Rapid Responses to:

PAPERS: Richard G A Feachem, Neelam K Sekhri, Karen L White, Jennifer Dixon, Donald M Berwick, and Alain C Enthoven Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente • Commentary: Funding is not the only factor • Commentary: Same price, better care • Commentary: Competition made them do it BMJ 2002; 324: 135-143 [Abstract] [Full text]

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Rapid Responses published:

Bed days

Hugh Matthews   (18 January 2002)

Contribution of PAs and NPs

David E. Mittman   (19 January 2002)

Apples and Oranges

A. C. Anilkumar   (19 January 2002)

The Kaiser vs NHS comparison

J K Anand   (19 January 2002)

Re: The Kaiser vs NHS comparison

Samer A M Nashef   (20 January 2002)

Is this a like for like comparison?

Charles O Lister   (21 January 2002)

Comparison of the NHS with California's Kaiser Permanente

David Baker   (21 January 2002)

The end of General Practice?

Andrew Roberts   (21 January 2002)

More efficient or cost shifting?

Dennis P Briley   (21 January 2002)

Competition works in two ways

Anisur Rahman   (21 January 2002)

are long term social costs factored in

john sharvill   (21 January 2002)

Problems with the comparison

Azeem Majeed   (21 January 2002)

NHS versus Kaiser conclusions are back to front

Paul S Meadows   (22 January 2002)

Getting more for their dollar

Simon J Douglass   (22 January 2002)

Low waiting times -but at what cost?

ted a willis   (22 January 2002)

Length of stay not the problem

Julian M Bene   (22 January 2002)

Kaiser Permanente and the NHS

James I. Storer   (22 January 2002)

Re: The end of General Practice?

Peter Davies   (22 January 2002)

Kaiser fudge factor

Stephen D Blair   (22 January 2002)

Getting more for their dollar

Dr. Graham Curtis Jenkins   (22 January 2002)

The Increased Cost of Efficiency

Tom Aslan   (23 January 2002)

Article Should Not Be Published In Its Current Form

Timothy C. Wilding   (23 January 2002)

Time to retract the Kaiser headline?

Julian M Bene   (23 January 2002)

Social experiment

Kevin Pearce   (24 January 2002)

Important conclusions despite vague figures

Gerald T Freshwater   (24 January 2002)

An alternative explanation.

Stephen J. Morgan   (24 January 2002)

One American social worker's view.

Michael L. Wong   (25 January 2002)

Kaiser – A Model of American Success or an Aberration?

Jeremiah D Schuur   (25 January 2002)

NHS inefficiency?

Richard Blakemore   (25 January 2002)

Re: Kaiser Permanente and the NHS

Giselle Martinez   (25 January 2002)

The NHS versus Kaiser

george p mason   (25 January 2002)

NHS v Kaiser

Rhodri A Davies   (25 January 2002)

Are the two systems comparable?

Stephen Brown   (25 January 2002)

Dollars vs pounds: business vs care

shahana Hussain, Darren J Fowler   (25 January 2002)

NHS versus Kaiser conclusions are back to front & BMJ Editorial impartiality in doubt

Paul S Meadows   (25 January 2002)

How much more for their dollar.

Kalman M Kafetz   (25 January 2002)

The USA. Paying more and getting less

John P Robson   (25 January 2002)

A comparison between the NHS and California's Kaiser Permanente

Afschin Gandjour   (25 January 2002)

The Kaiser study - being precisely wrong rather than vaguely right.

David P Kernick   (25 January 2002)

bed days - possible error

Gordon Pledger   (25 January 2002)

Why was the flaw not spotted sooner?

Adam Jacobs   (25 January 2002)

OK, but try persuading the Medical profession

Jon C Hughes, Bridgend   (25 January 2002)

"Getting what you pay for," not "getting more for your money"

Kevin Grumbach   (25 January 2002)

Kaiser vs NHS - round 1 not won due to flawed methods and reporting

Martin D Tobin, Mary Dixon-Woods   (25 January 2002)

Comparative information on health status

Malcolm Grant   (25 January 2002)

Comparison of the two systems

Susan Williams   (26 January 2002)

Kaiser-NHS comparison a landmark study

Meng-Kin Lim   (26 January 2002)

If it seems too good to be true, maybe it isn't

Tom Hughes   (26 January 2002)

Politicians lack courage to undertake meaningful change

Simon Smith   (27 January 2002)

Metaphors of Cultural Assumption

Ned Hoke   (28 January 2002)

Kaiser California, is it better value for money than the NHS, or, is it creative accountancy?

Magdi M Kirollos   (28 January 2002)

Invalid comparison

Charles W Angus   (29 January 2002)

Misuse of NHS Resources

rajiv k singh, Gaia Nebbia, SHO General Medicine, King George's Hospital, Goodmayes, Essex.   (30 January 2002)

Think harder next time

Jason Bernard   (30 January 2002)

Competition is good for doctors and pharmaceutical companies but not necessarily for patients

Rudiger Pittrof   (31 January 2002)

What have we really learned from the NHS v Kaiser comparison?

Clive H. Smee   (2 February 2002)

Kaiser vs NHS: Lessons from Economics

Heather M Gage, Wendy Knibb and Neil Rickman   (3 February 2002)

Kaiser performs about the same as the NHS but costs half as much again

Nicholas Steel   (3 February 2002)

the editor should repond

Gordon Pledger   (5 February 2002)

kaiser v NHS. More bang for the buck?Time to empower the pound

Rhian J Evans   (6 February 2002)

All is not well in Florida

Elizabeth C Evans, Abergavenny NP7 5DL   (6 February 2002)

Oh NHS, art thou sick or just poor?

Jack BL Howell   (6 February 2002)

Poor Performance of NHS due to inequalities in primary care

Monica Lall, Sudhin Thayyil   (6 February 2002)

Kaiser Permanente versus the NHS

Barbara Starfield   (6 February 2002)

Major errors in the bed days calculation

Nigel C Edwards   (6 February 2002)

The Authors Respond

Neelam K. Sekhri, Richard Feachem, Karen White   (8 February 2002)

Corporate Bottom Line vs. Patient Care

Victoria L. Travis, Board of Directors of The Kaiser Permanente Reform Committee   (8 February 2002)

War is Peace. Freedom is Slavery. U.S. HMOs are More Efficient than the NHS

David U. Himmelstein, Steffie Woolhandler, M.D., M.P.H.   (9 February 2002)

A comparison of the NHS with California Kaiser Permanente

Malcolm Forsythe   (12 February 2002)

Re: Kaiser Permanente versus the NHS

Jonathan Shapiro   (12 February 2002)

Conflict of interest in NHS

Dinesh Verma, University of Southern California, Los Angeles   (12 February 2002)

The NHS conveyor belt

colin w Jones   (13 February 2002)

Kaiser Reminds Milburn to Act on Election Promises

Michael F. Bone   (17 February 2002)

Re: Bed days

Souheil M. Habbal   (23 February 2002)

Comparing like with like?

Colin A McIlwain   (23 February 2002)

Success in Spite of Competition

Steve L. Juniper   (2 March 2002)

Has the case been understated?

James G Bartholomew   (6 March 2002)

KAISER OUTPERFORMS THE NHS

David S. David   (6 March 2002)

Re: Has the case been understated?

Nigel Edwards, SW1E 5ER   (26 March 2002)

New Zealand already implementing Berwick’s proposal

Laurence A Malcolm   (4 April 2002)

Health care results in the US relatively poor

Tom Rawlinson   (9 November 2003)

Re: Getting more for their dollars: a comparison of the NHS with California's Kaiser Permanente

Lawrence J. O'Brien, none   (11 November 2003)

Bed days 18 January 2002
Hugh Matthews, GP registrar East Kent Send response to journal: Re: Bed days	Editor, I am sure there will be much debate about the comparability of the two health systems and the results of this paper. The most striking feature seems to me to be the different number of bed days occupied under the NHS and Kaiser systems. I cannot think of any confounding variable not covered in the paper which would explain why we in the UK need three times more bed days per capita than Californians. Indeed, given the cost of keeping a patient in a hospital bed (even in a relatively spartan NHS ward), if we could find ways to cut our hospital stays even halfway towards the Kaiser level the savings would be immense. We could then start using the money to improve patient outcomes, rather than tinkering with a system which fails to get the results for a number of important diseases that other countries achieve. Writing from a part of the UK which has hit the headlines for trolley waits in A&E corridors, there is still not the imperative to see every unnecessary day in hospital as a 'defect' (as Berwick's commentary puts it). The lack of continuity between primary and secondary care means that a patient may stay several days in hospital waiting for 'everything to be ready' at home, when they are at their premorbid functional level and additonal requirements could be met with them out of hospital, if community services were informed of the situation. Elective surgery is cancelled daily because of lack of beds, to the extent where we are sending patients abroad. Given the evidence from this paper, senior NHS representatives should visit the US system described, try to work out why patients spend far less time in hospital, and then start applying the lessons learned to NHS primary care, outpatient management and support services to allow this to happen here. Far better to have a pilot scheme based on something that works elsewhere than the current tinkering based solely on Government ideology. Hugh Matthews GP Registrar, Ashford & Dover VTS.
Contribution of PAs and NPs 19 January 2002
David E. Mittman, P.A. Clinicians Group, Clifton NJ USA 07012 Send response to journal: Re: Contribution of PAs and NPs	The contribution of the physician assistant (P.A.) and nurse practitioner (N.P.) clinicians at Kaiser may play more of a part in the comparison than noted. Although I do not have Kaiser's figures to review there is a considerable percentage of care (both primary care and specialty care) provided by these two groups. I would like to know what percentage of visits were provided by NPs and PAs in this study and if it differs from the percentage they provide at Kaiser generally. We do know that NPs and PAs cost less than MDs to employ, have high patient satisfaction and increase accessability to health care in California.
Apples and Oranges 19 January 2002
A. C. Anilkumar, Pediatrician Elizabethtown, KY42701 , USA Send response to journal: Re: Apples and Oranges	Sir, I think comparing Kaiser and NHS is like comparing apples and oranges. The way American healthcare works is different from that of the U.K. In the UK, you have your children managed by a GP as primary care provider; in the United States, you have the paediatrician see your children, for both in-patient and primary care. So if you admit a child with asthma exacerbation, you do not have to keep the child till the patient is 100% symptom free. The managed care restrictions on length of stay will make you discharge the patient early because you are giving the post hospital discharge care. You are judged on your ALOS (average length of stays) against national norms. Another issue is the lack of structured subspecialty training in the UK. This makes the hospital specialists like paediatricians, jack of all trades. Under-utilization of investigations and over-emphasis on the clinical judgment is the culture in the UK. It is unthinkable in the demanding healthcare field of the united states. The cost of malpractice suits and the coverage expenses drive the cost of medical care high. Probably in the UK ,you will never get sued for the hardships and mental suffering caused by the waiting for a hip replacement or a delay in getting a thrombolytic treatment in the accident and emergency department.
The Kaiser vs NHS comparison 19 January 2002
J K Anand, Retired public health physician Send response to journal: Re: The Kaiser vs NHS comparison	I seek information from the authors and the referees. On p 139 the authors state that both populations live in temperate climates, share similar risk factors and have many occupational and cultural similarities. I have no first-hand knowledge of california but I see Californian citrus and dates on sale here in England. We have no orange groves, nor date- palms waving their fronds on Blackpool beach. Similar risk factors? I do not know but perhaps the authors could enumerate these and the methodology for the ascertainment of their prevalence. Occupational and cultural similarities: Again it would be helpful to know what these are and whether there are also differences. Are the genetic pools of these countries similar? Are the doctors, nurses and other,related professions identical in training and outlook? Thank you JK ANAND (Retired)
Re: The Kaiser vs NHS comparison 20 January 2002
Samer A M Nashef, consultant cardiac surgeon Papworth Hospital, Cambridge, CB3 8RE Send response to journal: Re: Re: The Kaiser vs NHS comparison	There is a serious methodological error in this paper. The authors have corrected for "purchasing power parity" and added some $700 to the NHS per capita cost. This, they explain, is because the NHS gets drugs more cheaply than Kaiser, but also because the salaries of staff in the NHS are lower. This correction is not acceptable, because the relatively low cost of these resources to the NHS are an integral part of the way the NHS functions. This difference forms part of the NHS efficiency as a state -run, publicly owned non-profit system. When this "correction" is removed, Kaiser costs become double those of the NHS. Does Kaiser offer a service that is twice as good? Possibly, but not certainly. Of course there is inefficiency in the NHS, but it is largely the inefficiency of resource starvation. Because of longstanding capital and revenue underinvestment, we have a system in which slack has been reduced to nearly zero, with bed occupancy in some intensive care units like ours running at over 95%. It takes only the slightest hiccup in the service to bring the system to a halt, with empty operating theatres and idle staff. Inefficient? of course, but only because of the relentless prior pursuit of impossible efficiency targets. The NHS has, for far too long, tried to deliver health care of quality and of quantity that is also cheap. This is not possible. You can only have two out of three. Quantity and cheap, but not quality, quality and cheap, but insufficient quantity. If we really want sufficient quality and quantity, we must be prepared to put in the resources.
Is this a like for like comparison? 21 January 2002
Charles O Lister Retired Send response to journal: Re: Is this a like for like comparison?	This paper talks about money and what it buys but does not discuss the relative workforces. The fact is that the UK has 40% fewer doctors per 1000 of population than any country in Europe save Turkey, we have one of the lowest ratios of nurse/patients in Europe, again with the exception of Turkey and one of the lowest ratios of beds per patient in Europe, again with the exception of Turkey. It would be interesting to know how these parameters compare with the same comparators in the area covered by the Kaiser Permanente service in California. When compared with our European neighbours, one of whom (France)has been said to offer the best health care service in the world by the WHO, the most striking difference is in the number of doctors per 1000 population - UK (1999) 1.8,France (1999) 3.0. Not surprisingly we have less beds per head of population and fewer nurses too. It would also be interesting to know how many bureaucrats Kaiser Permanante employs compared with the NHS to look after a similar population size. I would suggest that 50 years of underfunding has produced a health care service in the UK that is woefully short of staff and the facilities that are needed to support those staff.
Comparison of the NHS with California's Kaiser Permanente 21 January 2002
David Baker, GP Canford Heath Surgery Bh17 8UE Send response to journal: Re: Comparison of the NHS with California's Kaiser Permanente	This article was fascinating reading, but it needs to be interpreted as a cross-sectional survey. Everyone will apply their own spin in responding, but to infer from this that resources are not the issue is totally wrong. In my view, this is all about capacity. When there is no spare capacity, systems become inefficient. If patients have to wait in hospital for investigations or access to nursing home beds, or if CABGs are cancelled due to a full ITU, then every patient behind them in the queue suffers, & costs rise. A recent report into UK neonatal units showed that those with most spare capacity had the lowest mortality. NHS capacity is grossly inadequate because of a lack of investment over the last 22 years. One of the striking features of this study (that directly affects me) is medical staffing levels. Is it unreasonable to infer that more doctors leads to greater efficiency? I suspect the same applies to nurses, midwives & all other NHS staff. Did you see "The Trust" on channel 4? NHS staff have been misused and exploited for 2 decades. Staff shortages seem to have caught the DoH by surprise - where have they been?
The end of General Practice? 21 January 2002
Andrew Roberts, consultant orthopaedic surgeon Robert Jones & Agnes hunt Orthopaedic and District NHYS Trust, SY10 7AG Send response to journal: Re: The end of General Practice?	EDITOR - I approached the comparison of the NHS with Kaiser California with a closed mind(1). Kaiser's not for profit profit of $668M needs to be put back in as it must lead to an alteration in the motivation and hunger of the organisation to succeed and the 152% purchasing power parity correction needs to come out. Working for 47% of the salary of a Kaiser specialist seems like good value for money to me and if the NHS manages to drive down it's drugs bill with purchasing muscle then so much the better. The second phase in my reaction to the paper was a deepening despondency at what it showed. Although the NHS is cheap it is not apparently cost effective. We spend too much on keeping patients in bed and not enough on staff. Of the remedies offered, achieving real integration and treating patients at the most cost effective level of care are the same thing and cannot be properly fixed with add on measures such as NSFs. Competition has clearly been useful in the development of the Kaiser model but couldn't we adopt what works rather than turn the NHS into an evolutionary battlefield? The greatest numerical difference in the two systems was contained in that Table 3. Primary care facilities in the Kaiser organisation have at least eight times the number of medical staff even before the medical extenders are added in. Kaiser manages offices with up to 40 specialists who often also work in hospitals, have list sizes averaging 20,000 and have diagnostic facilities on site. The change needed cannot occur unless the self employed status of GPs is ended. A significant number of new partners are requesting salaried status anyway, preferring medicine rather than small business management. Small practices cannot deliver the benefits of scale necessary for a diagnostically accurate(2), readily available service with the level of knowledge and expertise demanded by the public. The pressures on family doctors are totally unsustainable in their current environment because it is not structurally suited to deliver a 21st Century service. Only when we are one service can the integration occur with patients receiving more care in Primary Care Centres and spending less time in hospital beds. Modernisation comes at a price of 10% more funding even on Feachem's figures but structural change is needed as well. The question is, who will lead a Strategic Health Authority into answering Berwick's(3) challenge? Andrew Roberts consultant orthopaedic surgeon andrew.roberts@rjahoh-tr.wmids.nhs.uk (1) Feachem RGA, Sekhri NK, White KL Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324:135-43. (2) Barraclough K. Actually, making a diagnosis is quite important. BMJ 2002;32:179. (3) Berwick DM. Commentary: Same price, better care. BMJ 2002;324:142-3. Declaration of interest: None
More efficient or cost shifting? 21 January 2002
Dennis P Briley, Consultant Neurologist Stoke Mandeville Hospital, Mandeville Road, Aylesbury, Bucks HP21 8AL Send response to journal: Re: More efficient or cost shifting?	As a consultant who moved from the US to the UK at a senior level, I read the article by Feachem et al comparing the NHS to the California Kaiser Permanente system with interest (1). My personal experience certainly supports the conclusion that more rapid access to care in the US correlates with the availability of far more specialists per capita than the NHS. However, I am concerned that the overall conclusions of the article are incorrect. I am very surprised that the calculated cost per capita is similar between the two systems. It is difficult to compare medical systems across boundaries, and the authors could be correct in concluding that Kaiser achieved better performance. I do find it difficult to reconcile precisely how a system that has multiple numbers of better paid specialists than the UK who are spending more time with their patients could possibly end up with similar costs and I wonder if an error in the calculation of costs has occurred. If the costs are indeed similar there are two possible explanations besides concluding that Kaiser is more efficient. The Kaiser population is likely to be a relatively healthier population compared to the UK population. Although the authors have attempted to correct for differences in the population, they have not considered that the majority of Kaiser Permanente members are insured through their employment. Thus, while Kaiser does not reject members on the basis of illness, employers can and do. Secondly, there is often cost shifting in the American system to the patient. As the authors show, the length of stay in US hospitals is much shorter and admission is more selective than the UK. Many of these patients are having to care for themselves at home i.e. the patient or patient’s family bear the cost of the illness, not the health care system. The issue of comparing quality is very difficult. If the overall outcome, as measured by average lifespan, is similar, then if one system is better in one aspect, then presumably this is compensated for in another aspect, otherwise there would be a clear difference in overall quality. Thus, I agree that Kaiser does have a superior performance in prompt diagnosis and treatment, but the data presented by the authors do not support the conclusion that Kaiser performs better on an overall basis. Comparing health systems, while difficult, can be useful. The message regarding waiting times and specialist numbers should be acknowledged at the highest levels in the NHS. I also support the authors comments about integration. It was a shock to me on returning to the UK, particularly given the diversity of the situation in which I worked in the US, to discover how poorly integrated health care is the in UK. However, the conclusion that Kaiser Permanente is a more efficient system than the NHS appears highly dubious and potentially very misleading. 1. Feachem RGA, Sekhri NK, White KL: Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002;324:135-143 Yours sincerely, Dennis Briley Consultant Neurologist
Competition works in two ways 21 January 2002
Anisur Rahman, Senior Lecturer in Rheumatology Centre for Rheumatology, University College London, 40-50 Tottenham Street, London W1T 4NJ Send response to journal: Re: Competition works in two ways	Editor The study by Feachem et al is an admirable effort to compare value for money in two health care systems. It is very clear that the NHS can, and probably should, learn things from the way in which Kaiser Permanante supplies and funds care. However, the claim that the per capita costs of the two systems are similar only holds water if one accepts the adjustment for purchasing power parity of 1.52 suggested by the authors. This implies that if Kaiser operated in the UK, its costs would be a good deal cheaper than they are in California. This is not necessarily true. Kaiser pays higher salaries to staff than the NHS does. Surely this must arise partly because as well as competing for patients, the various healthcare organisations in the USA must also compete for staff. If the same were to be true in the UK, in a situation where there is a shortage of skilled staff (especially nurses), one would expect staff salaries to be higher than those paid by the NHS. Competition in this case could drive costs up rather than down. Yours sincerely Anisur Rahman
are long term social costs factored in 21 January 2002
john sharvill, Family doctor Deal england Send response to journal: Re: are long term social costs factored in	Do the Kaiser costs make an allowance for the 'burden' of hosptal costs due to difficulties in long term placementof people no longer needing hospital care but who are unable to be discharged or decline the servplacement offered? One reason for the high costs in this country must be because Surgeons and facilities are under utilised if patients cannot get a bed. Stand alone operating facilities are frowned upon in the UK.John Sharvill
Problems with the comparison 21 January 2002
Azeem Majeed, Senior Lecturer in General Practice University College London Send response to journal: Re: Problems with the comparison	I agree with Samer Nashef that this paper contains a serious methodological flaw, namely the correction for purchasing power parity, which inflates NHS costs by a factor of 1.52. The reason why the NHS has lower salary, prescription and procedure costs than the USA is integral to the way in which the NHS works. Hence, the lower cost of health services in the UK should not have been adjusted for. The NHS also takes on many functions not provided by US health plans such as Kaiser Permanente. The authors did try to correct for this by reducing the NHS costs by 6%, but a more valid solution would have been to increase the Kaiser Permanente costs by including a proportion of the costs of the US Department of Health & Human Services, Federal agencies such as the Centers for Disease Control and the Agency for Healthcare Research & Quality, the costs of training health professionals, and the costs of the Californian public health system. Other problems with the paper include the very crude adjustment for age and socio-economic status. Once these methodological problems are corrected for, the conclusions of the paper about the cost- effectiveness of the two systems will change markedly. The other striking difference between the two healthcare systems, the substantially lower number of bed days in the Kaiser Permanente system than in the NHS, should also be treated with caution as detailed information on how the number of bed days was calculated has not been given. The BMJ should not have allowed publication of this measure unless the authors were able to provide detailed definitions about what constitutes a ‘bed day’ in each system and how the average number of bed days was calculated.
NHS versus Kaiser conclusions are back to front 22 January 2002
Paul S Meadows, GP Principal Priory Surgery, 326 Wells Rd, Bristol, BS4 2QJ, UK Send response to journal: Re: NHS versus Kaiser conclusions are back to front	“NHS v Kaiser conclusions are back to front” Editor, Has the BMJ employed tabloid headline writers? “Kaiser outperforms the NHS”1 could just as well have been written the other way around. The editorial2 on NHS efficiency drew unwarranted conclusions from the article comparing the NHS with Kaiser Permanente3. The “reviewers and editorial staff concluded that the results could not be explained by. . . differences in the two populations”. The article simply does not have enough detail to justify this conclusion. The comparison of the two systems assumes the same morbidity in each population but provides no substantiation for this. Case mix is really the essential element that would allow a more accurate comparison of workload. This element is acknowledged as missing. Without this the estimate of relative cost, and therefore effectiveness is seriously flawed. Adjustments in terms of socioeconomic status and age appear essentially inaccurate approximations to calculate workload ( case mix). There is no clear method shown for comparing Californian and UK morbidity by socioeconomic group. The adjustment for cost associated with age4 seems to have been taken government’s expenditure plans for the NHS. These derive from estimates of the percentage of acute care expenditure used by patients aged 65 and over. There is no reason to suppose that this percentage is accurate as an estimate of primary care and ongoing prescribed medication costs. Case mix ( ie morbidity) and volumes of consultations, investigations, operations and time to diagnose or treat might allow better comparison between the two systems. I think all NHS doctors – and my patients know there are inefficiencies in the NHS. Delays in investigations may increase either inpatient stay or time to diagnose. I am very much in favour of inefficiencies being eliminated, as I am sure are my patients. Any rigorous analysis from any source which aids this is welcome. The fact of NHS inefficiencies does not show that the NHS is “outperformed “ by Kaiser. Kaiser’s average length of acute admissions was given as 3.9 days compared with the NHS 5.0 days. Assuming a similar admissions case mix any increased efficiency on Kaiser’s part reduced average inpatient stay by only about twenty percent. Kaiser’s age adjusted average acute bed days admissions per 1000 population was 327, about a third of the NHS’s 1000 bed days. Enthoven’s3 belief that “Feacham et al got it about right” and that Kaiser had “reduced” hospital use by two thirds is not based on any demonstrated equivalent morbidity. Everyday experience here in the UK does not suggest that two thirds of admissions are unnecessary or avoidable, even with better availability and accessibility of specialists. The belief that the NHS has three times as many unavoidably acutely sick patients as Kaiser is just as tenable. On the evidence presented therefore the headline “This week in the BMJ” should have read “NHS outperforms Kaiser”as it has about three times the bed days admissions at 90% of the cost. Paul Meadows (GP) Priory Surgery, Knowle, Bristol BS4 2QJ 1 Headline in “This week in the BMJ” BMJ 2002; 324;. 2 Smith R. O NHS, thou art sick. BMJ 2002; 324; 127-8. 3 Feacham RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002; 324; 135-43. 4 Department of Health. The government’s expenditure plans 2001-2002. London: Department of Health, 2001. www.gov.uk/dohreport/ Conflicts of interest - none
Getting more for their dollar 22 January 2002
Simon J Douglass, GP principal Radstock BA3 3PL Send response to journal: Re: Getting more for their dollar	Very interesting article.I think the most important factor not allowed for in comparing "Kaiser" with the NHS is 50years of political interferance that the NHS has had to endure.It is significant that elsewhere in the BMJ this week,there is a call to have government influence on the NHS severed in much the same way that it has with setting the Bank of England interest rates. Yours sincerely Dr.Simon Douglass MBBS DRCOG MRCGP
Low waiting times -but at what cost? 22 January 2002
ted a willis, gp principal brigg n lincs dn20 8nt Send response to journal: Re: Low waiting times -but at what cost?	GP's like myself waste a lot of time with patients who are waiting ludicrous lengths of time for investigations and specialist treatment in the nhs. Over 6 months for a patient with a small stroke to have a ct scan is todays example. Wouldnt it be lovely to work in California for the Kaiser? The answer is yes and we have obviously got a lot to learn from the US about efficient utilisation of our facilities. However, there must be drawbacks and it looks as if there at at least 2 major ones from the evidence of this article. First the bed days less than a third of the NHS! I have trouble admitting patients often and many of them seem to come out very fast indeed. Logically this means that many patients in the Kaiser system that need admission do not get it. Second, the primary care "physician extenders". In the UK, patients have ready access to GP's ie doctors. It sounds as if Californian patients do not, but must first see physician assistants. I am also worried about the conflict of interest that is implied by the doctors being shareholders in the Kaiser scheme. This article is very welcome, and will hopefully wake up the NHS, which often seems to exist mainly for the benefit of staff and not patients, but it is dangerously easy to focus on the negative aspects of our own system, while ignoring the drawbacks of alternatives.
Length of stay not the problem 22 January 2002
Julian M Bene, Mgt consultant Atlanta, GA, USA Send response to journal: Re: Length of stay not the problem	Some readers have assumed that the NHS has three times Kaiser's hospital days per head because average length of stay is that much higher. Explanations have occurred to readers like bed blocking because of poor social service care for recuperating patients, weak coordination of services in hospital, weak clinical practices, lack of emphasis on getting patients out quickly, etc. There's likely some validity to all of these inefficiencies, but let's not jump ahead of the data. Feachem's Table 3 shows length of stay of 5 days for NHS and 4 days for Kaiser. That's 20% more, not 200% more than Kaiser! And before assuming that the NHS must change to emulate Kaiser, let's recall recent American outrage at "drive- by delivery" of babies and the legislation it provoked. Reduction of length of stay can be pushed to politically unacceptable extremes, even in the US. Additionally, the push to limit length of stay can turn out to be an accounting misconception, if either costs of care migrate from inpatient to outpatient or that last day turns out not to cost much to provide, with minimal actual resource savings when it is eliminated. The big difference between the two systems is not in length of stay but in admissions per head. While the NHS may be admitting patients that Kaiser would treat on an outpatient basis, this cannot explain the huge gap. Almost certainly, Kaiser's population is much less sick than the NHS's. Indigent and trauma cases in the US go to the county-funded public hospitals, not to Kaiser, for a start. And one suspects that Kaiser, acting in its own competitive interests, structures its benefit offering to the elderly to attract the healthiest and deter those who are likely to need hospitalization. (This may be true of employees, too, since employers offer them multiple health options with different premiums and co-payments, and the Kaiser package may be designed not to appeal to those with known illness.) Finally, given the intensity of health resources devoted to the dying, it would help to have a comparison of death rates in the Kaiser membership to compare with the UK death rate. If the health of the populations is as different as the admission rates suggest, then Feachem's conclusion that Kaiser gets more for the dollar may be invalid. Some of Kaiser's techniques may still be worth adopting in the NHS. However, the despondency felt in Britain on hearing that the poor old NHS is not even efficient may be quite unwarranted. Sincerely Julian Bene
Kaiser Permanente and the NHS 22 January 2002
James I. Storer, General Practitioner and PEC Chairman Bosworth Medical Centre, 16 Crabtree Drive, Chelmsley Wood, B37 5BU Send response to journal: Re: Kaiser Permanente and the NHS	Editor – The paper by Feachem et al. must surely give new heart to those of us that believe in a truly integrated health service. Such integration is the only way we will achieve a truly patient centred system with which we might be proud. However I was somewhat surprised that there was no direct comment at what might be perceived as important factors in how Kaiser Permanente has achieved this enviable goal. The fact that doctors are shareholders or partners and that specialists cannot work outside the system are surely important motivating factors. A major problem within the NHS is that developments occur both within primary and secondary care that bear little or no relationship to other developments within the system or the over riding needs of the system. Individual general practices develop their services in almost total isolation from the neighbouring practices, individual hospital consultants strive to develop their own departments irrespective of the overall needs of the service either in primary or secondary care. The benefits obtained by Kaiser will only occur within the NHS when professionals recognise the merits of true integration and interdependence over and above individual pursuit. Sharing in the profits of an organisation and having nowhere else to practice concentrate the mind to those merits. James I. Storer, general practitioner and PEC chair No competing interests
Re: The end of General Practice? 22 January 2002
Peter Davies, GP (salaried) Mixenden Stones Surgery, Mixenden, Halifax. HX2 8RQ Send response to journal: Re: Re: The end of General Practice?	I am surprised to find myself agreeing with an orthopaedic surgeon's view of general practice. However I think Andrew Robert's comments are accurate and I look forward to seeing greater integration between primary and secondary care. I think all specialites can benefit and learn from working more closely alongside one another.
Kaiser fudge factor 22 January 2002
Stephen D Blair, Consultant Surgeon Wirral Hospital Trust CH49 5PE Send response to journal: Re: Kaiser fudge factor	This article was leaked to the popular press before we got our copies and is promoted on the front cover of the BMJ this week. However it is the most outrageous abuse of statistics for political purposes I have ever seen. Look at the figures in Table 1. Per capita expenditure for NHS is :- NHS $1402 vs Kaiser $1951. After adjustment for age and socio-economic group the figures become NHS $1161 vs Kaiser $ 1951. That means that costs in California are a collosal 68 % more than the NHS. So how do they claim that the costs are similar. - Easy , you introduce a fudge factor called Purchasing power parity. This is defined as the rate which equalises purchasing power in different countries, or in other words cuts out the higher costs in America. In the full text they admit that the starting salary for Consultants is 115% more than in England and that there are for example 3 times as many cardiologists. It is not rocket science to know that if you doubled the salary in England and double the number of consultants, each would have a smaller case load and therefore with more individual attention, the clinical markers such as the number of post MI patients on beta blockers will improve. Surely it is the role of the BMA to pick this sort of erroneous information up and to tell government that this is a fiddle before Mr Milburn starts making political capital out of it by saying that we don't need more money to become more efficient. Remember health care in Kaiser California is actually 68% more expensive than the NHS.
Getting more for their dollar 22 January 2002
Dr. Graham Curtis Jenkins, Director TW18 4DG Send response to journal: Re: Getting more for their dollar	Dear Sir, The Authors ‘Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente’ BMJ 2002; 324:135-43 have made an important contribution to the discussion about health care cost comparisons between USA and the UK. However, there is one area, of patient demand management which is given significantly different priorities in the Kaiser model of healthcare provision which accounts for some of the success of the Kaiser model. For the past 50 years, Cummings and his colleagues have developed and fine tuned a behavioural health service provision which supports the health care providers. Professional psychologists with extensive psychotherapeutic counselling expertise work alongside the family healthcare teams and accept referrals of patients whose health needs have a psychological component (and also patient self referrals). The service is highly developed and has been widely copied (although not invariably accurately) by HMOs across the USA with varying degrees of success. In the UK the nearest parallel is the growth of primary care counselling services, often woefully underfunded but still able to demonstrate effects similar to the findings reported by Cummings. Falls in patient demand for healthcare by targeting high utilisers of service, improvements in patient compliance with desirable healthy behaviour, advice and self care, and reductions in referrals to traditional mental health services are all highly cost effective have all been reported. It is not therefore just better management of healthcare providers to ensure compliance with protocols, guidelines and he rest but because of an acknowledgment of the large psychological component to patient distress and feelings of illness and malaise without evidence of disease (that causes so much extra workload to the NHS) and the provision of services required to manage and treat those needs. Yours sincerely GRAHAM CURTIS JENKINS
The Increased Cost of Efficiency 23 January 2002
Tom Aslan, Salaried GP Stockwell and Health Economist at BUPA 1 Binfield Rd Stockwell SW4 6TB Send response to journal: Re: The Increased Cost of Efficiency	The fact that Kaiser can provide a very responsive health system at a similar cost to the NHS seems to be at least in part a result of keeping patients out of hospital. This may be possible because Kaiser will diagnose and treat patients sooner as outpatients. The savings from reduced hospital stay help pay for the increased staffing levels. For the NHS to try and mirror this, it would require an increase in the number of specialists and GPs, as well as other staff. There would undoubtedly be a lag time before the increased staffing levels resulted in a reduction of hospital bed stays. The UK system would be more inefficient during this transitional phase and would need an increase of funds to cover this time. Trying to increase the staffing levels in the NHS may prove difficult with current salaries. Recruitment and retention of doctors in the UK is poor. Increasing the time spent seeing each patient and reducing bureaucracy would all help but salaries should also be more in line with the American equivalent. Much more work is needed to try and define and measure outcomes before detailed analysis can be made comparing effectiveness and cost of different systems. All the outcome measures discussed in the article are still crude, even though they present a valid difference overall between the two systems. More detailed work is needed to identify the parts of the Kaiser system that work better than the NHS. It is essential to fully evaluate any changes before they are implemented. The NHS has seen so many changes of direction and emphasis over the last two decades that the people working within it often seem to be suffering from change fatigue. Before we rush in to alter the way we work it is vital that we are certain of what we are doing and are prepared to fund it properly.
Article Should Not Be Published In Its Current Form 23 January 2002
Timothy C. Wilding, Risk Analyst Paoli, PA, 19301 Send response to journal: Re: Article Should Not Be Published In Its Current Form	After reading this article, I am forced to conclude that the article should not be published in its current form. I would like to add my voice to the chorus of people who have already stated that the cost comparison is seriously flawed. There is one major flaw - the PPP adjustment. Potentially, there is a second major flaw since the article does not indicate whether the operating expenses have been adjusted for tax revenues flowing back to the government. But, even ignoring these worries, I would further like to add that the article compounds these errors by selectively interpreting most of the statistics they present. I sincerely hope that a correction will be issued to the press before any major damage is done. As far as I am aware, a press-release based upon this article has already appeared on the BBC website http://news.bbc.co.uk/hi/english/health/newsid_1764000/1764713.stm . Let us start with the calculation of costs shown in Table 1. First, the authors calculate an average cost per capita for health treatment via the NHS. The authors choose to deduct profit and capital depreciation when calculating the comparison. By deducting profits, their comparison is only relevant to the shareholders of Kaiser. The users of Kaiser still have to pay to provide these profits. This adds another $100 per capita on to the Kaiser users’ costs. Second, the authors use a conversion rate of $1.6 per pound to calculate the NHS costs in dollars. While the currency conversion was near that rate at the beginning of 2000 and throughout most of the 1990’s (the period of the study), it was significantly lower by the end of 2000 (1 pound = $1.40) and averaged around $1.51 per pound for the year (see www.oanda.com for details). Effectively, this increases any estimate of NHS costs by a further 7% over the year compared to Kaiser. So, using their own figures, the true comparison should be: Kaiser cost per capita $2060, NHS cost per capita $1322. Finally, in one of the most outrageous adjustments of all, the authors then adjust this number by multiplying it by the PPP number for healthcare on the basis that healthcare is more expensive to provide in the US. Let us examine the PPP number. The PPP number is the ratio of the average healthcare cost per capita in the US to the healthcare cost per capita in the UK. In other words, their final estimate of the cost is that the UK costs per capita are (average US Cost Per Capita / average UK Cost Per Capita) x NHS Cost Per Capita. Since I think we can all agree that the average UK Cost Per Capita and the NHS Cost Per Capita are likely to be very similar indeed given the dominance of the NHS in the UK healthcare market, we can see that the number that the paper derives for the NHS Cost Per Capita is actually closer to an estimate of the average US Cost Per Capita of healthcare. From Table 1, we can and should conclude that Kaiser is cheaper per capita than the average US healthcare provider. This should be no surprise given the size of Kaiser relative to most US healthcare organisations. We can also conclude that the costs of running the NHS are significantly cheaper per capita than the costs of running Kaiser. We may be able to say something about how much it would cost to run an NHS-style organisation in the US, but this seems to be a very abstract concept given that such an organisation would be able to use its bulk purchasing power to lower drug costs and physician costs substantially. The authors proceed to try and use Table 2 to adjust the estimated costs for the different demographic profile of Kaiser members. However, before we do that we should us Table 2 to construct an estimate of the average NHS Costs Per Capita from Table 2. Table 2 is a list of government statistics showing the cost per capita of different demographic groups. The average cost per capita of an NHS patient from the table is 404 pounds or, using the authors’ preferred conversion rate of $1.6 per pound, $646.40. This estimate conflicts significantly with the PPP-adjusted estimate of $2130 per capita derived by the authors in Table 1. Where is the difference coming from? I don’t know, but, if I were refereeing this paper, I would have suggested that the authors investigated this a little more closely. I personally believe that it may be because the authors ignore the fact that a significant portion of the expenses of the NHS comes back to the government in tax. If the authors have ignored this, then the effective end-user costs of the NHS could be decreased by a further 20-30%! In other words, and assuming 25% flows back to the government, the comparison would now read: Kaiser cost per capita $2060, NHS cost per capita $985. However, there is no way to tell whether tax is a significant issue since the authors have not provided any detail in the breakdown of the operating expenses. One should further note that adjusting these costs for the demographic profile is likely to lead to a very inaccurate measure of the costs. Any adjustment for the fact that the NHS has to provide service for all is likely to be little better than a guess. In that spirit, I would agree with the authors’ adjustment of the NHS costs downwards by 17%! If we assume that tax revenues are not accounted for, this leaves us with the following like-for-like comparison: Kaiser cost per capita $2060, NHS cost per capita $817! The authors then use Table 3 to show that Kaiser provides a much higher quality of care than the NHS. Without statistics on the quality of service, such a comparison is meaningless. Each of the statistics could be turned on their head to show that the NHS is much more efficient than Kaiser. For example, why does Kaiser provide only one cardiologist for every 42000 people when the NHS seems to be able to provide coverage with only one cardiologist for every 125000 people? We can interpret this two ways – Kaiser is providing a high level of service or the NHS is incredibly efficient. Until the paper more properly compares the quality of service of the two organisations we cannot conclude anything about the relative efficiency of either organisation. In a similar vein, the authors use Table 3 to show that Kaiser cuts costs significantly by having a lower average acute length of stay. We can turn this statistic on its head and interpret it as showing Kaiser cuts quality of care by throwing people out of hospitals early on in their treatment. Again, without any data on quality of care or reasons for hospital stays, we should conclude that such data tells us nothing about the comparison between Kaiser and NHS. Finally, the authors use Table 4 to attempt to show that Kaiser is more responsive to consumers than the NHS. They cite the time spent with the doctor as a key statistic. They show that an NHS doctor spends an average of 8.8 minutes with each patient compared to the average of 20 minutes that a Kaiser doctor spends with a patient. Alternatively, we can see that an NHS doctor treats approx 2.3 times more patients than a Kaiser doctor. What are the Kaiser doctors doing all day, filling in forms and playing golf? Of course, this comparison is also meaningless unless we account for the quality of care experienced by the end-user of the Kaiser system and the NHS system. Table 4 also tries to compare waiting times for the NHS and Kaiser. The authors do not present comparable statistics leaving the reader to wonder what the data hide and hindering any constructive analysis of the waiting times. For instance, do all NHS patients classified as urgent get to see a doctor within 24 hours? What is the waiting time experienced by 80% of the NHS patients? Is it less than 7 days? Similarly, what is the average waiting time of a Kaiser patient? Is it more than three days? Table 4 shows that repeat prescriptions are available in Kaiser without calling or visiting a doctor. Again, this statistic is meaningless unless one accounts for the average prescription length. For example, is a woman prescribed the pill for 6 months or 1 month? In the NHS, such a prescription is typically for 6 months. In the US, this prescription may be for a significantly shorter time period. The length of the time period will be a key factor in the customer’s view of how responsive the NHS is. If I were to draw a conclusion about the Kaiser and NHS systems from the data, I would wonder why the Kaiser people are not trying to get the NHS to take care of some of their patients. It would certainly be more cost effective for Kaiser!
Time to retract the Kaiser headline? 23 January 2002
Julian M Bene, Mgt consultant Atlanta GA 30306 USA Send response to journal: Re: Time to retract the Kaiser headline?	It was the huge difference in hospital admissions between Kaiser and the NHS that led Feachem et al to claim that the NHS wastes 10 billion pounds on unnecessary hospital days. To sustain this, they assert that Kaiser takes care of essentially the same population as the NHS in terms of health risks. A few hours of research provides enough counter information to throw the core of their article in doubt. 1. The suspicion that Kaiser obeys economic forces and finds ways to select healthier-than-average members among the elderly is given credence by two research abstracts. One recent review of the literature confirmed that HMOs “still attract healthier Medicare [over-65] beneficiaries,” but not healthier employees. (1) A second article’s title says it all – “The Medicare-HMO revolving door--the healthy go in and the sick go out.” (2) It found “marked selection bias” for Medicare HMO enrollment and disenrollment in South Florida. HMOs captured members whose prior use of inpatient services was 66% of the average level of fee-for-service members, while those who left HMOs subsequently used 180% of the fee-for- service average level of inpatient services. This research does not prove that in California Kaiser’s bed days are minimal because the system manages to avoid the most burdensome population. But it puts the onus on Feachem et al. to prove that Kaiser is treating a population with the same level of ill health as the NHS contends with. 2. The assertion that Californians’ and Britons’ health risks are similar seemed questionable, given the renowned Golden State lifestyle. And sure enough, ASH reports that smoking prevalence in California is 17%, vs 28% in UK. (3) Obesity is also less of a problem in California, where the obession with body image pays off, than in the UK. 25% of Californians had BMI of 27.3 to 27.8 or more in 1993/94 (4), versus 58% of Britons above 28.1 BMI in 1998 (5). Finally, California is famously affluent: the state’s GDP equivalent per head in 1999 was about 45% above the UK’s.(6) The OECD has found that GDP per head is a major driver of health outcomes, and 45% is significant. (7) So it is not true that the two populations “share similar risk factors,” as the authors claim. The UK has far more smokers, far more weight problems and far lower incomes. Taken together, these facts suggest that the authors have not substantiated their claim that the NHS is wasting bed days and that Kaiser delivers better value for money. In addition, it was misleading not to credit the NHS with obtaining the services of its staff and buying drugs at much lower cost than Kaiser. A cursory review would have raised all of these red flags. The decent thing now would surely be for the BMJ to retract the claim of NHS inefficiency with as much fanfare as it gave to the article’s findings last week. Julian Bene (1) Hellinger FJ, Wong HS. Selection bias in HMOs: a review of the evidence Med Care Res Rev 2000 Dec;57(4):405-39 (2) Morgan RO, Virnig BA, DeVito CA, Persily NA. The Medicare-HMO revolving door--the healthy go in and the sick go out. N Engl J Med 1997 Jul 17;337(3):169-75 (3) Cited in ASH comments on the Wanless Review, January 2002 (www.ash.org.uk) (4) California Department of Health Services website, citing Behavioral Risk Factors Survey (5) BBC Online news item 15 February, 2001 citing National Audit Office report 'Tackling Obesity In England' (6) California Statistical Abstract, UK Blue Book, author analysis (7) Discussed in the Wanless Review, section 5
Social experiment 24 January 2002
Kevin Pearce, GP HA2 6 HL Send response to journal: Re: Social experiment	One of the constraints of evidence based medicine is that you must actually use the evidence. Berwicks' suggestion of a "social experiment" is an excellent one. Of course I would have to be paid an additional 43% of my current salary but I would be happy to join those specialists flocking to join at 115% of their salary.The numbers of such specialists would have to be increased per 100,000 of the population ;3 times the number of paediatricians and cardiologists and twice the number of obstetricians and oncologists. In addition we would have to put in place the extra nurse practitioners and physician assistants.Bed closures should be no problem and since no mention is made of bed blocking or social care after discharge we will disregard this when making discharge arrangements. When all of this is achieved then, and only then, will we be able to compare systems.
Important conclusions despite vague figures 24 January 2002
Gerald T Freshwater, occupational physician Lerwick, Shetland ZE1 0EL Send response to journal: Re: Important conclusions despite vague figures	Dear Editor, Although I freely admit that I am no economist, I do believe that Feachem et al have made some unwarranted adjustments in their comparative costings. Firstly, the "purchasing power parity"; basically drugs and doctors are more expensive in America. No adjustment is made for cheap food or fuel costs, so why adjust for expensive items? Secondly, and the most important difference, is the figure for depreciation, about six times more per capita for Kaiser, suggesting a similar disparity in investment. It is ludicrous to propose that choices in capital management are not important, since scarcity of resources as much as inefficient use, is an important cause of poor performance. These criticisms aside, this is an excellent paper which should give us all cause for thought. The lessons offered can be applied, although there may be extra costs. More staff can be attracted by better pay and much better job satisfaction. Better facilities for investigation and treatment will lead to shorter hospital stays. Unfortunately for the Government (any government), big investment is required at the beginning, whilst the results will not appear for several years. I applaud Berwick's proposal for a large pilot scheme: perhaps Scotland might not be too large? It is already devolved and thus semi- autonomous. However, let no such trial be condemned to failure by lack of adequate and early investment. Gerald Freshwater, Occupational Physician, Shetland Isles Conflicting interests: NHS employee for 30 years, member of trade union negotiating salaries within NHS, patient of NHS
An alternative explanation. 24 January 2002
Stephen J. Morgan, Consultant Ophthalmologist Sunderland Eye Infirmary, SR2 9HP Send response to journal: Re: An alternative explanation.	Sir- The authors of the article "Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente"(1) have certainly presented much food for thought. However, the analysis of the article seems to miss the point. The authors have shown (table 3 of their article) that over five leading clinical specialities, in Kaiser Permanente there are by my calculation between 37% (radiology) and 200%(cardiology) more specialists per capita of population. I am amazed that neither Richard Smith in his leader article(2), nor the three leading pundits in their own commentaries(3,4,5), even mention this finding, let alone address it. Could this not be a major contributor to shorter waiting times and greater efficiency in the American system? 1. Feachem RGA, Sekhri NK, White KL: Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002 324, 135-141. 2.Smith R: Oh NHS, thou art sick. BMJ 2002 324, 127-128. 3.Dixon J: Commentary: Funding is not the only factor. BMJ 2002 324, 142. 4. Berwick DM: Commentary: Same price, better care. BMJ 2002 324, 142-143. 5. Enthoven AC: Commentary: Competition made them do it. BMJ 2002 324, 143. (No competing interest).
One American social worker's view. 25 January 2002
Michael L. Wong, Medical Social Worker 2 Kaiser Permanente, 3400 Delta Fair Blvd., Antioch, CA 94509 Send response to journal: Re: One American social worker's view.	This article was summarized in our email newsletter, and I found it quite interesting. Let me offer my perspective as a social worker in California. Kaiser is consistently rated far better than the majority of Health Care Organizations (HMOs) in the United States. This holds true whether it is being rated by news media surveys, consumer reports, professional organizations, or government surveys. Kaiser is not typical of the U.S. healthcare system; it is well above average. I don't know anything about the NHS system, so I can't speak to comparsions with NHS. However, one should not confuse Kaiser's success with the quality of the American health care system as a whole. In America, there are large numbers of people who have no medical coverage, and some of them have serious medical conditions. Fear of losing one's coverage and becoming ill is a common fear of many Americans. The aged are particularly vulnerable. Kaiser has one advantage I would guess the NHS system may not: Kaiser only takes those patients who can afford Kaiser. Somehow, they have to pay, either via their work plan, their retirement plan, Medicare, Medi- Cal, or some other means. In other words, the poorest, most needy, and often most at risk populations are not generally part of Kaiser. They are probably the patients who would be the most expensive and difficult to care for. Examples would be homeless persons, drug addicted persons who cannot maintain themselves, chronically mentally ill, etc. Kaiser is an good example of an excellent health care organization. But it is not the American health care system as a whole, which has very serious problems and leaves far too many people un-served or under-served. We literally have people dying in our streets as a result of our national (non)system, and this should not be happening in one of the world's richest countries. If your system serves the underclass, be proud of it and work to continue improving it.
Kaiser – A Model of American Success or an Aberration? 25 January 2002
Jeremiah D Schuur, Resident Physician in Emergency Medicine Rhode Island Hospital, Brown University Medical School, 493 Eddy St., Providence, RI, 02906, USA Send response to journal: Re: Kaiser – A Model of American Success or an Aberration?	Feachem et al (1) make a strong case for the efficiency and quality of the Kaiser-Permanente system. Although comparing health systems is difficult, most health policy experts point to Kaiser as the best model of American health care. It is disingenuous to extend these results to other American managed care policies as Feachem et al attempt to do. They state that “managed care, of which the Kaiser system is one manifestation, is now the norm in the United States, covering 92% of all those with health insurance sponsored by an employer. Despite this, managed care has recently been criticized....Most members of health maintenance organisations, however, report satisfaction with their own health plans.” Their glowing report of Kaiser’s success in a competitive market place raises several questions about the benefits of competition. First, although there is great financial incentive to decrease hospital utilization, there is almost no benefit for insurance companies to implement prevention programs. The average U.S. insurance plan has 25% annual turnover, discouraging such long-term investments. Second, Kaiser’s quality has not resulted in market success. Their plan is not growing and staff model HMO’s are the exception rather than the rule in the U.S. Instead of adopting plans similar to Kaiser most insurance companies are turning away from “defined benefits” programs to “defined contributions” programs.(2) These programs will require more out-of- pocket payments from the sickest individuals. There will be more financial barriers and disincentives to accessible care. Unfortunately for most Americans, there is no reason to believe that the future of health care in the U.S. will resemble Kaiser. 1 Feachem RGA, Sekhri NK, White KL: Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002;324:135-143. 2 Milt Freudenheim, A New Health Plan May Raise Expenses For Sickest Workers. New York Times. December 5, 2001, Section A, Page 1, Column 6.
NHS inefficiency? 25 January 2002
Richard Blakemore, GP principal Castlehead Medical Centre, Keswick, CA12 4DB Send response to journal: Re: NHS inefficiency?	I would agree this is an interesting study but to suggest that NHS inefficiency is the cause of the poor performance is outrageous. I work in a system where patients with diagnosed malignancy are sent home without an operation due to lack of beds. Our own national government has agreed to pay another counry to operate on patients as the NHS does not have the capacity to cope. Of course the US system is more efficient - they do not have patients sat in bed for days waiting for MRI/endoscopy etc. Nor will they have patients in beds for weeks on end waiting for social service funding for nursing homes. Patients will also be seen more frequently by specialists which will reduce bed days. Consultants cannot afford the time to do frequent ward rounds that will no doubt happen in this system. Even if these figures are valid the conclusions are not. The NHS desperately needs more staff at all levels and more access to diagnostic and therapeutic equipment. If this were the case then much of these supposed differences would disappear.
Re: Kaiser Permanente and the NHS 25 January 2002
Giselle Martinez, Consultant Psychiatrist Whitchurch Hospital, Cardiff CF4 7XB Send response to journal: Re: Re: Kaiser Permanente and the NHS	I am sad that this article will inevitably be used as an excuse for further "efficiency" improvements at a time when at least some ministers finally admit to severe and chronic underfunding of the NHS. The points that undercapacity and staff shortages create inefficiency have been made but will no doubt be ignored by the popular press and number crunchers. Far more worrying is the authors belief that they have taken into account the differences in our health systems and the talk of financial outcomes as the important ones. Wnat about clinical outcomes and mortality statistics? What about the long term care of thousands of patients with, for example, mental illness and neurological problems not covered by some health plans? What about those among the uninsured who were uninsurable in the first place because of pre-existing chronic disabilities, the disorganisation caused by deprivation or genetic loading? Adjustments for socioeconomic status do not take this into account. These costs incurred by the NHS are transferred to families and the public health systms in the US. It could be argued that we should do the same (not by me)but if that is what the authors believe it should be clear. If all patients have a right to choose that should include the people insurers won't touch. No conflict of interests
The NHS versus Kaiser 25 January 2002
george p mason, family doctor banbury ox16 2ej Send response to journal: Re: The NHS versus Kaiser	Even if the conclusion that Kaiser's costs are greater than those of the NHS by 10.6% were correct, -and other correspodents have cast convincing doubts on the figures- the NHS should congratulate itself. What wonders an extra 10.6%, or even 1.06%, could achieve! The costs of the two organisations are not "similar". Would the BMA notice if we all dropped our subscriptions by 10.6%?
NHS v Kaiser 25 January 2002
Rhodri A Davies, Consultant Radiologist Prince Charles Hospital, Merthyr Tydfil. CF47 9DT Send response to journal: Re: NHS v Kaiser	Sir, It is hugely illogical to use a 1.52 multiplier to finesse Kaiser's inflated funding when the excess is itself a reflection of the failure of the private sector to control costs over a 25 year period. Over the same time period, the NHS used (?abused) its monopoly power to keep down wage costs, though its overzealous application in the 1990's led to a worsening of our chronic underinvestment, in the pursuit of '' Value for Money''. Market forces and competition are as capable of increasing costs and prices as of reducing them, as we are seeing currently in the British railway industry. Privatisation and fragmentation have enabled train drivers to exploit their market value to increase their wages, where industry-wide collective bargaining had previously held them in check. Kaiser and the rest of the American health system should not be rewarded for previous profligacy when comparisons are being made with our own hyperefficient system. Our failings are in most part due to having had no resources to invest in the kind of facilities enjoyed by Kaiser patients, not the absence of competition. Furthermore, I doubt whether anyone in this windswept land would recognise the observation that Californians and ourselves live in comparable climates. Excess winter month mortality figures should be checked before this kind of assertion can pass muster. The extraordinary thing is, that despite every fudge they could muster, the authors of this comparison could only get the Kaiser figure down to 10% ABOVE the NHS figure.In this cash-tight world, 10% is a pretty massive shortfall. I just hope Mr Milburn et al take wiser counsel than that proffered by Feacham, Sekhri, White and Enthoven. R.A.Davies Radiologist. Prince Charles Hospital, Merthyr Tydfil
Are the two systems comparable? 25 January 2002
Stephen Brown, Consultant Paediatric Surgeon Royal Belfast Hospital for Sick Children Send response to journal: Re: Are the two systems comparable?	Dear Sir, The article on 19th January 2002 comparing the cost of health care in the UK and Calafornia(1) makes fascinating reading. It strongly suggests that investing in specialists and equipment in order to improve the immediacy of consultation and investigation will substantially reduce the need for hospital admission. However, I am sure there are a number of questions about the comparability of the two systems. I will raise two. My experience in the United States has taught me that the system does not cope well with what they call the “indigent poor”. About 30% of the American population comes into this group, but it represent a large proportion of the patients admitted as emergencies, often as a result of trauma. It would be of interest to know how the Californian system manages this group. In most American cities they become the responsibility of the County hospital. I would also be concerned about the contribution made by Kaiser Permanente to education and training of nursing and medical staff. This is a costly item, and it significantly affects the distribution of specialists in the NHS. My understanding of the system in the USA is that training is the responsibility of the University hospital, and that this cost would need to be factored into the equation. Yours faithfully Stephen Brown Consultant Paediatric Surgeon The Royal Belfast Hospital for Sick Children, Belfast BT12 6BE sbrown.osborne@btopenworld.com
Dollars vs pounds: business vs care 25 January 2002
shahana Hussain, Locum Psychiatrist London, Darren J Fowler Send response to journal: Re: Dollars vs pounds: business vs care	BMJ Letter Dollars vs pounds: business vs care The transAtlantic healthcare debate has been sparked. A government- inspired NHS 2000 Plan states that “The NHS gets more and fairer healthcare for every pound invested than most other healthcare systems”. A novel paper, Feachem et al., seeking to test the hypothesis, originating in the USA, comparing California to the UK NHS, is published early 2002, in the British Medical Journal, what would the BeachBoys say? The commentators (Don Berwick, Jennifer Dixon, Alain Enthoven) note the comparability of the two healthcare systems. However, there are important differences. First, demographics. Californians have a high standard of living with some of the most expensive city property prices in the world. The population sizes in Feachem et al’s study are different by ten-fold (59.5 million (UK) vs 6.1 million (Kaiser), but the per capita expenditure is less in the NHS compared with Kaiser (£876 vs £1951) even after adjustments (£1764 vs £1951) despite the larger absolute population number (Table 1, Feachem et al). The fact that costs are cheaper in the NHS is important because it might be expected that a larger organisation (the NHS is the largest employer in Europe) might have significantly increased costs compared with a smaller more integrated unit. Feachem et al, rather than challenging, supports the belief that the NHS is highly efficient. Second, Kaiser does not cover “longterm psychiatric care”. This is important because NHS mental health beds comprise about half of the total NHS bed capacity. Mental health services are a vital, but often neglected, clinical service with high demand but short supply. It would be helpful if the authors could clarify what is meant by longterm psychiatric care, since by its nature psychopathology is usually chronic. This point raises significant questions: do the authors mean that Kaiser does not cover all psychiatric services, if yes, which services are covered? If services are not covered, then Kaiser is not offering a comprehensive service to their members, especially since the lifetime risk for clinical psychiatric disorder is approximately 25%. Why do Kaiser not cover psychiatric care? We suspect this population is not covered for economic reasons. BMJ readers and the public should be aware that this is the case for most of the USA: mental health care services are simply not covered. Third, longterm care in general. Feachem et al devote one paragraph to this, yet managing chronic multifactorial illness is one of the most important aspects of medicine and the most economically draining. The authors state that Kaiser covers up to 100 days per year of subacute care, including rehabilitation and other medical services requiring skilled nursing, speech and physical therapy, social services for the housebound and hospice care. The proof is in the pudding: what happens when 100 days (approximately 3 months) of coverage cease? BMJ readers will be able to think up many examples from their own experience: autistic children requiring speech and language therapy, diabetics with chronic foot ulcers, terminally ill cancer patients who live for more than 100 days, these issues have to be addressed by healthcare professionals but not necessarily by insurance companies. Fourth, public service. The NHS spends 6% of its budget on education and training, research and development and other obligations. NHS consultants are contracted to teach trainees. Kaiser spends 3.5% on “equivalent items” (about half the NHS figure) plus 4% on administration (total: 9.5%). Could the authors clarify what is meant by “equivalent items”? Lastly and most importantly, the NHS offers universal healthcare, Kaiser offers healthcare based on insurance to a subpopulation, Individual choice, yes, but the choice only exists for those who have financial independence since healthcare and employment are directly related in the USA. The consumer “choice” of changing health plans every year (Alain Enthoven) leads to discontinuity of care and migrant patients. As Feachem et al mention, 24% of Californians are uninsured which is a figure mirrored across the States. The USA is the richest country in the world, but denies 20-25% of its population healthcare access on economic grounds. As Jennifer Dixon (Funding is not the only factor) and Richard Smith (Oh NHS, thou art sick) suggest there is an abundance of political ideology but a dearth of knowledge in healthcare economics research data; this paper is just the starting point. The devil is in the detail. M Shahanara Hussain, MRCPsych Darren J Fowler, Harvard Medical School, Boston, MA 02114 USA. Feachem FGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente BMJ 2002;324:135 -43. Dixon J. Commentary: Funding is not the only factor BMJ. 2002;324:142. Berwick D. Commentary: Same price, better care. BMJ 2002;324:142. Enthoven AC. Commentary: Competition made them do it. BMJ 324, 143. Smith R. Oh NHS, thou art sick BMJ 2002;324:127-8.
NHS versus Kaiser conclusions are back to front & BMJ Editorial impartiality in doubt 25 January 2002
Paul S Meadows, GP Principal Priory Surgery, 326 Wells Rd, Bristol, BS4 2QJ, UK Send response to journal: Re: NHS versus Kaiser conclusions are back to front & BMJ Editorial impartiality in doubt	Editor, By publishing this article1 and editorial2 the BMJ has brought its own competence into question in two ways. Firstly, that the factual and statistical basis of the article is flawed has been highlighted by myself and other commentators. The time periods of comparison are not clear. Some source data is unpublished and some of the mathematical adjustments are not either transparent or justifiable. For me most importantly the two populations compared are not shown to be equivalent. The article is really a “back of a fag (cigarette) packet calculation”, in colloquial English. The deficiencies are obvious even to a cursory week-end reader. That the BMJ editorial board or its reviewers did not identify and remedy these deficiencies prior to publication smacks of neglect. Secondly, the published data itself shows the NHS having similar inpatient stays with roughly three times the number of admissions at a lower adjusted cost than Kaiser. To have this headlined as “Kaiser outperforms NHS” indicates editorial tendentiousness. I expect rigorous standards of content and argument in my BMJ. The BMJ editorial team has brought its own impartiality into doubt by the headlining and inclusion of this article in its current form. Paul Meadows (GP) 1 Headline in “This week in the BMJ” BMJ 2002; 324;. 2 Smith R. O NHS, thou art sick. BMJ 2002; 324; 127-8. 3 Feacham RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002; 324; 135-43. 4 Department of Health. The government’s expenditure plans 2001-2002. London: Department of Health, 2001. www.gov.uk/dohreport/ Conflicts of interest - none
How much more for their dollar. 25 January 2002
Kalman M Kafetz, Consultant Physician, Department of Medicine for Elderly People Whipps Cross Hospital, London, E11 1NR UK Send response to journal: Re: How much more for their dollar.	Feacham and colleagues' fascinating article stands up only if allowances for the care of elderly people are accurate. The difference between lengths of stay in the NHS and Kaiser Permanente that are critical to their analysis may occur if Kaiser does not provide the sort of care for elderly people that involves relatively long stays. The NHS provides assessment for elderly psychiatric patients and slow stream in-patient rehabilitation for physically disabled elderly people. Their table 1 allows for long term care in psychiatry but not assessment. However both these clinical services may be provided in the USA by nursing homes, funded by Medicare without involvement of Kaiser. This cost and these bed days would need to be added to the Kaiser costs and bed days to give a true comparison. It would be invaluable if the authors could provide this data.
The USA. Paying more and getting less 25 January 2002
John P Robson, Senior Lecturer Department of General Practice, Queen Mary University of London, London, E1 4NS Send response to journal: Re: The USA. Paying more and getting less	The claims of Feacham et al[1] show a dogmatic disregard for fair comparisons. The NHS figures for people on beta-blockers after a myocardial infarction of 42% are unadjusted for contraindications and are based on 1988-97 data from a single inner-city hospital in Britain's most deprived borough. These are compared with 1999 Kaiser data extensively adjusted for contraindications. A more appropriate comparator would be the figure of 38% reported from Kaiser Northern California hospitals 1990- 1992[2]. Similarly, the authors compare 1999 Kaiser data with 1996 NHS retinopathy screening data based on a telephone survey of consultants "perceived" local estimates of coverage. The figure of 60% is taken from a secondary source and is not ascertainable from the data reported[3]. A more appropriate reference was available[4]. The Kaiser data on prevention all exclude 15% of the population who were recent entrants and were not registered "members" for a full year. The NHS data need to be adjusted to exclude this proportion of the population who have lower rates of uptake. In Table 1, the NHS prevention data have been adjusted to exclude this group who are assumed to have a rate 0.75 that of those full "members". After membership exclusions and a more appropriate reference, the proportion of the NHS population with retinopathy screening is 68%4. NHS mammography and cervical screening increase to 71% and 91% respectively. Kaiser comparisons with the NHS should include the 24% of the population who are uninsured. Table 1 adds uninsured uptake to the Kaiser figures. In Table 1 the uninsured have been generously assumed to have an uptake of preventive services of 50% for women's screening and 75% for childhood immunisation. In the USA, uninsured women from ethnic minorities have considerably lower rates of screening[5]. Similarly, immunisation rates for Hispanic children in Los Angeles were only 58%[6] and the completed immunisation rate for California as a whole was 75.3%. Not a single health authority in the NHS had levels as low. In the real world the poor do not disappear from the equations and NHS immunisation figures based on whole rather than selected populations, are superior. The adjusted rates in Table 1 lend no support to the claim that Kaiser preventive care is better. Furthermore the data do not support greater hospital productivity. NHS specialists do the same number of procedures per doctor as Kaiser. The exception is obstetrics where NHS midwives could do much to enhance the efficiency of the Kaiser service. The article omitted to mention that Kaiser charges $10-15 dollars for an office visit, $50 for casualty and many other fees and co-payments depending on coverage. Kaiser doctors do not visit their patients at home, in or out of hours. In the NHS large centralised hospital laboratories work to national standards and larger volumes of work tend to be more efficient. In the USA there have been major concerns over standards in smaller units. The financial assumptions suffer the same sleight of hand that turned beta blockers on their head. Where did all the money go? In 1997 America spent 14%, France 10% and Britain 6% of Gross Domestic Product on health. Annual adjusted per capita health spending in 1997 was three times greater in the USA ($3724) and twice as high in France ($2125), than in the UK ($1193)[7]. A quick walk around any Kaiser facility will confirm that it is more modern, better equipped and has more support staff than the NHS. That costs more. The NHS could do three times the heart surgery with three times the cardiologists. There is much to learn about efficient use of hospital services, but under investment in the NHS remains the major problem. NHS hospital stock is often decrepit and the lack of basic imaging equipment such as CT and MRI scans, echocardiography and ultrasound remains a daily scandal. Kaiser is one of many providers in a fierce market characterised by corporate battles, industrial unrest, concern over standards and down-sizing. The system is expensive and inefficient. Perhaps Kaiser is America's best - but as Enthoven and his muse Margaret Thatcher grimly remind us, the market demands you have all the rest. The USA ranks 37th in World Health Organisation health system performance, Britain 18th and France 1st. A per capita public expenditure twice that of Britain, ensures that French cardiologists do twice as many heart interventions as their British counterparts[8]. The NHS is a total system serving all the people without payment at the time of use, without restrictions and without stigmatisation. Kaiser does not do any of that. By comparable World Health Organisation standards, even a grossly underfunded NHS out-performs the USA by a wide margin. Table 1 Revised outcome measures NHS compared to Kaiser (original figures in brackets) *Kaiser data including the uninsured and NHS data excluding people within a year of changing practice. NHS England Kaiser PREVENTION Beta blockers 42% 38% after myocardial infarction[2] (42%) (93%) Mammography*[5] 71% 73% (69%) (78%) Cervical screening* 91% 72% (84%) (80%) Diabetic retinal exam*[4] 68% 68% (60%) (70%) DTP+pol x3 completed 95% 88% (unchanged) (91%) PRODUCTIVITY Angiography per cardiologist 47.5 48.3 CABG per cardiologist 58.7 52.9 C-section per obstetrician 58 27 References 1. Feachem R, Sekhri NK, White KL, Dixon J, Berwick DM, Enthoven AC. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente and commentary. BMJ 2002;324:135-143. 2. Barron HV, Viskin S, Lundstrom RJ, et al. Beta-blocker dosages and mortality after myocardial infarction: data from a large health maintenance organisation. Arch Intern Med 1998;158:449-453. 3. Bagga P, Verma D, Walton C, Masson EA, Hepburn DA. Survey of diabetic retinopathy screening services in England and Wales. Diabetic Med 1998;15:780-782. 4. Khunti K, Ganguli S, Baker R, Lowy A. Features of primary care associated with variations in process and outcome of people with diabetes. Br J Gen Pract 2001;51:583-584. 5. Centre for Communicable Diseases. Self-reported use of mammography and insurance status among women aged greater than or equal to 40 years. United States 1991-1992 and 1996-1997. MMWR 1998;47:825-830. 6. Wood D, Donald-Sherbourne C, Halfon N, et al. Factors related to immunization status among inner-city Latin and African-American preschoolers. Paediatrics 1995;96:295-301. 7. World Health Organisation. World Health Report 2000. 8. Petersen S, Rayner M, Press V. Coronary heart disease statistics. Annual compendium 2000. London, British Heart Foundation, 2001.
A comparison between the NHS and California's Kaiser Permanente 25 January 2002
Afschin Gandjour, researcher Institute of Health Economics, University of Cologne, 50935 Cologne, Germany Send response to journal: Re: A comparison between the NHS and California's Kaiser Permanente	Richard Feachem and colleagues[1] present a comparison of health care costs, quality, and service performance between the British NHS and California's Kaiser Permanente. This country-to-country comparison is interesting because it does not perform the usual evaluation at the system's level; instead, it compares characteristic delivery models. Such evaluation is in line with the trend towards a more diversified organisation of health care delivery in many industrialised countries. Despite the study's useful approach its cost comparison as presented in table 1 seems to be seriously flawed. The adjustment of per capita expenditures by purchasing power parities (PPPs) is certainly helpful because it eliminates differences in the price level of health care goods and services and thus allows to evaluate differences in resource utilisation. While differences in the price level are more inherent to the system and cannot be readily influenced, a variation in resource utilisation is more likely to be explained by differences in structural features such as financial incentives or the diffusion of technology. Thus, a comparison of resource utilisation helps to derive stronger recommendations regarding what health care structures should be changed. It is important to note, however, that PPPs are based on national currency units. If, for example, a drug costs $15.20 in the US and £10.00 in the UK, then the PPP for that drug between the UK and the US is 15.20/10.00, or 1.52. Thus, the authors should not have performed a currency conversion in addition to equalising purchasing powers. This results in an overestimation of per capita expenditures in the NHS by 60%. Further, costs of Kaiser Permanente are underestimated by the exclusion of profits from the calculation of per capita expenditures. Health care costs do not only contain medical costs but also administrative costs and profits.[2] Therefore, profits should be accounted for, regardless of whether they are used for raising salaries or for investment into medical technology. Finally, it is interesting to read the argumentation of some of the commentators. Their strong recommendations about how the NHS should reorganise its health care delivery is likely to be explained by the fact that the study confirms what they had known already. Drawing scientific conclusions should go the other way round, however, namely from evidence to conclusions. Otherwise, there is a risk of interpreting evidence arbitrarily. References 1. Feachem RG, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324(7330):135-43. 2. Sullivan K. On the 'efficiency' of managed care plans. Health Aff 2000;19(4):139-48.
The Kaiser study - being precisely wrong rather than vaguely right. 25 January 2002
David P Kernick, GP St Thomas Health Centre, Exeter, EX41HJ Send response to journal: Re: The Kaiser study - being precisely wrong rather than vaguely right.	The Kaiser study - being precisely wrong rather than vaguely right. Economic evaluation offers a framework to compare alternative courses of action in terms of their costs and consequences. Against a background of increasing demands on limited health care resources, it seeks to organise and clarify information to inform explicit decision-making from a perspective of efficiency. The Kaiser study (BMJ 2002;324:135-143) undertakes an analysis of two health care systems but must be treated with caution for three reasons. Firstly, how costs are derived and combined will depend on the assumptions that have been made in their derivation. Although there are a number of costing rules which help to maintain consistency across studies there remain serious drawbacks in the quality and coverage NHS cost data that demonstrate how difficult estimating costs are. The derivation and manipulation and derivation of cost data in this study should be treated with caution. Secondly, outcomes should be encapsulated in a single measure to allow incremental cost/benefit ratios to be calculated - what is the extra benefit enjoyed for the extra cost? This is rarely possible and an alternative pragmatic approach is demonstrated in this study that presents outcomes in a disaggregated form, allowing health care decision-makers to apply their own context and values . However, the limited outcomes considered here are proxies for health outcomes and over-look many other attributes of health care that are important to patients such as continuity, reassurance and choice. Finally, comparing systems at this level is difficult due to the complexities of cause and effect. Change in one aspect of the socio- economic system of which health care is a part can produce disproportionate ripple effects throughout the rest of the system leading to often insurmountable problems with attribution. The importance of this paper is to demonstrate the danger of economic studies that attempt to compress the complexities of health production into a rigid disciplinary framework that bears little relationship to the nature of cause and effect in the real world; that there are no simple solutions or sophisticated tools for analysing and predicting system behaviour at this level; and that predictive and analytical power often comes from standing back and taking a broader view . Or as the economist Keynes said - "being vaguely right rather than precisely wrong." Dr David Kernick St Thomas Health Centre, Exeter EX41HJ SU 1838@eclipse.co.uk
bed days - possible error 25 January 2002
Gordon Pledger, retired Director of Public Health Send response to journal: Re: bed days - possible error	In table 3 the authors state that 1000 bed days are used per 1000 UK population per year compared with 327 (adjusted) in Kaiser. However Department of Health data for 1999/2000 show that in England 49.5 million people used on average 87,400 acute beds per day. This gives a utilisation of 645 bed days/1000 population/year. It is possible that the other 10m population of the UK use more bed days given their better funding but this could not raise the UK utilisation to 1000. It does seem that the Kaiser plan may not give as much more for their dollar compared with the UK than the authors state. However it would be useful to know if they have ways of supporting patients better in the community, either to prevent hospital admission, or to facilitate earlier discharge, or even to discharge patients to other facilities which do not count as hospital beds. gordon pledger
Why was the flaw not spotted sooner? 25 January 2002
Adam Jacobs, Director Dianthus Medical Limited, SW19 3TZ Send response to journal: Re: Why was the flaw not spotted sooner?	As several other correspondents have already pointed out, Feacham et al’s analysis is seriously flawed by their use of ‘purchasing power parity’ as a fudge factor [1]. It should be glaringly obvious to anyone that, in a comparison of the costs of two healthcare systems, adjusting the price of the cheaper system by the ratio of the costs between the two systems is bound to lead to a conclusion that the two systems have similar costs, no matter how different the costs are in reality. It is therefore surprising that Feacham et al should conclude that the per capita costs of Kaiser Permanente and the NHS are similar. But what I find really astonishing is that, in their commentaries on the paper, Dixon, Berwick, Enthoven [1], and Smith [2] seem to accept that conclusion. Did they read the whole paper, or just skip to the conclusions? 1. Feacham RG, Sekhri, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002;324:135-143. Commentaries by Dixon J, Berwick D, Enthoven AC 2. Smith R. Oh NHS, thou art sick. BMJ 2002;324:127-128
OK, but try persuading the Medical profession 25 January 2002
Jon C Hughes, Consultant Anaesthetist Princess of Wales Hospital, Bridgend Send response to journal: Re: OK, but try persuading the Medical profession	On the face of it, this paper illustrates big contrasts between the two services, particularly with regard to length of hospital stay. This backs up something that I've alsways felt in this regard - patients stay too long in hospital. However, more efficient doesn't necessarily mean better. Do the patients who have shorter stays with Kaiser, have a similar complication rate to the NHS patients ? Are their family or friends more likely to be around to accept these patients back in America, or do they have better funded Social Services backup. These points would have to be addressed before we could persuade the medical profession in the UK that the American system is in fact 'better'.
"Getting what you pay for," not "getting more for your money" 25 January 2002
Kevin Grumbach, Professor, Department of Family and Community Medicine University of California, San Francisco 94143 Send response to journal: Re: "Getting what you pay for," not "getting more for your money"	The comparison of Kaiser and the NHS is thought-provoking. Unfortunately, the presentation and analysis of cost data are muddled and lead to misleading inferences. Overall health care costs can be described by the equation C=P x Q, where C represents total costs, P prices, and Q quantity (or volume and intensity) of services. International comparisons require conversion of C to a common currency. Feachem et al convert NHS costs to US dollars using the “average exchange rate for the 1990s.” This conversion is proper, although most economists use overall national purchasing power parities for this purpose. However, Feachem et al. proceed to make an unconventional further adjustment, inflating NHS costs by the relative purchasing power parity for medical inputs. This additional adjustment substitutes the US “P” for the UK “P” in the NHS cost equation, with a resultant increase in the value of “C” for the NHS. The final adjusted NHS cost becomes $1764, instead of a cost approximately one-third lower ($1192) as would occur using the actual UK “P” term. It is important to recognize what this extra adjustment actually means for interpretation of NHS costs. It is wrong to conclude that the per capita cost in the NHS is “really” $1764. The true cost of the NHS is $1192 (the cost figure including the age and socioeconomic adjustments but not the price adjustment). The $1764 figure is best interpreted as representing what the NHS would cost if the NHS paid US prices for the quantity of services provided by the NHS. But the NHS does not pay US prices. Virtually no nation in the world pays the inflated amounts for pharmaceuticals, biomedical supplies, health plan CEO stock options, and consultant physician incomes that the US pays. This price difference across systems is not just a matter of currency conversion. Public regulation of health care prices is an integral feature of most national health care systems and is one of the important ways by which these systems control costs. The US has such high prices in health care because the US has a disorganized, market driven system that operates to the advantage of the incomes of suppliers and specialist physicians, at the expense of those footing the bill. To adjust away these differences in prices is to obliterate a very real strength of the NHS in restraining profits and incomes in the health care sector. Once price differences are synthetically equalized, as was done by Feachem et al, any differences across systems that remain in the “C”terms become entirely attributable to differences in the “Q” terms. The final “adjusted” cost that is about 10% greater for Kaiser than for the NHS ($1951 vs. $1764) is most appropriately interpreted as indicating that Kaiser is providing 10% more “Qs” of services per capita, not as indicating that actual costs are only 10% greater at Kaiser. When the price-adjusted cost differences are more properly presented as signifying differences in the volume and intensity of care, several findings become noteworthy. First, how is it that Kaiser has a greater quantity of services when Kaiser has only about one-quarter the acute bed days per capita of the NHS? Feachem et al. imply that Kaiser redirects vast savings of unnecessary Qs of inpatient services into delivering more Qs of mammograms and other ambulatory services. But the focus on bed days obscures the fact that acute hospital costs still dominate the Qs delivered by Kaiser. A bed day in Kaiser (and in the US in general) is a much more intensive bed day than the average hospital day in the NHS. Shortening lengths of stay compresses, rather than simply eliminates, a large amount of the volume and intensity of an episode of hospital care into fewer hospital days. Modest real savings in the quantity of hospital services occur by discharging patients sooner and eliminating some of the low-acuity days at the end of a hospital stay, but these days tend to be the low, marginal cost days. Contrary to the implications of Feachem et al., Kaiser is delivering more mammograms than the NHS because Kaiser is providing a greater quantity of services overall, and spending more overall in the process. (Feachem et al., in their table citing evidence on patient convenience, also selectively overlook data from the US indicating that many Americans consider the pressure for early hospital discharge a major inconvenience, if not an outright threat to quality of care.) In addition, it is important to note that the NHS delivers 90% of the quantity of services produced by Kaiser despite having half the number of consultants per capita. This finding indicates that the NHS in fact has achieved substantially greater productivity among its physicians in terms of the volume and intensity of services delivered per physician. Within the disorganized and inefficient context of the overall US health care system, Kaiser does stand out as an admirable model of health care integration. Feachem et al. correctly observe that Kaiser performs better than the NHS on some quality measures, and undoubtedly the Kaiser model holds many valuable lessons for the NHS. However, the authors’ conclusion that Kaiser members are “getting more for their dollar” is wrong. Kaiser members (and their financial sponsors) are paying much more for their health care than British taxpayers, and purchasing marginally more services overall along with somewhat better quality or convenience of care for this expense. For macro-level economic efficiency in health care, the NHS remains the standard bearer. While it is always regrettable when methodological mishaps in research occur, particularly disturbing is the spectacle of a flawed study so uncritically embraced by an entourage of BMJ editorials and commentaries. The plaintive wailing of “Oh NHS, thou art sick” and the predictable paean to privatisation of the American Tory Alain Enthoven might have been more tolerable if the social science had been more sound.
Kaiser vs NHS - round 1 not won due to flawed methods and reporting 25 January 2002
Martin D Tobin, MRC Clinical Research Fellow Department of Epidemiology and Public Health, University of Leicester, Leicester LE1 6TP, Mary Dixon-Woods Send response to journal: Re: Kaiser vs NHS - round 1 not won due to flawed methods and reporting	Sir Feachem et al (1) conclude that, for similar costs, the Kaiser model performs better than the NHS. The significance of these conclusions for policy and practice cannot be underestimated, and the methods used to reach them warrant careful scrutiny. In our view, this paper demonstrates basic weaknesses in both methods and reporting. Population differences are clearly crucial to the costs of care and to the interpretation of findings, yet these are scantily reported: not only was there insufficient detail relating to characteristics of the population of California, but also direct and indirect factors affecting the acceptance of Californians into the Kaiser Permanente health plan were not adequately explored. While the NHS takes all-comers, the vast majority of Kaiser Permanente members are insured through their employer. It has been repeatedly shown that uninsured individuals in the USA are more likely to have poor health and to have multiple vulnerable characteristics (2). Furthermore, Feachem et al’s adjustment factor for purchasing power parity specifically for the health care sector is nothing short of bizarre – this effectively adjusts out the efficiencies of the NHS over US health care. The per capita healthcare costs that should be compared are $1402 for the NHS vs. $1951 for Kaiser Permanente (Table 1). Finally, Feachem et al did not consider the costs incurred outside of the healthcare system in the US. These costs are likely to be considerable given that the Kaiser inpatient admission rate was three times lower than that of the NHS. There are some lessons from this paper: it underlines again that integrated and accessible care is indeed a feasible aspiration. The NHS could develop the capacity for multi-specialist centres of the type already available to Kaiser Permanente members within a decade or two. This is unlikely to be achieved through yet more traumatic reorganisation based on needless competition as suggested by Enthoven (3), but through carefully planned and evaluated strategies for investment that avoid the hole-filling exercises we have witnessed in the recent past. (1) Feachem RG, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324:135-41 (2) Shi L. The convergence of vulnerable characteristics and health insurance in the US. Soc Sci Med 2001;53:519-529 (3) Enthoven A. Commentary: Competition made them do it. BMJ 2002; 324: 143 Martin Tobin MRC Clinical Research Fellow Mary Dixon-Woods Lecturer in Health Policy Department of Epidemiology and Public Health University of Leicester 22-28 Princess Road West Leicester LE1 6TP
Comparative information on health status 25 January 2002
Malcolm Grant, GP & Internet Consultant London SW19 Send response to journal: Re: Comparative information on health status	This article contains so many flaws, it is surprising that the BMJ first allowed it to be published and then gave its findings so much prominence. Several respondents have already pointed out the perverseness of the adjustment for ‘purchasing power parity’ in the article. Another major flaw is the lack of information on the health status of the populations covered by Kaiser Permanente and the NHS. As health status will be the major predictor of use of health services, this information should have been included in the article – otherwise its conclusions are meaningless. The authors of the article claim the two populations have similar health status but all the references about the health status of Kaiser Permanente population are to ‘unpublished data’. As a minimum, we need to know the age-sex specific death rates for the two populations. Ideally, we also need to know about other factors, such as smoking status and the prevalence of obesity, that can have a major impact on health, as well as chronic disease prevalence rates in the two populations. The authors need to post this information on the BMJ website urgently, before the credibility of their article is damaged still further.
Comparison of the two systems 26 January 2002
Susan Williams, RN Kaiser, California. Send response to journal: Re: Comparison of the two systems	I am writing to you, after reading the article which concluded that patients in California were receiving better care than patients in the NHS. I am a British Registered Nurse who has decided to gain some experience working in the USA. I have spent the last two years working in California, the past six months have been within Kaiser Permanente. I was appalled your article, and wish to state that the overall quality of hospital and nursing care, is infinitely better in the NHS. Healthcare in the US is dominated by the opinions of faceless insurance companies, and the consequences of this system is only leads to worsening standards. Patients at Kaiser are now referred to as 'customers', by administrative staff, a sign they are seen as a resource, rather than individuals who require a service. Those few patients who may be entitled to State funded healthcare, are treated as second class citizens, with the hospitals own 'Utilization Managers' (staff employed to move unprofitable patients out of the hospital as soon as possible) pushing doctors and nurses to discharge patients, long before they would be considered fit to leave a British hospital. Do not let the term 'non-profit organisation' fool anyone to think these large companies are not interested in making money.....in fact large annual bonuses are offered to staff, if they fall below their budget, encouraging staff to save resources instead of 'wasting' them on patients! I am fully aware the NHS is far from perfect (and I hope future funding will be directed wisely), and remember too well the long waits hospital patients have for tests and procedures in the UK, but I can not express greatly enough that the NHS is a far more Superior, Comprehensive, and Compassionate system, which enables its staff to act as advocates to the public they serve, rather than as puppets of a profit making organisation. I look forward to working for the NHS again soon.
Kaiser-NHS comparison a landmark study 26 January 2002
Meng-Kin Lim, Associate Professor National University of Singapore, Faculty of Medicine, MD3 16 Medical Drive, Singapore 117597 Send response to journal: Re: Kaiser-NHS comparison a landmark study	Feachem and co-authors’ novel attempt at comparing the performance of Kaiser and the NHS is admirable, but there are many more differences that need to be taken into account when comparing an HMO and an entire national health system (adjusting an orange to make it look as much as possible like an apple doesn't make it an apple). For example, Kaiser essentially covers the employed, whereas the NHS covers all and sundry. Adjustments for case mix would have been preferable. Furthermore the 152% purchasing power parity correction does seem a little drastic, and may have given Kaiser a decided and possibly unfair edge in the cost comparisons. But the stark difference in hospital length of stay does jolt. The signal contribution of this landmark research is that it will spur a new genre of comparative health systems performance studies, leading ultimately to improved accountability and stewardship of health care resources across the globe. The authors are to be congratulated.
If it seems too good to be true, maybe it isn't 26 January 2002
Tom Hughes, Emergency Physician Ballarat, Australia 3350 Send response to journal: Re: If it seems too good to be true, maybe it isn't	Sir, The authors of this paper (1) have corrected for the population over 65 years (16% NHS vs. 10% Kaiser) using a factor of 12.2%. This may be a substantial underestimate for two reasons: The cost to the NHS continues to increase as patients become older, whereas Medicare data (2) suggests that US expenditure peaks at 70-74yrs. A plausible explanation would be that the NHS spends more money on [inappropriate] long term nursing care in acute care beds. If so, it would also help explain the gross disparity in bed-days data. This would represent a failing of the system in which the NHS operates, rather than of the NHS per se. Kaiser patients are not yet dying at the same rate as NHS patients. Approximately 30% of total healthcare expenditure is in the last year of life (2). Therefore an important driver of healthcare expenditure will be the number of people dying: 1998 data California UK Crude Death Rate /1,000 6.7 (3) 10.6 (4) As a rough estimate, the conversion factor should be at least 10.6/6.7 x 0.30 + 0.70 = 1.17. i.e. 17%, not 12% as used by the authors. To estimate the minimum extra money the NHS would have spend to make the comparison fair: Multiply the 5% difference by the UK per capita spending (GBP 876), and the UK population (59m) This gives an annual figure of about GBP 2.5bn, which would probably be sufficient to keep several cardiologists in the manner to which they are accustomed. References Feachem RG, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324:135-41 Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med 1993; 328:1092-6 California Department of Health Statistics: http://www.applications.dhs.ca.gov/vsq/Default.asp UK National Statistics: http://www.statistics.gov.uk/ Competing interests: None.
Politicians lack courage to undertake meaningful change 27 January 2002
Simon Smith, Consultant Psychiatrist Shelton hospital, Shrewsbury Send response to journal: Re: Politicians lack courage to undertake meaningful change	EDITOR - Comparing different healthcare systems will always raise questions as to methodology however the study of Kaiser Permanente vs. the NHS provides much food for thought (1). My impression is that the NHS is indeed inefficient. Not at a day-to- day operational level but at a structural and institutional level. An example: yet again the NHS is undergoing organisational upheaval. What is the evidence suggesting that the change will benefit healthcare delivery? There is none. In Shropshire the Community Trust for which I work is to be dissolved and its staff split accross two PCTs. Was this the preferred option of our consultant body? No. Did the local GPs want to go to PCT status in April 2002? No. Will the new configuraion benefit service users more than the present. There is no evidence that it will. Has this been exceedingly time consuming. Yes. Has this led to planning blight. Yes. Consultants in mental health were in favour of developing a mental health and social care Trust on the grounds that one of the problems faced by our service is that of bed blocking. Breaking down boundaries between organisations can only help this. However this option was discounted at this time for no reason that we could see other than local politics. Furthermore we have just learnt that new money allocated to the county has already been spent funding a number of projects begun last year, last year's pay round and NICE sanctioned drugs. As a result a number of plans developed to implement the Mental Health NSF have had their funding cut, including plans to develop the fairly basic right of 24 -hour access to mental health services. We are told this is not currently a priority. This would be easier to accept if such problems were equally shared throughout our local health economy. However the county feels it is appropriate to run 3 acute trusts, with all the duplication of management costs that entails, for a total population of a little over four hundred thousand. Why? Local politics again. Raising such issues does not make one popular. There are many other inefficiencies around the country. Services are delivered from buildings unfit for purpose often geographically distant from their ideal location. There is not the capital money to change things for the better. Planning and bringing about such change takes far longer than it should due to bureaucracy and local politics. So what is needed? Apoliticisation seems mandatory. To sort out this mess needs difficult decisions to be made and implemented. I know of no politicians in the modern era who want to preserve the good that there is in the NHS yet have the courage to take the flak for making the changes that are needed to save the service. It is all too easy for them to fall back on prevailing polical ideology as the way "forward". They are also too prone to make knee-jerk responses to media pressure with little concern for the long term consequences. Frankly, they don't have the courage to tell the nation the truth about the extent of the difficulties the service faces and what is needed to turn things around. If the NHS is to be saved, and I truly believe that it is worth saving, services will have to be streamlined as will their management organisations. Parts of local authority social care function will also need to be brought into the same organisation. More money will be needed to be spent on capital and IT, perhaps in the short term at the expense of other government targets. GPs will have to lose contractor status. Inefficient local services will need replacing and there will be significant anger when this occurs. There can be no sacred cows. Sadly, such pain will need to be faced if we are to have an NHS that provides care to all, free at the point of delivery, in a decade's time. Just don't expect any politician to deliver it. Simon Smith Consultant Psychiatrist Shelton Hospital, Shrewsbury References: 1.(1) Feachem RGA, Sekhri NK, White KL Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324:135-43.
Metaphors of Cultural Assumption 28 January 2002
Ned Hoke, Private practice/Ecological Medicine California Send response to journal: Re: Metaphors of Cultural Assumption	Gratefully this articles many weaknesses have been considered effectively at length by previous respondents. BMJ has received likely appropiate criticism. Standing back from the specific details I see an Ode and Celebration of (a hallowed business model) Medicine. "We can do it better, faster and cheaper". It might be useful to remember California has, in recent years, been a frenzied hot house for business models in all manner of applications. The enormous explosion of wealth "created" by these themes has proven to be quite uncertain over time while still combined with shameless self-celebration. (See Enron and the dot.com busts etc.) Upper management salaries and options/perks have gone through the roofs supported by the illusions created amidst. I hope the entire British public and the actual funding managers of it's system of healthcare look at this presentation with unrelentless scepticism and appreciation for the enviroment of it's credo.
Kaiser California, is it better value for money than the NHS, or, is it creative accountancy? 28 January 2002
Magdi M Kirollos, Associate Specialist Torbay Hospital, Torquay, Devon TQ2 7ED Send response to journal: Re: Kaiser California, is it better value for money than the NHS, or, is it creative accountancy?	To the editor, Feachem et al (1) attempt to answer the question of whether, or not, the NHS provides good value for money, in comparison to a system mainly based in California. Since the answer could have wide reaching implications, particularly in the current political climate of looking for alternatives based on other countries experience, this paper deserves the strictest of scrutiny. The authors admit to the great difficulties encountered in making the comparison between the two systems, but they give the impression that the comparison, after the adjustments they made, is fair. However, it seems to me that one of the adjustments they made, namely that for ‘medical cost environment or purchasing power parity (PPP)’ was one adjustment too far. As shown in table (1), the authors reached an estimation of the annual per capita health expenditure of £876($1402) and $1951, for the NHS and the Kaiser California systems respectively. They then made the mentioned adjustment to reverse the balance between the two systems to $2130 versus $1951. The authors then made a justified adjustment for the more elderly population looked after by the NHS, thus reaching a final estimation of per capita expenditure of $1764 and $1951for the two respective systems. This adjustment for PPP is justified in the paper on the basis that it “corrects for the underlying price difference in medical inputs- that is, if the NHS operated in California or if Kaiser operated in Kent”. This adjustment is ludicrous as it corrects for the difference in the cost factor that the paper is supposed to measure. In other words, it assumes an increase in the cost of the healthcare system in the UK to parallel that in California, for example by increasing the salaries of G.Ps by 43%, hospital specialists by 115% (we wish!) and an increase in the price of pharmaceuticals by 20-60%. None of this, particularly the salaries increase, is even remotely possible in practice. If this adjustment for ‘medical cost environment’ is omitted, as it should, to make the comparison meaningful and realistic, then the final comparison between the per capita expenditure in the two systems should be $1161 and $1951, for the NHS and Kaiser California respectively. This is hugely different from the authors’ conclusion that claims a parity of cost between the two systems. As a worker in the NHS for over 20 years, I am aware of its deficiencies like any other reasonable observer. The access to specialist care and the waiting time are two clear disadvantages that need addressing. The finding in this paper that the age adjusted rate of use of acute hospital services in California was one third of the use in the NHS, if confirmed, would be worthy of investigation for causes and remedies with great benefits to the NHS. The NHS is not perfect; however, let us not allow the NHS to be written off financially on the basis of flawed calculations. I would be interested to hear the views of others on the realistic, rather than any academic, value of the adjustment referred to. Magdi M Kirollos FRCS (Urol), Urology Department, Torbay Hospital, Torquay (1) Feachem RGA, Sekhri NK, White KLGetting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002; 324:135-141. I declare that I have no competing interest.
Invalid comparison 29 January 2002
Charles W Angus, general practitioner Primrose Lane Medical Centre, Rosyth, Fife KY11 2UR Send response to journal: Re: Invalid comparison	Sir, This paper (1) has invoked much well deserved criticism. However, there is much of value that could be learned from Kaiser Permanente particularly in the areas of management and communication. There is no doubt that NHS performance could be enhanced by more and better equipment, longer consultations, extra doctors and nurses. As a general practitioner I wonder how Kaiser Permanente would deal with the drug addicts, unemployed, single parents, chronic sick, and politically fuelled expectation that is a daily part of my workload? These can be high demand users of primary care, some with fortnightly or even weekly contact. An e-mail enquiry I made to Kaiser Permanente one week ago requesting details of their patient contracts has not received an acknowledgement. It would appear that Kaiser Permanente is not a comprehensive all embracing health care system and should not be equated to the NHS. I did receive a response from a relative in California, a copy of which is enclosed for the patient insight it portrays. “I have been a member of Kaiser Permanente for years. I have also been very healthy until recent years, when I have had a struggle with high blood pressure. During the time I was very healthy, they were really good! Since then, my report is a mixed bag. Plus side: I like my doctor and trust him. I liked the previous one, also, but he died. They are very into preventive care. If I do not get a mammogram when they think I should, for example, I will hear about it. They have a lab on the premises, so test results are available while I wait. Down Side: Try not to need a hospital unless you are in a Kaiser area. I fainted in a restaurant in Newport Beach about 6pm one evening (turns out it was too strong blood pressure medicine, but nobody knew at the time) and the medics took me to a local, private, hospital where I got emergency room treatment. They wanted to keep me overnight to check my heart; nothing doing. I had to be transported by ambulance to a Kaiser hospital about 90 miles away, and it did not have a bed available until 3 am. I was mad and very tired. (But Kaiser did pay for the Newport Beach hospital services and the ambulance.) Kaiser does not like to make appointments. They think they can reduce no shows by making members phone in at 7 am on the day they want to come in. They may, or may not, have an opening that day. This procedure makes me mad, too. Overall, Kaiser Permanente is not a bad choice as a supplement to the National Health Service. Like the NHS, Kaiser runs like a big lumbering bureaucracy that has a rule for everything, and not a lot of room for making judgments. But they are always there, always open, and if you have what they term "a short term emergency" (like you have just come down with the flu, and your own doctor can't see you) they will provide a doctor who will do what is necessary.” C. W. G. Angus FRCGP general practitioner Primrose Lane Medical Centre, Rosyth, Fife, KY11 2UR willieandgina@bigfoot.com 1. Feacham RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002; 324; 135-43.
Misuse of NHS Resources 30 January 2002
rajiv k singh, SpR in General Medicine/Diabetes & Endocrinology c/o Brent & Harrow Health Authority, Bessborough Road, Harrow, HA1 3EX, Gaia Nebbia, SHO General Medicine, King George's Hospital, Goodmayes, Essex. Send response to journal: Re: Misuse of NHS Resources	Editor- Feachem et al go some way towards exploding the oft repeated mantra that the NHS is the best value for money healthcare system.(1) While we all accept that there is a great deal to be admired in the NHS, a more critical appraisal of what works and what does not, is required if we are to achieve the vision of healthcare anticipated and expected by many.(2) One of the key findings in the study was that bed occupancy was much higher in the NHS and this comes as no surprise to those of us at the coalface of the NHS. On our last on-call period for general medicine, we had 19 admissions of which at least 6 could have been managed without admission to an acute bed. However it seems to us from previous experience and that of many colleagues, that admission to an acute medical bed is seen as a perfectly acceptable response to many non-medical crises such as poor social circumstances and difficulty in coping. Fellow NHS professionals seem to be just as culpable of this as “pushy” relatives. Until a radical change occurs in the mindset of healthcare professionals as well as in society at large, we will continue to misuse scant NHS resources that could be put to much better use elsewhere as appears to be the case in California. Rajiv K Singh, SpR General Medicine/Diabetes & Endocrinology, North Thames Deanery. c/o Brent & Harrow Health Authority, Bessborough Road, Harrow HA1 3EX. Gaia Nebbia, SHO General Medicine, King George’s Hospital, Goodmayes, Ilford. 1. Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002; 324: 135-43. 2. Department of Health. The NHS Plan: a plan for investment; a plan for reform. London: Stationery Office, 2000.
Think harder next time 30 January 2002
Jason Bernard, SPR ortho St George's London Send response to journal: Re: Think harder next time	Oh dear. There are just one or two things in this paper that make me wonder who accepted it for publication. First. Are gross costs comparable? Obviously only after the 152% fiddle factor to take into account the fact that US health care costs proportionately this much more. I would have to believe that 1+1=3 using this logic. Second. Bed stay. It is apparent that Kaiser's lucky patients get to stay on average 1.1 days fewer in hospital for each stay. This cannot however explain how the NHS manages to use proportionately three times more bed days per head of population when the mean bed stay is 4 or 5 days in each system (ie only 25% more time per admission in a NHS bed). The explanation can only be that the NHS is admitting three times more patients per head of population. Third. Quality markers. Uptake rates for immunisation and screening rely on patient motivation, whether through self interest or legal compulsion. I suspect that if you are motivated to pay for your healthcare, then you are motivated to use it.There does not appear to be a real difference in time to see your GP. Mean of 3 days vs 80% by 7 days are not able to be compared and it would not be accepted in any other paper as a comparison. Fourth. Turnover. Markers of turnover such as elective cardiac and ophthalmic intervention are closely related to the numbers of cardiologists and ophthalmologists available. Not surprisingly, Kaiser employ relatively many more of these lucrative individuals. To summarise, the paper fails to support its conclusions with its data at each and every stage of the process. The conclusions which could be supported are as follows: Bed usage in the NHS is higher per head of population. Likely explanation - either we have an older and sicker population, or this is the demographic who do not avail themselves of Kaiser's services (and are therefore excluded from their costs).
Competition is good for doctors and pharmaceutical companies but not necessarily for patients 31 January 2002
Rudiger Pittrof, SpR GUM London SW17 0QT Send response to journal: Re: Competition is good for doctors and pharmaceutical companies but not necessarily for patients	According to the World Health Report 2000 the average USA citizens spends 3724 international dollars per year on health care while his UK counterparts gets away with 1193 international dollars per year if purchasing power is taken into account (1). The higher costs in the US are almost entirely explained by higher drug and wage costs (2). High drug and wage costs in the US are not the result of chance but the result market of forces (competing managed care providers compete for a finite number of doctors). In the UK, the near monopoly positions of the NHS as an employer and consumer of drugs keeps wage and drug bills low. It is exactly the absence of an effective market for health care workers and health care products that benefit the ultimate consumer of health care services. Compared to California the UK has a lower supply of health care providers (2). An effective market following the introduction of health maintenance organisations into the UK should lead to higher wages in the UK than in the US. In his commentary Enthoven (3) suggest that competition increases quality of care without increasing cost. The opposite effect will appears more likely if competition also results in a market for health care providers and the fragmentation of purchaser power. When comparing quality of care between Kaisers and the NHS Feachem et al2 choose 9 high level indicators. These cannot sufficiently describe the performance of complex health systems. The choice of indicators is somewhat arbitrary and a different choice would have resulted in different outcomes. Kaisers doesn’t cover long-term mental health care and Kaisers requires a health check prior to admitting a family to their plan. The use of indicators assessing equity and inequality or mental health care should give a very different quality ranking of Kaisers and the NHS. I am not convinced by the cost or quality arguments presented. References 1 http://www.who.int/whr/2000/index.htm 2 Feachem RGA, Neelam K Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324:135-41 3 Enthoven AC, Commentary: Competition made them do it. BMJ 2002;324:143
What have we really learned from the NHS v Kaiser comparison? 2 February 2002
Clive H. Smee, Chief Economic Adviser, Department of Health Department of Health, Skipton House, 80 London Road, Lonodon, SE1 6LH Send response to journal: Re: What have we really learned from the NHS v Kaiser comparison?	When Richard Feachem sought my help with an early draft of this paper last June I welcomed the boldness of his aspirations but warned of the data difficulties and strongly recommended the use of ranges and sensitivity analyses. I still welcome the courageousness of the objectives, but my concerns about data weaknesses and deficiencies and the importance of using ranges and sensitivity tests have been reinforced. International comparisons of healthcare costs are very difficult. Comparisons of overall efficiency are a separate matter - and harder still. Kaiser is indisputably much more expensive than the National Health Service, per capita. At the currency conversion rate used by the authors and after their adjustments for differences in service and population coverage the per capita cost of the NHS is barely 60% of Kaiser - $1161 compared with $1951. If we are looking at the total costs or macro- efficiency of two systems it is simply wrong to adjust for differences in healthcare prices, over and above adjusting for general differences in prices. But, to suggest that NHS per capita costs are 60% of those in Kaiser is to give the comparison a spurious accuracy that is not warranted by the data presented. The relative costs are highly sensitive to assumptions made about a large range of factors including: the appropriate currency conversion rate; the treatment of Kaiser’s profits and administrative costs; the adjustments for differences in the characteristics of the two populations served; the adjustments for differences in the benefits provided; and adjustments for out of pocket payments. Alternative (and arguably more defensible) assumptions - e.g. about treatment of Kaiser’s profits, their “considerable” administrative costs, and the currency conversion rate – would reduce NHS costs per capita to barely half those of Kaiser. Other adjustments for differences in the populations covered and the services provided would make the gap in total costs even larger. The point here is not that my assumptions are better than those of the authors. It is that where there is large uncertainty and room for different views about what adjustments are conceptually correct a credible comparison of costs must show ranges and sensitivity tests that reflect this uncertainty. Judging the overall performance and efficiency of different health care systems is even more challenging – especially given differing objectives. The NHS has equity and universal coverage objectives that are irrelevant to Kaiser. The NHS also aspires to provide a range of health services that is significantly more comprehensive than is available under Kaiser. The article is necessarily limited to comparing performance in those areas where the two systems have similar objectives: patient responsiveness and measures of health outcomes in those disease areas and for those populations covered by both systems. On some of those measures Kaiser would definitely appear to perform better than the NHS; on others probably not. But the important point is that one cannot draw conclusions about the overall performance of the two systems when some of the critical objectives of the NHS are not accounted for. When judging technical efficiency, or the success of the system in turning resources into desired services and outcomes, it can be appropriate to adjust per capita costs for differences in healthcare input prices. In this particular case it would be appropriate to do so if the higher prices paid by Kaiser are not integral to the way in which Kaiser funds and delivers healthcare. Adjustment would be appropriate if Kaiser could achieve the same service outcomes in the UK as in California while continuing to pay existing UK prices to suppliers, physicians and other health service staff. But if Kaiser’s performance is dependent on competition and dismantling current public policies to regulate healthcare prices then it is not appropriate to fully adjust estimated costs for healthcare input prices. Sensitivity analysis would help illuminate this. My personal judgement is that some adjustment for healthcare input prices is appropriate for the technical efficiency comparison. However the adjustment should be based on the price differences actually faced by Kaiser, not those facing US healthcare as a whole. As Kaiser is one of the most efficient bulk purchasers of care in the United States it must obtain many inputs, such as pharmaceuticals, at much lower prices than the average for the United States. The conclusion I would draw is that from the information in this paper it is not possible to make firm judgements about the overall technical efficiency of the two systems. Kaiser may achieve better outcomes for some selective services and, on further investigation, may be found to achieve them with greater efficiency than the NHS average. But it will require much more work to adjust for differences in objectives, population coverage and services packages before this can be confidently asserted. In terms of policy the more pressing task is to explore the relevance to the NHS of the specific Kaiser design features that are highlighted by the authors, notably service integration, improving the location of care, choice and larger investment in information technology. It may also be of interest to refine the comparisons of the overall costs of the two systems. But from the data in this paper there can be no doubt at all that in terms of total costs per capita or macro-efficiency, Kaiser is far more expensive than the NHS.
Kaiser vs NHS: Lessons from Economics 3 February 2002
Heather M Gage, Senior Lecturere in Economics University of Surrey, Guildford, GU2 7XH, England, Wendy Knibb and Neil Rickman Send response to journal: Re: Kaiser vs NHS: Lessons from Economics	Kaiser vs NHS: Lessons from Economics There is a dearth of evidence about the cost-effectiveness of different healthcare systems to inform debate about the NHS. In this respect, Feachem et al’s [1] attempt to compare the NHS with Kaiser, a US managed care organisation (MCO), is welcome. However, the value of the study depends on the robustness of its methodology and data. The unit cost comparison is based on debatable assumptions, particularly regarding the exchange rate, purchasing power parity, and adjustments for differences in socio-economic and demographic characteristics of the populations, packages of care, and skill-mix. Even minor changes in any of these parameters can markedly affect cost relativities. For example, if the current exchange rate were used, Kaiser would appear about 20%, rather than 10%, more costly than the NHS. A methodological deficiency is that the authors do not acknowledge such uncertainties and investigate the sensitivity of their findings to variations in the underlying assumptions. Various estimates of bed days are available in the UK, and information on differences in institutional features is required in order to interpret reported differences with Kaiser on this major cost driver. But fifty years of cost containment does not necessarily guarantee cost-effectiveness in the NHS, and economic principles offer reasons why Kaiser might have an efficiency edge over the NHS. First, Kaiser operates in a competitive environment that engenders transparency and accountability. US healthcare consumers make value-for-money choices between MCOs using publicly available performance indicators. In theory, this provides suppliers with strong incentives to improve quality and reduce costs. In contrast, the NHS monopoly relies on cumbersome regulations and targets. Second, specialised use of human and physical resources, as in the US healthcare system, can result in efficiency gains. Third, as a result of the integrated nature of its care network, Kaiser is able to realise economics of scale and scope, and avoid delays that result in costlier treatments or lengthier hospitalisations. Moreover, the philosophy of MCOs (alternatively called Health Maintenance Organisations) is that prevention is not only better (for outcomes) than cure, but also cheaper in the long run. We still have much to learn about how the organisation and financing of healthcare systems affects their performance in practice, and Feachem et al’s [1] broad-brush approach raises more questions than it answers. Its findings need validating through more detailed investigations that include collecting evidence on the ultimate comparator, patients’ experiences in the two systems. Heather Gage, MSc; Senior Lecturer Wendy Knibb, MSc; Associate Lecturer Neil Rickman, PhD; Reader Health Research Group, Dept. of Economics, University of Surrey, Guildford, GU2 7XH [1] Feachem RGA, Sekhari NK, White KL. Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002; 324: 135-143
Kaiser performs about the same as the NHS but costs half as much again 3 February 2002
Nicholas Steel, Hon Fellow and SpR Public Health Medicine Institute of Public Health, University Forvie Site, Robinson Way, Cambridge CB2 2SR Send response to journal: Re: Kaiser performs about the same as the NHS but costs half as much again	I welcome Feacham et al’s timely challenge to the view that the NHS is efficient and that its inadequacies are mainly due to underinvestment.1 However, their conclusion that ‘Kaiser Permanente costs about the same as the NHS’ is based on a circular argument that is not adequately explored in the paper or its accompanying commentaries.2-4 The authors found NHS costs per capita ($1402) to be only two thirds of Kaiser costs ($1951), but then multiplied NHS costs by 1.52 to allow for higher prices in the US health sector. The NHS is cheaper than Kaiser because NHS costs are 52% less. All the authors have done is to adjust NHS costs upwards by 52% so that they are the same as US costs, and then claim that the costs are ‘about the same’. This obscures the fundamental point that Kaiser costs half as much again per capita as the NHS. The authors other main conclusion that ‘Kaiser performs considerably better’ is based largely on HEDIS (Health Plan Employer Data and Information Set) quality indicators for 2000. However, the first release of HEDIS data to the public in 1996 was followed by considerable improvement in these indicators over the next few years. For example, beta blocker treatment after a heart attack increased from an average of 62% in the US in 1996 to 85% in 1999 after public release of the data.5 This indicator is given as 93% in Kaiser in 2000, compared with the shockingly low figure of 42% in the NHS in 1997. Kaiser’s high rates on selected publicly released quality indicators may not be representative of the overall quality of health care. The authors conclude that ‘Kaiser costs about the same as the NHS but performs considerably better’. They could have used the same data to conclude that ‘Kaiser performs about the same as the NHS but costs half as much again’ with greater justification. 1. Feacham RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002;324:135-43. 2. Dixon J. Commentary: Funding is not the only factor. BMJ 2002;324:142. 3. Berwick DM. Commentary: Same price, better care. BMJ 2002;324:142 -3. 4. Enthoven AC. Commentary: Competition made them do it. BMJ 2002;324:143. 5. National Committee for Quality Assurance. The State of Managed Care Quality. Washington DC: National Committee for Quality Assurance, 2000.
the editor should repond 5 February 2002
Gordon Pledger, retired diretor of public health Send response to journal: Re: the editor should repond	In the edition that included this article the editor stated " the opening paper in this edition provides some good data" and "Kaiser achieves better performance (than the NHS) at roughly the same costs." The many comments on the web site, and especially the authoritative remarks of Clive Smee, clearly question both these statements. As relatively few of the BMJ's readers will have read all the website letters, surely the editor should make some comment in the paper version soon.
kaiser v NHS. More bang for the buck?Time to empower the pound 6 February 2002
Rhian J Evans, GP Sixways Clinic, Charlton Kings, Cheltenham Gl529NN Send response to journal: Re: kaiser v NHS. More bang for the buck?Time to empower the pound	Kaiser v NHS More bang for the buck? Time to empower the pound! Editor- I read the comparison of the NHS with the Kaiser HMO(1) with great interest, especially noting that the per capita spend on health was similar despite Kaiser’s double number of specialists and eight fold primary care physicians/capita. The differential in the senior doctor budget is compounded by Kaiser consultant salaries 115% higher than those in the NHS. Where does the NHS put the rest of its resources? I suspect that a mighty chunk goes to treat the ‘poorest half of all the UK population under the age of 65’, who I very much doubt incurr only the 5% of the NHS budget cited by the authors. Nevertheless, Kaiser obviously shows a substantial bang for the buck and we can certainly learn from their organisational practices. But as for sending a delegation of NHS movers and shakers to examine the system, as Jenny Dixon advocates(2) -let’s not reinvent the wheel. A delegation of senior NHS figures from Cambridgeshire HA visited a Washington State HMO, where I worked, back in 1993. Why not start by talking to them? I do not support the notion of competing health care providers suggested by Enthoven(3) as a solution , giving opportunity for the less scrupulous to adopt exclusion criteria for greater profitability which although not carried out by Kaiser, are rife in the USA. The greatest achievement of the NHS and its most envied quality in the world healthcare market is its universal coverage. I applaud Donald Berwick’s(4) suggestion of a social experiment whereby a HA redesigns patient care as per the Kaiser programme given it’s share of additional resources.I would go futher and seek a mixture of public and private funding. Then we would have the potential to test drive an invigorated national health system -preferably outside political control-that maintains universal coverage and delivers the improved quality of care that we all wish to provide. Rhian Evans GP Sixways Clinic ,Charlton Kings,Cheltenham GL52 9NN RhianJEvans@AOL.com 1.Feacham R G A, Sekhri N K, White K L.Getting more for their dollar: a comparison of the NHS with California’s Kaiser Permanente.BMJ,2002;324:135-141. 2.Dixon J.Commentary:Funding is not the only factor.BMJ 2002;324142 3.Enthoven A.Commentary:Competition made them do it.BMJ 2002;324:143 4.Berwick D.Same price,better care.BMJ 2002;324:142
All is not well in Florida 6 February 2002
Elizabeth C Evans, GP Principal Tudor Gate surgery, Abergavenny NP7 5DL Send response to journal: Re: All is not well in Florida	Sir; I have just returned from two weeks holiday in Florida. While I was there my hostess, who had just retired, was bemoaning the fact that the only cover she could afford was one in which she had to pay high co-payments for almost all services, and not every service was available under her plan. News stories also covered the fact that there were now quite considerable waits for some services for many patients (this was Florida with a high proportion of elderly); and that the USA’s COBRA scheme, which covers the unemployed, could not be used by the vast majority of people who needed it because the payments were 102% of the actual cost - typically about 300$ per month. (People in work would only pay about 10% of the actual costs because the employer paid the rest.) The NHS needs more trained personnel across the board and more capital investment in diagnostic facilities. That would reduce bed occupancy. It does not need managed competition or private finance – they result in a bewildering array of choices for the patient, dependant on ability to pay, or if free at the point of use will result in wide variations in different areas. There is no magic answer to provision of health care but let’s keep it simple.
Oh NHS, art thou sick or just poor? 6 February 2002
Jack BL Howell, Retired SO16 3PT Send response to journal: Re: Oh NHS, art thou sick or just poor?	Editor, Your editorial on the paper by Feachem et al (Jan 19th 2002) states that "this study might shift the emphasis from funding to other issues". I hope you are wrong: after years of denial, it is now admitted by government that underfunding has been and still is a major factor in the inability of the NHS to meet its objectives, and they have begun to act accordingly. For nearly three decades, governments have sought to improve performance in the NHS by a succession of reorganisations and restructuring - presumably because they thought that the problems lay there. Thus, in 1974 Regional Hospital Boards became Regional Health Authorities, and Area Health Authorities (AHAs) were created. In 1982, AHAs were abolished and District Health Authorities (DHAs) created. In 1990, DHAs became purchasers and Hospital Trusts became providers. When problems persisted, there was further reorganisation and the 'internal market' disappeared. The service became 'primary care-led' with the creation of Primary Care Groups leading in turn to Primary Care Trusts. DHAs are about to merge and become Strategic Health Authorities, not unlike the old AHAs. Unhappily, there is little evidence that these costly and sometimes disruptive 'reforms' solved any major problem. They failed to stop overspending or reduce waiting lists. The restructuring wheel has kept turning and getting nowhere, not necessarily because the changes were wrong, but they did not address the crucial problem - underfunding. At last, substantial improvement in funding of the NHS is promised, hopefully to bring it to the level of other European countries. This is not the time to risk weakening this resolve by arguing that underfunding is not a key issue, based on questionable conclusions from the comparative study of the NHS and the California Kaiser Permanente . Evidence is adduced that Kaiser had 10% more funding than the NHS, but this difference is dismissed as insignificant by the authors, two of the three commentators, and yourself in your editorial. I do not accept that a difference of 10% in funding can be dismissed as insignificant. In the case of the NHS a 10% difference currently amounts to £6 billion pounds per annum which, for the Southampton and SW Hants HA for example, would amount to an additional £40 million per annum. Infrastructure costs having been largely met, an additional £40M per annum would transform our district's ability to deliver many services including specialist services, access to which were highlighted by Feachem's study as a major difference between the two systems. While an additional 10% for the NHS would not be enough to raise standards to the desired level it would be a good start in showing what could be done. Further changes in the way the NHS manages its resources may well be needed, as long as they are directed at clearly defined problems. I believe the prognosis for the NHS is good provided we can avoid further major restructuring until we have tested the long overdue hypothesis that a key problem is, and always has been, underfunding. J.B.L.Howell Declaration of interest: I was chairman of the Southampton and SW Hants HA, 1983-97.
Poor Performance of NHS due to inequalities in primary care 6 February 2002
Monica Lall, SHO in Public Health Medicine Birmingham, Sudhin Thayyil Send response to journal: Re: Poor Performance of NHS due to inequalities in primary care	One of the reasons for superior performance of Kaiser system is that in primary care all children is cared by paediatricians rather than general practitioners with very little paediatric experience as in NHS. This result in less hospital admissions and less follow-up with hospital consultants as the paediatric care is delivered at the primary care. The NHS modernisation plan has made it clear that the frontline care of children in hospital should be provided by consultants of 7-10 years of paediatric experience. However, vast majority of the children will be still managed or mismanaged by general practitioners in primary care. This inequality of care is one main reason for the poor performance of NHS. It is common joke among paediatric registrars that if a GP has given penicillin to a child suspecting meningococcal sepsis before referring the child to hospital, you can be certain that it is a viral illness and not meningococcal disease. Vica versa if a GP refers a child with a viral illness only because parents are very worried, there is a high chance that it is indeed meningococcal disease. It is high time that we migrate into a system where trained paediatricians care for children in primary care. In a long run this system will be more cost effective and will perform better than having consultants doing 1st on call in hospitals.
Kaiser Permanente versus the NHS 6 February 2002
Barbara Starfield, University Distinguished Service Professor Johns Hopkins University, Baltimore, MD 21205, USA Send response to journal: Re: Kaiser Permanente versus the NHS	Without detracting from their point about the excellence of the Kaiser-Permanente system and the elegance of their analysis, the article by Feachem et al1 fails to mention two critical features of its success: 1) it owns and runs its own hospitals; and 2) it selects its doctors and its doctors select it for just those characteristics that we regard as excellent. To quote its own informational material: "We not only recruit for technical excellence but for fit with the organization." There is not a nationwide health system in the world that could compete with this. Sincerely, Barbara Starfield, MD, MPH, FRCGP University Distinguished Service Professor Professor of Health Policy 1. Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002; 324:135-43. 2. Shearn D. Kaiser Permanente: Our Structure and Approach to Workforce Planning. Report to the Council on Graduate Medical Education, December 5- 6, 2001.
Major errors in the bed days calculation 6 February 2002
Nigel C Edwards, POlicy Director NHS Confederation Send response to journal: Re: Major errors in the bed days calculation	The weight of opinion is that PPP adjustments that show Kaiser to be close to the costs of the NHS are completely illegitimate and effectively simply inflate UK health care costs to the average of the USA. This effectively destroys the conclusions about relative cost. There are a number of other flaws in the economic analysis which are also close to fatal in particular the concern that externalities have not been properly dealt with, the way profit has been treated and the possibility that the higher levels of pay could significantly affect clinician behaviour. These concerns have been very well explored by other respondents and require an answer. Only one correspondent has noted a second major flaw which is so egregious that it should have been picked up. Feachem et al have based their analysis of admissions and bed day use on the OECD data base. Anyone who is familiar with this dataset would know that this is very foolish not to triangulate it with other sources: 1) It is not clear that it always uses UK data - Professor James Buchan has discovered that a number of variables are for England only but the denominator is often UK population. In fact the figure given for length of stay by OECD is exactly the same as that in the HES summary for England. 2) Admissions has been submitted in FCEs not admissions - I think this has now been addressed but I am not sure that the historical record has been put straight 3) Data are incomplete 4) There are major definitional problems about defining what is acute care, day cases, long term care, etc. It can not be assumed that these definitional differences, which have a major effect on a number of key variables in this analysis have been controlled for by OECD - the authors make no mention of this. This is the table for bed days from the OECD2000 database: Acute care beddays - Number /capita 1993 1994 1995 1996 1997 1998 France 1.4 1.3 1.3 1.2 1.2 1.2 Germany 2.1 2.1 2 2 2.1 2.1 Hungary 1.8 1.8 1.8 1.6 1.9 U.K. 1 1 1 1 1 Copyright OECD HEALTH DATA 2000 It is very suspicious that the UK figure is the same for all these years. The concern grows when looking at how these figures would have been constructed. Bed days per capita shown above = (admissions*length of stay)/population. These are the figures for admissions, LOS and population in the OECD database: 1993 1994 1995 1996 1997 1998 Admissions: acute care - /100 000 population Total population - Thousands of persons 58191 58395 58606 58801 59009 59237 ALOS: acute care - Days 5.4 5.2 5.1 5 Copyright OECD HEALTH DATA 2000 There are no data for admissions in the database! So the calculation of bed days is not actually possible. Furthermore population is stable but LOS is falling - the only way that bed days per 1000 would be constant is if inpatient activity was falling exactly in line with LOS - it was not, it was rising. Triangulating these data with other sources further undermines the conclusion: 1) Beds - could 1000 beds days per 1000 actually be accommodated? In 1996 in England there were 108869 NHS beds and 11363 private beds - the LOS data for the private beds may not be in the data base. 120232 beds gives a maximum number of bed days available at 100% occupancy of 43,884,680. This means that if every bed was full on every day of the year with no gap between patients of more than one day the maximum number of bed days per 1000 would be 897. In fact overall occupancy in the NHS in 1996 was 72% (as acute beds include maternity and paediatrics which have lower occupancy) and the private sector typically have occupancy rates of less than 60% the most the bed days per 1000 could be is 648. Even allowing for the use of corridors 1000 bed days per 1000 appears to be a fiction. 2) What do the other data suggest? These are the data for England: Inpatients LOS Bed days Population Bed days per 1000 1992/93 5987000 5.8 34724600 48378348 717.77 1993/94 6127000 5.5 33698500 48532705 694.35 1994/95 6210000 5.4 33534000 48707459 688.48 1995/96 6340000 5.2 32968000 48903400 674.15 1996/97 6395000 5.1 32614500 49089100 664.39 1997/98 6514000 5 32570000 49284200 660.86 Conclusion Kaiser did better in 1996 on hospital use and probably still does but no where near as well as the article suggests. The authors must tell us how acute care is defined in the OECD data base and how they have defined it. Particular concerns are · The treatment of cases with less than 24 hour stay - these count as having a LOS of one day if the stay includes midnight, the US would usually count all hospital use for less than 24 hours as not counting in bed day or admission statistics · Whether maternity services are counted in either data - the data about include maternity stay · Older people - the NHS provides (somewhat against its will) a significant amount of social care in acute inpatient beds - some adjustment should probably be made for this The lesson that Kaiser much more actively manages care and invests much more in making sure processes work properly - which is perhaps the most important conclusion could be lost by poor quality data analysis, dubious economics and a tendency for all concerned to see in these data support for their own previously held convictions.
The Authors Respond 8 February 2002
Neelam K. Sekhri, CEO, The Healthcare Redesign Group Inc. , Richard Feachem, Karen White Send response to journal: Re: The Authors Respond	We are delighted with the thoughtful comments and debate that our article comparing the NHS with Kaiser Permanente has stimulated. We had hoped that our high level comparison of these two delivery systems would encourage discussion and an exchange of ideas, which would form the basis both for a more detailed analysis of the data and, for sharing of best practices. We also hoped that this paper would draw attention to the importance of the organization and management of health care delivery systems and the incentive environments in which they operate. We will not attempt to respond to all of the recommendations and insights sent by BMJ readers, but would like to comment on several overall themes, which emerged from the letters. 1. What are we comparing? National health systems have several key components including: financing health services, purchasing health services, providing services, and regulating services. In the U.K., all of these functions are undertaken by the same entity, the NHS. In the U.S., these functions are disaggregated. For example, employers, governments and individuals finance services; insurers or health plans purchase services; and doctors, hospitals and integrated delivery systems (IDS) provide services. In some cases, such as Kaiser, organizations both purchase and provide health care for defined populations (1). The comparison we have undertaken in our paper is between two delivery systems that provide health services, not two financing systems. As Don Berwick suggests in his commentary (2), an integrated delivery system (IDS) can operate within the context of a single payer system. In fact, he argues that a single payer system, such as the NHS, may be in the best position to provide services through an integrated delivery model. When we discuss the benefits of competition, we refer to competition among service providers, not among funders. 2. Purchasing Power Parity: Some readers took issue with our adjustment of costs for medical purchasing power parity (ppp). We would argue that in the context of comparing delivery systems (not financing systems), the costs of inputs are exogenous to the two systems. If the NHS were to take Don Berwick's challenge and pilot an IDS in one region of the U.K., the costs of buying hospital and physician services, pharmaceuticals, and medical supplies, would be lower than if that same IDS were piloted in Los Angeles. Clive Smee's comments to the BMJ support this view "Adjustment would be appropriate if Kaiser could achieve the same service outcomes in the UK as in California while continuing to pay existing UK prices to suppliers, physicians and other health service staff."(3) Some would argue that this is "unfair" to the single payer system in the U.K. which has, through its monopsony power, kept salaries and medical inflation low. These same incentives have constrained capital expenditures and the availability of consultants and support staff. In the U.S, the fragmented employer-funded insurance system has resulted in high medical costs, but has also contributed to increased capacity in facilities, doctors and support personnel. Each financing system has its inherent weaknesses and benefits. If we were comparing the U.K.'s single payer system to the employer-funded insurance system of the U.S., we might likely conclude that the U.K. has a more efficient and definitely, more equitable, financing system. When comparing technical efficiency, however, we believe that the price and availability of inputs are external to the delivery system and to ensure better comparability, we adjust for the relative costs of inputs based on the best numbers available to us. Clive Smee agrees with the need for an adjustment, " My personal judgment is that some adjustment for healthcare input prices is appropriate for the technical efficiency comparison" (3), but argues that the adjustment should be based on Kaiser's costs, not overall U.S. healthcare costs. We agree, although we note that Kaiser-specific medical salaries are strikingly higher than those in the NHS. We hope that the next round of analysis will refine the cost adjustment methodology and also develop the basis for a valid sensitivity analysis as suggested by Professor Smee. 3. Case Mix and Morbidity: Several people suggest that demand for services based on significant differences in case mix or population morbidity explains the large differences in access between the NHS and Kaiser. As we point out in the paper, we have not adjusted for case mix, because comparable data are very difficult to obtain. We encourage further research, however, which would make the comparison between the delivery systems more robust by adjusting for case-mix, morbidity, medical culture, patient expectations and other confounding variables. Our expectation is that large differences in some measures of performance will still be found following such comprehensive adjustments. 4. Bed Days: A number of readers were struck, as we were, by the significant difference in bed days between the two delivery systems. Because the NHS does not routinely calculate and publish acute bed days/1000, we took our numbers from the most recent (1997) published data available (from the OECD). We hope that this may prompt an up-to-date calculation of acute bed days by the NHS, which would provide a more accurate comparison with Kaiser. In terms of how each system defines acute bed days, the definition in the OECD data set is: "A bed day is a day during which a person is confined to a bed and in which the patient stays overnight in a hospital. Day cases (patients admitted for a medical procedure or surgery in the morning and released before the evening) should be excluded" "Acute care is one in which the principal intent is one or more of the following: * to manage labour (obstetrics) * to cure illness or to provide definitive treatment of injury * to perform surgery * to relieve symptoms of illness or injury (excluding palliative care) * to reduce severity of an illness or injury * to protect against exacerbation and/or complication of an illness and/or injury which could threaten life or normal function * to perform diagnostic or therapeutic procedures" This is very similar to the definition used by Kaiser to calculate bed days. Although a more detailed analysis may reveal some differences in the exact calculation of bed days between the two systems, these should not be significant if the NHS published bed day figures conform to the OECD definition. We note that many respondents cite anecdotes of unnecessary admissions and longer than necessary lengths-of -stay awaiting laboratory results, theatre availability, consultant input, or social services placement. This suggests that even if, on updating the NHS numbers, Kaiser's bed days are one-half of the NHS rather than one-third, there are still significant efficiencies to be gained in hospital utilization. The purpose of our paper was to look at large differences in cost and performance which could contribute to sharing best practices between two health care delivery systems. We encourage further analysis of the details of the comparison, both in refining the methodology, but perhaps more importantly, as the commentators and many BMJ readers suggest, in exploring what can be learned. Thank you, Richard G.A. Feachem Neelam K. Sekhri Karen L.White (1) Sekhri, Neelam K. Managed care: the US experience. Bulletin of the World Health Organization 2000; 78 (6): 830-844. (>2) Berwick DM. Commentary: Same price, better care. BMJ 2002; 324:142-3 (3) Smee, Clive. What have we really learned from the NHS v Kaiser comparison? electronic responses, BMJ; 2 February 2002.
Corporate Bottom Line vs. Patient Care 8 February 2002
Victoria L. Travis, Currator of Kaiser Patient Abuse Histories 93590, Board of Directors of The Kaiser Permanente Reform Committee Send response to journal: Re: Corporate Bottom Line vs. Patient Care	In the event you are interested in first hand global experience from patients of KP,I refer you to The Kaiser Papers at: http://home.earthlink.net/~tomnvic/kaiserpapers.html The facts on this web are compilations from newpaper articles and patient stories written in their own words. We would present more positive information if there were any but to date there hasn't been. If Kaiser California were dealing with animals in a zoo their system might make sense but it is dealing with humans. What makes sense on paper does not necessarily work with people. Kaiser is Health Maintenance Insurance. It is for the well,and the healthy. It is not for the sick, the long term patient, nor is it for end of life care. The article, as presented to the public is in many places inaccurate and misleading and totally slanted to the self promotion of Kaiser which is attempting to franchise out, for lack of a better word, to other governments. Kaiser is failing in this country, the evidence being that they have been removed from numerous states. Where they were functioning and doing business in 18 states they are now only in 9 states and the District of Columbia. Their population figures are also misleading. The bulk of Kaiser patients in this country are in California where they have contracts with most metropolitan workers unions to provide medical care. The people do not have that much of a choice in their health insurance. The governments arranging their insurance do though and what looks like a reasonable fee to these negotiators does not really present the reality of the situation. If it were not so, then why do numerous union representative throughout this state have to constantly intervene on behalf of the workers and guarantee to their workers that they will protect them against Kaiser? Sincerely, Victoria L. Travis
War is Peace. Freedom is Slavery. U.S. HMOs are More Efficient than the NHS 9 February 2002
David U. Himmelstein, Associate Professor of Medicine, Harvard Medical School 1493 Cambridge Street, Cambridge, MA 02139, Steffie Woolhandler, M.D., M.P.H. Send response to journal: Re: War is Peace. Freedom is Slavery. U.S. HMOs are More Efficient than the NHS	Sir: The NHS is little cheaper than U.S. health care, or so Feachem and his colleagues would have us believe. What's next on their agenda? War is peace? Love is hate? Freedom is slavery? Using sleight of hand that borders on outright falsehood, Feachem purports to demonstrate Kaiser's efficiency relative to the NHS. His task is a hard one given two undisputed facts: (1) the U.K.'s per capita health expenditures are $1569, the U.S.' $4358 (both figures are from the OECD for 1999, using GDP purchasing power parities); and (2) Kaiser's per capita costs are not significantly lower than the U.S. average, once its case mix is taken into account. Undeterred, Feacham employs an outrageous price "adjustment" to bias the comparison in Kaiser's favor; improperly, if conveniently, excludes several categories of Kaiser's costs; and ignores clear evidence that Kaiser avoids many of the sickest and most expensive patients. The authors' adjustment for purchasing power parity for medical inputs inflates the NHS' cost figures by a whopping 52%. This adjustment assumes that the NHS can take no credit for holding down drug prices, administrators' or specialists incomes, or the costs of any of the myriad other items the NHS buys. Conversely, it excuses the market-driven system in the U.S. from any responsibility for our inflated pharmaceutical costs and the billions wasted on health care executives and other hangers on. In effect, Feachem starts out by slyly adjusting away the price difference between the two systems - in effect, excluding from analysis the advantages of a non-market public service - and then feigns surprise that after eliminating the basis for the cost difference Kaiser is only a bit more expensive than the NHS. But his deception goes further. He excludes Kaiser's profits, a cost borne by patients and one which Kaiser executives loudly proclaim is essential to the functioning of their plan. (One wonders whether he would have made this exclusion had he examined the 1998 data, a year when Kaiser lost money.) He further deducts Kaiser's high administrative costs, as if these are extraneous to Kaiser's operations rather than a necessary concomitant of the competitive market environment that he and the commentators extol. He passes lightly over the fact that Kaiser covers only minuscule amounts of nursing home care for elderly patients, leaving the entirely false impression that Kaiser's coverage is comparable to the NHS'. Finally, he ignores the fact that many Kaiser patients - more than 12% according to an internal Kaiser memo - receive care outside the health plan, and that those costs are excluded from his calculations. In sum, Feachem grossly understates Kaiser's actual costs. A further point - a critical one in any cost comparison - is whether Kaiser's patients are comparable to those cared for by the NHS. Several lines of evidence indicate that they start out far healthier, and are thus inherently less costly to care for. Feacham claims that Kaiser "membership cannot be withdrawn if a member becomes chronically or seriously ill," implying that Kaiser cannot avoid the expensively ill by booting them out. This is technically correct, but reality is far different. When a Kaiser member loses her job (e.g. because of chronic illness) and hence her employer-paid coverage, the plan must offer her an individual policy to continue coverage. But it may charge whatever premium it likes - often thousands per month in the case of someone with chronic illness. Hence, few can actually afford Kaiser coverage when they become so sick that they can no longer work. Moreover, because the overwhelming majority join Kaiser through their job, few of the severely disabled ever get into Kaiser - they're mostly covered by the public Medicare program. (Though disabled Medicare patients may join Kaiser, few of them do). Since the small minority of very ill patients account for a large proportion of total health costs, the underrepresentation of the disabled among Kaiser patients biases cost comparisons. Hence, Feachem's failure to adjust for severity of illness is a fatal flaw; adjustments for age and income are a completely inadequate substitute. Finally, there is no evidence that Kaiser is significantly more efficient of cheaper than other U.S. insurance plans. Kaiser's premiums (and costs) are virtually identical to other insurance plans in California (as indicated at the website: www.calpers.ca.gov/open- enrollment/plancompare/selectplans.asp), which serve similarly healthy populations. And per capita costs in California are little different from the U.S. average. Hence, Feachem's claim for Kaiser is tantamount to a claim that U.S. per capita costs are little different than the U.K.'s. The NHS has grave problems, and Kaiser is far from the worst that U.S. health care has to offer. However, Feachem's conclusion that Kaiser surpasses the NHS in value for money is pure hogwash. David U. Himmelstein, M.D. Associate Professor of Medicine Harvard Medical School Steffie Woolhandler, M.D., M.P.H Associate Professor of Medicine
A comparison of the NHS with California Kaiser Permanente 12 February 2002
Malcolm Forsythe, Chairman South West Kent Primary Care Trust, Allen Gardiner Cottage, Pembury Road, Tunbridge Wells, Kent. Send response to journal: Re: A comparison of the NHS with California Kaiser Permanente	Editor Over 30 years ago I had the great fortune to visit Kaiser, Permanente at Berkeley. At that point they were introducing their multiphasic- screening programme and heavily investing in what were then called automated patient medical records and utilisation data. It would have been nice to know whether these developments had contributed to the truly remarkable difference in bed utilisation. Dr Maurice Collen and others also demonstrated remarkable vision and medical leadership, which may have contributed to what Feachem et al described as “real integration through partnership between physicians and administration”. The NHS is badly in need of such leaders if we are to break down the barriers between primary and secondary care so that patients are treated at the most cost effective level of care. Malcolm Forsythe Chairman Allen Gardiner Cottage, Pembury Road, Tunbridge Wells Kent TN2 3QQ Malcolm.Forsythe@swkent-pct.nhs.uk
Re: Kaiser Permanente versus the NHS 12 February 2002
Jonathan Shapiro, Senior fellow Health Services Management Centre, University of Birmingham UK Send response to journal: Re: Re: Kaiser Permanente versus the NHS	The wide ranging and fascinating article on Kaiser (1) has already received much attention, so I would add only one point: where professionals feel in control of their work, they work in a more responsive, responsible way. In the UK, there are several perverse incentives that cross the boundary between primary and secondary care: apart from the obvious cost shifting (which would mitigate for shorter lengths of stay if hospitals were paid on a 'per diem' basis), there is the more subtle but equally important question of 'who controls the patient?' As long as the consultant keeps the patient in hospital, he (or she) may be assured that the care is under their control. Once the patient is in the local GP's clutches, there is no saying what disaster might befall. Conversely, any GP worth her (or his) MRCGP will hang onto the client to ensure that a 'patient-friendly, whole person approach' to their care is maintained, and do their utmost to prevent a stay in the technocratic factory that is the local hospital. In Kaiser, where primary care is provided by doctors who also have a foot in the hospital, one person appears to retain responsibility for the care of their patient throughout the pathway of care, and the conflict of interests is obviated. I'd prefer that clinician to be a generalist with a more broadly based view of care than mere technical intervention, but the principle underlying the short lengths of stay in the Kaiser system may well be that the incentives for that stay are all aligned: it is in everyone's interests (the patient, the clinician, and the financial director) to get the patient home again as quickly as possible. What happens once the patient is back in the community is another issue, not covered in the article, but the point remains that if the NHS followed through the notion of case management, and allowed one clinician (or clinician team) to follow the patient through the entire system, we could see similar reductions of lengths of stay. I'd be happy to follow Don Berwick's suggestion (2) of an experiment, but would suggest that it should lie more specifically in the area of case management rather than structural integration. Yours faithfully Jonathan Shapiro 1. Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002; 324:135-43. 2. Berwick DM. Commentary: same price, better care. BMJ 2002; 324:142
Conflict of interest in NHS 12 February 2002
Dinesh Verma, Visiting Professor Doheny Retina Institute, University of Southern California, Los Angeles Send response to journal: Re: Conflict of interest in NHS	Editor: In the paper “Getting more for their dollars…” (1) authors comment on a very important difference between NHS and Kaiser Permanente in the introduction. Specialists working for Kaiser cannot work outside the system while those in the NHS can. Surprisingly this was not considered a factor for the disparity in performance in the discussion of the paper, in the commentary from three authorities in the area and indeed in your editorial itself (2). A vast majority of NHS consultants work for the private sector creating a clear conflict of interest in providing quick access for their patients to the services in the NHS but the profession has been very reluctant to accept that officially. There have been isolated voices from some of us (3,4) followed by the suggestion of not allowing private practice for some years to the new appointees in the NHS plan (5) that was met with intense disapproval by our own political organizations like British Medical Association (BMA). May be it is time to rethink that strategy and give serious consideration to the alternative of NHS consultants not being allowed to work in the private sector. Kaiser has provided enough evidence to suggest that a large number of high quality doctors can be adequately compensated and are willing to work in that system, in spite of the apparent lure of private practice available in California. Alain Enthoven’s vision of a truly competitive “wide open market” (1) has no chance of working if the key players in the market are allowed to have a clear conflict of interest. A start could be made by giving patients in Donald Berwick’s social experiment (1) an “opt-out” clause from the NHS and allow the NHS and private hospitals to compete on even ground. The current system in the United Kingdom allows private hospitals to have a distinct advantage over the NHS Trusts as they can “pick the cherries” of highly efficient, day cases like cataract surgery as part of “waiting list initiatives” and “dump” the highly complex, less cost effective care (including complications from the initiative lists) on the NHS. Kaiser does not suffer from that disadvantage, as private hospitals in California cannot have that choice. May be the suggestion by the Editor (2) of removing the influence of politics on NHS functioning should apply not only to the government politicians but also to the politicians in our own organizations like BMA. Dinesh Verma MD FRCS Visiting Professor Doheny Retina Institute, University of Southern California, Los Angeles dverma@dei.hsc.usc.edu Competing interests: DV is a Consultant Ophthalmologist to Hull & East Riding Hospitals NHS Trust, currently on a sabbatical in USA. He has also been working for the private sector since 1992. He is a fully paid member of BMA. References: 1. Feachem RGA, Sekhri NK, White KL.Getting more for their dollars: a comparison of the NHS with California’s Kaiser Permanente. BMJ 2002;324:135-43. Commentaries from Dixon J, Berwick D, Anthoven AC. 2. Smith R. Oh NHS, thou art sick. Editorial. BMJ 2002;324:135. 3. Verma D. Professors key to reform. Opinion. Hospital Doctor. 26 October 2000. 4. Price S. More thought is needed. Letter. Hospital Doctor. 16 November 2000. Department of Health. The NHS plan. A plan for investment, a plan for reform. London: Stationery Office, 2000. www.doh.gov.uk/nhsplan/contents.
The NHS conveyor belt 13 February 2002
colin w Jones, Practice Manager Support Officer Merthyr Tydfil CF48 4TQ Send response to journal: Re: The NHS conveyor belt	Dear Sir, "Kaiser outperforms the NHS" BMJ 2002; 324:. C'mon lads, everyone knows it's blindingly obvious. Work in the NHS is represented by the patient. This work moves "down the line" via the conveyor belt known as the referral/discharge system. Unknown quantities of inefficiencies occur at the point of movement between referrer and referree. In the NHS there is no "natural" mechanism for dealing with these inefficiencies (cf an operative in a washing machine factory, whose pay depends on output, getting machines passed to him where 10% of the sides are on upside-down. One can imagine the "naturalness" of his/her mechanism for dealing with the inefficiency - not to mention the foreperson's). Kaiser puts the two operatives with the biggest "referrer/referee" relationship in the same department and gives them a line manager. The line manager is answerable to a director, who is in turn answerable to a Chief Executive who is answerable to a board and some shareholders. Consultant: "The guy who works down in Santa Monica keeps sending me patients with no FBC. I've had a word with him but I don't think it's sunk in." Line Manager: "OK. I'll speak to him. I've got the protocol. I might send him on a refresher session." The great and the good can look at the NHS until they're blue in the face, until they put referrer and referree together and establish "normal" working relationships they will never be able to see the woods for the trees. Yours sincerely, Colin Jones
Kaiser Reminds Milburn to Act on Election Promises 17 February 2002
Michael F. Bone, Consultant Physician South Tyneside Healthcare Trust NE34 0PL Send response to journal: Re: Kaiser Reminds Milburn to Act on Election Promises	Am I alone in seeing clearly the reason why the performance of the NHS is failing so badly in comparison with Kaiser Permanente. 1 It is fairly obvious that employing twice as many specialists per head allows far better access to specialist services. Whereas comparisons in terms of acute bed days per 1000 population showed the NHS having more than triple that of Kaiser Permanente, average length of stay was only an extra 1.1 days. This suggests that patients in hospital are being processed fairly efficiently despite the paucity of Information Technology support. The argument about bed numbers is old and sterile. The Kings Fund has had a long held view that many hospital beds were unnecessary wishing most patients to be managed in the community. This influence has had a major impact, contributing to the many trolley waits in our hospitals today. Much of hospital activity in Britain is generated by emergency admissions and beyond our control, related more to socio-economic factors. 2 Admission and outcomes, measured by standardised mortality ratios, are most strongly associated with numbers of doctors serving a community and with only 59% those of similar countries 3 it is not surprising that our NHS is failing In my local area, one of the most impoverished in England, the demand and activity of our local Medical Admissions Unit have increased from an average of 360 admissions per month 7 years ago to over 660 currently, an increase of 83%. My average bed stay has fallen from 8.8 to 3.1 days. We have done this with innovative team working but early discharge puts a considerable strain on outpatient resources and reduces access for new patients. The work pressure on junior medical staff with reduced hours also impacts on their quality of training. The only answer for any further improvement is an increase in Consultant numbers, especially as the NHS is rapidly evolving into a Consultant run service. Without an investment in specialist numbers and an immediate increase in the number of trainees to fill these places no amount of indiscriminate funding will achieve the goals of the present government. I would contend that there has been considerable under-investment in the NHS but largely in terms of medical manpower. This paper from California illustrates that this is a false economy and simple analysis points the way forward supporting the Labour Party Manifesto to increase doctor numbers by 10,000.4 When will Alan Milburn facilitate this election promise? Michael Bone Consultant Physician South Tyneside District Hospital, Tyne and Wear NE34 0PL Michael.Bone@eem.sthct.northy.nhs.uk 1 Getting more for their dollars: a comparison of the NHS with California’s Kaiser Permanente Richard GA Feachem, Neelam K Sekhri and Karen White BMJ 2002;324: 135-43. 2. Explaining variation in hospital admission rates between general practices: cross sectional study Fiona D A Reid, Derek G Cook, and Azeem Majeed BMJ 1999; 319: 98-103 3. Explaining differences in English hospital death rates using routinely collected data Brian Jarman, Simon Gault, Bernadette Alves, Amy Hider, Susan Dolan, Adrian Cook, Brian Hurwitz, and Lisa I Iezzoni BMJ 1999; 318: 1515-1520. 4. Labour Party Manifesto 2001
Re: Bed days 23 February 2002
Souheil M. Habbal, chief of allergy department baldwin park, USA 90275 Send response to journal: Re: Re: Bed days	Reducing bed days can not be established before establishing a good integrated out of the hospital strategy (hmoe health, visiting nurse, out patient infusion center, home IV therapy, access to subspecialist follow up appointment, also coordinating the information regarding the hospital course. As an allergist and an asthma care manager in Kaiser permenante, I had to work with a large group of asthma specialists, pharmacists, information techology, hospital admitting staff and emergency department staff to reduce our hopital admission rate and our ED visits rate. Working together as an integrated team, we were able to reduce our admissions from 210 admissions per year (1998, 1999) to 65 admission in the year 2000 and 47 admissions in the year 2001. Our ED asthma visits was 2300 vistes per year in 1998 and 1999, to 870 ED visits in the year 2001. This was done by funding for the information technology, funding more time the asthma specialists, so a an asthmatic can be seen within 5 days of their ED visit or hopsital admission, to integrate a referral to asthma specialist in the ED system and hospital system. When the asthmatic is seen in my office, I turn to my PC to find all the critical information needed to continue the work. The point I am trying to make, you can not wait for the saving from your length of stay to build the intergrated system, you have to invest first then enjoy the fruit of that investment (better outcom, less admissions, shorter length of stay etc..)
Comparing like with like? 23 February 2002
Colin A McIlwain, Assistant Director, Planning Shipley, Yorkshire BD18 3LD Send response to journal: Re: Comparing like with like?	As has been commented upon, the business of making comparisons between health systems is difficult. In addition to the several issues already cited by respondents the article by Feacham et al gives an NHS cost of £58.5 bn but revenue allocations this year to Health Authorities in England are in fact £37,157m. If the £58.5 bn cited includes all NHS expenditure (and not just allocations to health authorities) in England then there are some very real comparative problems. Not included in the £37 bn figure above, but possibly in the £58.5 bn figure, would be central budgets of the Department of Health that fund - amongst other things - undergraduate nursing tuition and bursaries as well as those for allied health professionals and additional costs associated with teaching hospitals. These alone total to nearly £1.5 bn. Presumably the Kaiser figures do not include the costs of training and educating the health workforce in California. The £37, 157m figure for health authority allocations includes amongst other things includes expenditure on public health and ambulance services. Presumably Kaiser Permanente does not fund the Public Health departments at state, county or municipal level in California or ambulance services in the state? The article also refers to the UK and uses the population of the UK. The Department of Health is the health department for England only and not for Scotland, Wales or Northern Ireland. Nor is it the UK's department of health as responsibility is split between the four constituent countries of the UK. The Secretary of State for Health is accountable to the UK Parliament but only for the money voted for use in England. It is not clear therefore whether the £58.5 bn relates to England alone or is an aggregate of the funding in the four countries. Given the central conclusions in the article about the comparability between the NHS in the UK and Kaiser Permanente it would be important for the NHS funding and population figures to clearly relate to one of the countries alone or the UK as a whole and for the NHS expenditure figure to be analogous to the services covered by Kaiser Permanente.
Success in Spite of Competition 2 March 2002
Steve L. Juniper, Health Care Analyst Retired - Berkeley CA 94708 Send response to journal: Re: Success in Spite of Competition	Kaiser Permanente is not successful because of competition - it is successful in spite of it! Kaiser has a long history of providing better care for the same or less money than any other major health care provider. Its rates used to be 'community-based' - every employer or enrollment group member paying the same premium regardless of individual acuity, age, or medical history. This is not surprising, because Kaiser provided all aspects of health care as a nonprofit organization. Technically, the medical groups are for- profit, while the health plan is nonprofit. The doctors can show a profit, which they distribute to themselves in the form of shares, with the money going back into the health plan instead of their pockets (As a nonprofit the health plan cannot make a profit, although it can make an 'operating margin,' to reinvest in infrastructure). Kaiser does not bear the additional burden of the necessity of making a profit for shareholders nor of providing expensive perks such as stock options for top executives. The steps the government and its consultants took in the 90s to "open up the health care market" were not wholly unlike those promoted by Enron lobbyists to "open up the energy market to free competition," and we can see where that led! Unfortunately, there is an inherent conflict of interest in for-profit insurance companies: they answer primarily to their shareholders and are in business to make money, not to provide health care. Consequently, it is to their advantage to enroll only young, healthy members ('cherry picking'), to get rid of expensively sick people ('dumping') and, generally, to deny care whenever they can get away with it - hence the nonmedical claims authorization people whose job is just that! On a more basic level, these insurance HMOs are just middle men. Unlike Kaiser, they don't own hospitals or clinics, or directly care for anyone, and bear no risk. They aren't really 'Health Maintainance Organizations' at all - they just shell organizations that contract with the hospitals and medical group providing the care. They have been successful because as more and more employers signed up with these insurance companies, their bargaining power increased, enabling them to ratchet down payment to hospitals and medical groups (that's why independent doctors bad-mouth HMOs - not because of the quality of care, but because they saw their huge incomes deteriorating, and why many want to return to the old fee-for-service insurance reimbursement model). The other reason for their success was to deny claims and to introduce acuity-based premiums, in which employers with young and healthy employees pay less for insurance than employees with old/sick employees. The insurance companies did three things that they are good at: low balling costs; denying claims; and being actuaries. That's been the key to their success. Employees are often not permitted to choose the health plan they want. Employers with young and healthy employees began to drop Kaiser, switching to the cheaper insurance companies, leaving Kaiser with, on the average, older and sicker members. Kaiser was forced to increase its rates to cover their higher costs, leading to more employers opting for cheaper plans. In the industry this is known as the 'death spiral'. As younger groups leave and older groups remain, premiums escalate until on one can afford you any more. Kaiser almost went bankrupt. Unfortunately, what they then implemented, on the pricing side, was not much different from what the insurance companies implemented. Employers with younger members now pay less than employers with older members. (When a member without national health insurance through the social security system who pays for his/her own premium (through a group) turns 65, his/her premium now jumps to US$1649/month!) The only difference is that Kaiser retains its own delivery system. Being run by doctors, the emphasis remains on providing quality care. The 'insurance' side of Kaiser is more like a poorly-run insurance company - an insurance company handicapped by a conscience! The biggest change in the health care industry is that drugs keep people out of hospitals, resulting in lower hospitalization costs but very much higher drug costs. While Kaiser provided drugs almost free of charge ($5 per prescription for decades, without limit), most other insurance plans do not, often forcing the sick, and especially the elderly sick, to choose between medicine and food or heat. To remain competitive, Kaiser has been forced to raise per prescription drug charges to $15 and to implement a $1,000 per year cap because many companies and public entities are concerned only with which health plan is the cheapest - not which one is the best, or the most cost-effective. Drug cost is increasing faster than any other cost in the health care industry. Much of the cost is driven by the drug companies themselves. For example, since the ban on prescription drug advertising was lifted, companies spent thousands of millions (yes - US 'billions') of dollars advertising brand-name drugs. Both patients and doctors fall for these ads, resulting in a huge amount spent on over-prescribed or inappropriate drugs. There is also the controversy about 'lifestyle' drugs. Clearly, an HMO should pay for a drug that keeps you alive, but what about paying for Viagra, so you can have sex more often. Heavily-lobbied California insurance regulators said, "Yes!" And should I pay higher premiums so you can take Rogain to have more hair? So far, they say, "No." Kaiser's members have traditionally been mostly low and middle class workers. Big corporations often have different, and far better, plans for those who least need them - the top-paid executives. Probably the worst possible steps for a publicly-funded health care system to take would be to implement a two-tiered system, a 'private' one for the affluent or those with organizations providing top health insurance and another for the 'others,' starting a downward spiral in which those with better care (and more influence) oppose funding for the system they don't use, weakening it and making more people anxious to get out, further reducing its funding... The NHS, of course, needs to increase efficiency and reduce unnecessary hospital stays, but more important is the concomitant need to control drug costs, recognizing the rapacious greed of many of the drug companies. Other than direct price controls, prices can be kept under control by reasonable patent expirations (something drug company lobbyists in the US pay politicians many tens of millions of dollars to avoid) or by direct governmental control of the fruits of basic research at public institutions leading to these drugs. Virtually every major drug on the market today was developed in part with tax dollars - direct clinical support, not just the R & D tax breaks given to pharmaceutical companies! Ideally, you would have a single international body, which could contract with private companies, for international research and approval of drugs. One thing NOT to do is to hire a phalanx of expensive, self serving and well-connected consultants to tell you what to do. Kaiser made this mistake over several years recently. The major blunders that resulted were extremely expensive, leading to the first sea of red ink in Kaiser's history and almost to its collapse, also taking a serious toll on the morale of those attempting to provide caring, quality services! Find out how best to improve services by talking to those on the line providing them!
Has the case been understated? 6 March 2002
James G Bartholomew, journalist London W8 7NA Send response to journal: Re: Has the case been understated?	Most responses have tried to find faults in making a comparison between Kaiser and the NHS which may tend to be unfairly in favour of Kaiser Permanente. However, one should also look at possible faults of comparison go the other way and tend to understate the case in favour of Kaiser. I would offer the following possibilities: 1. No adjustment, as far I understand it, has been been made for the fact that Kaiser has had to buy or rent its premises and property whereas the NHS started with assets built up over centuries. 2. No adjustment, as far as I understand, has been made for the much higher awards that are made in litigation for malpractice in the USA compared to those made in Britain. This increases insurance bills, time spent on litigation and the amount of "defensive" treatment and diagnosis. 3. No adjustment has been made - and admittedly this would be hard to estimate - for the vastly higher expectations of patients in the USA. 4. No adjustment has been made for the way in which the superior treatment and shorter waiting times at Kaiser must lengthen the lives of people who are seriously ill, thus increasing the costs of looking after them. It is much cheaper, to put it brutally, to let people die on a waiting list. That enables the NHS to keep costs down. Keeping people alive increases Kaiser's costs. 5. Kaiser keeps on the payroll many more specialists than the NHS. In these ways, the performance of the NHS may be perceived as even more lamentable than the bare report suggests.
KAISER OUTPERFORMS THE NHS 6 March 2002
David S. David 2222 Santa Monica Blvd. Suite 302 Santa Monica, CA 90404 Send response to journal: Re: KAISER OUTPERFORMS THE NHS	Editor I was very disappointed by the publication of the article by Feachem et.al. in comparing the California Kaiser system to the NHS (1). One has to live in California and be a physician and have some working knowledge with the HMO before passing any judgement about the quality of their care. ------------------------------------------------------------ First, Kaiser is not a "non-profit" HMO. It is for profit, with the profit being divided between shareholder practicing Kaiser physicians. The fact was made known by a Kaiser physician(2). So the profits shared are labeled as money spent on medical care for their patients, and therefore this justifies their classifying themselves as a non-profit HMO. ------------------------------------------------------------ Secondly the data presented for their performance was collected and analyzed by Kaiser personnel, and obviously can involve selection and information bias. In fact, I have recently responded (3) to another outcome report by Southern California Kasier regarding their observation that less studies and procedures results in better cardiovascular outcomes(4). My response (3) and that of others (5) exposed their self- serving bias and distortions. ------------------------------------------------------------ Lastly, the commentary by Alain Enthoven(6) has to be interpretd with the knowledge that he was not only a consultant for Kaiser, but also one of the directors of Blue Cross in California (another alleged non-profit organization)and a leading proponent for the advent and proliferation of the HMO helth care delivery system. ------------------------------------------------------------ I,like many of my other colleagues in the U.S.were hoping to someday have our country copy the much more humane and cost effective single payer universal health care coverage system in place in Europe and Canada for many decades. Unfortunatly, with the globilization of the health care providers, (pharmaceutical companies, insurance companies, HMOs, etc.), acting through the auspices of the powerful World Trade Oganization, Europe and Canada run the very real risk of acquiring our very inhumane wasteful and diseased health care system. I remain respectfully yours, David S. David, M.D., F.A.C.P. Clinical Professor of Medicine UCLA School of Medicine ------------------------------------------------------------ REFERENCES: 1. Feachem, RGA, Sekhri NK, White KL. Getting More For Their Dollar: A Comparison of the NHS with California's Kaiser Permanente. BMJ 2002; 324:135-141. 2. York, GK. Executives with White Coats-Managed Care Medical Directors. New Eng.J.Med 2000;342:130. 3. David, DS. Putting Patients First. Cardiovasc Rev Rep 2001; 22:402. 4. Mahrer PR.Outcome Study of Two Large Populations wih Different Rates of Cardiac Interventions. Cardiovasc Rev Rep 2000;21:638-651. 5. Weiss SR. Putting Patients First. Cardiovasc Rev Rep 2001; 22:575. 6. Enthoven AC. Commentary: Competition Made Them Do It. BMJ 2002; 324:143. 7. David, DS. Evidence Based-Medicine. Am J.Med 1998; 105:361-362.
Re: Has the case been understated? 26 March 2002
Nigel Edwards, Policy Director NHS Confederation, SW1E 5ER Send response to journal: Re: Re: Has the case been understated?	James Bartholomew should have declared an interest as a journalist who has already written on this subject for a newspaper that has an explicitly anti NHS agenda. His column was written in a way that suggests he had not read or understood the critiques of the Feachem paper. He makes an attempt to deal with the criticisms of the paper by providing his own points to bolster a position he has already taken publically. 1) The costs of capital are included in NHS accounts so this point is irrelevant 2) This is an interesting point. The costs of malpractice in the UK are high and using the methodology of the paper they would need to be treated using US PPP adjustment - Mr Bartholomew needs to show that the costs are proportionately higher before this argument can be entertained. 3) It is not clear why controlling for difference in expectations is legitimate even if it were possible 4) This point is an extraordinary piece of twisted logic. Maintaining people on a waiting list is expensive, delaying their treatment is expensive and the idea that dying is a cheap option is contradicted by the evidence. If Kaiser use high cost treatment to keep people alive a little longer at a higher cost, for which he offers no evidence, then he must demonstrate how this constitutes a major improvement in cost effective outcomes. 5) It is not clear what point is being made here. Mr Bartholomew has an axe to grind about the NHS as his last paragraph shows. He should declare his interests before writing and perhaps should be more ready to accept views that do not accord with his position.
New Zealand already implementing Berwick’s proposal 4 April 2002
Laurence A Malcolm, Professor Emeritus and Consultant Aotearoa Health, RD1 Lyttelton, New Zealand Send response to journal: Re: New Zealand already implementing Berwick’s proposal	The extensive, largely critical commentary on the article by Feachen et al1 has almost completely ignored Berwick’s proposal to pilot a more fully integrated NHS2 through a strategic health authority. However experience in New Zealand of such authorities as purchasers does not give me much confidence in this approach. It was abandoned in 2000 in favour of a fully integrated district health board (DHB) as both purchaser and provider. DHBs are accountable for better health outcomes for their defined populations. This is being achieved through integrating the effort of all providers, government and non-government, primary and secondary, hospital and community, public health and disability. This model is even more comprehensive than Kaiser. It may be the experiment that Berwick is looking for. A study of 10 DHBs, completed earlier this year, showed the building of a new partnership between clinical leadership and managers, with increasing accountability by clinicians for both quality and cost3. Of particular importance has been the development of primary care organisations (PCOs) which are now accepting accountability for all GP related expenditure and promoting quality primary care3,4. They are also building a new partnership between primary and secondary care. For example, within the DHB framework, Pegasus Health in Christchurch, with a membership of 230 GPs and global budget of $80 million, is significantly reducing acute admissions through alternative community-based care. Our PCOs would appear to be much more advanced than the NHS PCG/Ts3,4. They now have the advantage of becoming fully integrated into the DHB system. Building new and trusting relationships within a lead organisation, especially between primary and secondary care as in Kaiser, will more successfully achieve the cultural and organisational changes needed than failed purchasing strategies. References 1. Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. BMJ 2002; 324:135-43. 2. Berwick DM. Commentary: same price, better care. BMJ 2002; 324:142 3. Malcolm L, Wright L, Barnett P, Hendry C. (2002) Clinical leadership and quality improvements in district health boards in New Zealand. Clinical Leaders Association of New Zealand, Auckland. www.clanz.org.nz and www.moh.govt.nz 4. Malcolm L, Mays N. New Zealand’s independent practitioner associations: a working model of clinical governance? BMJ 1999; 310: 1340- 1342.
Health care results in the US relatively poor 9 November 2003
Tom Rawlinson, IT support Huntingdon, PE29 3BD Send response to journal: Re: Health care results in the US relatively poor	Much of the response to this article by Kaiser assumes that health care in the US is comparable to ours - the information I've found suggests it's not. Indicators such as infant mortality and life expectancy for the US are the worst in the western world. Here's one link that (I think) puts the matter in some kind of perspective: http://www.thirdworldtraveler.com/Health/How_USHealthCare_StacksUp.html I have plunged into the sea of WHO 2000 Report figures to extract the relative rankings in various composite tables of the U.S., the UK, France, and the top rank country where it is not one of these. In the cases of Overall Health System Performance and Performance on Level of Health, I have pulled up the top three countries. The total number of countries ranked, btw, is 191. Overall Health System Performance (based on a weighting of five components -- 25% level of health, 25% distribution of health, 12.5% level of responsiveness, 12.5% distribution of responsiveness, 25% fairness of financial contribution): U.S. = 37 UK = 18 France = 1 Italy = 2 San Marino = 3 Performance on Level of Health: U.S. = 72 UK = 24 France = 4 Oman = 1 Malta = 2 Italy = 3 Health Level (DALE -- Disability-adjusted Life Expectancy): U.S. = 24 UK = 14 France = 3 Japan = 1 Equality in Distribution of Health: U.S. = 32 UK = 2 France = 12 Chile = 1 Responsiveness Level: U.S. = 1 UK = 26-27 France = 16-17 Responsiveness DIstribution: U.S. 3-38 UK = 3-38 France = 3 -38 United Arab Emirates = 1 Fairness in Financial Contribution: U.S. = 54-55 UK = 8-11 France = 26-29 Columbia = 1 Overall Goal Attainment: U.S. = 15 UK = 9 France = 6 Japan = 1 Health Expenditure Per Capita in International Dollars: U.S. = 1 UK = 26 France = 4 Competing interests: None declared
Re: Getting more for their dollars: a comparison of the NHS with California's Kaiser Permanente 11 November 2003
Lawrence J. O'Brien, author; retired Arlington, Virginia, USA 22209, none Send response to journal: Re: Re: Getting more for their dollars: a comparison of the NHS with California's Kaiser Permanente	Richard G A Feachem, et al., reached these conclusions: "The widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely explained by underinvestment are not supported by this analysis. Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology." These conclusions by Feachem and his colleagues are plain wrong. To avoid fooling themselves and others, they need to go back and take a more careful look. There are certain unmentioned but nonetheless stubborn realities about medicine in the U.S. that must be fully recognized before any accurate evaluation of comparative performance can be made between the British National Health System and any part of the American medical care delivery system, including the Kaiser California HMO. In one of its recent reports, the Pew Health Professions Commission, chaired by Senator George Mitchell, offered these observations about American medicine: "During the last century, the U.S. medical profession has been transformed from a system dominated by general practitioners into a body of highly specialized physicians. In 1931, more than four out of five physicians (80%) were in general practice, yet after World War II, the proportion of physicians who were generalists fell rapidly. By 1965 the proportion dropped to about one-half (50%), and by 1990, the percentage of physicians in generalist areas had decreased to approximately one-third (33%) of all physicians. In most Western nations, the percentage of primary care physicians far exceeds that of the United States, with 50% of Canadian physicians and 70% of the British as general practice or family physicians. ...Some studies indicate that the relative emphasis on specialized services in the United States does not result in improvements in broad measures of health status." An Advance Data Report issued by the U.S. Communicable Disease Center on August 11, 2003 and entitled: "National Ambulatory Medical Care Survey 2001 Summary," includes a breakdown of the distribution of total annual patient visits between primary and specialty care physicians. There were 880.5 million total patient visits with physicians during calendar year 2001. Sixty percent of these, or a total of 528.3 million visits, were with primary care physicians "general or family physicians, pediatricians, general internists, and ob/gyns." There were 707,000 active physicians in the U.S. in 2001, with 235,000 of them being primary care practitioners, the remainder being specialists of one sort or another. Doing the math, primary care physicians handled an average of 2,248 patient visits that year, while the various specialty physicians had an average of 539 patient visits. That is, thirty-three percent of the physician workforce primary doctors -- received seventy-six percent of the total visits. Sixty-seven percent of the physician workforce specialist physicians had twenty-four percent of the total visits. Assuming an average of 180 days spent seeing patients for all U.S. medical doctors, primary doctors saw an average of 13 patients per day, while specialists saw an average of 3 patients per day. However, the income distribution was in inverse proportion to the distribution of visits: the higher the average number of patients seen, the lower the annual income of the physician, and vice versa. Because specialist physicians are able to realize average annual incomes at least twice as large as the earnings of the average primary doctor, and in some instances as high as forty times the average income of a primary physician, the Kaiser plan "which salaries its physicians" often has difficulty in holding onto top-notch specialists. Some of the adverse results of this specific reality might be seen by focussing study on a single disease, for example diabetes milletus, and examining the relative outcomes between the NHS and the Kaiser plan. The general quality and efficacy of diabetes care in America as compared with diabetes care in the U.K. can be judged by reference to World Health Organization (WHO) statistics. The WHO regularly gathers clinical data on the causes of death, based upon ICD-9 (International Classification of Diseases, ninth edition) codes. The WHO reports include deaths from all causes, and deaths in each specific ICD-9 category. A comparison of the incidence of deaths caused by diabetes in the United States with those in the United Kingdom over a similar five-year period provides a concrete and reliable means of measurement. The following table is based on data from the World Health Statistics Annual for 1993: Year Nation Deaths/All Causes Deaths/DM %/Total + or - 1988 USA 2,167,999 40,368 1.8% 1992 USA 2,185,673 50,067 2.3% +24% 1989 UK 657,733 8,486 1.3% 1993 UK 658,733 6,748 1.0% -20% In the United States, there were 17,674 more deaths from all causes in 1992 than in 1988. There were 9,699 more deaths from diabetes mellitus in 1992 than in 1988. This means that 55 percent of the increase in American deaths in 1992 were attributable to DM. There was a 27 percent increase in the rate of DM-caused deaths as a percentage of deaths from all causes. In the United Kingdom, the statistics tell a quite different story. There were 748 more deaths from all causes in 1993 as compared with 1989; and there were 1,663 fewer deaths from diabetes in 1993 than in 1989. During an analogous period, the United Kingdom experienced a 76 percent decrease in the rate of DM-caused deaths as a percentage of deaths from all causes. Making these statistics appear even worse for U.S. medicine is the fact that the federal National Institutes of Health has published findings of serious underreporting of diabetes mellitus by physicians, and has suggested that the correct number of DM-caused deaths in the United States in 1992 was 169,000, or 3.4 times the number reported to the World Health Organization. In either event, the comparison of WHO data for an analogous five- year period demonstrates clearly that British GPs and their patients are managing diabetes in a manner that yields outcomes far superior to those resulting from the medical practices of American physicians in coping with this disease. The disturbing morbidity and mortality statistics cited here for Americans with diabetes mellitus are the direct result of an approach to medical care that values tons of cure very highly, and that places no value whatsoever upon the ounce of prevention. Because Kaiser physicians are drawn from the same pool of residency graduates as non-Kaiser physicians, despite the different financial incentives that result from being salaried rather than fee-based, their patterns of clinical behavior do not differ in any significant way. Kaiser physicians tend to exhibit the same lack of insight concerning the ways and means to train DM patients to self-manage their disease as do American medical doctors generally. During 2002, one of the regional Kaiser plans terminated the position of Diabetes Educator and assigned the pivotal responsibility for training DM patients in managing their disease to already overwhelmed staff nurses. In this region, didactic courses are being offered to fill this enormous gap, with no provision made for patients to undergo interactive learning opportunities within the clinical setting. It ought to be clear that lecturing will never produce effective self-managers of NIDDM. The hard fact has been entirely missed that this is one of the most penny-wise and pound-foolish things that could be done within a plan that is based on prepayment, such as the Kaiser plan. Each year, the eight million people who have been diagnosed with NIDDM account for over sixteen million physician visits. What happens to them during those visits adds up to a very sad, persistent story of inadequate and sub-standard medical performance. Diabetic patients too often leave their primary physician's office with no complete, accurate knowledge about their disease. Many have reported being told: "Take one of these pills daily, and don't eat sugar." Until very recent years, U.S. health insurers did not pay for blood sugar monitoring equipment unless the disease had progressed to the stage of insulin dependence; and few insurers paid for the test strips required to use the monitor. As a consequence, blood sugar levels skyrocket and plunge in individual patients; many complications occur; urgent or emergent care or hospitalization for "diabetes out of control" is frequently required; toes, feet, and legs are amputated; people lose their eyesight; and these patients suffer a much higher incidence of stroke, heart attack and peripheral vascular problems. In the United States, the percent of visits for diabetes went up 63 percent between 1992 and 2001, and diabetes was the primary diagnosis at 27 million doctor visits during 2001. One third of all babies born in the U.S. now carry the gene for diabetes, thus these already depresssing numbers are bound to continue exploding in future years. Even if all primary doctors whether in fee-based practice or within HMOs such as the Kaiser plan -- had all of the information needed to effectively manage NIDDM, which they generally do not have, they would not have either the time or the inclination to effectively transfer this information to their diabetic patients. Within a fee-for-service practice, there is no reimbursement to be had for teaching patients how to manage their disease, creating an overwhelming disincentive for the physician to attempt this. In terms of clinical performance, doctors in the Kaiser plan tend to exhibit the same practice patterns with diabetes mellitus patients as their fee-based colleagues, even though the economic imperatives are quite opposite. In diabetes education, the key commitment for the teacher and for the learner must be to focus on the management of a process of care, in contrast to American medicine's habitual focus on treatment of an episode of illness. A 1995 Pew Health Professions Commission report includes the following observations: "The system is orientated to serving individuals and their immediate treatment needs and not to recognizing disease and disability as products of multiple influences: psychological, social, behavioral, economic and political. ...The American health care system, without the benefit of a capacity for self-correction, has grown to the point where it endangers public and private spending on other essential activities. In the face of this unsustainable growth a frightening reality confronts the American public...the largest cohort in the nation's history, the Baby Boom generation, does not turn 60 until 2006. When this cohort reaches retirement, it will place even more strain on a system which is failing today." *In a study of the overall effectiveness of diabetes care in the United States, epidemologist David Marrero offered the following concluding remarks: "How might we judge the quality of care being provided to people with NIDDM by primary care physicians? The brief overview presented here using state and national samples suggests that despite considerable efforts to disseminate practice guidelines in the last decade, there continue to be gaps between the current recommendations for care and actual PCP practices. Specifically, for patients with NIDDM, methods for assessing chronic glycemic control and strategies for the screening and treatment of retinopathy, nephropathy, and foot problems are not uniformly applied. Moreover, in most surveys, the data suggest that patients with NIDDM receive less aggressive treatment and fewer preventive services than patients with IDDM. The reasons for this finding are unknown. However, it may be inferred from the data that [primary physicians] may perceive NIDDM as a less serious illness than IDDM. From a public health standpoint, providing fewer preventive services to people with NIDDM greatly increases the burden of diabetes, because NIDDM constitutes the majority of cases, and some complications, such as cardiovascular and foot disease, are more common in NIDDM patients." *Anne L. Peters, M.D., Professor of Medicine in the Division of Endocrinology at UCLA's School of Medicine, wrote as follows in her 1996 commentary on a study by R.G.Hiss, RM Anderson, G.E. Hess, C.J. Stepien and W.K. Davis entitled Community Diabetes Care, published in the journal Diabetes Care: "Why, with the advances in technology and an increasing awareness of the value of maintaining near-euglycemia, is the quality of diabetes care so poor in almost every setting in which it is measured? Part of the problem stems from a lack of knowledge on the part of both patients and physicians regarding appropriate glycemic goals and how to achieve them. Second, while busy physicians may ask patients to collect SMBG (self-monitoring blood glucose) data, these physicians often do not act upon the data in a timely and effective fashion. Management decisions must be closely linked to the collection of SMBG and laboratory results. (Often the required laboratory tests are not obtained at all.) One example, from a chart review of patients with diabetes, is a chart on which it was noted 'blood glucose level=450 mg/dl, continue glyburide, return to clinic 1 year.'" Obviously, a patient with a blood glucose level of 450 mg/dl should not be permitted to leave the clinic without immediate treatment to gradually reduce their blood glucose level.It is unconscionably bad medical practice to otherwise release these patients, much less to dismiss them for an entire year. *The Diabetes Educator dated July/August 1991 reports that Pennsylvania State University researchers surveyed over 600 primary care physicians and discovered that over 90% "did not read any diabetes publications. Only 2.6% read Diabetes Care, the primary clinical journal of the American Diabetes Association. The care provided by the physicians was deficient in four major categories: patient use of home blood glucose monitors, frequency of glycoslyated hemoglobin measurement (a measure of the amount of sugar attached to red blood cells), routine referrals to eye doctors, and routine foot examinations." *In the July 1996 issue of Diabetes Care, William W. Fore, M.D., one of twelve partners in a physician clinic, stated that many physicians: "talk the talk, but they don't walk the walk." * The February 1997 issue of Diabetes Care, Raymond Fabius, Medical Director of U.S Healthcare/Aetna, [an HMO] is quoted as stating that 90 percent of the direct costs for nearly 40,000 diabetic members were incurred by 2,000 of those patients; and 50 percent of total costs were incurred by the 300 most ill patients. These are the disastrous wages of "talking the talk, but not walking the walk" when it comes to caring for patients who have diabetes. In the United States, medicine cannot progress as a true science unless it recognizes the need to resituate its generalist physicians in a central role, as the key managers of the processes of care for patients with chronic and acute problems, and as effective agents in the promotion of health. Achieving the changes in academic medicine that would reposition primary care physicians to perform the functions of general medical managers, directing the entire field of non-emergent medical practice, will prove to be extremely difficult. Specialist physician free barons, particularly those in academia, are not likely to surrender any part their present power, status, influence, or income on a voluntary basis, much less as the result of a sudden reawakening of Hippocratic zeal. In their December 1995 report titled Critical Challenges: Revitalizing The Health Professions for the Twenty-First Century, the Pew Health Professions Commission said this: "The difficulty of changing the established patterns of professional education and practice should not be underestimated. For instance, while there is little doubt that medical specialties are in oversupply, the government still subsidizes graduate medical education with over $6.5 billion annually, [$12 billion in 2002] most of which goes to train more specialists. ...The subsidy for education that is tied to care delivery must be broken. ...To address the changes in health in a responsive manner will require the bold action of leaders in all sectors of the system. Bold action is not something that has typified the governance of the profession or, for that matter, higher education. Like so much of today's health care system, this attitude must change. Fundamental alterations in the processes that govern professional education, regulate the professions, orient professions to practice and finance education will be required. This will mean action at the federal, state, institutional and professional levels. ...Professional training and practice should place more emphasis on developing the qualities of a superb generalist, capable of comprehensive management of care, as opposed to the current orientation toward specialization. ...The current environment of overspecialization, orientation toward high technology medicine, and preference for institutionally based education is the result of over 40 years of direct and indirect federal policies. Only a purposeful reformation of these policies will bring significant change." Feachem et. al. need to take another, much more disciplined look at Kaiser California and at the structure and practice of American medicine in general, touted as it often is as representing "the best medical care in the world." The sooner they do this, the better. Competing interests: None declared