We have the UK system in America in two forms… the least efficient model is the VA… a government run health care system that is similar to the UK’s NHS. We also have a non profit private health care system in California call Kaiser Permanente, which is an interesting option for America.
In the last year the VA has gotten much better. Kaiser has always been very good. Why has the VA gotten better and Kaiser been very good all along. Because they piggyback on the far larger private sector health care system. The underlying “service” problem with both and with the NHS in the UK is they are built around “estimated demand”. While annual demand is generally predictable except when something like the current virus hits, both seasonal factors and regional variation mean whether you are in the UK, going to the VA, or going to Kaiser… you inevitably wait. For example, I was born with heart defect that meant at some point I would need pretty major open heart surgery… when I reached that point, it took four months before Kaiser could do the procedure, because I was not at risk of dying at that very moment, though I did have a large aneurysm that if it burst would have meant game over. It did not burst (obviously) and when my “turn” came I had an excellent physician who did a wonderful job. When I needed a hip replacement with Kaiser, it took nine months to get it even after I had already been limping around on a cane for two years.
So these systems are efficient because they tightly manage capacity and so do not have a lot of excess capacity when demand changes. It is why people in England and the VA complain about “waiting to be seen”, “waiting for a test to be done”, or waiting for a non emergency procedure. Even necessary open heart surgery is not an emergency.
Why can’t the system “flex” more like the regular private health care system we have in the US. There are two reasons. The first is sheer capacity. Health care is profitable and competitive except in England, the VA, and Kaiser. If one provider cannot give you the medical care you want, then another will. So providers compete for customers through “fast service” and quality (not so much price since the average consumer is not paying the bill). There is no competition when it comes to care with respect to the UK’s NHS system, our VA, or Kaiser. So while in most instances the “quality of care” is pretty good, the speed of getting care can be really frustrating… now if you have never known anything better, then perhaps it does not bother you.
In addition, the NHS, the VA, and Kaiser all suffer from the opposite problem of “abusing” the health care system. In our Medicare, Medicaid, and private health insurance system, I already went through how both patients and providers abuse the system. Patients seek care that they don’t need and providers provide care that patients don’t need. At least in the instance of patients seeking care they don’t need, it not profit related but behavioral or psychological.
Unlike the normal health care system in America made up of a bunch of providers that operate “entrepreneurial” businesses trying to grow volume to increase profits, the NHS in the UK, the VA, and Kaiser generate no profits by delivering care all they experience is costs. And so individual provider productivity is terrible in these systems. In effect, they suffer the opposite problem. These staff model delivery systems that pay physicians primarily salaries save money over the traditional American health care system by avoiding “abuse”, which as mentioned is extremely expensive.
But typically there average care giver is one third to one half as productive as a care giver in the American health care system. Whether we are talking about physicians or nurses. For example, I ran a primary care physician group where our average doctor saw 28–35 patients a day and during flu season that might jump to 40–45 (patients coming in the with “whatever is going around” take very little time to diagnose (literally around seven or eight minutes of physician face time if they have no other medical complaints). At Kaiser and most staff model physician practices the target is 18–22 patients a day and during the flu season that number increases to maybe 18–22 patients a day (in other words, it does not change because the physicians do no work overtime). While most staff systems have some form of urgent care centers, the result is that emergency rooms get “flooded” with patient overflow due to lack of “flex” in the lower cost primary care locations.
I also ran the second largest home care and health care staffing company in the country at the time. Our home visit nurses were paid “per visit” and typically did 5–6 visits per day or 25–30 visits per week. Typically salaried home visit nurses due around 15–20 visits per week. In other words, each system has different strengths and weaknesses to manage. Staff models like NHS, the VA, and Kaiser do not suffer from providers abusing the system, but do suffer from a dramatic lack of productivity relative to the more entrepreneurial provider system in America. That is good.
But they also can’t flex their capacity much (creating wait times during sudden shifts in demand) and the cost per patient encounter is far higher because you have to spread the physician or nurse cost over fewer encounters or surgeries or whatever other health care transaction is occurring.
In the end, if the private health care system has no private health insurance company managing abuse, the staff model works better. That is how expensive abuse can be and why government health care programs in the US suffer so much because of it. On the other hand, if you can get the physician productivity that the US private health care system rewards and tightly managed utilization so abuse is limited (it never goes away totally), then you can actually get an equally or even more cost efficient system than the staff models offer.
But besides matching the cost of a staffing model, you also get a health care system with more more flexible capacity and hence better service and since time delays do occasionally end up with terminal outcomes, a better health care system. This explains why so many people talk about the waits associated with some government single payer systems… they are a function of the fact that in one way or another the government controls the demand for services by limiting the availability of resources… in staff model systems that limit is virtually always capacity.
Other single payer models like Germany and Japan as examples which are not really single payer systems in the sense that multiple entities administer the government programs have different means built into them to try to control health care costs. The single most powerful tool used by virtually all non staff model single payer systems are price… but using price as a toll to manage health care costs has issues… I will address those in another response…
As an aside, I do like Kaiser even if it does require me to wait on occasion, because I trust them and they not only have a tremendous incentive to keep me healthy… profit, but their doctors have no incentive to provide me unnecessary care (abuse). But service times are less good than the traditional health care system.
