Yeah, because the world only consist of English speaking countries. You forgot Australia and New Zealand btw.Originally Posted by Loki
Yeah, because the world only consist of English speaking countries. You forgot Australia and New Zealand btw.
"Wer Visionen hat, sollte zum Arzt gehen." - Helmut Schmidt
You were the one attacking the idea of getting extra tests. Don't see why the actual system matters.
Hope is the denial of reality
To be fair, fee-splitting is frowned upon, and self-referral is basically illegal... unless the service/equipment is within the same facility. Sooner or later, with these conflict-of-interest issues, you end up having to decide whether or not you want to charge most healthcare providers with fraud/racketeering. But at that point you may as well charge everyone with it, because, ultimately, it's just regular people responding to financial incentives
"One day, we shall die. All the other days, we shall live."
That's not what I was saying. I said, you wont be able (as a client/patient) to optimize your cost/effect ration by buying extra opinions by other doctors, as those extra opinions will be very costly.
There is a fundamental difference in getting an extra opinion to make sure to get the best threatener or to get a second offer to get the best deal. Lewk didn't claim that free market is more effective, but that it is more efficient.
"Wer Visionen hat, sollte zum Arzt gehen." - Helmut Schmidt
Prestige and obstinacy are our enemies, and the people I know who've worked in the UK tell me it's a greater problem in the UK than it is in Sweden. Depression is common and frequently underdiagnosed, but the doctors I've worked with always seem to keep it in mind. A downside of that is that women are more likely to get diagnosed with depression or anxiety when they're suffering from a somatic illness >_< We contradict each other all the time, we just usually try to do it without badmouthing each other too much.
But you mention one of the greatest challenges doctors in almost all countries face: time pressure. That's true even in the US, where talking and listening just don't pay enough anymore. The same goes for complexity, both of theory and of reality. The solution isn't to genetically engineer doctors with bigger brains, but rather to recognise these challenges and try to mitigate them. Planning, follow-up, education, cooperation with other doctors, constant revision/reassessment, guidelines, checklists.
As for rare diseases, you're right. We generally don't think about them easily and quickly, if at all, except for the "classics" and the serious emergencies. But even if you put aside the cognitive limitations of doctors, rare diseases pose diagnostic challenges, esp. in unselected populations. Once you've removed most of the horses, finding zebras becomes easier.
If you don't mind, I'd love to learn what was behind the wrist thing, the threatened blindness and the sleeping problemsThe sleeping thing actually was in regard to someone I know. The wrist thing turned out to be a genetic bone issue, a possibility the first two doctors I've seen completely ignored (the third was an NYU professor who automatically came up with the diagnosis).and if they survived of course
"One day, we shall die. All the other days, we shall live."
In the US it can be all of the above, *plus*. Sometimes a second opinion means the physician doesn't like the 'quality' of a scan (often one done at a non-affiliated ambulatory site, or one performed out-of-state), or they think it's not 'recent' enough (more than 30 days old), or isn't comprehensive. It's fairly common that a test/result can't even be found in the patient chart, and it takes more time to hunt it down than do another one. Or medical record-keeping and access to files aren't well coordinated.
It just so happens that duplication and redundancy means more money for doing more, some doctors practicing CYA diagnostics, *plus* patients who're led to believe they're getting the best care.
The actual system does matter, though. Isn't that what we're discussing in the big picture?No one has said adopting UK's NHS would be a good model for the US, as far as I can tell, so those comparisons have limited use.
Your anecdotal stories of conditions not diagnosed properly or timely (depression, sleep disturbances, joint problems) also happen in the US, so don't make it sound as if the US is doing a bang-up job. More US patients are likely to be diagnosed with common ailments (anxiety, depression, insomnia, joint stress) by the first doctor they see, or the doctor-of-the-moment, and prescribed meds/treatment.....than they are to be referred to specialists. As with most things, it's multi-factorial.
Patients presenting at university teaching hospitals emergency rooms are more likely to be referred within their specialized clinics system, but "most" Americans aren't accessing that kind of system just by going to their local ER (even though millions "use" an ER for primary care).
So?
If it's their money, and their decision, what's it to you? If some private citizen wants to pay private money for something you deem "unnecessary," or "excessive," what's the problem? The person in question is probably a fucking moron, but until such time as we outlaw stupidity and purge the sheeple from this planet with fire, it's no one's business but their own.
Simply not true. I don't need to as much about cars as a Toyota engineer to make an informed buying decision when it comes to getting a new car, nor do I need to know as much about medicine as a doctor to make an informed decision about my healthcare.
Again, how is this different from any other market?
You may feel that my shiny new[ish] Dell SAS server is much more than is "necessary" for my single-user home network, but I bought it all the same, and really don't care about what other people think about the purchase. Likewise, if I want more than is "necessary" when it comes to my medical purchasing decisions, I should be allowed to pay for it anyway, and to hell with what anyone else thinks.
Much like the cases Loki brought up, my family's experience with the Canadian medical system is that you're actually better off without it.If you don't mind, I'd love to learn what was behind the wrist thing, the threatened blindness and the sleeping problems
One of my grandmothers, for example, is now blind, despite going to an optometrist every six months, who apparently never bothered to do a glaucoma test on an 80+ year old woman. Well, she had it, it wasn't caught because her government-provided doctor was incompetent (was actually disbarred in Scotland, but moved to Canada and got a medical license, sigh) and she's now blind. Luckily for her, she'll be dead soon, which is about all the solace any of us will receive for that government mandated ass-fucking. Or one of my uncles who died a few years back, who despite also being a senior citizen and doing the annual physicals and checkups, up and died out of the blue one day, and was found by the coroner to have been riddled with cancer for years (aside from the usual places, he even had some advanced bone cancer). Or the uncle who had to wait 3 days after his heart attack to see a doctor, because he had it on a long-weekend with a government-mandated holiday. And I could go on. Suffice to say that there are a few Canadian medical professionals who will be in serious danger of eating a bullet if I ever get back to my homeland... and that I'd rather pay for quality healthcare out of my own pocket than take my chances with the clusterfuck that government-run healthcare is, in my experience.
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them."
"The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants."
-- Thomas Jefferson: American Founding Father, clairvoyant and seditious traitor.
The eye problem in question also wasn't caught for over two decades, despite bi-annual checkups (assuming the problem was present from birth as the doctors currently claim).
In terms of more routine problems, it takes over half a year to see the dentist in parts of the country, referrals to psychologists can take over a year, drug refills require a doctor's appointment, which either takes weeks to arrange or requires you to take a day off work, a referral to any kind of specialist easily takes 4-6 weeks, and getting an x-ray requires a trip to the hospital (a month or two after it being asked for). Quite frankly, anyone who wants this system in the US must be insane.
So if the worst problem the US system has is too many tests, I'll take that over being forced to die or become a cripple (coincidentally, you can't sue the NHS for making you a cripple, and can expect no more than 10-25k pounds for incompetence like cutting off the wrong leg in a surgery).
Hope is the denial of reality
Cain, you've explained the importance of licenses and regulations within the healthcare industry. Being disbarred from practice in Scotland, but moving to Canada to continue the same bad medicine, shouldn't be an excuse for....practicing bad medicine, or giving license to bad practitioners.
That said, no physician has Superman x-ray vision, and relies on some level of negative symptoms...especially for senior citizens. That can be a tricky pickle-in-the-middle. Should every senior have a total body scan, even though their symptoms could be common to all seniors, just to rule out the remote possibility that they're riddled with cancer? I'm sorry your uncle died, and that in hindsight his autopsy showed systemic cancer
I hesitate to think about every senior citizen undergoing a coroner's or medical examiner's autopsy. They'd all exhibit internal maladies that couldn't be seen by "routine" examinations and non-invasive tests. Heart disease without hypertension, diabetes without obesity, dementia without CVAs, slow organ failure without symptoms. Does that mean everyone after a certain age should get a whole host of the newest tests....?
What ever happened to preventive medicine?
Hope is the denial of reality
Well done. You've managed to incorporate types of care, quality of care, costs of care, redundant testing, unnecessary testing, physician responsibility, legal accountability, delivery and payment systems, and patient outcomes into one big hunk of....
I can't say how the UK NHS works, but in the US
any potential loss of life, limb or vision are considered emergencies. It's up to physicians' agents to triage that kind of thing when making appointments.
We have to make dental appointments six months in advance, but only for routine cleanings and x-rays. Those with dental pain/swelling/fever/traumatic injury/tooth loss are treated as emergencies...and get to the head of the line. People with newly red, itchy eyes and morning exudate might call a family doctor, an allergy specialist, an optometrist or ophthalmologist. It's reliant upon the professional group (and their agents) to decipher that information, and get the possible pink-eye/infectious conjunctivitis patient in ASAP.
Those who are actively self-destructive, severely disabled or impaired don't have to wait a year to get a psychologist or psychiatrist referral. That's poppycock. People with suicidal ideation are always treated as emergencies and seen right away.
You might want to change your dentist if it takes you 6 months to see them.I've booked appointments here two days ahead of time (it never took more than a week in New York either). Could have gotten one same day if the problem was urgent. This was whether I had insurance or not (it would obviously cost more without the insurance).
Hope is the denial of reality
I like my dentist just fine, thanks. I could also find a new dentist who'd take me on right away, just for routine cleaning and x-rays, hoping to turn me into a regular client for the future. That's rather how dentistry operates in the US, ya know. People "who have a dentist" will call their dentist for any urgent problem. I know my dentist could be called out of bed at 3am if one of my (his) inlays/onlays/crowns failed, and he'd drive from Baltimore to south central PA to tend to my needs. I know his answering service has been given specific instructions, and those operators would never tell me to take an aspirin and call back in the morning (or suggest I go to a 24 hour pharmacy and buy some OTC product and wait another week or two to be seen).You might want to change your dentist if it takes you 6 months to see them.
Why the fuck not?I'm sorry your uncle died, and that in hindsight his autopsy showed systemic cancer
This is a beautiful example of the quality of care offered by "universal" health care systems. If my relatives had other options for healthcare that they could pay for, some of them would still be alive today, and others would have useable eyes. But thanks to the same bullshit system you and your leftie buddies are trying to push down here, they're dead. Maybe that's something to think about next time you're up on your high horse... all the people who will suffer and die if you get your way. (Not that this has ever mattered worth a damn to you lefties, but your policies harm and kill the very same people you claim to be helping.)
The only thing worse than not being able to get health care is getting health care that's so bad, you'd have been better off without it.
So why do you want to change it so that it everyone's on a several week long waiting list, huh?
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them."
"The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants."
-- Thomas Jefferson: American Founding Father, clairvoyant and seditious traitor.
And the odds of a government-employed (and government-paid) doctor doing this to you is what? 0%?
Hope is the denial of reality
Methinks you're using the wrong model to foist your complaints. If your Canadian....they'd be among the small percentage of US citizens who can buy premier care.relatives had other options for healthcare that they could pay for, some of them would still be alive today, and others would have useable eyes.
Yep, 0 % chance of that. But it's because there's no national or majority consensus for "government-employed and government-paid" doctors taking control of our healthcare system, despite the fear-mongering from the far-right wings who'd like to make us think so.
I will make a proper reply later, but I'd like to point out that we, in holland, do have socialized healthcare (albeit in a public/private hybrid). In my own, limited experience, and from what I know from people I have talked to...In terms of more routine problems, it
takes over half a year to see the dentist
in parts of the country, referrals to
psychologists can take over a year,
drug refills require a doctor's
appointment, which either takes weeks
to arrange or requires you to take a
day off work, a referral to any kind of
specialist easily takes 4-6 weeks, and
getting an x-ray requires a trip to the
hospital (a month or two after it being
asked for). Quite frankly, anyone who
wants this system in the US must be
insane.
- Getting an appointment at the dentist is usually within a week for a checkup, faster for urgent stuff. Followups are also within a week or so.
-Friends of mine got referred to a psychologist in also about a week.
-Getting a prescription does require a doctor's appointment, but I've always been able to see my GP the same or next day, and that was usually for non-urgent things. Also you get a time so no need to take a whole day off (most I had to wait was one hour, because an emergency had come up).
-X-rays are at the hospital, but I got mine the very afternoon I visited the GP (again, for something that wasn't even urgent at all, and fir something both me and the doctor agreed probably wasn't needed but just to be certain)
So your criticism is completely invalid here. We can also ask second opinions, you can choose your own specialist (to some extent at least, they have to have time of course). Hospitals and insurers are private, and you can purchase more extensive coverage if you want, or uninsured treatments/tests/consultations (uninsured being determined by your insurer, not the government which only sets what has to be included in basic insurance plans), if you so please. So all your bullshit about how ypur criticism is valid for every country here is simply wrong.
I would also like to point out that while undertesting is obviously very bad, overtesting is also harmful, both for you, and the society. So just because one place tests too little, does not mean another place can't test too much. There is such a thing as middle ground.
Well, you're wrong on both counts, but no surprise there.
It'll be paid for by unicorns, with pixie dust, then?
Only when you force society to pay for it. Private systems don't have that problem. You can actually <gasp> get what you pay for, and pay for what you want.
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them."
"The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants."
-- Thomas Jefferson: American Founding Father, clairvoyant and seditious traitor.
Except you've previously said you'd want the public option.
Hope is the denial of reality
I was commenting on the British system; I have no idea how the Dutch one works, and will refrain from passing judgments on it for that reason.
I see nothing wrong with an individual paying money to get tests that are not necessary. Do you also think it's wrong for an individual to buy two houses? Or a yacht? Lots of things might seem unnecessary to you, but provide some utility to the person paying for them. As Cain says, the problem is only if society is forced to bear the cost.
Hope is the denial of reality
Yes, as an option, and a choice.
Now, before anyone harangues me for what that 'choice' means, all subsidies are on the table. Whether it means employers using employee insurance tax breaks, personal HSAs with tax deductions, itemized OOP cash payments to find tax breaks, or payroll taxes to fund Medicare.....using the tax code to define and fund our healthcare system this way is fubar.
Just because our system has flaws is no excuse to replace it with one that is far worse.
Hope is the denial of reality
They aren't morons, they're just afraid and have a hard time understanding eg. how prior probability interacts with uncertainty in testing to influence medical decisions.
The issue of waste--driven by excessive/inappropriate testing--isn't the only problem with healthcare in the US. I've focused on this specific issue because of Lewk's earlier comments about the causes of waste in the healthcare system. On the one hand, you're kinda right: if the money only comes out of the patient's pocket, then why is it anyone else's business? But on the other hand, the money isn't just coming out of the patient's pocket. It's coming from the patient, from insurance companies, from taxes. Every wasted dollar is a dollar that could have been put to better use elsewhere. More money for the patient and his family, perhaps increased access to insurance for others, perhaps a better funded school system or whatever else it is your gummint pays for with. If over a third of your healthcare expenditure is pure waste then that's a problem for anyone in the US who doesn't want/need to waste money.
Minimizing expenses for the government is just one (important, admirable) goal. Do any of you want to go through (and pay for) a prostate biopsy, a coloscopy and a CT every time you go to the doctor? Do you want to go through unnecessary surgeries? A lot of patients are trying to buy peace of mind, and that's fair enough, but a lot of doctors are also trying to get these patients to buy more peace than they need to. Even in the US you have huge disparities between different regions and facilities that are/should be similar. It's not because you have huge regional variation in patient intelligence. It's because you have huge variation in how doctors behave.
Now excessive testing isn't the worst problem plaguing US healthcare, although it is one of the most expensive. Even across the board overutilization of healthcare--for small gains and at great cost eg. due to side-effects--isn't the worst problem (although one wonders why approaches that are villified in eg. the climate debate--and in medical research--are warmly embraced in medicine). It's the question Loki himself asks: whatever happened to preventive medicine? Well, you tell me what happened. Basic cheap preventive medicine has taken a back seat to everything else. Defensive medicine and preventive medicine aren't the same, and preventive medicine in the US is suffering.
Names damn you, I need names or ICD-codesWell the wrist example was of me.
The eye thing is probably something that occurred at birth and won't get worse. Then again, if this happened to me, I'd get a second opinion, something which isn't an option for most Brits.
As far as I know, the person with the sleep thing still has the problem because the doctors tried two different drugs (which didn't work) and then said to live with it. The wonder that is the NHS.
[...]
The eye problem in question also wasn't caught for over two decades, despite bi-annual checkups (assuming the problem was present from birth as the doctors currently claim).
Granted, but you do need good information as well as at least some medical judgement and experience, both of which can be sabotaged by everyone's strong incentives for, well, manipulating you. Sure, you personally may be a super-genius, but I am guessing you were trying to make a more general point that also applies to dumdums.
I can't say why your grandma never got her eye pressure measured. If someone had checked it then that would probably not have fallen into the category of unnecessary defensive medicine. As for your first uncle, I don't know what to say without more info to go on. Re. your second uncle, what the hellOne of my grandmothers, for example, is now blind, despite going to an optometrist every six months, who apparently never bothered to do a glaucoma test on an 80+ year old woman. Well, she had it, it wasn't caught because her government-provided doctor was incompetent (was actually disbarred in Scotland, but moved to Canada and got a medical license, sigh) and she's now blind. Luckily for her, she'll be dead soon, which is about all the solace any of us will receive for that government mandated ass-fucking. Or one of my uncles who died a few years back, who despite also being a senior citizen and doing the annual physicals and checkups, up and died out of the blue one day, and was found by the coroner to have been riddled with cancer for years (aside from the usual places, he even had some advanced bone cancer). Or the uncle who had to wait 3 days after his heart attack to see a doctor, because he had it on a long-weekend with a government-mandated holiday.are the EDs closed on govt. holidays?
"One day, we shall die. All the other days, we shall live."
Your elderly uncle could have used the US private system, paying cash OOP for all sorts of tests....if he'd wanted to demand monthly total body scans, with or without radioactive contrast isotopes, regardless of medical need, and could afford it. Hell, he could buy hyperbaric oxygen tank treatments and install a lab grade chemical ventilation hood in his kitchen, if he wanted to and had the pocketbook to do so.Well, you're wrong on both counts, but no surprise there.
It'll be paid for by unicorns, with pixie dust, then?
Only when you force society to pay for it. Private systems don't have that problem. You can actually <gasp> get what you pay for, and pay for what you want.
But your average for-profit group insurance policies don't work that way, and neither do non-profit public insurance policies.
Btw, re. self-referral:
http://dl.dropbox.com/u/8869611/self...ral%20JAMA.pdf
"One day, we shall die. All the other days, we shall live."
Optometrists and Opticians aren't necessarily Ophthalmologists. Professionals who test vision and make prescription-grade lenses/glasses aren't the same physicians who diagnose and treat pathologies of the eye. Some of the better optometrists will do the glaucoma puff test, even if it's not required, and refer a patient with high intraocular pressures to an Ophthalmologist to diagnose/treat glaucoma....but in some states it's not even required that eye doctors tell patients, so patients can know the differences.
Again, the only "problems" there arise from everyone being forced to pay for other people's spending habits. As such, they're an argument against the government-run part of our health care system, and not an argument for expanding government control to include the whole thing.
Could be. Kinda proves the point me and me libertarian brethren have about regulation, though, doesn't it? What the hell good is it, given that several hundred thousand pages of laws later, we're basically still stuck with the realities of caveat emptor? All those mountains of paper have done is make things more expensive and slower, but haven't actually fixed a damn thing, have they?
Another problem caused by government, particularly our legal system and legal climate... and as I see it, another great reason *not* to trust our government with more power authority and reach when they're so thoroughly fucking up everything they already do.
Well, no, the point is that if you're not an informed consumer in any arena, you're probably going to get ripped off in any purchase. Health care is no different, and should be treated no differently. No need to force "what's best" on all of us because some people are irrepressibly stupid. Applies to buying a new car, ought to apply to health care decisions as well.
Or should the government step in and regulate car buying and grocery shopping and every other financial transaction (well, even more so) like they do/want to do with healthcare because stupid people make poor decisions there as well?
The ER was open... just no doctors around. He got in to see a nurse, who couldn't prescribe anything or actually help him with his problem, but was able to schedule him to see an actual doctor first thing after the long weekend.I can't say why your grandma never got her eye pressure measured. If someone had checked it then that would probably not have fallen into the category of unnecessary defensive medicine. As for your first uncle, I don't know what to say without more info to go on. Re. your second uncle, what the hell
Coulda been worse... he could have been the kid who got stabbed in Toronto, and bled out on the way to the ER... because the first ER the ambulance took him to actually did close after 8PM (or something like that), on account of budget cuts. It's just what happens when you force everyone into a system where some bureaucrat gets to put a dollar value on someone's life and the quality of medical care they receive.
"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them."
"The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants."
-- Thomas Jefferson: American Founding Father, clairvoyant and seditious traitor.
IMO you're making a fallacy in logic. Not all 'arenas' are the same, and not all 'markets' work on the same consumer principles. Buying a car is NOT the same thing as buying healthcare...or broccoli. The stupid people who make poor decisions often find themselves needing the same care as smart people who make good decisions.
ie, young athletes suffer early bone and joint problems, spinal cord injuries and traumatic brain injuries, need physical therapy and joint replacements earlier in life than most any sedentary senior. Life styles and genetics are cumulatively funny that way, huh.
Make up your mind. If you want 24 hour ERs within every 'golden hour' logistical distance, then prepare to pay for that using public taxes. If you don't think a kid should bleed out from a stab wound while the ambulance drives to a closed ER, then either pay for better EMS communications, or more ERs...or bite the bullet and have more medical helicopters.
And don't kid yourself into thinking only government-run systems have reinforced peoples' high expectations of care. That's just a by-product of every new technology or treatment that hits the airwaves.
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