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andreasklinger

As an european now living in America:

The reason the EU model works is that people treat their problems early.

You have a concern - you go to the doctor.

NHS - with all it's short comes - has the same principle

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The reason the EU model works is that doctors (and other medical professionals) get paid less. A quick google search suggests a US ER doctor or radiologist gets paid more than 3x what a British one does, a family practitioner 2x.

http://www.payscale.com/research/UK/People_with_Jobs_as_Phys...

http://www.payscale.com/research/US/People_with_Jobs_as_Phys...

"You have a concern - you go to the doctor" is a waste of money. We've done randomized controlled trials to study this question and the result is more money spent with no increase in health.

https://www.nber.org/oregon/

http://www.rand.org/health/projects/hie.html

>> "The reason the EU model works is that doctors (and other medical professionals) get paid less. A quick google search suggests a US ER doctor or radiologist gets paid more than 3x what a British one does, a family practitioner 2x."

I'm not sure if you were posing this as a problem or not but as long as doctors want to work for the NHS it isn't one.

Going by the standards required to get into medical school in the UK from high school I don't think there is any lack of applicants!

Might also be worth comparing the cost of qualifying as a medic in the UK and the US!

I'm not posing it as a problem. I'm simply pointing out the real reason things work in the UK is that people pay less for the same thing.

Tangentially, if anyone proposes UK-style solutions to health care problems in the US without proposing 50-66% wage cuts for doctors/nurses, they are lying to you.

as said above - almost all jobs are Nx paid in the US. Doesnt necessary mean you have more money NET in the end

Well, the NHS is socialism so as far as I can see an approach like that wouldn't be ideologically acceptable in the US.

NB Regarding the "socialism" part, from NHS founder Aneurin Bevan:

"A free health service is pure Socialism and as such it is opposed to the hedonism of capitalist society."

I always think it is worth noting that the title of Bevan's book on the NHS was "In Place of Fear" - which I think sums it up nicely.

https://en.wikipedia.org/wiki/Aneurin_Bevan

I have no problem, in theory, with socialized medicine that we drastically underfund. It's probably a great way to waste fewer resources on medicine.

In practice that's just not politically feasible in the US. An illustrative example: a few years ago, a major study found that mammograms before age 50 are financially wasteful and medically harmful. Congress passed a law requiring insurance companies to pay for them anyway.

https://www.bloomberg.com/view/articles/2012-07-31/in-mammog...

http://www.uspreventiveservicestaskforce.org/Page/Document/U...

Medicare, Medicaid and the must stabilize mandate for ERs are underfunded.

It's one of the reasons that out of pocket costs are so high.

> Medicare, Medicaid and the must stabilize mandate for ERs are underfunded. It's one of the reasons that out of pocket costs are so high.

Exactly. This is the hidden secret about US healthcare that very few people are aware of. Even providers usually don't see this anymore, because they're so removed from the billing process (especially now that most providers are salaried and not running their own practices).

Medicare and Medicaid are the reasons that sticker prices for treatment in the US are absurdly high. Incidentally - and most people don't know this - if you're uninsured and self-paying, you almost never have to pay the sticker price. Hospitals really don't care, and if you just tell them that you're self-paying and can only afford (say) 10% of what they billed you for, they'll almost always immediately agree to a 90% discount. The only reason they're showing you that bill is that they need to present high bills to private insurers (to make up for the loss on Medicare/Medicaid reimbursements) and they're not legally allowed to present differently-priced initial bills to patients based on their insurance status.

No, they aren't underfunding. US government health care spending was $4,034/person. UK total health expenditures per person was $3,935.

http://data.worldbank.org/indicator/SH.XPD.PCAP

http://www.usgovernmentspending.com/year_spending_2014USbn_1...

For us to underfund it to UK levels, we'd have to expand medicare or medicaid to every single person while simultaneously cutting the total government budget for health care by 2.5%.

The UK system isn't competing with private US consumers for a limited pool of services. The comparison perhaps illustrates the poor value/dollar achieved in the US, it isn't instructive as to whether US government funded healthcare meets the costs of providing the services it mandates (a perfectly reasonable definition of underfunded).

To clarify, when I said I'd favor socialized medicine that we drastically underfund, the goal was to stop wasting resources on medicine. I.e., we should bring our health care utilization/spending down to UK levels, since evidently that doesn't significantly harm health.

Using a definition like "meets the costs of providing the services it mandates" inherently contradicts this philosophy since in the US, all sorts of crazy services will be mandated. E.g., mammograms for women under 50.

So I have read through the US Preventative Service Task Force Recommendation about 10 times in conjunction with Obamacare and preventative services, as well as been involved in some of the politics behind the data sets.

The US government actually tracks mammograms in the US through the Breast Cancer Surveillance Consortium. http://www.bcsc-research.org/

Their research basically has it come down to a massive case of Simpson's Paradox among many important subgroups needing early screening (black women, ashkenazi women, previous radiation to the chest) that suddenly disappears when they are added together en masses.

The US Preventative Service Task Force, however, is not in the business of explaining stats: it is basically a guidebook of what insurance will or will not cover, and they went with the rating they did as a compromise over the simpson paradox over the fear that these subgroups would lose coverage in high deductable plans

In exchange, they actually did cause problems by not doing comprehensive DNA testing and ONLY covering BRCA testing - which is bad science.

Except that the per-capita spend on health in the US is approximately three times what it is in the UK, which seems to corresponds quite nicely to what you're saying is the difference in salaries.

So, actually, yeah, you probably could move to a UK style solution, with the same per-capita spend as in the US while still preserving the seemingly very high wages for doctors and nurses.

It's always possible to get someone to be a doctor. Since there are many other jobs paying competitive salaries for smart folks, paying doctors less necessarily means they will be lower quality all other things equal.

They don't. Doctors in the NHS work longer hours than their U.S counterparts, and those who go through the system tend to move to either private practice, Australia, or the U.S after their residencies. For now, the system is still working, but it's clear that medicine is a much less lucrative/desirable job in the U.K than, for example the U.S. (And maybe that's a good thing – I don't know).

> k longer hours than their U.S counterparts, and those who go through the system tend to move to either private practice, Australia, or the U.S

The figures suggest you are wrong. The substantial majority stay in the NHS

> but as long as doctors want to work for the NHS

Current under-funding of the NHS means there's a shortage of consultants (especially in A&E and mental health) and a shortage of nurses.

Some A&E units are being downgraded and closed at night because of these shortages of staff.

It's possible the problem is that we don't have enough qualified staff. Any source showing is that's the issue or it's that a huge number of people are going abroad?

I'm not claiming staff are going abroad.

Some, although I don't know how many, definitely are, though, especially after the junior doctors contract change.

I agree. I have several friends who have went abroad because they get paid more, work is less stressful and the weather is nice. I'd like to see a proper breakdown. From what I can see the problem is more of an increase in total jobs that was not met by the number of people qualifying which could just be poor planning.

Peronsal (european biased) thoughts to this:

1) I cant believe that it's only the doctor costs.

I see people with all kinds of health problems in the US that should be treated early. Classic example is people with foot problems not treating them asap -> soon stumbling, crutch, amputee.

2) Comparing salaries in the US to the UK/EU are super hard. We have by usually lower costs of livings in europe (health, education, housing).

eg SE: http://www.payscale.com/research/US/Job=Software_Engineer/Sa... http://www.payscale.com/research/UK/Job=Software_Engineer/Sa...

Personal anecdote: i could earn half my money i earn in california and would still be top paid in germany/austria. i would be able to save more money though.

3) I am unsure how much doctors should earn. They earn very good money in Europe. But maybe that's just my "it's a mandatory service not a privilege" pre-trained mindset speaking.

1) It's also nurse costs, etc. The bulk of health care costs is labor.

Again, I linked to RCTs showing that improving access to health care doesn't improve health and does increase costs/utilization. Do you have any evidence to the contrary?

2) The UK is 6% more expensive than the US. I don't know where to find the exact PPP factors, but you can back them out of GDP statistics by dividing GDP(PPP) per capita / GDP(nominal) per capita.

https://en.wikipedia.org/wiki/List_of_countries_by_GDP_(nomi...

https://en.wikipedia.org/wiki/List_of_countries_by_GDP_(PPP)...

Where do people get the crazy idea that the US is more expensive than the EU? Is it just personal experience from their vacation to NYC?

They get paid what their market value is in the EU.

Which is less than the market value of US

See my previous comment about per-capita healthcare spend in the US vs the UK .

One reason EU doctors get paid less is that in most EU countries you don't have to go into massive debt for your education

Also, the per-capita healthcare spend in the US is nearly 3 times that in the UK, for outcomes that are very similar. One might even suggest that the insurance companies, private hospitals and doctors in the US aren't very good value for money...

That depends on your socio economic status. If you're rich, the service is unbelievably good, if not, it's not. You can't treat figures about the US the same way while ignoring the massive inequalities.

If you're rich, the health service you will receive is incredibly good anywhere. Not sure what point you're trying to make.

Define "rich". Most people go to the same hospitals as everyone else and get similar treatment to everyone else. Contrary to popular belief, the US doesn't have signs reading "NO POORS" posted everywhere. I live in an affluent suburb and the people here go to one of the four hospitals in the area just like everyone else.

Yes, it's true at the far extremes there are people that can both afford and choose to pay personal doctors, but it's very rare, even among "the rich". Most people don't consider that a good use of funds.

It's illegal for American hospitals to deny necessary medical care due to inability to pay. I've gone to American hospitals both when I was indigent and when I was well off, and I feel the service quality was identical. In fact, hospitals usually have a designated administrative employee who handles the billing; the actual health professionals involved in treatment will often have no idea what your financial situation is and/or whether you even have insurance.

It is now illegal for Americans to fail to carry some form of health insurance. If someone absolutely can't afford it, there's Medicaid, the government-sponsored insurance program, which is actually really good. For people in-between, there's the government-subsidized health exchanges.

Healthcare in the US is a complete mess, but it's not as simple as "rich v. poor". Practically, most of the poor continue to get medical care, and if they don't manage their insurance or care properly, they just take big hits to their credit. Which, don't get me wrong, is not good either, but it's definitely recoverable and survivable.

Immediate necessary. Once you are out of the emergency room they no longer have to provide care

To add to this, certain professions in healthcare receive free education because there's such a large demand. My cousin is a radiologist and paid nothing for her degree (or rather the NHS paid for it).

> "You have a concern - you go to the doctor" is a waste of money.

Wrong, depending on the angle. Prevention is the key, it's the same with computer bugs

Correct, don't send them to a doctor for anything that shows up, that's why the initiatives are to have Nurses evaluating the problem and escalating if it's a bigger/more urgent issue

theoretically people should go to the ER only when it's urgent or life-threatening

> a US ER doctor or radiologist gets paid more than 3x what a British one does, a family practitioner 2x

In US you need to get paid more, so you can afford health insurance for you and your family, pay for daycare and school and college for your kids. In Europe you get these mostly free, so you can get the same quality of life with a lower salary.

The numbers I've listed are salary. Most doctors have health insurance paid for by their employer, so their total compensation (including health benefits) is likely higher.

I linked to numbers elsewhere in this thread showing that cost of living is higher in the UK.

How many US employers provide the kind of health insurance that you don't end up anyway paying over $1000 a year (for a family) in all kinds of fees and deductibles and whatever?

Let me do the math and illustrate that you are arguing about irrelevancies. Let me assume all doctors spend $10,000/year in fees/etc, or 10x the number you suggest.

US ER doc: $209,161 - $5,000 = $199,161.

UK ER doc: $60,504 - $0 = 60,504. ($57,709 after adjusting for purchasing power, which is lower in the UK.)

This really doesn't change my conclusion at all. (PPP factors, salaries are taken from links I've posted in other comments.)

$1000? At my last job the premiums for this year for a couple with children is $12,000 plus deductibles and coinsurance. The only cheaper option is an HSA+ catastrophic plan which is kind of a joke but they were encouraging us to take it because employee premium was $0.

HN will be full of Googlers and startups with funny money who can throw around gold plated plans to their people but in the real world this is how it is, and premiums are getting worse every year.

>>> The reason the EU model works is that doctors (and other medical professionals) get paid less.

They also don't get sued so much. Or have crippling depth to pay of.

>>> You have a concern - you go to the doctor" is a waste of money

It's called preventive care and it actually saves money in the long run.

If you have evidence that providing more preventative care will either save money or make people healthier, present it. All the evidence I've seen (see my links in other posts on this thread) suggests the US provides too much of it.

Strangely, not a single person telling me I'm wrong has cited a single source or done a single back of the envelope calculation.

Because your sources aren't proving what you think they do.

The Oregon trial was only two years long and it actually did report some health improvements, diabetes and depression in particular. It also found improvements across a lot of other medical issues, they were just considered statistically insignificant (given it was only two years, not really a surprise).

The RAND experiment found that money does reduce unnecessary medical treatment (and therefore reduces costs). But it also found that it reduced necessary treatment too.

I agree that the exact numbers and costs are controversial, but basically everyone aggress that it improves the quality of life for everyone. And even if preventing disease is costlier, isn't better that fewer people get a serious disease in the end?!

Also, here's a study that supports preventative care. There's many more if you just look for it. http://www.medscape.com/viewarticle/735245

The Oregon trial had no effect on diabetes. It caused people to consume more diabetes medication which the authors speculate might make them healthier.

You are correct that having insurance made people feel better. So what?

It also found improvements across a lot of other medical issues, they were just considered statistically insignificant...

And you've just demonstrated that you have goals here other than finding truth, or perhaps you just don't understand hypothesis testing.

Your medscape article is just a press release parroted by some innumerate reporter. Further, the article is focused on stuff like "stop smoking" and "stop drinking" support, not medical interventions. The full study isn't even linked.

>>> The Oregon trial had no effect on diabetes. It caused people to consume more diabetes medication which the authors speculate might make them healthier.

It increased the rate of diagnosis of diabetes. And what do you mean speculate? What's the point of giving medication if it doesn't help?

>>> You are correct that having insurance made people feel better. So what?

Treating depression is part of healthcare.

>>> And you've just demonstrated that you have goals here other than finding truth

I don't think so. I just thought it's an interesting observation. Combined with the fact that it was a short term experiment it makes one think. But you're right, it's not significant.

>>> "stop smoking" and "stop drinking" support, not medical interventions

Stopping smoking and drinking is part of healthcare. At least in the UK. Perhaps you don't think preventive care works because you don't think improving ones wellness is part of it? Why are insurance companies including preventative care in their packages if it actually costs them money?

Here's a study that found a list of preventative measures that do save money: vaccinating children and adults, smoking cessation, daily use of aspirin, and screening for issues with alcoholism, obesity, and vision failure.

http://www.nejm.org/doi/full/10.1056/NEJMp0708558#t=article

But you're right. In part. Other preventative measures do not save money. Like preventing heart attacks by treating hypertension early on with drugs did not save money in the long run. It's more cost effective to let people have heart attacks. But at least the insurance company saves a few bucks (rolls eyes).

Doctor and nurse salaries are higher in the US than in most other countries, but as a percentage of healthcare costs they're very small.

> You have a concern - you go to the doctor.

But the NHS keeps telling us to not go to the doctor!

"See a nurse rather than a doctor! See a pharmacist rather than a doctor! Phone a helpline rather than see a doctor! Go to your high street chemist rather than see a doctor! Self-treat rather than see a doctor!".

I had subpar experiences in the UK with the NHS but not horrible.

Telling people not to go to a doctor is dangerous but i can understand the intend.

Eg: (Can only judge with Austria/Germany experience)

Pharmacists are extremely highly trained there. They are implicitly used as a simple doctor. We do the same. You feel bit weird you go to the pharmacy just to gauge what it could be and how serious they take it. If serious enough you go to a doctor asap.

> You feel bit weird you go to the pharmacy just to gauge what it could be and how serious they take it. If serious enough you go to a doctor asap.

They must be very confident pharmacists. If anyone ever asked me 'do you think I should see a doctor' I would say 'yes' every time.

What happens if you get it wrong? Doctors are protected by major institutions, insurance, legal precedents. What about someone working in Boots (UK high street pharmacy chain) who tells you not to bother seeing a doctor and then you die?

1) they are really well trained usually

2) If they are unsure they will tell you.

3) If the judgement is the same as any one else would have done i dont think it could be considered grossly negligent.

Pharmacists, in the UK at least, have to train almost as much as doctors, and have much of the same knowledge.

We have a bunch of different health advice, from NICE and Public Health England and etc. So if a pharmacist is getting close to that advice they're going to be protected.

Admittedly their advice would be "You probably don't need to see a GP for this, but if you're at all worried you should make an appointment".

You're missing the wood for the trees. The 'doctor' part of the statement wasn't the important part, it's that early diagnosis is encouraged. For example, the NHS has the NHS 111 helpline for times when you want medical advice but it isn't something that requires visiting a doctor (they can refer you to a doctor if it is something that requires further investigation).

http://www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandur...

If you do any of those things and it turns out to be something they can't handle, they send you to a doctor. I've phoned 111 a couple of times, once had an appointment made for me with an emergency dentist, and once been told to wait my illness out (severe stomach pain) as it was unlikely the doctor could do anything for me aside from prescribe painkillers. If I'd seen a doctor the second time, it would've been a waste of the doctor's time.

Yes, but look at how many people go to see a doctor with a cold or at the first signs of a sore throat. That, along with missed appointments, are what makes the process so inefficient.

And this is all reasonable advice. If the nurse or helpline or pharmacy can help - great. If not, they will escalate

That's the way it works now I live in Germany. It's very cheap an easy to go to the doctor here, and they are keen to do tests that get them early warning problems. This is all a way of clawing money back from the compulsory roughly "Obamacare" style insurers.

But it was much worse when in the UK. The providers get funding for you, but once you are registered, it seems actual service is a pure cost to them. My GPs practice in London only allowed same day-appointments and only pretended to allow them over the phone.

My cousin there got sicker and sicker for months in because instead of testing her, they just gave her the wrong medicine. In the end she flew to Sri Lanka where she got tested, rediagnosed and operated on within 48 hours.

> My GPs practice in London only allowed same day-appointments and only pretended to allow them over the phone

Some GPs are bad, and in general GPs are under a lot of pressure, but you can change your GP surgery at any time, for any reason.

And let's not forget that your "NHS GP" is not employed by the NHS, but is employed by a private company that does work for the NHS.

GPs are shit because of the fucking awful semi-privatisation they've been forced through.

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