Getting more for their dollar: a comparison of the NHS with California's Kaiser PermanenteCommentary: Funding is not the only factorCommentary: Same price, better careCommentary: Competition made them do it

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