This is not a plus. But he, the US is also the leader in unnecessary imaging. So we have that going for us.
That’s not a statement of fact. What is fact is that delays in medical care have consequences.
I’m not sure facts are what you’re going for right now. I’ll leave you to it.
Correct. And you know why? Because such enormous fees can be charged for outpatient services that everybody and his dog is rushing into the business, like carnival barkers at a circus sideshow, and imaging centers can be highly profitable while sitting idle half the time – and performing completely unnecessary imaging much of the rest of the time – all of which you are paying for. While in Canada, as I said, access is priority based to maintain optimum utilization. In a hospital, access is immediate for everyone; outside, it’s based on urgency. In Ontario, for a priority outpatient referral the target time is two days and typical time is one day, and for the lowest priority outpatient referral it might be as long as six weeks.
So what, exactly, is that 4X excess of MRI machines doing for your health? Why don’t we check in term of medical outcomes. Emphasis mine in the abstract below:
We identified 38 studies comparing populations of patients in Canada and the United States. Studies addressed diverse problems, including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies that included extensive statistical adjustment and enrolled broad populations, 5 favoured Canada, 2 favoured the United States, and 3 showed equivalent or mixed results. Of 28 studies that failed one of these criteria, 9 favoured Canada, 3 favoured the United States, and 16 showed equivalent or mixed results. Overall, results for mortality favoured Canada (relative risk 0.95, 95% confidence interval 0.92-0.98, p= 0.002) but were very heterogeneous, and we failed to find convincing explanations for this heterogeneity. The only condition in which results consistently favoured one country was end-stage renal disease, in which Canadian patients fared better.
My understanding is that a lot of the problem in the US is that any respectable medical facility needs an MRI to be competitive, and once you have an MRI your staff is going to be incented to use it. Since doctors are happy to get an image just in case, there is no ethical reason for them not to. However do no harm doesn’t seem to extend to harm to wallets.
How does Canada keep from having an excess of MRIs for this reason? I understand how you keep facilities from doing unnecessary mapping.
It seem to me that if the MRIs were not clogged up with unnecessary stuff, true needs could get met faster.
My best guess is that it’s because diagnostic imaging centers like those doing MRIs are paid moderate, cost-controlled fees and are therefore not enormous profit centers. This is actually a bit more than a guess – my unique insight into this is that I have a copy (a few years old) of the Ontario health system fee schedule AND a few years ago I had to pay out of pocket for an MRI for my dog. Pissed me off that our otherwise excellent health plan doesn’t cover dogs, who I consider to be legitimate loyal citizens, but that’s another story. Anyway, although MRI costing is a bit complicated, because it depends on the procedure and the number of image “slices” that are taken to reconstruct a 3D image of the area in question, my impression was that my dog’s MRI cost about twice as much as the health system would have paid for a human. Meanwhile, from what I’ve heard, MRIs in the US can cost four to ten times as much. Same equipment, same procedure. The difference? Profit$$$.
Spain does it by putting things in the opposite order: you begin by not doing unnecessary mapping and by figuring out how many slides that means.
How many MRI views are needed in an area? X many.
How many MRI machines does that mean? Y.
If the local hospitals already have that many, there’s no need to buy another one.
As X increases, eventually there is a need to buy another machine. Whether this is done by a public hospital or a private one will depend on who makes that decision first, but in the end and since all* MRI machines are used by both public and private systems, that new machine goes into the general pool and that means everybody is covered. Having too many machines just means idle machines, which in turn means the accountants will be real, real cranky next time someone asks for a shiny new machine. You don’t meddle in the affairs of dragons, you don’t piss off the healer, and you definitely do not want to make the accountants cranky.
- OK, the immense majority. I can’t promise there is some private clinic somewhere whose MRI machine is never touched by the plebe but, given how much those machines cost and unless your clients pay supermegaextra for exclusivity, it makes sense to contract your downtimes to the public system or to other private clinics nearby.
Note that this also applies for other expensive diagnostic equipment, such as CATs.
You’ve addressed the revenue side, not the cost side. The difference isn’t necessarily profit.
You talk about optimum utilization, but that assumes a certain utility curve. Some folks may be willing to pay more for a different level of utilization to reduce wait times.
I think it’s more a case of people being able financially, not “willing”. I am more than willing to get better than crappy medical service, but I cannot afford it.
The difference isn’t entirely profit, no, but it’s a big component of it, or the US wouldn’t have such an excess of MRI machines and private imaging centers that run them. According to one source that was quoting US Census data (I no longer have the link, this is from some notes I took today) the US has about 6,600 diagnostic imaging centers with combined revenues of about $16.4 billion annually, though it’s not clear how many of these are in hospitals or are partnerships with hospitals. But when there are more than 11,000 MRI machines in the nation, mostly privately owned – compared to a grand total of about 320 in Canada – it’s a good bet that they’re there to make money, and not for benevolent charitable reasons!
The excessive cost of MRIs in the US medical system is thus due to a combination of profiteering and high administrative costs. This excerpt on hospital costs gives some insight into the latter, and applies as much to diagnostic imaging centers as it does to hospitals in general:
… about $1 of every $4 of U.S. hospital spending goes to bureaucracy rather than patient care. Other countries manage modern, first-rate hospital systems for far less. While administration devoured $667 per capita annually in the U.S., we found that Canada spent only $158, Scotland $164, England $225 and the Netherlands $325. If U.S. hospitals ran as efficiently as Canada’s, the average U.S. family of four would save $2,000 annually on health care.
… Why are U.S. hospitals so inefficient? Our multiple-payer insurance system forces every hospital to negotiate rates with dozens of insurance plans, each with its own coverage rules, billing procedures and documentation requirements. And each hospital must collect deductibles, co-payments and co-insurance from tens of thousands of patients.
https://evidencenetwork.ca/why-canadian-hospitals-outperform-u-s-hospitals/
The common meaning of “optimum utilization” of an expensive resource is making the most productive use of it and minimizing the waste of idle time. Like what airlines do with their very expensive aircraft, scheduling them to spend the maximum time in revenue service.
There are two problems with the “willing to pay more for a different level of utilization” argument. One is that there’s no evidence that very many of these hypothetical people actually exist. Out of curiosity I looked around for such private clinics in different provinces here, and although at first glance there seem to be a few around (though not many), on closer inspection some are just American centers advertising here, and others are just consulting services. A few are specialized collaborations offering expedited access to MRIs for workmen’s compensation claims and other very specific insurance issues only. I imagine that when a major sports star has an injury that requires an MRI, this is the kind of service they use. But in general, from what I could see, there is virtually no demand for an expedited-access service that many people would be willing to pay for.
The other problem with that argument is that any such expedited access scheme has a moral imperative not to weaken or undermine the existing public system, and sometimes that’s hard or impossible to do, especially if you’re reallocating finite resources. It’s a constant worry with any two-tier health care system. The province of Alberta, for example, being of a somewhat conservative mindset, allowed one of the more aggressive intrusions of private MRI centers, partly in the expectation that it would improve wait times for everyone. In fact, wait times only got worse for the public sector, and are now one of the worst in Canada, in part because that same system – spurred on by the private centers – has been promoting an American-style culture of over-utilization.
A nice article on administrative spending: https://www.nytimes.com/2018/07/16/upshot/costs-health-care-us.html?smtyp=cur&smid=tw-nytimes
I have co-pays, in-network, and out-network costs.
How much is your leg worth to you? Mine is worth the cost of the insurance I have and a considerable amount more. I don’t understand why young people today are willing to blow off their responsibilities. Their policies are cheaper and they can bank money in an HSA for when they’re older. If they don’t need it they get to keep it upon retirement or use it to supplement their medicare.
I’ve purchased insurance between good jobs and I’ve worked 3 jobs at a time to make that happen. I was beholden to me.
It makes no sense for you to argue the middle class should give up the health care afforded the rich. fixing the gap in medical coverage doesn’t require that.
That’s rational. But I bet hospitals in Spain don’t advertise. All the expensive ads for the latest cancer treatment facilities or hot new medical technology must be for a reason. Our local hospital, whose quality numbers could be better, buys up an entire section of the weekly paper.
I assume they think that if you go to hospital H for an MRI you’ll try to get yourself admitted to hospital H for the money making stuff. Or choose a doctor who admits patients to hospital H.
And that profit saved my leg. Just as it puts food on the table and a roof over my head.
Which is fine if we’re talking restaurant reservations. If people are paying more to cut in line in front of people with greater need, maybe it isn’t such a great idea.
You are very fortunate. There are many who, no matter how much their leg was worth to them, were not able to save it due to lack of money. You were beholden to an insurance bureaucrat who could have decided to make a few extra bucks on his bonus and found a way to deny your claim, or just to delay it long enough for it to no longer matter. You know what your leg was worth to the insurance company? Nothing, it was instead a liability, one they would have denied had they found a way.
How much did your leg cost? What are the chances that you could have saved up enough in your HSA to cover it? Even if you had, after it was wiped out, then you wouldn’t have been able to cover your heart surgery.
Is your leg worth more to you than your heart?
Actual good insurance that would cover any complications with your leg or heart? Are you really saying that people should be required to work 3 jobs in order to have insurance?
Honestly, that statement doesn’t make any sense from a parsing standpoint. What are you trying to claim that I am arguing here?
You guys keep talking about insurance company bureaucrats like they’re all powerful claim deniers. But these are just people within their own company, dealing with their own population of policyholders, and in the vast majority of cases, doing things the right way and not screwing anyone. For every anecdote you can find, I could probably find a million where there were no problems with claims.
Do you want to turn over the entire US healthcare sysem to the likes of Donald Trump? He’s the guy that cut off CSR payments within the ACA framework, which will price hundreds of thousands, if not millions, out of the exchanges. He’s also the guy who is not going to argue against a lawsuit that will attack pre-ex protections, which will price millions more out of the exchanges, and increase our uninsured population. His HHS is going along with states that want work requirements on Medicaid recipients.
I’m sorry, but in the US, we don’t need single-payer for many reasons. And one big one is to not put the entire system under the thumb of a goon like Trump. And scare tactics about the evils of private insurance hold no weight with me. I have private and I’m doing fine, just like the rest of my family…and the vast vast majority of the other 158 million people in the US who have it.
You know, at this point I have little patience left with this eternally ongoing argument. I just dropped in briefly to correct some very blatant factual errors.
If you’re trying to suggest that the ratio of denied claims to paid claims is one in a million, I would inform you that it’s more like 1 in 7 for employer health plans overseen by the Department of Labor, which one would expect to be among the best plans. In Vermont where ratios must be reported by law, Cigna reports denying more than 1 in 5 claims, MVP nearly 1 in 6. It’s deceptive to suggest that claims denials are a rare occurrence. The Department of Labor employer-plan statistics alone show 200 million denials a year. There’s a reason that medical costs are the #1 cause of personal bankruptcies in the US, even among those who thought they were well insured.
Well I’m sorry, too, since you still don’t appear to understand how single-payer works. Look at all those terms you used:
[ul]
[li]CSR payments[/li][li]price hundreds of thousands, if not millions, out of the exchanges[/li][li]price millions more out of the exchanges [/li][li]increase our uninsured population[/li][li]work requirements on Medicaid recipients[/li][/ul]
Quite simply, none of those terms or concepts exist in single-payer. There are no insurance companies, no exchanges, no “prices” paid for coverage*, no uninsured. The whole concept is completely different than what I think your understanding is, if you’re making comparisons like that.
Oh, and one more term that does not exist in single payer: “claim denial”.
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- In some provinces everyone pays a small annual fee, usually geared to income.
I’m glad you picked up on these, because as someone who lives in the ultimate single payer system (UK NHS), I had not a clue what any of those terms meant.
I’m trying to think of a way, other than simply slashing budgets, any UK government could undo anyone’s reasonable expectations of the NHS. It would have to involve a parliamentary majority committed (and presumably with the mandate of a general election manifesto) to rewriting the law to allow ministers to both (a) prescribe and proscribe treatments on any ground other than safety **and **(b) forbid people from buying private insurance or private medical care and forbid professionals from offering it.
That all that’s unthinkable just underlines the importance of broader culture/expectations, which doesn’t make it any easier for the US to have any chance of getting from here to there in this case.