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Rapid Responses: Rapid Responses published:
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US medicine is not market driven
- Britt Daniel (30 November 2007)
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Healthcare and Markets: We need to be more pragmatic
- Adam Paul Fitzpatrick (1 December 2007)
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Canada also is sliding towards private care layered over a public base.
- John Hoey MD (3 December 2007)
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Equity and markets
- Clive D Hadfield (3 December 2007)
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Public health machinery also works
- Om Prakash, National Institue of Mental Health & Neurosciences, Bangalore-560029, INDIA (3 December 2007)
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Britt Daniel, neurologist Dallas Texas 75230
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With all due respect, I must reply to editor Godley's statement that medicine in the US is market driven. This statement is wrong. Medicare, HMOs, and PPOs have set fees in medicine for the last 20 years or so. It is the lack of market or free enterprise forces in the US that has driven health care prices up so much. The money in US medicine is not going to doctors, hospital, or patients. The CEO in America with the largest salary is the head of United Health Care, the biggest insurance company. The efficient engine of a free, economic market is the best means of controlling prices and providing innovation. Sadly, this is lacking now in the US. BTDaniel MD Competing interests: None declared |
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Adam Paul Fitzpatrick, Consultant Cardiologist Manchester Royal Infirmary M13 9WL
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I worked for 2 years as an attending at the University of California, San Francisco, and the last 12 years as a consultant in the NHS. Rampant commercialism in healthcare doesn't work well, as Ms Godlee & Woolhandler and Himmelstein attest, but nor does healthcare by slavish social dogma, as in the UK. In my experience in the USA, university medicine was of a very high calibre, knowledge and procedural skill levels were the best I have encountered, and patients were treated as individuals, and routinely attended by a specialist every day, something that is unheard of in the NHS. Politics of a parliamentary or hospital kind were subservient to care. Before I went to the USA, the NHS was lean and efficient, and served the sickest patients in greatest need first, with an exceptional standard at very reasonable cost, albeit with long waiting times for elective care. In the 12 years since I got back, the NHS has become overrun by managers, average waiting times have been cut at very high cost by targeting hips and cataracts, and the experience of sick patients in need has deteriorated. Spending has skyrocketed, but we have little to show for it, and bigger salaries don't seem to have made medical professionals happier. The big money has ruined a cherished institution. Many of the 47m American without insurance chose not to purchase it although they are able to afford it, because they are young and well. US critics of their own system, such as Woolhandler & Himmelstein, and Michael Moore, never write about the systems the OECD ranks highly, such as those of Australia, France, Belgium and Austria, because they all involve a large dollup of realism and pragmatism, and avoid the extremes of commercialism and socialism. However, more than any of these, the future of successful healthcare lies in the Kaiser Permanente model. This integrates primary, secondary and tertiary care in a single managed "wedge", with a single budget linked to clinicians remuneration, with formulae for discouraging overuse. Kaiser can't function in a socialised setting such as the NHS, and needs competition between similar "wedges" to thrive. It is not beyond our wit to create such a system of healthy competition and incentives, care before politics, and cost-control, without rampant commercialism, but I don't see sense prevailing in my working lifetime. Competing interests: None declared |
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John Hoey MD, Professor Queen's University Canada k7h3c6
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Neurosurgery or depression and virtually all aspects of health care are not tradeable commodities. This is so obvious that the efforts to move health care into the commercial marketplace can only be motivated by greed. Many physicians and their backers think they can make more money in an open market. They have not forgotten, however, that after the introduction of universal health insurance for physician services in this country physician incomes actually increased dramatically, probably because there were no more unpaid doctor bills. The strategy, therefore, is not to abolish the public sector, but to create a distorted non-transparent (the patient will never have enough information to make a rational decision on price and value) pseudo-market in health care, one that will only result in shifts of income from patients and taxpayers to physicians. Competing interests: None declared |
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Clive D Hadfield, Staff specialist in General Internal Medicine Cairns Hospital, QLD, Australia, 4870
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Universal access to market-based health care can be achieved if taxpayer-funded premiums are allocated to competing licenced insurers at the discretion of each consumer (perhaps default to random ballot). The consumer is quite capable of choosing in complex markets as they do in super-annuation in Australia. Regulation of markets ensures broadly similar products but a choice of risk-benefit. In health care, tradeable risk includes health-determining consumer behaviour. The government would monitor safety and regulate the market through licencing. Monopoly would need to be addressed. Government would mercifully exit service provision. Competing interests: None declared |
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Om Prakash, Assistant Professor of Psychiatry Geriatric Clinic & Services, Department of Psychiatry, National Institue of Mental Health & Neurosciences, Bangalore-560029, INDIA
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I read the editorial (1st December, 2007) with a great interest. It is true that private sector also failed to fulfill people's health care demands in developed countries. Similar conditions are also true for developing World where private sector is increasing its base. In developing countries like India, there is a lot of pressure on public health system. More than 40 National programmes for communicable and non- communicable diseases are running by public health machinery. Though it is difficult to accomplish Hercules targets and demands but the Indian government is not hiring services from private sector like USA and UK and it is too expensive to involve private sector in healthcare. Despite a lot of administrative and financial hurdles, public sector is somehow providing minimal health services to needy ones. Nevertheless like UK, there is a need to strengthen these existing services rather falling into preys of private sector. Competing interests: None declared |
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