Wednesday, May. 20, 2009
Health Lessons from Europe
By Eben Harrell / Copenhagen
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Denmark: Electronic records save money and improve outcomes
At the Frederiksberg University Hospital in Copenhagen, there are no clipboards. Instead, doctors and nurses carry wireless handheld computers to call up the medical records of each patient, including their prescription history and drug allergies. If a doctor prescribes a medication that may cause complications, the PDA's alarm goes off... President Obama recently pledged $19 billion to computerize America's medical records by 2014. Denmark has already made the transition. The country has a centralized computer database to which 98% of primary care physicians, all hospital physicians and all pharmacists now have access... Now, instead of a single system, record-keeping utilizes various compatible systems, linking networks established by regional health agencies.
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Germany: Easing the burden of chronic disease; strengthening peer review
Sudden illness may be what scares most people, but chronic conditions place the greatest strain on health care. Around 75% of the U.S.'s $2 trillion annual health-care expenditure goes toward ailments such as heart disease, asthma, diabetes and certain cancers, and the vast majority of that is spent when these conditions require hospitalization and emergency care. The problem is particularly acute in the U.S. public sector: over 20% of U.S. Medicare patients have five or more chronic illnesses... The solutions can be as simple as educating patients about their condition, having nurses call patients to make sure they are staying on top of their medication and allowing doctors to compare their success rate with other physicians... The challenge is finding the funding to implement such schemes. In America's health system, there are few financial incentives for providers to take proactive measures to keep people healthy: the longer and more extensively a doctor or hospital treats a patient, the more income they recoup... In 2007, Geisinger Health System began a pilot program in Pennsylvania, hiring nurses to check on patients with diabetes, heart disease and other chronic ailments, as well as linking 20% of physician income to targets in areas such as patient weight loss, smoking cessation and cholesterol levels. After the first year of the study, hospitals reported a 20% fall in admissions in the area and health-care expenditure dropped 7%.
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Britain: How much is a year of life worth?
Placing a cap on drug costs could save U.S. health care billions. But it's not without controversy. England and Wales have set up a body called the National Institute for Health and Clinical Excellence (NICE) which reviews treatments to decide which are the most cost-effective and which the National Health Service (NHS) should pay for. A new drug has to offer value for money — and if it doesn't, whether it is life-saving or not, NICE won't approve it. NICE uses a metric called "quality-adjusted life year," or Qaly, which grades a person's health-related quality of life from 0 to 1. Say a new drug for a previously untreatable condition comes on the market and the drug is proven to improve a patient's quality of life from .5 to .7 on the scale. A patient on the drug can expect to live an average of 15 years following the treatment. Taking the new drug thus earns patients the equivalent of three quality-adjusted life years (15 years multiplied by the .2 gain in quality of life). If the treatments costs $15,000, then the cost per quality-adjusted life year is $5,000. Taking its lead from Britain's Department of Transport — which has a cost-
per-life-saved threshold for new road schemes of about $2.2 million per life, or around $45,000 per life year gained — NICE rarely approves a drug that costs more than $45,000 per Qaly Not only does the equation make hard-nosed sense in a public-health system, its use can reduce costs in other ways. Eager to gain NICE's approval, drug companies have started giving away portions of expensive treatment for free in Britain in order to ensure their drugs meet the threshold.
Aware that the idea of "rationing" health care would prove controversial in the U.S., advocates of reform — from the American College of Physicians to the advocacy group Center for Medicine in the Public Interest — have suggested a system of review that doesn't take into account the cost of new treatments. This would help doctors decide a course of treatment, as currently they have no way of comparing the efficacy of different drugs for the same condition. But it could also raise prices. "In a free-market economy the manufacturers may use the effectiveness review to charge higher prices for the best drug," says Jeffrey Harris, president of the American College of Physicians.
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France: The benchmark system is neither truly socialized nor fully equal
In 2000 the World Health Organization (WHO) used statistical measures, such as life expectancy and infant mortality, to rank the world's health-care systems. France topped the rankings. In 2008, researchers at the London School of Hygiene and Tropical Medicine followed up the WHO study by showing that France is not only a good place to stay healthy, but also a good place to be sick: of 19 industrialized nations, France has the lowest number of "amenable deaths" — fatalities that could have been prevented by good health care. (The U.S. had the highest.).. France's state-run health insurance scheme reimburses 60% to 70% of most medical bills. The remaining costs are assumed by the patient. More than 90% of French citizens pay for supplementary health insurance to cover these costs — mostly from state-run providers called mutuals. But those who can afford it are increasingly abandoning mutuals in favor of private insurance. For most ailments, that makes little difference: 80% of France's general practitioners work under a regime that caps how much they can charge. But the reverse is true for specialists and surgeons — 80% of them set their own fees, often exceeding the reimbursement ceiling of most mutuals. The result: a two-tiered system that runs counter to the utopian ideals of most health-care reformers... Rua and others say that what's exemplary about France's system is that it has managed to foster patient choice while continuing to provide a generally high level of care for even the most vulnerable.
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http://www.time.com/time/magazine/article/0,9171,1899873,00.html
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