Monday, August 13, 2012

An NHS Patriot

And now in honor of the close of the London Olympics, my tribute to the NHS...

"We're always trying to give the NHS as much publicity as possible in a positive light." -- Sarah Parish

I first became familiar with actress Sarah Parrish when I watched the miniseries Pillars of the Earth. Loved her performance as the evil Lady Hamleigh! More recently she gave an outstanding performance as Levicy Hatfield opposite Kevin Costner in the Emmy-nominated miniseries, Hatfields and McCoys. Sarah lives with her real life actor husband, James Murray, in Southampton, England. I met them in Vancouver last year where James was working on a TV series with my husband.

As a proud supporter of the National Health Service (NHS) in the UK, Sarah was enthusiastic about sharing her viewpoint on the British health care system with me. So we met up one day for tea and a chat about the NHS.

"Our first daughter was born with a severe congenital cardiac condition," Sarah began. "She would have died immediately had it not been for the outstanding care from the pediatric cardiology department at Southampton General Hospital." She continued, "The NHS had everything we needed."

"So, you don't have private health insurance?" I asked. "I don't want to buy into it," she responded. "You have to invest in the NHS for it to work-- That's the way I'm politically inclined," Sarah said firmly.

I took a sip of tea while I let that sink in.  "Do most high earners have private health care benefits?" I asked. Sarah thought they probably did. She attributed that to the tendency for people to believe if they pay more money they're going to receive superior care. But in her opinion, "You might get it quicker but you're not going to get any better care."

Sarah stated that you see the same doctors whether you have NHS coverage or private insurance. "The pride doctors take in working for the NHS is what makes it so special."

A little research on my part confirmed strong resistance on the part of British doctors' to the recently passed Health and Social Care law, which moves toward expanded privatization and disparities in care based on ability to pay. The British Medical Association, in fact, said that the relationship between family doctors and patients will suffer irreparable damage and that the reforms will be "irreversibly damaging to the NHS". Health care professionals have actually created a political party, the National Health Action Party, to fight the changes to the National Health Service. The voting was mainly along party lines with Labour voting against it and Conservatives and many Liberal Democrats voting for it. According to Sarah, right-wing and coalition governments are always a bum deal for the NHS, "Things get privatized, funds cut." 

Any experience with those waiting lists we hear about so much in the US? Sarah told me about her father's bout with colon cancer. Yes, he had to wait. In fact, his surgery was postponed at one point because someone with a more urgent condition took his place. From diagnosis to operation ended up being about two months. It caused the family some anxiety but everything ended up fine.

The system prioritizes the urgency of surgeries. Usually the system works. But of course, on occasion, Sarah said, "Mistakes are going to be made."

Getting back to health care cuts, Sarah and James have a particular concern about the threat to eliminate the pediatric cardiology departments in some of England's public hospitals. The program at the Southampton hospital where their daughter received such good treatment may be going under the knife. They have embarked on a public campaign to fight it.

Sarah said they like to be public about their use of the NHS, saying that when people learn that high profile actors are using the public system, "They figure if it's good enough for them [Sarah and James], it's good enough for us."

Outside the windows of the marina-side restaurant, a beautiful afternoon beaconed and we gathered our belongings to leave. "That's really quite something that you would forgo the convenience of the private system to support the NHS," I said admiringly. Sarah flashed me a confident smile and said, "You have to support your country."

Wednesday, February 15, 2012

The Doctor Down Under

I’m back to my blog after a few months hiatus. Since I wanted to continue my examination of the Australian health care system, I was thrilled that my Canadian pal, Rosie, was able to give me an email introduction to Dr. Sue O’Brien, a general practitioner in the health care clinic for Flinders University in Adelaide, Australia. Dr. O’Brien and I were able to chat via Skype about her experiences with the Australian health care system.

I was particularly interested in her perspectives as a physician in the Land Down Under. I decided to begin at the beginning with the cost for doctors to get their training. The tremendous student debt our young US physicians rack up is part of the case they make for being paid more here than in other countries. “Is it very expensive to train to be a physician in Australia?” I asked. “Well, at the time that I trained,” Sue responded, “it was completely free, plus I had a little bit of living support, which the federal government paid for.” Wow, can’t beat that with a stick!

But, as it turns out, the system is a bit different now. Still, most medical students who are Australian citizens only have to pay 1/3 of the tuition while the government pays the other 2/3. That averages about $9,000 per year for which the student is responsible. And a student at any income level can get a government loan for the full $9,000, which they don’t have to start paying back until they are earning a certain amount of money. If for some reason they never reach that threshold of earnings, they don’t have to repay the debt.

Do young Australian physicians still feel they finish school with an oppressive amount of debt? “They do feel that. They certainly do feel that,” was Dr. O’Brien’s reply. I guess starting one’s professional career already $36,000+ in debt is somewhat daunting but it can’t quite compare to the hundreds of thousands young US physicians owe.

My mind still on money, I asked Sue how she got paid. She told me that for her general practice patients, she does bulk billing. Bulk billing means that a doctor is willing to accept just the amount that Medicare covers. So the care is free for the patient. Australian docs are not obliged to bulk bill and can charge whatever they want. But even when Sue was in other practices, before she worked at the university, she accepted bulk billing. Consequently, she has seen many patients who were particularly needy.

In my previous post, “An American in Oz”, I wrote about how the Medicare Safety Net protects Australians from high non-hospital medical costs. When I asked Sue about the Safety Net, she mentioned there is also a Pharmaceutical Benefits Safety Net, which protects Australians from high medication costs. Even before Australians incurs high medication costs, they all qualify for the government Pharmaceutical Benefits Scheme. Under this plan, general patients can get most medications for $35 or less. When patients qualify for a concession because they: make less than $25,000 per year, are a student, are seeking work, are a pensioner – they can get generic prescriptions for $5.80. If a patient uses a brand name drug when a generic exists, the patient will have to pay more.

After a general patient has spent $1363 on medications in a year, the Pharmaceutical Benefits Safety Net kicks in and the rest of their medications cost $5.80. This benefit is not means-tested. If a patient is a Concession Card holder, their medications are free after they spend $348.

The Pharmaceutical Benefits Scheme covers only medications that are on the Schedule of Pharmaceutical Benefits. Dr. O’Brien informed me that most necessary medications are covered – most life saving drugs, medications for diabetes, hypertension, cardiac disease, infections, as well as medications for pain, anti-inflammatory agents, and oral contraceptives. Drugs that are not covered include some very new drugs, often for cancer, that haven’t been evaluated and approved by the government yet. “Are you ever unable to prescribe in a way that is in the best interest of your patients?” I enquired. “Hardly ever,” Dr. O’Brien stated emphatically. “Very rarely do I feel that a person needs a medication that they won’t be able to afford and there’s no alternative.”

Continuing this line of questioning regarding restrictions on what the government will cover, I asked whether in general she felt limitations on government health care coverage ever prevented her from giving her patients the best possible care. Her response was that Medicare doesn’t usually cover ancillary care – dieticians, physical therapists, podiatrists, dentists, psychologists – except for patients with serious chronic illnesses, for example diabetes, rheumatoid arthritis, or asthma. So occasionally Sue has patients who really need those services but because they don’t qualify for special chronic illness health support they aren’t able to afford it. However she added, “It’s quite unusual for me to feel that my patient really needs something that they won’t be able to get or that they will need something that they will not be able to afford.”

Sounds pretty good, doesn’t it?

Let’s look at some statistics that reflect the relative problem of affordability in Australia, Canada, and the US. According to a Commonwealth Foundation study, the percentage of people in these countries that had medical problems but didn’t visit a doctor due to cost concerns was 13% Australia, 4% Canada, and 22% US. Among below average earners, lower income US residents were about 2½ times more likely to have a serious problem or complete inability to pay medical bills than lower income Canadians or Aussies. Even above average US earners were twice as likely as above average Australian earners to have problems paying medical bills and about 5 times more likely to have difficulties than Canadians with above average income. So while some Australians have affordability issues, it’s a far less severe problem than in the US.

Going broke in Australia due to medical debt? “It would be rare,” said Sue. “Because hospital care, everybody’s covered for hospital care in the public sector. There are no costs for that.”

What about my favorite question: waiting lists? “Would you say that patients’ medical conditions deteriorate due to the waits?” I asked Dr. O’Brien. “I think that may happen sometimes,” she answered. “If somebody needs a hip replacement, there’s an optimal time to do it. And if the person has a lot of other medical problems, if they have chronic health problems like cardiovascular disease or diabetes, then because they have to wait, and they might have to wait for a year or something like that, then their other health conditions might deteriorate. And they may not be such a good operating risk.” But on the other hand, “What I find though, is that, and I’m sure other doctors would agree with this, if it’s a serious problem, let’s say it’s a dermatological problem and the person has a terrible rash, which is difficult to diagnose. Then you [the doctor] ring up somebody in the public system, you ring up the clinic, or the referral that you send, sends it as an urgent problem. And they’re very likely to be seen quickly.”

When I asked Sue whether there was anything that bothered her about the Australian health care system she asserted, “I think it’s quite a good system!” She went on, “If I try to think of ways in which it could be improved – There could perhaps be more direct funding of doctors who are willing to work in public hospitals. It used to be the case that there was more direct government funding for that. But the government has tried to get the private system to pay for more, a bigger proportion of the health service… More direct funding for doctors who are willing to work in the public system would presumably lessen the waits for people who can’t afford to get their health care in the private system. Because that’s probably the biggest problem. Waits in the public system.”

Australia’s national health care system, while not perfect, gives residents the option of health care that costs them nothing at the point of service. Medications are available to everyone at a relatively low cost. And although affordability is an issue for some, it is on a much lesser scale than in the US. There is also a private insurance industry that gives speedier access, more covered ancillary benefits, and upgraded hospital choices. Perhaps this is a model more palatable to Americans than systems that are more strictly egalitarian.