Methods used in the UK and US
Technology and the Socialization of Healthcare
Darren Hinze
2007
This is an overview (draft) of methods used in the United States and in the United Kingdom in their efforts to socialize health care. The US has fevently resisted the socalization of their healthcare system, but at the same time they have done exactly what they are attesting to be against. Medicare is socalized medicine, The major Health Maintenance Organizations (HMO) are also involved in a limited social medicine structure. This paper although a draft it has references listed so you can do additional research if you feel the need. NOTE: If you are ripping this information for a particular class in school be sure to add my web site as a reference. I only note this because some of the plagarism checkers have found my posting (before I put them here). I would not want you gettign kicked out of school for copying my questionable work.
———
Methods used in the
UK and US for the Socialization of Healthcare
The attempt in the paper is to give a through background on the approach to cost effective health care processes and technology used in the United Kingdom and the
United States. The assumption in the paper is that both countries share the same goals and values in achieving appropriate health care for their citizens. The arguments insinuated throughout the article is that the US can implement the UK system of managed health care and bring medical technology advances to the marketplace faster in the U.S., according to the article these are simply two methods that are equally valid.
Value-Based Coverage Policy in the United States and the
United Kingdom: Different Paths to a Common Goal, published by the National Health Policy Forum, makes a nice utopian argument for combining the research, testing, and implementation of health care advances.
Overview of Health Plan Policies
Irrelevant of the health plan, private or public services are defined in terms or benefit categories; physician and clinic service, outpatient, inpatient, and rehabilitative or physical therapies. Plans will limit benefits based on visits per period, number of days of inpatient services (hospital stays), and types of services provided. Many plans will limit coverage to institutionally recognized therapies, denying payment for modalities that are deemed experimental. When private medical insurance was still young, services were generally approved or denied based on the provider not the modality. As the list of services grew and new technologies were introduced to the industry listing categories for inclusion did not provide the controls necessary for insurance agencies. The insurance agencies added exclusions to the list of covered and non-covered services. Policies set by the insurers determine how the services they pay for are used and to what extent they are made available to the insured. Through their funding they can determine the quality or care, procedures used, and the outcome of the health care process.
In 1965 Medicare was enacted in theUnited States. Medicare took policy verbiage from the private insurance industry and since its inception it has changed little. Medicare still makes service determination based on “reasonable and necessary” treatments. The paper cites that “medical care has become too complex and too expensive to rely on professional consensus” and therefore professional judgment is not enough to adequately determine what is “reasonable and necessary.” The authors calculations based on information from Centers for Medicare and Medicaid Services showed, “In 2004, health care accounted for 16 percent of the U.S. gross domestic product (GDP) or $6,280, on average, for every man, woman, and child. In 1970, the corresponding figures were about 7 percent of GDP and $480 per capita (in today’s dollars).”
The author postulates that the increase could be from inflation, additional use of services by an aging population, and a greater number of people making use of the system. It is not clear in the paper if technological advances have pushed the cost higher through greater use of necessary infrastructure, the cost of implementing the technology or reimbursement of research through higher costs for the technology. It is possible that the advanced technology has created a longer lived population that is now adding to the cost burden. If this is the case then we should see a continued climb in expenses as services are expanded and the general health of the population increases. The challenge in determining the cause of a patient’s beneficial outcome involves scientifically tracking the patient and his or her response to specific therapies; however, there is little time and even fewer resources available for a physician to track their patients at this level. The busy schedules and workloads of practicing physicians preclude many of them from investigating new treatments and applying them in their practice; this means that even though the technological advancement exists it is not used.
The paper notes that the trend in increased costs is not limited to theUnited States. Other developed nations with different financing structures are similarly affected with rising costs and increased service use. Based on the authors calculations, using information from the, “Organisation for Economic Co-operation and Development”, OCED Health Data 2006, “Between 1999 and 2004, for example, the annual rate of growth in per capita health expenditures (in real terms) was 4.0 percent for Canada, 4.5 percent for New Zealand, 3.9 percent for Sweden, 5.4 percent for the United Kingdom, and 4.8 percent in the United States.”
Other nations are seeking advancements in medical technology and are challenged in distributing this information to their clinical professionals. As advances are discovered they are shared through various channels both public and private. At some point the procedure may be accepted by insurance companies and it will then be included in their policy as a covered service. It can take years for a new procedure, treatment or research information to make its way through all the insurance companies and be openly accepted in theUS healthcare model. TheUnited Kingdom has a much more centralized system to distribute new techniques and as a result they have a much shorter time from testing to implementation. A newly accepted technique is socialized throughout their health network rapidly because it was tested inside the same network. The National Health Services (NHS) is a centrally financed service that manages health care policies. The NHS works in conjunction with the National Institute for Health and Clinical Excellence (NICE). NICE provides guidance on the use of new technologies within the NHS.
Combining the technology research sector with the policy making and provider sectors allows the United Kingdom’s health care system to rapidly deploy new treatment methods much faster than theUnited States system of disconnected public and private insurers.
A Paradigm Change
The twentieth century was an age of examination, experimentation, and research in the medical industry. The number of clinical trials grew exponentially, “more than half of the clinical trials conducted between 1954, when the first trial was conducted, and 1995 were completed in the last five years” of that period (NHPF, 2006). According to the NHPF there were “over 10,000 new trials reported in 1995”. This intensive research gave rise to a change in the approach of healthcare management called Evidenced-Based Medicine (EBM). Evidence-Based Medicine relies on the reviews and journals that contain testing results and methods to conduct the treatments outlined in the journals. Several standards were adopted for evaluating the results and accuracy of the documentation. In addition to verifying the accuracy, standards were adopted so that physicians could understand and make use of the information presented. The Physicians Desk Reference may come to mind as an example of some of these collected resources. MEDLINE is a bibliographic online database that is managed by the United States National Library of Medicine. MEDLINE warehoused over 13 million references in 2004, and over 500,000 of those were added in 2004.
Evidence-based medicine has been promoted through the West and inEurope as a way to improve the “statistical lives” of the population. Clinical methods and treatments that appear to increase the general health of the population and extend life expectancy are considered to be appropriate to implement across the broad spectrum. The individual remains to be treated using diagnostic and therapeutic methods. Although the technology has advanced considerably and methods have improved, NHPF states in this paper, “The desire to do something rather than nothing for people presenting with illness or injury is strong. It can override the analytical and critical question of whether what can be done is actually effective or beneficial.” Several preventative services were not included in medical care coverage, such as immunizations, and other diagnostic tests that did nothing to treat the patient.
Preventative Services Task force
As the need grew for patient diagnosis in order to use the evidence-based medicine techniques it became apparent that insurers were going to need education on preventative treatments and their value. The United States Preventative Services Task Force (USPSTF) was first established in 1987. The USPSTF according to their web site is “An independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services” (Agency for Healthcare Research and Quality, 2007). The Task Force is a cooperative effort between experts in health care services, public and private enterprises and several government agencies including, “Federal partners include the Centers for Disease Control and Prevention (CDC), Department of Defense (DOD), Centers for Medicare and Medicaid Services (CMS), Department of Veterans Affairs (VA), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH), U.S. Army Center for Health Promotion and Preventive Medicine, and the U.S. Food and Drug Administration (FDA)” (AHRQ, 2007). Public Law Section 915 mandates that “AHRQ convene the USPSTF to conduct scientific evidence reviews of a broad array of clinical preventive services, develop recommendations for the health care community, and provide ongoing administrative, research, technical, and dissemination support” (AHRQ,2007). The information presented by the USPSTF has made significant impact in the adoption of EBM. Health TechnologyHealth care technologies go hand in hand with evidence-based medicine. However, what technologies will be used and to what extent? Established in 1938 the FDA was concerned with the safety of new drugs and formulations before they were distributed to the public. As the focus in the medical industry shifted from expert consensus-based to evidence-based medicine the scope of the FDA’s charter was expanded in 1976 to include the application of drugs and, high-risk devices. FDA started requiring evidence for the suitability of medical devices for treatment. Manufacturers were required to show “valid scientific evidence” that their device was safe and effective. There was a provision in the 1976 amendment that exempts new devices that are “substantially equivalent” to existing devices (FDA, 2007). In addition to the approval process the FDA requires manufacturers to continually monitor the devices and formulations in order to determine additional side effects or contradictions that were not apparent in the initial test trials. If an issue arises the FDA can then call for the formulation or the device to be removed from use. A move to standardize services was enacted in 1989 when Congress authorized the Agency for Health Care Policy and Research (AHCPR) and charged them to develop, disseminate, and evaluate clinical practice guidelines. They were provided a $100 million, budget and two fifths of this budget was earmarked for development of clinical guidelines (Eisenberg and Zarin, “Health Technology Assessment”). The agency, in 1992, was directed to include information regarding cost effectiveness of their proposed guidelines. An Institute of Medicine (IOM) committee was formed to review and address the guidelines that were being created by the AHCPR. They were tasked with the development of methodology standards. The IOM concluded that there was a lack of consistency in the guidelines and a lack of evaluative quality. Two years later they recommended “using clinical practice guidelines as evaluative tools to improve the quality of care”, thus they included physicians in developing and testing applications of the guidelines. In addition to developing a road map for implementing the guidelines they also developed a strategy for research evaluation. (NHPF, note 21). In 1999 the AHCPR was renamed, the new organization Agency for Healthcare Research and Quality (AHRQ) was provided and expanded their charter. The AHRQ’s Focus and Strategic Goals include:· Safety and quality: Reduce the risk of harm by promoting delivery of the best possible health care. · Effectiveness: Improve health care outcomes by encouraging the use of evidence to make informed health care decisions. · Efficiency: Transform research into practice to facilitate wider access to effective health care services and reduce unnecessary costs. · Organizational excellence: Use efficient and responsive business processes to maximize the Agency’s resources and the effectiveness of its programs.
(AHRQ, 2007) The AHRQ relies on reports and evaluations from 13 Evidence-based Practice Centers (EPCs). EPCs are typically organizations associated with a university and generate scientific reports and assessments on specific areas. These reports then serve as the basis for future practice guidelines. The EPCs evaluate various proposals derived from professional societies, insurers, health providers and consumer groups to name a few. In addition to the EPCs the AHRQ also works with the Effective Health Program. Tis Health program was authorized by Section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The MMA directs the AHRQ to conduct research and evaluations to improve the quality and efficiency of Medicare, Medicaid, and the State Children’s Health Insurance Program. Their research is focused on health outcomes and clinical effectiveness. The research is made widely available to providers, insurers, and the public.
The Rise of National Health Care in the United States
Medicare, Medicaid, and the State Children’s Health Insurance Program are the most recognized US run medical insurance programs. Medicare has two layers of management for determining coverage; Local and National. The local level is made up of regional intermediaries that pay service providers, hospitals, clinics and physicians on behalf of the Medicare organization. The local level helps to ensure that payments are timely and accurate by managing a small region. They also make determinations on coverage and some locally allowed services. The Centers for Medicare and Medicaid Services (CMS) makes decision on a national level. CMS reported in 2005 that 90% of the decisions made regarding coverage were made at the local level (CMS Fact Sheet, 2005)
An analysis done in 2001, reported by Susan Foote in “Evolution of Medicare’s Local Coverage”, concluded that the local process was not necessarily quicker and a recommendation was made to move to greater standardization of coverage policies, at least for new technologies.
Medicare’s coverage overview is listed on the CMS web site as:
“…The law states that Medicare cannot pay for any items or services that are not “reasonable and necessary” for the diagnosis and treatment of illness or injury. For more than 30 years, the Medicare program has exercised this authority to determine whether specific services that meet one of the broadly defined benefit categories are covered under the program. Most Medicare coverage and policy decisions are made locally by HCFA contractors — the private companies that by law process and pay Medicare claims. HCFA also has authority to make coverage policies that apply nationwide. In the absence of national decisions for particular services, contractors have discretion to issue local coverage policies.”
This policy draft was dated May 01, 2000, there is a current discussion regarding the reigning in of local decision making authority and bringing that decision making body to a national level. The primary authority on “reasonable and necessary” is the Medicare Coverage Advisory Committee (MCAC). In 1999 the MCAC was put into place to review technology and therapy modalities in order to advise the Secretary of Health on what services should or should not be included in the coverage policy. The MCAC is typically used to review new techniques and practices that are controversial, either because of the method employed or the cost-benefit associated with the procedure. The MCAC board is comprised of experts in their respective fields. The committee can consist of up to 100 persons, but the actual attendance at a meeting is limited to 15 members most of whom have experience in the field or the actual procedure being discussed. Transcripts of review meetings are posted on the CMS web site. The meetings are attended by voting and non-voting members and often involve guest speakers that are present to answer questions in an open forum.
The British National Institute for Health and Clinical Excellence (NICE)
The British National Health Service (NHS) was experiencing a “crisis of public confidence” in the late 1990s. To relate this crisis to theUnited States we would compare the effects of the general population mistrusting our leading medical institutions and having the general belief that our top medical schools were not training new doctors appropriately. For example, one day it is decided that the Mayo Clinic is not to be trusted regarding anything the clinic published on cancer research and immunology. For the British to lose confidence in their primary health care system, the NHS, is a major blow to their medical services infrastructure.
The public became aware of disparities in the availability of new technology and new pharmaceuticals across different regions. Because local authorities could determine health fund budgets it became apparent which areas did not have healthcare as a priority. The NHS, also, was not able to keep up with the expense of implementing new technology at the pace of development and maintain it financial solvency. As a result, in 1999, the British National Institute for Health and Clinical Excellence (NICE) was created.
The responsibilities of NICE are to function as a special authority within the NHS. There are four components to the NICE charter that include 1) producing clinical guidelines, 2) conducting technology appraisals, 3) interventional procedures, 4) public health guidance (NICE, 2007). The process to move a new technology through the approval process involves the production of a Technology Assessment Report (TAR), which is a detailed review of the device or procedure. The TAR typically took 6 months to 1 year to produce and at the speed with which technology was advancing by the time the technology had been implemented it was no longer current or a vast number of patients suffered as a result of the slow process. As a remedy NICE implemented a fast track process for single products (Single Technology Assessment, STA). This enabled the board to meet on a single product and expedite the deployment. When an STA is used the manufacturer’s submission of the efficacy of the devise is used as the source of evidence. A team then reviews the submission, critiquing it for accuracy, no independent test is required. The summary findings are sent for comment along with a “provisional determination”.
NICE did establish guidelines for manufacturer submissions and covered among other items effectiveness, cost-benefit analysis and funding impacts. NICE has been able to move technology and new drug formulations into the regional clinics at a very successful pace that has bolstered the public confidence in the NHS. Their process and effectiveness has earned them recognition from the World Health Organization, as noted by Suzanne Hill in A review by WHO, the NICE program over its first four years has led the field internationally in innovations in technology appraisals, also noted was that NICE had been operating in a fiscal and policy environment that supported the approval of new, cost-effective medicines and technologies. (World Health Organization, 2003).
Much like the United States Medicare system theUnited Kingdom uses a system to support their entire health care system as a single payer system. A similar system exists inCanada and there has been considerable discussion in implementing the same single payer methodology to the U.S. Health care system. This paper written by the National Health Policy Forum at nhpf.org, has identified several similarities in the implementation of technology in the healthcare industry. If we are to believe that the system in use in theUK is solid, economically viable, and their citizens enjoy that luxury then we should ask if we can use the same model here.
There are significant cultural differences between the UK and theUnited States. One very sensitive issue is the involvement of the federal government in a citizens personal life.
In the UK the citizens are more willing to have direct government involvement where as the citizens in theUS are not. Is it possible to have a single source of medical services and not have government involvement? Yes. Medicare took many of its policy provisions from private insurance providers. If we look for a reasonably successful model in California our attention goes to Kaiser Permanente, a private Health Maintenance Organization (HMO) provider serving a vast area ofSouthern California. Adoption of services and technology is at the discretion of the HMO board. Their ability to use technological devices and drug formulations is still restricted by the FDA’s approval. Their system is not perfect by any means and for those o us that have spent any time in the military you are likely to feel right at home at a Kaiser facility. Because they are a private company they are more sensitive to dissatisfied clients because it affects their bottom line. An alternative to the private HMO is demonstrated in a social experiment that has been dubbed Arnoldcare inCalifornia. John Goodman expresses these concerns to socialized health care inCalifornia in his article, “Terminate This Plan.”
ARNOLDCARE
Gov. Arnold Schwarzenegger has declared that every Californian should be required to have health insurance. His effort, though, is unlikely to succeed and in some ways is likely to make matters worse, says John C. Goodman, president of theNationalCenter for Policy Analysis.
So what could go wrong?
· The plan encourages people with unsubsidized insurance to get subsidized insurance instead; that is, a lot of employers of low-income workers will drop their coverage and pay a 4 percent fine once they realize their employees will be eligible for free coverage under an expanded Medicaid program or will qualify for income-based premium subsidies.
· As employers drop their coverage, system costs will rise, and because of the new insurance regulations health insurance will cost more for everyone, encouraging healthy people to exit the system, leaving the sickest and most costly people behind, again driving up costs.
· The plan also opens the door for future legislatures to convert the employee mandate into an employer mandate, thereby increasing employer costs and encouraging businesses to leave the state.
Socialized medicine creates a welfare state that can not be easily remedied. To maintain some level of privacy and restrict government involvement inU.S. citizens lives it is critical that as we move closer to the impending state of social medicine that we restrict government involvement. If you are of the opinion that an expansion of the Medicare plan or a state sponsored health care system is beneficial it is necessary to look at the current involvement government already has in your private health plan.
Sally C. Pipes, writes in a February 2007 article, “Eliminating government mandates would lower cost of health insurance,”
Enthusiasm for universal healthcare coverage has swept the nation, with governors in Massachusetts andCalifornia leading the way. But the proposals under consideration do little to address the primary reason for the lack of coverage — very expensive insurance..
One major reason for the cost spiral is government meddling in the market for health insurance, particularly through the imposition of restrictive mandates and regulations:
· The average state has 36 mandates on an individual health insurance policy.
· With each mandate, the cost to the consumer goes up; these mandates often stand in the way of making health insurance more affordable in the first place.
Given that we all indirectly absorb those costs thanks to higher premiums, it should come as no surprise that the universal program placing mandates on employees is destined to fail because it’s prohibitively expensive, says Pipes :
· InMassachusetts, estimates now show that the monthly costs for an individual will be $380, almost double what the designers predicted.
· A movement to exempt those earning up to three times the federal poverty line or $60,000 per year for a family of four is already gaining momentum.
The process that theUnited States uses to research and approve new medical technology is long and protracted with many different steps and several communication disconnects. The flow of approvals through the FDA is slow and in many cases hampered by politics and lobbyist. The FDA is often accused of being overly cautious.
RESOURCES
Agency for Healthcare Research and Quality, USPSTF, 2007http://www.ahrq.gov/clinic/uspstfix.htm
Mark Chassin, “Is Health Care Ready for Six Sigma Quality?” Milbank Quarterly, 76
(1998), pp. 565–591.
National Library of Medicine, “Fact Sheet: Medline”; available at www.nlm.nih.gov/pubs/factsheets/medline.html.
National Health Policy Forum, Issue Brief No. 806, August 24, 2005; available at www.nhpf.org/pdfs_ib/IB806_ClinicalPrevServices_08-24-05.pdf.
Center for Devices and Radiological Health, “CDRH Annual Report, Fiscal Year 1997,”
U.S. Food and Drug Administration, October 14, 1997; www.fda.gov/cdrh/ annrep97.html.
AHRQ
Testimony on Technology, Innovation, and the Costs of Health Care. Testimony of Carolyn M. Clancy, M.D., before the Joint Economic Committee, July 9, 2003. Agency for Healthcare Research and Quality,Rockville, MD. http://www.ahrq.gov/news/test70903.htm
CMS, “Fact Sheet: CMS Responds to Stakeholder Feedback Regarding Coverage with
Evidence Development,” July 12, 2005; available at http://www.cms.hhs.gov/coverage/download/guidfactsheet.pdf
Susan Bartlett Foote, “Focus on Locus: Evolution of Medicare’s Local Coverage Policy,” Health Affairs, 22, no. 4 (2003), pp. 137–146; and Susan Bartlett Foote et al., “Resolving the
Tug-of-War Between Medicare’s National and Local Coverage,” Health Affairs, 23, no. 4 (2004), pp. 108–123.
CMS, MEDICARE’S PROCESS FOR MAKING COVERAGE DECISIONS, 2007
http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=381&intNumPerPage=10&checkDate=&checkKey=&srchType=&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=true&cboOrder=date
NICE
“New Guide to NICE”, newguidetoniceApril2005.pdf, http://www.nice.org.uk Suzanne Hill et al., Technology appraisal programme of the national institute of clinical excellence: A review by WHO (Copenhagen: World Health Organization, 2003); available atwww.nice.org.uk/page.aspx?o=85797 John Goodman, Arnoldcare, “Terminate This Plan; The shortcomings of Schwarzenegger’s health care reform,” Weekly Standard, Volume 12, Issue 21, February 3, 2007. http://www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=14163 Sally C. Pipes, “Eliminating government mandates would lower cost of health insurance,” Indianapolis Star, February 9, 2007. http://www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=14173