Links - 6th February 2020 (2) (US Healthcare)

How does the quality of the U.S. healthcare system compare to other countries?
The US system performs badly when measured by:
Age-adjusted mortality
Healthcare Access and Quality Index
Years of Life Lost
Age-standardized Disability Adjusted Life Years
Hospital admissions for preventable diseases
Medical, medication, or lab errors or delays
The US does do better on a few measures (post procedure outcomes) but the disparity in outcome is generally not a lot - and the costs are way higher. Plus they do badly on some post procedure outcomes too. Ironically, given how much people bang on about how wait times in the US are short, the US doesn't do well by this measure either (Percent of adults who made a same-day or next day appointment when needed care)

The Astonishingly High Administrative Costs of U.S. Health Care - "A widely cited study published in The New England Journal of Medicine used data from 1999 to estimate that about 30 percent of American health care expenditures were the result of administration, about twice what it is in Canada. If the figures hold today, they mean that out of the average of about $19,000 that U.S. workers and their employers pay for family coverage each year, $5,700 goes toward administrative costs... Like the overall cost of the U.S. health system, its administrative cost alone is No. 1 in the world.Using data from 2010 and 2011, one study, published in Health Affairs, compared hospital administrative costs in the United States with those in seven other places: Canada, England, Scotland, Wales, France, Germany and the Netherlands.At just over 25 percent of total spending on hospital care (or 1.4 percent of total United States economic output), American hospital administrative costs exceed those of all the other places. The Netherlands was second in hospital administrative costs: almost 20 percent of hospital spending and 0.8 percent of that country’s G.D.P.At the low end were Canada and Scotland, which both spend about 12 percent of hospital expenditures on administration, or about half a percent of G.D.P.Hospitals are not the only source of high administrative spending in the United States. Physician practices also devote a large proportion of revenue to administration. By one estimate, for every 10 physicians providing care, almost seven additional people are engaged in billing-related activities... “The extraordinary costs we see are not because of administrative slack or because health care leaders don’t try to economize,” said Kevin Schulman, a co-author of the study and a professor of medicine at Duke. “The high administrative costs are functions of the system’s complexity.”Costs related to billing appear to be growing... One obvious source of complexity of the American health system is its multiplicity of payers. A typical hospital has to contend not just with several public health programs, like Medicare and Medicaid, but also with many private insurers, each with its own set of procedures and forms (whether electronic or paper) for billing and collecting payment. By one estimate, 80 percent of the billing-related costs in the United States are because of contending with this added complexity.“One can have choice without costly complexity,” said Barak Richman, a co-author of the JAMA study and a professor of law at Duke. “Switzerland and Germany, for example, have lower administrative costs than the U.S. but exhibit a robust choice of health insurers.”"

Does Ownership Matter? An Overview of Systematic Reviews of the Performance of Private For-Profit, Private Not-For-Profit and Public Healthcare Providers - "The aim of this article was to provide an overview of what is known about the effects on economic, administrative and health related outcomes of different types of ownership of healthcare providers -namely public, private non-for-profit (PNFP) and private for-profit (PFP)... When comparing PNFP and public providers, as well as for PFP and public providers, no clear differences were found... PFP providers seem to have worst results than their PNFP counterparts"
So much for private is always superior to public, and so much for market incentives meaning the product will always be better (i.e. Private For Profit providers being the worst)

Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States - "To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians’ use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994–1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home."

5 Myths About Canadian Health Care - "Myth #5: Canada rations health care; the United States doesn’t.
This one’s a little bit tricky. The truth is, Canada may “ration” by making people wait for some things, but here in the United States we also “ration” — by cost. An 11-country survey carried out in 2010 by the Commonwealth Fund, a Washington-based health policy foundation, found that adults in the United States are by far the most likely to go without care because of cost. In fact, 42 percent of the Americans surveyed did not express confidence that they would be able to afford health care if seriously ill.Source: “How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries,” Health Affairs, November 2010.Further, about a third of the Americans surveyed reported that, in the preceding year, they didn’t go to the doctor when sick, didn’t get recommended care when needed, didn’t fill a prescription or skipped doses of medications because of cost.Finally, about one in five of the Americans surveyed had struggled to pay or were unable to pay their medical bills in the preceding year. That was more than twice the percentage found in any of the other 10 countries.And remember: We’re spending way more on health care than any other country, and for all that money we’re getting at best middling results."
Not to mention the top cause of bankruptcy in the US is healthcare costs

Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review - "providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers."

How do mortality rates in the U.S. compare to other countries? - "For most of the leading causes of death, mortality rates are higher in the U.S. than in comparable countries"
Some champions of US healthcare claim that once you take out traffic accidents, gun deaths/suicides and obesity-related causes, the US healthcare system performs excellently and is good value for money. Clearly the first two are red herrings from the mortality data. And other countries with a lot of fat people (e.g. Australia) still perform much better than the US

Survey: 79 Million Americans Have Problems with Medical Bills or Debt - "41 percent of working-age Americans—or 72 million people—have medical bill problems or are paying off medical debt, up from 34 percent in 2005. If you add in the 7 million elderly adults who are also dealing with these issues, a total of 79 million Americans have medical bill or debt problems... Nearly two-thirds of U.S. adults under age 65, or 116 million people, had medical bill problems or debt, went without needed care because of the cost, were uninsured for a time, or were underinsured—that is, whatever coverage they had was not providing adequate protection from high medical expenses."

'I live on the street now': how Americans fall into medical bankruptcy - "“My bills were hundreds of thousands of dollars, so I had no choice but to file bankruptcy.”LeClair is on the verge of having to file for bankruptcy a second time due to the mounting medical debt she has accrued for additional cancer-related surgeries, regular appointments, medications and supplies related to her recovery, despite having health insurance and paying as much as she can out of pocket for copays, deductibles and premiums to maintain insurance. “My medical bills are at $52,000. I’ve done everything from credit cards to consolidation loans, I just keep simply paying one credit card with another interest-free one until I can pay the next one,” LeClair added. “It’s the side of cancer most people don’t understand or know about and it’s never-ending. It just keeps adding up and adding up and before you know it you’re back in debt that you can’t believe again.” Bankruptcy can also make it difficult to find employment given that many employers will disqualify a candidate with a bankruptcy filing found from a background check. According to a study published in February 2019, about 530,000 bankruptcies filed annually are because of debt accrued due to a medical illness... “A lot of people, a little over 60%, are filing bankruptcy at least in part because of medical bills. Most of them are insured. It’s clear that despite health insurance, there are many, many people incurring costs not being covered by their insurance”... “Medical debt is incredibly common, it’s the main cause of calls from collection agencies, and the vast majority of people with it have insurance,” said Himmelstein, lead author of the study Medical Bankruptcy: Still Common Despite the Affordable Care Act. One out of every six Americans has an unpaid medical bill on their credit report, amounting to $81bn in debt nationwide, while about one in 12 Americans went without any medical insurance throughout 2018. Even as many Americans struggle to afford health insurance coverage in the first place, those that have it are not insulated from facing massive debt due to medical bills... “One of the biggest hurdles you face as a patient is just the sheer confusion of the process. You think you just show up and present your card, sometimes pay a copay, and that’s it. You don’t expect all these plan limitations and authorizations,” Hillman added. “What are you going to do if your authorization gets denied? You don’t really have a choice to not go get care. All these processes that are in the finest of fine print. And sometimes it feels like you are literally paying for nothing.”"

Thread by @MaryRobinette - "When I lived in Iceland, I found a lump. I had no idea how to navigate finding a doctor, so I went to our show's production manager.
Me: I found a lump. Can you help me find a doctor?
PM: Just go to the cancer center.
Me: Okay. How do a get a referral?
PM: What's a referral?
After I explain what a referral is, he looks baffled.
PM: Just go to the cancer center...
Having accepted that I don't need a referral, I say, "How do I make an appointment?"
CC: An appointment? Yes, we can do that if your schedule is very busy, otherwise just come in.
Me: I don't need an appointment?
CC: You found a lump! You know your body, yes? Come in.
So I go. The nurse checking me in apologizes because, since I'm not Icelandic, I'll have to pay for the visit.
It's 3 krónur. That's 3 dollars at that point...
CC: Yes, that does feel like a lump. Let's do a mammogram.
I prepare to hear about making an appointment for that.
CC: I'm sorry, but it's across the hall. Do you mind following me?
I've been in the building for about twenty minutes at this point when I'm strapped into the mammogram -- WHICH HAD WARMERS -- and she does her thing.
CC: There is something there, you are right. I want to see it with an ultrasound.
And then she leads me next door...
Forty-five minutes after walking into the Icelandic Cancer Center and 3 krónur poorer, I had the answer. In the US, a similar lump took two weeks and three different office visits.
I think about this every time I have to fight with medical insurance in the US.
The terrors of "socialised healthcare"
Curiously, if medicine in the US is so great, why do they need to make appointments and wait for followup treatments or investigations?

East Liberty Primary Care Doc Pulls The Plug On Insurance - "Wong’s practice is about as opposite of UPMC and AHN as a physician can get in Pittsburgh. He’s doesn’t accept any form of insurance. Patients pay up front for care at an iPad station when they check themselves into the clinic.For each medical visit, Wong charges a flat fee of just $35... A 2016 study found that for every hour a doctor spends on direct patient care, they spend another two hours on paperwork.“Everybody wants slightly different information,” said Julie Sakowski, a health care economist at Seton Hall University, in South Orange, N.J.*Sakowski has researched how much medical practices spend on communicating with insurance providers. Sakowski puts it between 10 and 20 percent of a practice’s income... Wong said his business model allows him more time to see patients and generate income.And he has no employees.Patients pay up front, so Wong’s practice doesn’t employ a biller. And since he doesn’t accept insurance, he also doesn’t have a medical coder, which is a person whose job is to submit documentation to insurance companies. These are the reasons, said Wong, why he can charge patients so little."
Of course, libertarians claim that government is always more inefficient so single payer will always cost more - even though the US has the most expensive healthcare in the world, which is more expensive than countries with single payer

The Truth About Waiting to See a Doctor in Canada - "SHANOOR SEERVAI: So one of the things that we hear about in the U.S. when our two health systems are compared is that Canada has really long waiting times for health services. How long do people really have to wait to get care?
CHRISTOPHER HAYES: So I guess it’s — it depends on what do you think you’re waiting for. So if you are in a hospital and you need surgery you don’t wait. It gets done in — if it needs to be done in 30 minutes it will be done in 30 minutes. If you need an MRI for care provided in a hospital you will get it whenever — depending on where you are because not every hospital has an MRI, but you will be prioritized and that will happen probably as quickly as it can be done anywhere. It is as the priority drops or is deemed less by whomever that the wait — so the waits are how long will you wait to see a specialist after seeing your family doctor. I mean, the one that people will talk about is cataracts, hip surgeries, non — not cancer type surgeries, where there — things will get worse if you don’t get treated. And so you can wait months for those surgeries."

Funding of US Biomedical Research, 2003-2008 - "In 2007, industry (58%) was the largest funder, followed by the federal government (33%)"
For all the clamour about how drug prices in the US are unjustly high because drug research is mostly funded by taxpayers (bonus points for blaming Trump even though he's actually done some good in this aspect), the facts are much less sexy

Graham Cox's answer to Why are Europeans so proud of their health care? I have been in hospital in Sweden and the care isn't better than in the US. - Quora
Comment: "The US system is ridiculously expensive, because it’s market based, and the market responds to consumer pressure. It used to be that most healthcare plans were HMOs; you’d designate a primary-care-physician (GP) who would refer you. Consumers said, “I don’t want to go to some under-qualified GP (obviosly that’s not true), I want a specialist!”; and insurance companies said mmmkay. In came PPOs; now patients go to a gastroenterologist when they have a stomach ache, a neurosurgeon when they have a headache, and an opthamologist to get their routine eye exam. The result is worse care (because it’s not coordinated by a single doctor), and many times more expensive. Same thing with brand name drugs. And dozens of other things. But in US culture, a government telling them that a GP will provide better care is NOT going to work - US psyche is trained to belief that government is ineffective. The FDA has gone crazy trying to push generic drugs, yet brand name drugs still outsell generics."
"Most of the battery of tests a US hospital will insist on are taken for evidence in case of a subsequent malpractice suit, not for an actual clinical need."