Friday, November 21, 2008

I worry

This is slightly edited from a forum post and is, I guess, kind of a thought about nationalised vs. private (patient pays) healthcare. There are other systems, I know, and HMOs could well work in a different (and possibly worse) way.

Someone was complaining that they were jealous of people with private, non-UK doctors who gave their patients more advice than in the UK. I wasn't convinced the advice was better.

"I have to say that my impression of the advice people get when they are dealing with private clinics outside the UK is that advice and protocols are based a lot on personal experience of the doctor, with quite a lot of "let's do this and see if it works for you", which if you are a doctor working with a patient that is paying themselves doesn't lose the doctor anything.

My impression of treatment within the NHS is, apart from IVF, treatment decisions are more evidence-based i.e. only prescribing treatments that are known to work for a lot of women in the same diagnosis category. That's certainly been my experience - when we were in the UK we asked whether it would be helpful for us to pursue a few different options and rather than saying "let's try it and see" we have been actually pointed to the medical evidence.

"I do work in a field where I have the skills to read medical journals, though they sometimes are a bit opaque, but I think if I couldn't read that sort of thing they'd still explain why a certain treatment didn't work.

"IVF in the UK is a bit different because although some areas follow the NICE protocols (3 paid cycles), which are based on how likely it is to succeed after 3 cycles, not really on cost, others go purely on cost, which basically means one cycle for almost no patients.

"Private IVF seems to be similar to private medicine everywhere, though. We went to an information evening at a purely private clinic that has had very good results; they do a specific technique (PGS) which we thought originally might be helpful for us, but as I said the NHS clinic explained why it wouldn't and what the current evidence was. They were still standing up and saying in their presentations that they offer it and that it's helpful for people in our situation. It was only when I spoke to the doctor presenting privately, after the presentation, that she admitted that she too knew about this evidence that it wasn't helpful. I wondered if she'd have recommended it for us if we'd gone along as new patients without the information from our NHS clinic."

Sorry for the recycling - I started writing on the forum and then realised about 3 sentences in it was really a blog post so I had the blog in mind!

Oddly our experiences with our current health provider (an HMO) have been pretty good and they do seem to make sure they are seen to be practicing on evidence. I've been cogitating about what healthcare would work for the US as a whole and although I don't know that much about how much is spent per person under different systems, I know we spend vastly less per person in all of the European nationalised systems. The premiums we're paying just now are very high, but if our current HMO didn't turn a profit, had more advantages of scale, no billing and eligibility staff (how much do they cost, one wonders??!), the cost per year on average would be close to what the average US citizen pays (averaging out the uninsured/can't pay and the wealthy/private medicine people).

Interesting article here. If everyone in the US paid $5000 per annum, we could have a giant nationalised, evidence-based HMO
(or, if people prefer, state by state or county by county). If that's too impersonal, people who can afford it would be free (as in all other countries with nationalised health care) to pay for private treatment. If that's too much (and it's less than we are paying, I don't mind saying, but more than some people could afford), then the costs need to be shared round more and/or the price of medical care items and services needs to come down. Does the hospital really need a grand piano in the lobby??

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