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U.S. HEALTH CARE: International Scholars Experience Our System — What They Found

October 16th, 2007

Editor’s Note: This is part one of a two-part blog by several of the 2006-2007 Commonwealth Fund Harkness Fellows. The post below describes the extent to which these international scholars felt able to make meaningful choices in their interactions with the American health care system. In part two of their blog, which will appear on October 17, the authors propose changes to strengthen the ability of consumers in the United States to make health care choices.

Vidhya Alakeson (United Kingdom) is the lead author. Other authors include Mark Booth (New Zealand); Robbie Foy (United Kingdom); Bruce Guthrie (United Kingdom); Richard Hamblin (United Kingdom); and Ruth Lopert (Australia).

In November 2006, health ministers, senior policymakers, and academic experts from Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States gathered in Washington, D.C., for the Commonwealth Fund’s annual international health policy symposium. Reflecting striking differences in how health care is funded and organized, their discussions nevertheless shared a common theme: the role of choice.

With the exception of New Zealand, choice was high on the political agenda across all the countries present. It was portrayed as a way of giving patients greater control and, in doing so, driving up the quality of their care. Whether in the British National Health Service, in German sickness funds, or in the U.S. private insurance market, ministers agreed that encouraging patients to exercise choice would empower them, giving them greater confidence and control over their treatment options. In addition, it would drive out poor performers, force mediocre ones to improve, and reward high performers with a greater share of the market.

We attended the symposium as recently arrived Harkness Fellows in Healthcare Policy. Each year the Commonwealth Fund awards Harkness Fellowships to a group of mid-career professionals from Australia, Canada, Germany, New Zealand, and the U.K., enabling them to spend a year in the United States, studying the health care system and working with U.S. health policy experts.

By and large, we were used to health care systems that have traditionally offered less choice than the U.S. offers and where freedom to move between different providers has not been a policy priority. By providing us with comprehensive health insurance, our fellowships gave us the opportunity to experience at first hand a health care system where choice is paramount. We were curious to find out whether we would be motivated to take greater control of our care in the U.S. system than in our own systems, and what our U.S. experiences could teach us about the likely outcomes of expanding choice in our home countries.

It soon became clear that our opportunities to exercise choice were less straightforward than we had been led to expect. At times it seemed as if we had a lot of choice, when in reality we had very little. In Washington, D.C., for example, our health insurer’s Web site provided a list of over fifty in-network primary care physicians, but when we called to make an appointment, most were not taking new patients. We got to number twenty-five on the list before someone agreed to see us. By this point, the need to find a physician — any physician — overrode any consideration of the quality of the provider.

Even when choice was possible, it was difficult to exercise in a rational manner. Over on the West Coast, faced with a dauntingly long list of potential providers, one of us set out to choose a high-quality physician. Two hours of Internet browsing turned up limited data about health plans, health maintenance organizations (HMOs), and large provider groups — all irrelevant to the choice at hand. There was minimal information available on individual doctors’ registration and disciplinary history, both of which are markers of minimal competence rather than high quality; what information there was had to be paid for. Since none of this was particularly meaningful, the tried and trusted U.K. method of finding a family practitioner was employed: choose the one closest to home.

We also quickly found that the fragmented nature of the U.S. health care system, with plans having relationships with certain providers and not others, created unanticipated costs and financial risks to exercising choice. One of us was ambushed by an unexpected bill, after failing to check that a radiology examination was being done in-network. The assumption that it must have been since an in-network physician had made the referral to a provider in an adjacent office proved to be simply naïve.

Elsewhere, a compatriot arranging an immunization required by the school system had two options: a local family doctor who insisted on providing a well-child check before vaccination, or the local public health department, which offered the immunization alone. Being cautious, he checked the potential costs of each option. Depending on the extent of coverage, the cost of going to a family practitioner could vary by $150, and depending upon income, the cost of visiting the public health clinic could vary by $70. It took a thirty-minute phone call to the health plan to determine the full extent of coverage. Even with this “clarification,” neither provider could give sufficient information to weigh this small, but not insignificant, financial risk.

Indeed, we found that choice was typically accompanied by a level of bureaucracy and micromanagement that belied the rhetoric of market efficiency. At every stage, our choices were strictly governed by which providers were “in” our health plan’s network, which medications were on the formulary, and which procedures required preauthorization. Strictly speaking, preauthorization was the physician’s responsibility, but the financial risk of not checking fell on us. The bureaucratic burden of choice not only created uncertainty about coverage, despite being comprehensively insured, but also, as we discovered, imposed both financial and time costs.

To date there has been little in our collective exposure to U.S. health care to suggest that greater choice has increased our sense of control. More often than not, we found we were making choices to knit together different providers and fragmented parts of the system to guarantee access and continuity of care. Frequently we had to choose between different options, even when the choices offered were of little value to us, and often with little information to support informed decision making. Rather than giving us a sense of greater control, these forced choices served only to create a sense of uncertainty.

Part two of this blog will appear on October 17.

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1 Trackback for “U.S. HEALTH CARE: International Scholars Experience Our System — What They Found”

  1. FrontPoint Systems Ltd » Blog Archive » Evidence based healthcare policy
    November 13th, 2007 at 3:39 pm

2 Responses to “U.S. HEALTH CARE: International Scholars Experience Our System — What They Found”

  1. Gary Vollan Says:

    “Regulating the denturist profession across the Nation in providing affordable denture care for the economically disadvantaged is the little thing we can do to make a big difference in the wellness of people. People are healthier and more productive when they have a denture that functions properly.” Gary W. Vollan L.D.

    Denturists and American People in Need vs. American Dental Association Policies

    The balance of the working relationship between the dentist and denture technician has always tipped more favorably on the side of the dentist than the denture technician.

    A number of denture technicians moved forward in the profession by becoming denturist because of the expectations of being the dentist’s counter-part but rarely with the denture technician receiving the deserved gratitude of those expectations.

    Instead we worked long hours (not by choice), didn’t get paid for those long hours which usually involved remakes due to error of the dentist or assistant doing procedures.

    Our jobs as denture technicians were usually held over our heads for us to jump, reach, and grab at, while the dentist decided which dental lab they would use if and when we complained or insisted that things be done differently and maybe even getting paid for the 60 or 90 day past due lab invoice.

    As a denturist I enjoy my work. I enjoy the working relationship of a chosen dentist or oral surgeon for referral services for my patients.

    The good fight is not with any current or past dentist. I’ve worked with some good dentist as a denture lab technician and as a denturist. A good majority of the dentist would rather spend their chairtime in restorative and cosmetic dentistry not dentures.

    So what’s the problem? Corporate ADA. The American Dental Association’s big money politics, waste and not being able to relate to the dental needs of the people. It’s nothing different than what denture technicians and denturist have always dealt with as the counter-part of the dental profession.

    Corporate ADA has no faith in its ability to provide for the dental needs of the American public. Even as denture technicians, we have always known we we’re better at being able to meet the denture needs of the American public and the American Dental Association knows it. We are a thorn in ADA’s side and they want us gone.

    The American Dental Association has in place, a number of build up and award programs for dental lab technicians for good reason and then it supports outsourcing of dental prostheses. Something’s not right with this picture.

    It’s one thing to pay pennies to the dental lab technician for dental prostheses but yet another thing to outsource the work away from the mom and pop dental labs across America.

    More and more people are doing without dental care because of ADA’s policy making. They spend 10’s of thousands of dollars for meetings to establish these policies that are leaving more and more people without dental care.

    The policies discriminating against the economically disadvantaged Americans are those that are directed at stopping denturist, dental health aides and independent practices for dental hygienist. The American Dental Association sends money to state dental associations with expectation that the state associations will uphold ADA’s policies but in turn it’s a negative reflection on the state associations because their using the money for reasons other than meeting the dental needs of the people of the state.

    The American Dental Association could better serve the dental needs of the American people by giving the dental hygienists the freedom of their own boards and independent practices so they can better serve the preventive needs of the American people by serving in the area of public health.

    Corporate ADA can take the necessary steps to establish boards for independent practice of the denturist profession and the dental health aides across the Nation. This would free up dentist to use their eight or more years of schooling and experience in extensive restorative dentistry and specialty areas of dentistry.

    It would direct the need for more money for education for all areas of the dental profession. This would create more qualified doctors and less of the unethically inclined dentists that are in practice today due to dental school programs one size fit all level of the DDS degree.

    Dental health aides or therapist would serve the same level that a physician’s assistant serves today. The American Dental Association would organize and regulate dentistry and associated professions across America to better meet the dental care needs of all people.

    People need to get on the American Dental Association internet site and do a watch dog of the programs in place and see the money that’s wasted. It’s disgraceful, with the number of Americans doing without dental care. You’d think with all the money, power, and intellect the American Dental Association has it would do things differently.

    Please consider this critique of corporate ADA.

    Thank you—Gary W. Vollan L.D. 307-568-2047

  2. roncrawford Says:

    US health system has its own pros and cons. Patients with chronic diseases like coronary artery disease have to shell out huge premium.

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