What can we learn about health care from Europe?

May I tiptoe onto a ledge for a moment?

Some (just-back-from-Europe) thoughts on health care policy, perhaps?

One of the many differences between the European Society of Cardiology (ESC) Congress and a typical American cardiology meeting was the scarcity of healthcare policy sessions at the ESC. That’s hard to explain; perhaps European countries are settled on their own systems and do not wish to — or can’t — influence their neighbors.

It goes without saying that little about healthcare is “settled” here in the US.

On return from Europe, the first article I saw in my local paper reports that 101,000 residents (16%) of my affluent county live without health coverage.

This is a real problem. So is the fact that it has become easy to gloss over this stuff. You get numb to it all. It’s normal, sort of.

Until you get an email like this:

Hi John,

I have a friend in his 60′s with no health insurance experiencing symptoms like great pressure on his chest and can’t get to a doctor because he can’t afford it. Is there a service in Louisville (a public health clinic or something like that) that you know of where he can get looked at by a doctor?

My e-response:

I don’t know. I think. Maybe. He could go to the ER. I could see him for free, but of course, there would be tests–that are not free.

I’ll get back to you.

This stinks, doesn’t it? Not for this particular guy. He got to me; I’ll see to it that this one patient gets cared for.

What about the other 100,999 residents of my county who don’t have a friend who can email a cardiologist?

This got me thinking about how Europeans approach healthcare. I spoke with an Austrian: “We have excellent healthcare … Everybody gets care.”

From a German cardiologist:

“All Germans get health coverage, whether they work or not. The extremely rich can buy ‘extra’ coverage that allows them to get private rooms in the hospital, or to make contracts with eminent professors and the like. We don’t buy private coverage because it’s expensive and the basic plan is enough for us.”

Lest you think everything German runs as perfectly as their trains, there’s this article published recently in the prominent Journal of the American College of Cardiology, showing that Germans also act according to human nature. It turns out that (even in Germany), if you compensate well for procedures, then it is procedures you will get.

I also learned some basics about British healthcare. Citizens are not billed for health services. You can be admitted to the hospital, treated and when discharged the paperwork includes instructions on medical matters, not a bill. The government pays all the medical bills. Wow.

But another British convention goer reminded me that British care isn’t exactly free. Primary care doctors control care. They determine whether a problem warrants further evaluation or referral to a specialist. And these gatekeepers are more than tacitly incented to contain costs. I guess it’s not surprising then that many of the sessions at ESC that centered on cost-effectiveness came from the UK.

I’ll try to distill my feelings about US healthcare reform down to four simple certainties:

  • In a country of such great wealth and wisdom, we mustn’t accept a system that doesn’t cover all the people. I mean all the people — not just citizens. To do so is not just sound policy; it’s more than that — it’s the right thing to do.
  • Everyone must start seeing (really seeing) the obvious–that healthcare spending isn’t infinite. We, as a people and a medical community, must accept limits. Choosing Wisely applies to both the patient and the doctor. This won’t be easy. It means making a 180-degree turn in current thinking. If we want things to be better, all parties must accept more responsibility.
  • Whichever new delivery system is implemented, be it the Affordable Care Act or an alternative, the patient-doctor relationship must be protected above all else. Medical decision-making should not come from an expert panel or third-party payer, but from the patient and doctor.
  • On risk. The idea that humans, not machines, practice medicine must be remembered. Humans make mistakes. They sometime fail to diagnose; they sometimes fail to perform perfect surgeries; they sometimes make real-time decisions that they wouldn’t have made in hindsight. The new US healthcare system must do better at accepting the humanness of its professionals.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • http://www.facebook.com/people/Brian-Mckenzie/1419117137 Brian Mckenzie

    Now go back and look at innovation, pharma, technology and foreign research that is Coming to Europe because the rules, regulations, fines and taxation in America has become too much. Weigh the previous Soviet Socialist Republics efforts to throw off Social medicine and move to market development, fee for service, insurance based markets, and critical infrastructure for attracting foreign capital. Speaking mainly of Ukraine – but Czech and Poland have done concrete avenues to move to market drive cash transfers outside of government delivered care models. Seven decades of Soviet Socialist imposed architecture – I would say they know first hand how bad it can get.

  • Marilyn Blundin

    I worked in the US health system for almost 20 years…administration. I know it well. I now know the National Health System of Italy. I have friends from England and Germany who tell stories of wonderful patient management.Maybe it’s the euro crisis, or maybe it’s the mismanagement of political parties for the last decade here in Lazio, but when I called on 19 Sept. to make an appointment for an MRI at a diagnostic center that services both private and NH patients, I was told that would be January. My response was shock and dismay at this as the spinal headache I have seemed to need attention sooner. Our experience with the National Health at this center in the past was stellar. I then asked about our quasi private insurance (contracts not accepted at centers for excellence facilities in both Rome and Bologna). That moved the appointment to next week. I then made an appointment for a neurologist … also private … to ensure that I can be seen within the time frame of the MRI results. Payment is made in full at the time of service and receipts submitted for reimbursement to the insurance carrier…a long wait and fight. Much the same story of insurance companies in US that look for every opportunity to deny claims.
    This was not the case 11 years ago when I arrived. I was very impressed with the system. I had surgery for breast cancer and follow up … all were excellent. Slowly it became more than difficult to get an appointment even one year out. Private practice creeped into the hospital setting that tried to balance the changing landscape. Not a bad idea just hasn’t ironed out the fine details of this transition yet.
    The doctors are increasingly frustrated to give the care needed and stay afloat. I’ve observed near heroic efforts using slashed resources to obtain sufficient outcomes. The distribution of wealth issues are everywhere. Political corruption is everywhere.
    If you have the money, you can get the appointments.
    The political system closed hospitals including ours. People made public protests to keep it open. They succeeded but the ER no longer has cardiology or orthopedic support, but is a triage for ambulance transport to hospitals one hour away including OB.
    There is so much more to this story than meets the eye on both sides of the Atlantic. I wish I knew the answers.

  • traumadoc

    i moved my practice to italy . i work 3 months a year, i come here (USA) and teach allied health and i go to 3rd world every summer and put my time in for 2weeks in a different country…………europe has come a long way and it takes care of it’s people.

  • 99bonk

    I see no comments about the health care system in France – can anyone discuss? My own experience with the NHS in England prior to immigrating to the US was perfectly acceptable, but I understand from friends and family that things have changed considerably since then. Health care in the UK is free at point of care, but is not “free” – employees have a payroll deduction ( similar to the SS deduction here) and of course, income taxes are higher.
    You get what you pay for. When 4000 families in the US with incomes of more than $1 million a year are paying no income tax at all, what do you expect.
    Incidentally – per the IRS, in 2009, six of the 400 wealthiest people in the US also paid no federal income tax. What is wrong with this picture?

  • Peggy Zuckerman

    As to free healthcare in the UK, and access to it, I am told by my daughter living in London–in an area with few doctors–that she cannot get an appointment in general. New rules indicate that she has a right to appts with doctors in other areas–after she has been turned down three times. However, those drs will not write the necessary papers to indicate that she had been turned down. Back to trying to get basic health care.

    Other patients from the UK indicate through an online group that they have much more difficulty getting CT and bone scans that would be typical in the US–or have to wait many months to do so. Anecdotal info only, but reality for the people involved.

  • http://www.facebook.com/victoria.ford.564 Victoria Ford

    Ok, so no system is perfect and with the cost of medical treatment as high as it is it just is not possible to do everything. Maybe you should be tackling the pharmaceutical companies which make enormous profits from medications where the main research has been done by tax payer funded work in hospitals and universities.

    As for the difficulty of getting a CT or bone scan in the UK, you get it if you need it and not because you want one. There is a limit to resources in every health care system and in the US tests are often done just to push up the income of a doctor, and not because of the need of the patient. http://www.medindia.net/news/Unnecessary-Medical-Tests-and-Treatments-Prescribed-Cost-67-Billion-Annually-Research-91558-1.htm Also CT scans can cause cancer, and bone scans aren’t exactly good for your health, especially if you are talking about the kind where radioactive material is injected prior to the scan. Treatment should always be based on medical need. If the need is urgent enough scans are done quickly.

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