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
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7330.135 (Published 19 January 2002) Cite this as: BMJ 2002;324:135All rapid responses
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Much of the response to this article by Kaiser assumes that health
care in the US is comparable to ours - the information I've found suggests
it's not. Indicators such as infant mortality and life expectancy for the
US are the worst in the western world.
Here's one link that (I think) puts the matter in some kind of
perspective:
http://www.thirdworldtraveler.com/Health/How_USHealthCare_StacksUp.html
I have plunged into the sea of WHO 2000 Report figures to extract the
relative rankings in various composite tables of the U.S., the UK, France,
and the top rank country where it is not one of these. In the cases of
Overall Health System Performance and Performance on Level of Health, I
have pulled up the top three countries. The total number of countries
ranked, btw, is 191.
Overall Health System Performance (based on a weighting of five
components -- 25% level of health, 25% distribution of health, 12.5%
level of responsiveness, 12.5% distribution of responsiveness, 25%
fairness of financial contribution): U.S. = 37 UK = 18 France = 1
Italy = 2 San Marino = 3
Performance on Level of Health: U.S. = 72 UK = 24 France = 4
Oman = 1 Malta = 2 Italy = 3
Health Level (DALE -- Disability-adjusted Life Expectancy): U.S. =
24 UK = 14 France = 3 Japan = 1
Equality in Distribution of Health: U.S. = 32 UK = 2 France =
12 Chile = 1
Responsiveness Level: U.S. = 1 UK = 26-27 France = 16-17
Responsiveness DIstribution: U.S. 3-38 UK = 3-38 France = 3
-38 United Arab Emirates = 1
Fairness in Financial Contribution: U.S. = 54-55 UK = 8-11
France = 26-29 Columbia = 1
Overall Goal Attainment: U.S. = 15 UK = 9 France = 6
Japan = 1
Health Expenditure Per Capita in International Dollars: U.S. = 1
UK = 26 France = 4
Competing interests:
None declared
Competing interests: No competing interests
The extensive, largely critical commentary on the article by Feachen
et al1 has almost completely ignored Berwick’s proposal to pilot a more
fully integrated NHS2 through a strategic health authority. However
experience in New Zealand of such authorities as purchasers does not give
me much confidence in this approach. It was abandoned in 2000 in favour of
a fully integrated district health board (DHB) as both purchaser and
provider. DHBs are accountable for better health outcomes for their
defined populations.
This is being achieved through integrating the effort of all
providers, government and non-government, primary and secondary, hospital
and community, public health and disability. This model is even more
comprehensive than Kaiser. It may be the experiment that Berwick is
looking for.
A study of 10 DHBs, completed earlier this year, showed the building
of a new partnership between clinical leadership and managers, with
increasing accountability by clinicians for both quality and cost3. Of
particular importance has been the development of primary care
organisations (PCOs) which are now accepting accountability for all GP
related expenditure and promoting quality primary care3,4. They are also
building a new partnership between primary and secondary care. For
example, within the DHB framework, Pegasus Health in Christchurch, with a
membership of 230 GPs and global budget of $80 million, is significantly
reducing acute admissions through alternative community-based care.
Our PCOs would appear to be much more advanced than the NHS
PCG/Ts3,4. They now have the advantage of becoming fully integrated into
the DHB system. Building new and trusting relationships within a lead
organisation, especially between primary and secondary care as in Kaiser,
will more successfully achieve the cultural and organisational changes
needed than failed purchasing strategies.
References
1. Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a
comparison of the NHS with California's Kaiser Permanente. BMJ 2002;
324:135-43.
2. Berwick DM. Commentary: same price, better care. BMJ 2002; 324:142
3. Malcolm L, Wright L, Barnett P, Hendry C. (2002) Clinical
leadership and quality improvements in district health boards in New
Zealand. Clinical Leaders Association of New Zealand, Auckland.
www.clanz.org.nz and www.moh.govt.nz
4. Malcolm L, Mays N. New Zealand’s independent practitioner
associations: a working model of clinical governance? BMJ 1999; 310: 1340-
1342.
Competing interests: No competing interests
James Bartholomew should have declared an interest as a journalist
who has already written on this subject for a newspaper that has an
explicitly anti NHS agenda. His column was written in a way that suggests
he had not read or understood the critiques of the Feachem paper.
He makes an attempt to deal with the criticisms of the paper by
providing his own points to bolster a position he has already taken
publically.
1) The costs of capital are included in NHS accounts so this point is
irrelevant
2) This is an interesting point. The costs of malpractice in the UK
are high and using the methodology of the paper they would need to be
treated using US PPP adjustment - Mr Bartholomew needs to show that the
costs are proportionately higher before this argument can be entertained.
3) It is not clear why controlling for difference in expectations is
legitimate even if it were possible
4) This point is an extraordinary piece of twisted logic.
Maintaining people on a waiting list is expensive, delaying their
treatment is expensive and the idea that dying is a cheap option is
contradicted by the evidence. If Kaiser use high cost treatment to keep
people alive a little longer at a higher cost, for which he offers no
evidence, then he must demonstrate how this constitutes a major
improvement in cost effective outcomes.
5) It is not clear what point is being made here.
Mr Bartholomew has an axe to grind about the NHS as his last
paragraph shows. He should declare his interests before writing and
perhaps should be more ready to accept views that do not accord with his
position.
Competing interests: No competing interests
Editor
I was very disappointed by the publication of the article by Feachem
et.al. in comparing the California Kaiser system to the NHS (1). One has
to live in California and be a physician and have some working knowledge
with the HMO before passing any judgement about the quality of their care.
------------------------------------------------------------
First, Kaiser is not a "non-profit" HMO. It is for profit, with the
profit being divided between shareholder practicing Kaiser physicians.
The fact was made known by a Kaiser physician(2). So the profits shared
are labeled as money spent on medical care for their patients, and
therefore this justifies their classifying themselves as a non-profit HMO.
------------------------------------------------------------
Secondly the data presented for their performance was collected and
analyzed by Kaiser personnel, and obviously can involve selection and
information bias. In fact, I have recently responded (3) to another
outcome report by Southern California Kasier regarding their observation
that less studies and procedures results in better cardiovascular
outcomes(4). My response (3) and that of others (5) exposed their self-
serving bias and distortions.
------------------------------------------------------------
Lastly, the commentary by Alain Enthoven(6) has to be interpretd with the
knowledge that he was not only a consultant for Kaiser, but also one of
the directors of Blue Cross in California (another alleged non-profit
organization)and a leading proponent for the advent and proliferation of
the HMO helth care delivery system.
------------------------------------------------------------
I,like many of my other colleagues in the U.S.were hoping to someday have
our country copy the much more humane and cost effective single payer
universal health care coverage system in place in Europe and Canada for
many decades. Unfortunatly, with the globilization of the health care
providers, (pharmaceutical companies, insurance companies, HMOs, etc.),
acting through the auspices of the powerful World Trade Oganization,
Europe and Canada run the very real risk of acquiring our very inhumane
wasteful and diseased health care system.
I remain respectfully yours,
David S. David, M.D., F.A.C.P.
Clinical Professor of Medicine
UCLA School of Medicine
------------------------------------------------------------
REFERENCES:
1. Feachem, RGA, Sekhri NK, White KL. Getting More For
Their Dollar: A Comparison of the NHS with California's
Kaiser Permanente. BMJ 2002; 324:135-141.
2. York, GK. Executives with White Coats-Managed Care
Medical Directors. New Eng.J.Med 2000;342:130.
3. David, DS. Putting Patients First. Cardiovasc Rev Rep
2001; 22:402.
4. Mahrer PR.Outcome Study of Two Large Populations wih
Different Rates of Cardiac Interventions. Cardiovasc
Rev Rep 2000;21:638-651.
5. Weiss SR. Putting Patients First. Cardiovasc Rev Rep
2001; 22:575.
6. Enthoven AC. Commentary: Competition Made Them Do It.
BMJ 2002; 324:143.
7. David, DS. Evidence Based-Medicine. Am J.Med 1998;
105:361-362.
Competing interests: No competing interests
Most responses have tried to find faults in making a comparison
between Kaiser and the NHS which may tend to be unfairly in favour of
Kaiser Permanente. However, one should also look at possible faults of
comparison go the other way and tend to understate the case in favour of
Kaiser. I would offer the following possibilities:
1. No adjustment, as far I understand it, has been been made for the
fact that Kaiser has had to buy or rent its premises and property whereas
the NHS started with assets built up over centuries.
2. No adjustment, as far as I understand, has been made for the much
higher awards that are made in litigation for malpractice in the USA
compared to those made in Britain. This increases insurance bills, time
spent on litigation and the amount of "defensive" treatment and diagnosis.
3. No adjustment has been made - and admittedly this would be hard to
estimate - for the vastly higher expectations of patients in the USA.
4. No adjustment has been made for the way in which the superior
treatment and shorter waiting times at Kaiser must lengthen the lives of
people who are seriously ill, thus increasing the costs of looking after
them. It is much cheaper, to put it brutally, to let people die on a
waiting list. That enables the NHS to keep costs down. Keeping people
alive increases Kaiser's costs.
5. Kaiser keeps on the payroll many more specialists than the NHS.
In these ways, the performance of the NHS may be perceived as even
more lamentable than the bare report suggests.
Competing interests: No competing interests
Kaiser Permanente is not successful because of competition - it is
successful in spite of it!
Kaiser has a long history of providing better care for the same or
less money than any other major health care provider. Its rates used to be
'community-based' - every employer or enrollment group member paying the
same premium regardless of individual acuity, age, or medical history.
This is not surprising, because Kaiser provided all aspects of health care
as a nonprofit organization. Technically, the medical groups are for-
profit, while the health plan is nonprofit. The doctors can show a profit,
which they distribute to themselves in the form of shares, with the money
going back into the health plan instead of their pockets (As a nonprofit
the health plan cannot make a profit, although it can make an 'operating
margin,' to reinvest in infrastructure). Kaiser does not bear the
additional burden of the necessity of making a profit for shareholders nor
of providing expensive perks such as stock options for top executives.
The steps the government and its consultants took in the 90s to "open
up the health care market" were not wholly unlike those promoted by Enron
lobbyists to "open up the energy market to free competition," and we can
see where that led! Unfortunately, there is an inherent conflict of
interest in for-profit insurance companies: they answer primarily to their
shareholders and are in business to make money, not to provide health
care. Consequently, it is to their advantage to enroll only young, healthy
members ('cherry picking'), to get rid of expensively sick people
('dumping') and, generally, to deny care whenever they can get away with
it - hence the nonmedical claims authorization people whose job is just
that!
On a more basic level, these insurance HMOs are just middle men.
Unlike Kaiser, they don't own hospitals or clinics, or directly care for
anyone, and bear no risk. They aren't really 'Health Maintainance
Organizations' at all - they just shell organizations that contract with
the hospitals and medical group providing the care. They have been
successful because as more and more employers signed up with these
insurance companies, their bargaining power increased, enabling them to
ratchet down payment to hospitals and medical groups (that's why
independent doctors bad-mouth HMOs - not because of the quality of care,
but because they saw their huge incomes deteriorating, and why many want
to return to the old fee-for-service insurance reimbursement model).
The other reason for their success was to deny claims and to
introduce acuity-based premiums, in which employers with young and healthy
employees pay less for insurance than employees with old/sick employees.
The insurance companies did three things that they are good at: low
balling costs; denying claims; and being actuaries. That's been the key to
their success.
Employees are often not permitted to choose the health plan they
want. Employers with young and healthy employees began to drop Kaiser,
switching to the cheaper insurance companies, leaving Kaiser with, on the
average, older and sicker members. Kaiser was forced to increase its rates
to cover their higher costs, leading to more employers opting for cheaper
plans. In the industry this is known as the 'death spiral'. As younger
groups leave and older groups remain, premiums escalate until on one can
afford you any more. Kaiser almost went bankrupt.
Unfortunately, what they then implemented, on the pricing side, was
not much different from what the insurance companies implemented.
Employers with younger members now pay less than employers with older
members. (When a member without national health insurance through the
social security system who pays for his/her own premium (through a group)
turns 65, his/her premium now jumps to US$1649/month!) The only difference
is that Kaiser retains its own delivery system. Being run by doctors, the
emphasis remains on providing quality care. The 'insurance' side of Kaiser
is more like a poorly-run insurance company - an insurance company
handicapped by a conscience!
The biggest change in the health care industry is that drugs keep
people out of hospitals, resulting in lower hospitalization costs but very
much higher drug costs. While Kaiser provided drugs almost free of charge
($5 per prescription for decades, without limit), most other insurance
plans do not, often forcing the sick, and especially the elderly sick, to
choose between medicine and food or heat. To remain competitive, Kaiser
has been forced to raise per prescription drug charges to $15 and to
implement a $1,000 per year cap because many companies and public entities
are concerned only with which health plan is the cheapest - not which one
is the best, or the most cost-effective.
Drug cost is increasing faster than any other cost in the health care
industry. Much of the cost is driven by the drug companies themselves. For
example, since the ban on prescription drug advertising was lifted,
companies spent thousands of millions (yes - US 'billions') of dollars
advertising brand-name drugs. Both patients and doctors fall for these
ads, resulting in a huge amount spent on over-prescribed or inappropriate
drugs.
There is also the controversy about 'lifestyle' drugs. Clearly, an
HMO should pay for a drug that keeps you alive, but what about paying for
Viagra, so you can have sex more often. Heavily-lobbied California
insurance regulators said, "Yes!" And should I pay higher premiums so you
can take Rogain to have more hair? So far, they say, "No."
Kaiser's members have traditionally been mostly low and middle class
workers. Big corporations often have different, and far better, plans for
those who least need them - the top-paid executives. Probably the worst
possible steps for a publicly-funded health care system to take would be
to implement a two-tiered system, a 'private' one for the affluent or
those with organizations providing top health insurance and another for
the 'others,' starting a downward spiral in which those with better care
(and more influence) oppose funding for the system they don't use,
weakening it and making more people anxious to get out, further reducing
its funding...
The NHS, of course, needs to increase efficiency and reduce
unnecessary hospital stays, but more important is the concomitant need to
control drug costs, recognizing the rapacious greed of many of the drug
companies. Other than direct price controls, prices can be kept under
control by reasonable patent expirations (something drug company lobbyists
in the US pay politicians many tens of millions of dollars to avoid) or by
direct governmental control of the fruits of basic research at public
institutions leading to these drugs. Virtually every major drug on the
market today was developed in part with tax dollars - direct clinical
support, not just the R & D tax breaks given to pharmaceutical
companies! Ideally, you would have a single international body, which
could contract with private companies, for international research and
approval of drugs.
One thing NOT to do is to hire a phalanx of expensive, self serving
and well-connected consultants to tell you what to do. Kaiser made this
mistake over several years recently. The major blunders that resulted were
extremely expensive, leading to the first sea of red ink in Kaiser's
history and almost to its collapse, also taking a serious toll on the
morale of those attempting to provide caring, quality services! Find out
how best to improve services by talking to those on the line providing
them!
Competing interests: No competing interests
As has been commented upon, the business of making comparisons
between health systems is difficult. In addition to the several issues
already cited by respondents the article by Feacham et al gives an NHS
cost of £58.5 bn but revenue allocations this year to Health Authorities
in England are in fact £37,157m.
If the £58.5 bn cited includes all NHS expenditure (and not just
allocations to health authorities) in England then there are some very
real comparative problems. Not included in the £37 bn figure above, but
possibly in the £58.5 bn figure, would be central budgets of the
Department of Health that fund - amongst other things - undergraduate
nursing tuition and bursaries as well as those for allied health
professionals and additional costs associated with teaching hospitals.
These alone total to nearly £1.5 bn. Presumably the Kaiser figures do not
include the costs of training and educating the health workforce in
California. The £37, 157m figure for health authority allocations includes
amongst other things includes expenditure on public health and ambulance
services. Presumably Kaiser Permanente does not fund the Public Health
departments at state, county or municipal level in California or ambulance
services in the state?
The article also refers to the UK and uses the population of the UK.
The Department of Health is the health department for England only and not
for Scotland, Wales or Northern Ireland. Nor is it the UK's department of
health as responsibility is split between the four constituent countries
of the UK. The Secretary of State for Health is accountable to the UK
Parliament but only for the money voted for use in England. It is not
clear therefore whether the £58.5 bn relates to England alone or is an
aggregate of the funding in the four countries.
Given the central conclusions in the article about the comparability
between the NHS in the UK and Kaiser Permanente it would be important for
the NHS funding and population figures to clearly relate to one of the
countries alone or the UK as a whole and for the NHS expenditure figure to
be analogous to the services covered by Kaiser Permanente.
Competing interests: No competing interests
Reducing bed days can not be established before establishing a good
integrated out of the hospital strategy (hmoe health, visiting nurse, out
patient infusion center, home IV therapy, access to subspecialist follow
up appointment, also coordinating the information regarding the hospital
course.
As an allergist and an asthma care manager in Kaiser permenante, I had to
work with a large group of asthma specialists, pharmacists, information
techology, hospital admitting staff and emergency department staff to
reduce our hopital admission rate and our ED visits rate.
Working together as an integrated team, we were able to reduce our
admissions from 210 admissions per year (1998, 1999) to 65 admission in
the year 2000 and 47 admissions in the year 2001. Our ED asthma visits was
2300 vistes per year in 1998 and 1999, to 870 ED visits in the year 2001.
This was done by funding for the information technology, funding more
time the asthma specialists, so a an asthmatic can be seen within 5 days
of their ED visit or hopsital admission, to integrate a referral to asthma
specialist in the ED system and hospital system.
When the asthmatic is seen in my office, I turn to my PC to find all the
critical information needed to continue the work.
The point I am trying to make, you can not wait for the saving from your
length of stay to build the intergrated system, you have to invest first
then enjoy the fruit of that investment (better outcom, less admissions,
shorter length of stay etc..)
Competing interests: No competing interests
Am I alone in seeing clearly the reason why the performance of the
NHS is failing so badly in comparison with Kaiser Permanente. 1 It is
fairly obvious that employing twice as many specialists per head allows
far better access to specialist services.
Whereas comparisons in terms of acute bed days per 1000 population showed
the NHS having more than triple that of Kaiser Permanente, average length
of stay was only an extra 1.1 days. This suggests that patients in
hospital are being processed fairly efficiently despite the paucity of
Information Technology support.
The argument about bed numbers is old and sterile. The Kings Fund has had
a long held view that many hospital beds were unnecessary wishing most
patients to be managed in the community. This influence has had a major
impact, contributing to the many trolley waits in our hospitals today.
Much of hospital activity in Britain is generated by emergency admissions
and beyond our control, related more to socio-economic factors. 2
Admission and outcomes, measured by standardised mortality ratios, are
most strongly associated with numbers of doctors serving a community and
with only 59% those of similar countries 3 it is not surprising that our
NHS is failing
In my local area, one of the most impoverished in England, the demand and
activity of our local Medical Admissions Unit have increased from an
average of 360 admissions per month 7 years ago to over 660 currently, an
increase of 83%.
My average bed stay has fallen from 8.8 to 3.1 days. We have done this
with innovative team working but early discharge puts a considerable
strain on outpatient resources and reduces access for new patients. The
work pressure on junior medical staff with reduced hours also impacts on
their quality of training.
The only answer for any further improvement is an increase in Consultant
numbers, especially as the NHS is rapidly evolving into a Consultant run
service.
Without an investment in specialist numbers and an immediate increase in
the number of trainees to fill these places no amount of indiscriminate
funding will achieve the goals of the present government.
I would contend that there has been considerable under-investment in the
NHS but largely in terms of medical manpower. This paper from California
illustrates that this is a false economy and simple analysis points the
way forward supporting the Labour Party Manifesto to increase doctor
numbers by 10,000.4
When will Alan Milburn facilitate this election promise?
Michael Bone
Consultant Physician
South Tyneside District Hospital,
Tyne and Wear NE34 0PL
Michael.Bone@eem.sthct.northy.nhs.uk
1 Getting more for their dollars: a comparison of the NHS with
California’s Kaiser Permanente
Richard GA Feachem, Neelam K Sekhri and Karen White
BMJ 2002;324: 135-43.
2. Explaining variation in hospital admission rates between general
practices: cross sectional study
Fiona D A Reid, Derek G Cook, and Azeem Majeed
BMJ 1999; 319: 98-103
3. Explaining differences in English hospital death rates using
routinely collected data
Brian Jarman, Simon Gault, Bernadette Alves, Amy Hider, Susan Dolan,
Adrian Cook, Brian Hurwitz, and Lisa I Iezzoni
BMJ 1999; 318: 1515-1520.
4. Labour Party Manifesto 2001
Competing interests: No competing interests
Re: Getting more for their dollars: a comparison of the NHS with California's Kaiser Permanente
Richard G A Feachem, et al., reached these conclusions: "The widely
held beliefs that the NHS is efficient and that poor performance in
certain areas is largely explained by underinvestment are not supported by
this analysis. Kaiser achieved better performance at roughly the same cost
as the NHS because of integration throughout the system, efficient
management of hospital use, the benefits of competition, and greater
investment in information technology."
These conclusions by Feachem and his colleagues are plain wrong. To
avoid fooling themselves and others, they need to go back and take a more
careful look.
There are certain unmentioned but nonetheless stubborn realities
about medicine in the U.S. that must be fully recognized before any
accurate evaluation of comparative performance can be made between the
British National Health System and any part of the American medical care
delivery system, including the Kaiser California HMO.
In one of its recent reports, the Pew Health Professions Commission,
chaired by Senator George Mitchell, offered these observations about
American medicine: "During the last century, the U.S. medical profession
has been transformed from a system dominated by general practitioners into
a body of highly specialized physicians. In 1931, more than four out of
five physicians (80%) were in general practice, yet after World War II,
the proportion of physicians who were generalists fell rapidly. By 1965
the proportion dropped to about one-half (50%), and by 1990, the
percentage of physicians in generalist areas had decreased to
approximately one-third (33%) of all physicians. In most Western nations,
the percentage of primary care physicians far exceeds that of the United
States, with 50% of Canadian physicians and 70% of the British as general
practice or family physicians. ...Some studies indicate that the relative
emphasis on specialized services in the United States does not result in
improvements in broad measures of health status."
An Advance Data Report issued by the U.S. Communicable Disease Center
on August 11, 2003 and entitled: "National Ambulatory Medical Care Survey
2001 Summary," includes a breakdown of the distribution of total
annual patient visits between primary and specialty care physicians. There
were 880.5 million total patient visits with physicians during calendar
year 2001. Sixty percent of these, or a total of 528.3 million visits,
were with primary care physicians "general or family physicians,
pediatricians, general internists, and ob/gyns." There were 707,000
active physicians in the U.S. in 2001, with 235,000 of them being primary
care practitioners, the remainder being specialists of one sort or
another. Doing the math, primary care physicians handled an average of
2,248 patient visits that year, while the various specialty physicians had
an average of 539 patient visits. That is, thirty-three percent of the
physician workforce primary doctors -- received seventy-six percent of
the total visits. Sixty-seven percent of the physician workforce
specialist physicians had twenty-four percent of the total visits.
Assuming an average of 180 days spent seeing patients for all U.S. medical
doctors, primary doctors saw an average of 13 patients per day, while
specialists saw an average of 3 patients per day. However, the income
distribution was in inverse proportion to the distribution of visits: the
higher the average number of patients seen, the lower the annual income of
the physician, and vice versa.
Because specialist physicians are able to realize average annual
incomes at least twice as large as the earnings of the average primary
doctor, and in some instances as high as forty times the average income of
a primary physician, the Kaiser plan "which salaries its physicians"
often has difficulty in holding onto top-notch specialists. Some of the
adverse results of this specific reality might be seen by focussing study
on a single disease, for example diabetes milletus, and examining the
relative outcomes between the NHS and the Kaiser plan.
The general quality and efficacy of diabetes care in America as
compared with diabetes care in the U.K. can be judged by reference to
World Health Organization (WHO) statistics. The WHO regularly gathers
clinical data on the causes of death, based upon ICD-9 (International
Classification of Diseases, ninth edition) codes. The WHO reports include
deaths from all causes, and deaths in each specific ICD-9 category. A
comparison of the incidence of deaths caused by diabetes in the United
States with those in the United Kingdom over a similar five-year period
provides a concrete and reliable means of measurement. The following table
is based on data from the World Health Statistics Annual for 1993:
In the United States, there were 17,674 more deaths from all causes
in 1992 than in 1988. There were 9,699 more deaths from diabetes mellitus
in 1992 than in 1988. This means that 55 percent of the increase in
American deaths in 1992 were attributable to DM. There was a 27 percent
increase in the rate of DM-caused deaths as a percentage of deaths from
all causes. In the United Kingdom, the statistics tell a quite different
story. There were 748 more deaths from all causes in 1993 as compared with
1989; and there were 1,663 fewer deaths from diabetes in 1993 than in
1989. During an analogous period, the United Kingdom experienced a 76
percent decrease in the rate of DM-caused deaths as a percentage of deaths
from all causes.
Making these statistics appear even worse for U.S. medicine is the
fact that the federal National Institutes of Health has published findings
of serious underreporting of diabetes mellitus by physicians, and has
suggested that the correct number of DM-caused deaths in the United States
in 1992 was 169,000, or 3.4 times the number reported to the World Health
Organization.
In either event, the comparison of WHO data for an analogous five-
year period demonstrates clearly that British GPs and their patients are
managing diabetes in a manner that yields outcomes far superior to those
resulting from the medical practices of American physicians in coping with
this disease.
The disturbing morbidity and mortality statistics cited here for
Americans with diabetes mellitus are the direct result of an approach to
medical care that values tons of cure very highly, and that places no
value whatsoever upon the ounce of prevention. Because Kaiser physicians
are drawn from the same pool of residency graduates as non-Kaiser
physicians, despite the different financial incentives that result from
being salaried rather than fee-based, their patterns of clinical behavior
do not differ in any significant way. Kaiser physicians tend to exhibit
the same lack of insight concerning the ways and means to train DM
patients to self-manage their disease as do American medical doctors
generally. During 2002, one of the regional Kaiser plans terminated the
position of Diabetes Educator and assigned the pivotal responsibility for
training DM patients in managing their disease to already overwhelmed
staff nurses. In this region, didactic courses are being offered to fill
this enormous gap, with no provision made for patients to undergo
interactive learning opportunities within the clinical setting. It ought
to be clear that lecturing will never produce effective self-managers of
NIDDM. The hard fact has been entirely missed that this is one of the most
penny-wise and pound-foolish things that could be done within a plan that
is based on prepayment, such as the Kaiser plan.
Each year, the eight million people who have been diagnosed with
NIDDM account for over sixteen million physician visits. What happens to
them during those visits adds up to a very sad, persistent story of
inadequate and sub-standard medical performance. Diabetic patients too
often leave their primary physician's office with no complete, accurate
knowledge about their disease. Many have reported being told: "Take one
of these pills daily, and don't eat sugar." Until very recent years,
U.S. health insurers did not pay for blood sugar monitoring equipment
unless the disease had progressed to the stage of insulin dependence; and
few insurers paid for the test strips required to use the monitor. As a
consequence, blood sugar levels skyrocket and plunge in individual
patients; many complications occur; urgent or emergent care or
hospitalization for "diabetes out of control" is frequently required;
toes, feet, and legs are amputated; people lose their eyesight; and these
patients suffer a much higher incidence of stroke, heart attack and
peripheral vascular problems. In the United States, the percent of visits
for diabetes went up 63 percent between 1992 and 2001, and diabetes was
the primary diagnosis at 27 million doctor visits during 2001. One third
of all babies born in the U.S. now carry the gene for diabetes, thus these
already depresssing numbers are bound to continue exploding in future
years.
Even if all primary doctors whether in fee-based practice or within
HMOs such as the Kaiser plan -- had all of the information needed to
effectively manage NIDDM, which they generally do not have, they would not
have either the time or the inclination to effectively transfer this
information to their diabetic patients. Within a fee-for-service practice,
there is no reimbursement to be had for teaching patients how to manage
their disease, creating an overwhelming disincentive for the physician to
attempt this. In terms of clinical performance, doctors in the Kaiser plan
tend to exhibit the same practice patterns with diabetes mellitus patients
as their fee-based colleagues, even though the economic imperatives are
quite opposite.
In diabetes education, the key commitment for the teacher and for the
learner must be to focus on the management of a process of care, in
contrast to American medicine's habitual focus on treatment of an episode
of illness. A 1995 Pew Health Professions Commission report includes the
following observations: "The system is orientated to serving individuals
and their immediate treatment needs and not to recognizing disease and
disability as products of multiple influences: psychological, social,
behavioral, economic and political. ...The American health care system,
without the benefit of a capacity for self-correction, has grown to the
point where it endangers public and private spending on other essential
activities. In the face of this unsustainable growth a frightening reality
confronts the American public...the largest cohort in the nation's
history, the Baby Boom generation, does not turn 60 until 2006. When this
cohort reaches retirement, it will place even more strain on a system
which is failing today."
*In a study of the overall effectiveness of diabetes care in the
United States, epidemologist David Marrero offered the following
concluding remarks: "How might we judge the quality of care being
provided to people with NIDDM by primary care physicians? The brief
overview presented here using state and national samples suggests that
despite considerable efforts to disseminate practice guidelines in the
last decade, there continue to be gaps between the current recommendations
for care and actual PCP practices. Specifically, for patients with NIDDM,
methods for assessing chronic glycemic control and strategies for the
screening and treatment of retinopathy, nephropathy, and foot problems are
not uniformly applied. Moreover, in most surveys, the data suggest that
patients with NIDDM receive less aggressive treatment and fewer preventive
services than patients with IDDM. The reasons for this finding are
unknown. However, it may be inferred from the data that [primary
physicians] may perceive NIDDM as a less serious illness than IDDM. From a
public health standpoint, providing fewer preventive services to people
with NIDDM greatly increases the burden of diabetes, because NIDDM
constitutes the majority of cases, and some complications, such as
cardiovascular and foot disease, are more common in NIDDM patients."
*Anne L. Peters, M.D., Professor of Medicine in the Division of
Endocrinology at UCLA's School of Medicine, wrote as follows in her 1996
commentary on a study by R.G.Hiss, RM Anderson, G.E. Hess, C.J. Stepien
and W.K. Davis entitled Community Diabetes Care, published in the journal
Diabetes Care: "Why, with the advances in technology and an increasing
awareness of the value of maintaining near-euglycemia, is the quality of
diabetes care so poor in almost every setting in which it is measured?
Part of the problem stems from a lack of knowledge on the part of both
patients and physicians regarding appropriate glycemic goals and how to
achieve them. Second, while busy physicians may ask patients to collect
SMBG (self-monitoring blood glucose) data, these physicians often do not
act upon the data in a timely and effective fashion. Management decisions
must be closely linked to the collection of SMBG and laboratory results.
(Often the required laboratory tests are not obtained at all.) One
example, from a chart review of patients with diabetes, is a chart on
which it was noted 'blood glucose level=450 mg/dl, continue glyburide,
return to clinic 1 year.'"
Obviously, a patient with a blood glucose level of 450 mg/dl should
not be permitted to leave the clinic without immediate treatment to
gradually reduce their blood glucose level.It is unconscionably bad
medical practice to otherwise release these patients, much less to dismiss
them for an entire year.
*The Diabetes Educator dated July/August 1991 reports that
Pennsylvania State University researchers surveyed over 600 primary care
physicians and discovered that over 90% "did not read any diabetes
publications. Only 2.6% read Diabetes Care, the primary clinical journal
of the American Diabetes Association. The care provided by the physicians
was deficient in four major categories: patient use of home blood glucose
monitors, frequency of glycoslyated hemoglobin measurement (a measure of
the amount of sugar attached to red blood cells), routine referrals to eye
doctors, and routine foot examinations."
*In the July 1996 issue of Diabetes Care, William W. Fore, M.D., one of
twelve partners in a physician clinic, stated that many physicians: "talk
the talk, but they don't walk the walk."
* The February 1997 issue of Diabetes Care, Raymond Fabius, Medical
Director of U.S Healthcare/Aetna, [an HMO] is quoted as stating that 90
percent of the direct costs for nearly 40,000 diabetic members were
incurred by 2,000 of those patients; and 50 percent of total costs were
incurred by the 300 most ill patients. These are the disastrous wages of
"talking the talk, but not walking the walk" when it comes to caring for
patients who have diabetes.
In the United States, medicine cannot progress as a true science
unless it recognizes the need to resituate its generalist physicians in a
central role, as the key managers of the processes of care for patients
with chronic and acute problems, and as effective agents in the promotion
of health.
Achieving the changes in academic medicine that would reposition
primary care physicians to perform the functions of general medical
managers, directing the entire field of non-emergent medical practice,
will prove to be extremely difficult. Specialist physician free barons,
particularly those in academia, are not likely to surrender any part their
present power, status, influence, or income on a voluntary basis, much
less as the result of a sudden reawakening of Hippocratic zeal. In their
December 1995 report titled Critical Challenges: Revitalizing The Health
Professions for the Twenty-First Century, the Pew Health Professions
Commission said this: "The difficulty of changing the established
patterns of professional education and practice should not be
underestimated. For instance, while there is little doubt that medical
specialties are in oversupply, the government still subsidizes graduate
medical education with over $6.5 billion annually, [$12 billion in 2002]
most of which goes to train more specialists. ...The subsidy for education
that is tied to care delivery must be broken. ...To address the changes in
health in a responsive manner will require the bold action of leaders in
all sectors of the system. Bold action is not something that has typified
the governance of the profession or, for that matter, higher education.
Like so much of today's health care system, this attitude must change.
Fundamental alterations in the processes that govern professional
education, regulate the professions, orient professions to practice and
finance education will be required. This will mean action at the federal,
state, institutional and professional levels. ...Professional training and
practice should place more emphasis on developing the qualities of a
superb generalist, capable of comprehensive management of care, as opposed
to the current orientation toward specialization. ...The current
environment of overspecialization, orientation toward high technology
medicine, and preference for institutionally based education is the result
of over 40 years of direct and indirect federal policies. Only a
purposeful reformation of these policies will bring significant change."
Feachem et. al. need to take another, much more disciplined look at
Kaiser California and at the structure and practice of American medicine
in general, touted as it often is as representing "the best medical care
in the world." The sooner they do this, the better.
Competing interests:
None declared
Competing interests: Year Nation Deaths/All Causes Deaths/DM %/Total + or -1988 USA 2,167,999 40,368 1.8% 1992 USA 2,185,673 50,067 2.3% +24%1989 UK 657,733 8,486 1.3%1993 UK 658,733 6,748 1.0% -20%