belief in change management.  It includes realization and communication of negative fallout of not being able to change.  I believe this culture of reacting to change should exist well before any changes comes our way.  Else, it is just too much work in too little time.  If we are not used to coping with small changes, how would we to a big one.
2. Continued quality and patient safety efforts:  As we know quality and patient safety is raison d’etre of hospitals.  It is imperative that boards and senior management should be behind any effort in this direction.  If they’re not by choice, then they’ll have to be by compulsion.  It is important that executives are familiar with the tools.  What is more important is that they create an atmosphere where staff are motivated enough to find shortcomings.  They should be able to report without the fear of retribution, and have confidence those points will be looked into.  In fact there should be incentives in place for finding the most critical shortcomings.  And recommendations for all shortcomings should be made a part of standard operating procedure and effectively communicated.  Executives should ensure that the cycle goes on.
3. Productivity: As important as patient safety, is increasing productivity and controlling costs.  As we know healthcare is a very different kind of industry, and so it must not be at the cost of care.  Also, it must be determined how benefits gained via increased productivity are channelized.  Benefits gained in terms of executive time and resources should be deviated towards something strategic.  They could be diverted towards being price competitive, or spending time and resources becoming even more productive.  Few of the tools being used these days are Lean, Six Sigma, Predictive Analytics etc.
4. Public Policy: Healthcare executives are invaluable in public policy formulation.  They have access to invaluable information from their staff and community agencies. 
5. Interpersonal Skills: They form the cementing medium of above mentioned points.

Bitter Pill: Why Medical Bills Are Killing Us – IV

ref : Bitter Pill: Why Medical Bills Are Killing Us

• It was prudent step on the part of insurance companies and other regulators to promote outpatient services.  But, businesses being businesses they’ll make profit either way.  A better idea would be pay for treating the patients and leaving up to the hospitals how they do it.  Believe me they’ll still find ways to make money and the only way is to allow greater competition.  We have seen great anti-trust law suits helping avoid monopoly in every sector, its time for such in healthcare sector.  Hoping that ACA will do its part, but I am pretty sure that it will not be sufficient.
• Also, the reporting of charitable expense too should be reported accordingly.  Not as a %age on the mark-up price (chargemaster)  but on actual cost incurred.  It can be argued that his will increase the %age figure and show them more charitable than the others. 
• Regarding doctors compensation by medical device manufacturers, its good that it is being disclosed by a website.  But, it helps only so much as patients have no choice when it comes choice of device, e.g. hip-knee implant.  What if the choice is genuine and doctor had also benefitted directly or indirectly?  The best way out is not to kill competition in any way.  Administrators may agree that signing contract with one or few might fetch them discounts, but it pretty much kills the competition.  Also, they can also seek greater discounts when all the manufacturers are in fray.  The article rightly states that the biggest problem is the mark-up prices that the hospital charges the patient, and not physician’s choice of equipment or the benefits being doled out to them.

Bitter Pill: Why Medical Bills Are Killing Us – III

ref: Bitter Pill: Why Medical Bills Are Killing Us

• Unlike other industries, technology in healthcare increases costs.  New and better diagnostic equipment is costlier, even though not always necessary for you.  You can trusts doctors to not use it if not really needed, but for the threat of being sued.
• There is little patient pushback for these treatment for variety of reasons: getting treated is their topmost priority; unlike other services cost is not discussed upfront with doctors; if your insurance covers you for it, then all the more reason not to discuss; no matter how much researched, patients aren’t qualified enough to argue with the doctor and discussing cost versus benefits with patients makes doctors decision making rather difficult.
• Sad that safe harbour reform was shot down, under which physicians and hospitals could have argued that they provided care that was within bounds of what peers have established.  It is a known fact that it is not new more expensive tests that save lives, but timely intervention.  Considering how little time doctors pay examining their patients, no amount of tests can counter lack of proper clinical judgement.  That would have also blunted the typical plaintiff argument that more test would have saved patient’s life.
• The article talks about ad campaign by AHA that Congress not cut hospital payments as that would endanger billions the hospital provide as care to poor or those failing to pay their debt.  Well is that discount they talk off on highly marked up chargemaster price?  Where the latter itself has no basis.

Bitter Pill: Why Medical Bills Are Killing Us – II

ref: Bitter Pill: Why Medical Bills Are Killing Us

• So as it comes out the chargemaster is something nobody is concerned about.  They really do not need to examine how the charges are created so long as they get paid.  And yes they do get paid by insurers, because they too have collection departments.  So, there is no incentive to revisit and revise it.  I am hoping that with healthcare exchanges round the corner, the insurance companies would be compelled to bring their premium rates down.  That “might” trickle down to hospitals being more competitive rate wise.
• Also the impression I am getting from this article is that Medicare rates are very conservative and accurate.  It states that Medicare ensures that non-profit hospitals are paid for all the costs but actually be non-profit after their calculation.  Also, it seems fair that Medicare reimburses hospitals not only the direct costs, but also all the overheads incurred.  In all the problems related to healthcare, the accuracy of calculation of Medicare costs is a saving grace.  Its time something is done about the chargemaster, esp in relation to non-profit hospitals.
• The article quotes an executive saying that very few  people actually pay the chargemaster rates.  I am sure almost all of such must be uninsured or inadequately insured.  Also what they charge the insurance companies isn’t as low as Medicare price either.  So, they actually go by those chargemaster rates.
• The costs structure is further complicated by probably unnecessary tests administered by defensive medicine practiced these days due to fear of litigation.  On top of that hospitals have recover the costs of equipment, so they too look the other way around.
• It is a real challenge to desist doctors from ordering multiple tests.  As it is a decision best left in the hands of doctors, we would need some sort of governance model to control it.
• The report talks about how profitable s the business of selling hospital equipment.  That’s because the hospitals are able to recover the costs rather fast.

Bitter Pill: Why Medical Bills Are Killing Us – I

ref: Bitter Pill: Why Medical Bills Are Killing Us

Reading this comprehensive article in pages, and thoughts are flowing.

• Asking for advance payment doesn’t seem entirely wrong to me unless the prices is not exorbitant.  But, seeking huge payment for life threatening disease seems criminal. 
• Why is it necessary for patients to purchase medicines from the hospital itself.  If they’re given the choice to buy themselves, it will drive the cost down.
• It compares the price of chest x-ray to individual versus Medicare patient.  I don’t know if the costs are purposefully kept high to cross-subsidise Medicare patients.  But there needs to be some sanity towards pricing.  It could be that insurance companies are willing to pay that much, so it doesn’t matter.  But, where does uninsured or inadequately insured go?  Do they have to pay the hospital as much as insurance companies do?  Do hospitals have any incentives in cutting down how much they charge the insurance companies?  If not, then they need to be created.  The article itself states that,”By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.”  So, what are these costs meant for.  I guess, I’ll find it upon reading further.
• I believe that hospitals able to generate such revenue because insurance companies are willing to pay them any amount so long as they are able to recover from payers.  It seems there aren’t enough incentives for hospitals to bring down their prices, such that they can be passed onto individuals.  In all this, an uninsured or inadequately insured get stuck, and they have no voices besides media.
• Shouldn’t it be mandated that non-profit hospitals spend only so much on administrative cost.  That is something along the lines of charitable organizations.
• I think these hospital organizations are penny wise pound foolish when they spend so much time and energy to save costs via process improvement and strategic sourcing.  It would be much simpler and easier if they were to just cut their executive compensation.  But, again what if the insurance companies doesn’t pass it on to their clients?  I think it would be much easier for HMOs as they have their own plan.
• With cost of Medicare/Medicare a big burden on exchequer and even greater burden via insurance, one really wonders what is happening.  I guess the key cost drivers are the tuition fee of doctors and lack of adequate emphasis on primary care.
• From the last paragraph, I would like to advice Republicans to help cut down healthcare costs so that business and individuals can invest that money to create more jobs. 

ER costs and how to circumvent them

Read this article on ER costs : An average ER visit costs more than an average month’s rent

It talks about great variations in prices depending on where they seek treatment and what type of coverage they have.  It specially talks about prices of emergency visits, and also states that they looked at the charges and didn’t into how much insurer or patients paid.

Talking about variation in payment first and type of coverage later.  I wonder why don’t insurers, HMO and others inform and educate the patient about where they can have treatment at lessor costs.  The article talks about various examples where people went to emergency for headache where they could have easily called up a tele-nurse.  I think healthcare system should educate and reward patients who take up less expensive option.  A patient who has a good coverage across all ailments will land up at emergency even for small reasons.  I think patients should be rewarded with greater coverage if they use less expensive option.  Just as utilities companies actively help you keep your bill down, healthcare companies should do the same.

Three uncertainties that can halt Obamacare

ref: If Obamacare survives, employers may do it in

The article talks about three uncertainties that can stall Obamacare: Supreme Court ruling, the elections and the behaviour of major employers. 

There is little to say about the Supreme Court’s ruling.  Coming to the next point that is the elections, it isn’t very clear, at least to me what Mitt Romney will do.  Even though Obamacare is extension of what Romney did in MA.  I think latter’s position prior to election is nothing but political posturing.  Once in power, he will bring his own tweaked version of Obamacare.

The most unpredictable of all is the behaviour of major employers.  One of the response possible is that employers stop providing coverage to the employees, and let them buy off these exchanges.  This will make life a lot simpler for the employers.  The can offer a fixed amount to employees, which they can use to buy insurance of their choice.  That will help cut down the administrative costs, and if employee manage to find inexpensive coverage, they can keep the top-up. 

Another possibility being considered is that employers tweak their plan such that it nudges the employees towards these exchanges.  Won’t even discuss how these nudges would mean in actual, as they look rather sinister. 

It will be really hard to manoeuvre/influence employer behaviour if we are to go buy what goes on at Wall St.