Running Head: HEALTHCARE IN THE UK AND THE US: II
Health Care in the United Kingdom and the United States: Part II
Katie Lebiedzinski, Raul Lopez
Northern Arizona University
There is much diversity in regards to the types of health care delivery systems across the world. The aim of this paper is to discuss the health care systems of the United Kingdom and The United States. There is a focal difference between the health care systems of the United States and the United Kingdom: funding. The United States has primarily private funding for their healthcare and The United Kingdom has primarily public funding for their healthcare (Kovner, Knickman, & Weisfeld, Jonas and Kovner's Health Care Delivery in the United States, pp. 2871-2895). In fact, the United States in the only industrialized country that does not have some structure of universal access to medical services (Light, 2003). This paper will further illustrate the process of health care delivery in the United States and in the United Kingdom, including the health delivery models used, availability of providers, the uninsured population, uncompensated care, rationed care, physician choice, and wait times. It will discuss how quality of care is measured and monitored, including comparative effectiveness research and how is it utilized for quality and cost-effective care, and incentives for quality of care. The paper will discuss the delivery methods of long term care, including population needs, barriers to quality of long term care, and cost of long term care in the United States and the United Kingdom.
Health Care Delivery
The United States and the United Kingdom use different models for their health care delivery. The United States uses a Private Health Insurance model and the United Kingdom uses the Beveridge model. The Beveridge model is a publically funded model that provides universal coverage. The Beveridge model was developed by Sir William Beveridge specifically for the United Kingdom after World War II. The Beveridge model is characterized by tax-financing that increases based on proportion to income. The Beveridge model is a single-payer system that is government run. The United States’ Private Health Insurance Model has limited government role and gives the greater part of the role to private health insurance companies. While the United Kingdom uses tax-financing to fund their health care system, the United States funds their health care system through employer and employee contributions. Private sector insurance is premium based, which means that the amount paid is determined by the insurance company instead of being based off of a percentage of income that is determined by the government. (Kovner, Knickman, & Weisfeld, Jonas and Kovner's Health Care Delivery in the United States, 2011, pp. 2871-2895), Although the majority of Americans have insurance that uses a Private Health Insurance Model, those covered by Medicare have insurance that combines the Bismarck and Beveridge models (Kovner, Knickman, & Weisfeld, Jonas and Kovner's Health Care Delivery in the United States, 2011, p. 2976).
The United Kingdom has more physicians per capita than the United States. Often people believe that America has the most physicians. This is because the United States has a much larger population than the United Kingdom. The United Kingdom has 166,006 physicians and the United States has 749,566 physicians (The World Health Organization, 2012, p. 128). The population in the United Kingdom in 2011 was 63,182,000 (Office for National Statistics, 2012). The population in the United States in 2011 was nearly five times that amount-313,232,000. (The Central Intelligence Agency, 2013). The United Kingdom, in fact, has more physicians per capita than the United States does. The United Kingdom has 27.4 physicians per every 10,000 people, while the United States has 24.2 physicians per every 10,000 people (The World Health Organization, 2012, p. 128). According the General Medical Council, there are currently 70,748 Specialists and 59,870 General Practitioners licensed in the United Kingdom (General Medical Council, 2013). In 2010, there were 437,639 employed medical specialists in the United States (The Kaiser Family Foundation). In the same year, there were approximately 209,000 practicing primary care physicians in the U.S. (Agency for Healthcare Research and Quality , 2011).
The most astonishing difference between the United States and the United Kingdom is the amount of people that are uninsured. In the United Kingdom, 100% of the population is covered under the National Health System (Saha). The United Kingdom provides National Health Service to all of its permanent residents (Chang, Peysakhovich, Wang, & Zhu). This means that no one in the United Kingdom is without health insurance coverage. In the United States, many citizens go without health insurance. In 2011, 15.7 percent of the population did not have health insurance, about 48.6 million people. The percentage of Americans that had health insurance in 2011 was 84.2 percent, or 260.2 million people (The United States Census Bureau, 2012).
According to the US department of Health and Human Services, uncompensated care is defined as “Health care or services provided by hospitals or health care providers that don't get reimbursed.” Uncompensated care often occurs when the uninsured cannot afford to pay for the cost of their care. (US Department of Health and Human Services, 2013). Uncompensated care in the United States has become a huge problem because of the immense population that does not have health insurance - nearly 16 percent. Although the number of people without health insurance is declining (The United States Census Bureau, 2012), the amount of uncompensated care that is paid out every year is increasing. In 2004, uncompensated care was estimated to be $40.7 billion (Hadley & Holahan, 2004 ). Four years later, total government spending to reimburse uncompensated care costs was approximately $42.9 billion (Executive Office of the President Councik of Economic Advisors, 2009). Given that uncompensated care is essentially unpaid medical costs due to the uninsured, the United Kingdom does not have uncompensated care because everyone has health insurance coverage and unpaid medical costs are low (Chang, Peysakhovich, Wang, & Zhu).
Health care rationing can be defined as “planning for the equitable allocation, apportionment, or distribution of available health resources” (Reference.MD). The United Kingdom has rationed health care in the traditional sense that they have a have a government agency that makes health care rationing decisions, the National Institute for Health and Clinical Excellence (NICE). NICE was established in 1999. NICE makes the decisions about which drugs and treatments can be provided by the doctors of the National Health System. NICE makes its rationing decisions based on the thought that the government should spend its “limited resources on treatments that do the most good for the money.” NICE uses a measurement tool, the quality-adjusted life year, or QALY, to determine if the treatments provided are giving them the most benefit for their money (Cox, 2010). Although America does not have rationed healthcare in the traditional sense, some argue that America’s health care is rationed based on the ability to pay. For example, Dr. Arthur Kellermann, professor of emergency medicine and associate dean for health policy at Emory University School of Medicine, states in an article "In America, we strictly ration health care. We've done it for years, but in contrast to other wealthy countries, we don't ration medical care on the basis of need or anticipated benefit. In this country, we mainly ration on the ability to pay. And that is especially evident when you examine the plight of the uninsured in the United States" (Horsley, 2009). The authors of Healthcare Delivery in the United states point out that some observers say that medical care is rationed now, primarily based on patients’ ability to pay—either through insurance or out-of-pocket (Kovner, Knickman, & Weisfeld, Jonas and Kovner's Health Care Delivery in the United States, 2011, p. 5934).
How does the United Kingdom compare to the United States when it comes to being able to make choices about your doctor? While the United Kingdom government claims that everyone has the right to choose their doctor, the United Kingdom population often has complaints about lack of choices, not the ability to choose. According to the National Health Service website, “You have the right to choose a GP practice and to be accepted by that practice unless there are reasonable grounds to refuse you, such as living outside the practice boundary.” Many of the comments on the National Health Service website from users of the National Health Service show concern about their lack of ability to chose a care provider due to limitations on number of providers that are within their practice boundaries. Many people are denied service from providers because they are outside of their “catchment areas” (National Health Service, 2011). In the United States, you have the ability to chose your doctor if you have health insurance, but many do not have health insurance. Limits can be placed on the population with insurance because many insurance plans have a list of providers that you must choose from. Often insurance companies will offer financial incentives to go to providers that are in their network of providers. The National Institutes of Health recommends that before Americans pick a doctor, they should first narrow down their options by seeing what will be covered by their insurance company (National Institutes of Heatlh, 2012).
One of the major concerns that opponents of publically funded health care systems have is the long wait times for diagnosis and treatment. According to the NHS choices website, “you have the right to start your consultant-led treatment within a maximum of 18 weeks from referral, unless you choose to wait longer, or it is clinically appropriate that you wait longer.” The website also lists many exceptions to this rule: if you choose to wait longer, if delaying the start of your treatment is in your best clinical interests- for example where stopping smoking or losing weight is likely to improve the outcome of the treatment, if it is clinically appropriate for your condition to be actively monitored in secondary care without clinical intervention or diagnostic procedures at that stage, or if you fail to attend appointment. Also, non-medical consultant-led mental health services and maternity services are not covered under this right (National Health Service, 2013). According to Harrison & Appleby, 2006, 85 percent wait less than three months and the government’s 18-week maximum wait target from referral to treatment (Harrison & Appleby, 2006). If a person is not seen within the maximum 18 weeks, the primary care trust (PCT) or strategic health authority(SHA) that commissions that persons’ treatment must probe and offer them a range of appropriate options for hospitals or community clinics that would be able to see or treat them faster (National Health Service, 2013). Wait times in the Emergency Departments in the United Kingdom have become a problem. The quantity of patients who spend more than four hours in emergency departments in the United Kingdom has risen by more than 25 percent the past year (Lipley, 2012). Research from Press Ganey Associates, a group that works with health care organizations to improve clinical outcomes, found that in 2009, patients admitted to hospitals waited an average of six hours in emergency rooms (Baystate Health, 2012). Although American have longer ER wait times, Americans report the shortest wait for specialist care, with 74 percent waiting fewer than 4 weeks (Kovner, Knickman, & Weisfeld, Jonas and Kovner's Health Care Delivery in the United States, 2011, p. 2800).Wait times for diagnosis and treatment in the United States are particularly lower than that of publically funded health care systems, but at what cost? Some attribute short wait times in the United States to health care prices being characteristically higher than in other industrialized countries. Another reason for low wait times in America is because demand is reduced by the large fraction of the uninsured population (Pizer & Prentice, 2011).
Quality of Care
The quality of care in the United Kingdom is measured on a system they call Quality Outcomes Framework (QOF). The QOF is a measured based on four main categories such as patient experience, clinical, organizational, and additional sources. Within these main categories it gets broken down even further specific categories i.e. patient experience would be graded on waiting time for the patient or a subcategory of a specific disease in the clinical category. This way the United Kingdom could actually measure how the care is measuring up to certain standards. As mentioned by Downing et al (2007) “The success or failure of this target based approach depends in significant part on two issues, namely whether it is possible to design a robust and clinically meaningful set of indicators, and whether financial incentives change doctors behavior and thereby improve patient care” (p. 7). Based on each indicator and how it is rated would then grade the quality of care in such as in a specific health problem. QOF is what the United Kingdom uses to score the quality of care in the country.
In the UK a study was made on health care inequalities in minority groups and this study was spearheaded with the measurement of quality. Whether the quality was good in the specific low minority populations and when they realized it was poor quality, the following task was to figure out the reasons for the lower quality. With a framework as mentioned above the conclusion was communication, more specific language barriers. As stated by Ansari et al (2009) in this specific research “Providing appropriate interpretation services and advocacy are both mechanisms by which BME (Black and Minority Ethnic) needs are articulated, therefore increasing the possibility of receiving appropriate care and participation in care decision making” (p 637).
The United States in contrast uses individual research by stakeholders or academic researchers to help understand the quality of care. The United States uses Comparative Effectiveness System to do research and help with quality improvement. With certain statistical studies on certain diseases give the measurement of quality one step at a time in America. Though the measurement could be skewed dependent on who is performing the statistical and quantitate research it’s how one could see how good or bad the American health care is. One example of a private study by McGlynn et al (2003), Americans receive the recommended care only fifty five percent of the time.
In the United States the general consensus of my research has demonstrated a much-relaxed way of measuring quality. The quality is dependent on who is doing the research, and actual model is not used evenly nationally. There is no one that restricts any of the research or who can carry out the research, as long as there are credible sources to what part of health care is being evaluated.
In the United States the American Recovery and Reinvestment Act (ARRA) brought Comparative Effectiveness Research or CER to the publics attention. This bill added a large sum of money to help this program grow, CER in the US is used to research certain medical and health care problems, such as treatments for certain diseases and how they work towards better results. Stated by Demaria (2009) “Nevertheless, despite the new designation of “Comparative Effectiveness Research,” and the enormous bolus of money directed to the effort, the concept of defining the most effective clinical practices and employing that evidence in our clinical decisions is not new” (p. 974). CER is used widely in the United States to set healthcare laws or health care procedures and therefore making certain procedures or algorithms universal Nationwide.
In the United Kingdom the program they use for research and decision-making is called the National Institute for Health and Clinical Excellence (NICE). As revealed by Chalkidou et al (2010) “NICE and NIHR (National Institute for Health Research) have directly and indirectly supported the development of methods of subgroup analysis to allow for decisions to take into account factors (such as co-morbidities, sex and race) affecting a treatment’s clinical effectiveness related either to the intervention itself or to underlying disease” (p 803). NICE allows the health care system run smoother and allows the decision making process easier without as much confusion.
In America incentives to a better health care system or better overall health of patents seems to be non-existent. Some research done by Promberger et al (2012) concluded that the costs of incentives are comparable to the costs of the medications or any other methods used to help people live healthier. The incentive programs seems to be in its infancy and the need for further research and data needs to be collected in order to being able to factually say incentives does or does not work. Shown by preliminary studies by Promberger et al (2011) of financial incentives, which concluded “ This preliminary study suggests that even if effective, the use of financial incentives to motivate health-enhancing behaviors may be seen to be less acceptable than similarly effective medical interventions”(p 686).
Incentives to the medical population for better or less care does exist but is extremely controversial. Whether physicians are getting incentives from private companies to use certain drugs or do certain procedures, thus possibly being bias when it comes to what’s better for the patients. When researched by Orenctlicher (1996) he mentions the following “However, when physicians are paid more to do less for their patients, patient trust in physicians will naturally be eroded as patients begin to wonder whether tests and treatments are being withheld because they are not medically indicated or because physicians have a financial interest in denying the care”(p. 162). Perhaps financial incentives to the physicians make it more difficult for them to not become more about the financial compensation and less about the people they help.
United Kingdom has several ways they give incentives to the general practitioners in their health care. The physicians have several option of which they choose to work from. They can choose between two types of contracts that are paid differently. One contract is with the facility they work for will pay them a predetermined salary, but the other contract is “via a national contract that offers a mix of remuneration methods, including fee-for-service (about 15 percent of GP income), capitation (40 percent), salary (30 percent), and capital and information technology (IT) (15 percent). The fee-for-service element includes incentive payments for reaching coverage targets for services such as vaccination and cervical cancer screening” (Smith et al, 2004). With studies in the United Kingdom also surprised the government as in the United States that financial incentives seemed to do more harm than good.
In the United Kingdom long term care is covered financially by the National Health System with a cost sharing from the patient dependent on the patients financial circumstances and as more and more people are coming to the long term age fiscal responsibility will become a problem if not addressed. “For those requiring a large range of services, LTC expenditure can represent as much as 60% of disposable income for all but those in the upper quintile of the income distribution” (Colombo et al, 2011). With this information the government in the UK is racing to attempt to fix the problem and help the citizens young and old. The cost for LTC in the UK is currently manageable but the older population is expected to substantially grow and need LTC by 2050. Advances in medical care and improvements in health status will increase the amount of population getting to an older age.
The United States uses the government if lower income in forms of Medicare to help with LTC, but like the UK the demand is increasing. In contrast to the UK in the United States approximately 45 percent of LTC the government covers cost and the rest is out of pocket and private insurances. “Medicaid spending must increase—from $43 billion estimated for 2000 to $75 billion for 2020—to ensure even current levels of service to low- and medium- income people” (Feder et al, 2000). With the increased demand of LTC in the UK and the US its imperative to do something now before its too late. The quality of both countries in LTC is taking a hit due to the large demand the facilities and the people to work in the field is limited and actually in a shortage stage.
In conclusion, the United States and the United Kingdom have very different health care delivery models. The United Kingdom uses the Beveridge model and the United States uses a Private Health Insurance model. The United Kingdom has more doctors per capita than the United States, but often care is limited in the United Kingdom because of the lack of choices within a person’s catchment area. The United States’ system also demonstrates placing limitations on choice of doctor by limiting choice to those under their insurances companies’ health provider network. America has a substantially higher uninsured population than other industrialized countries. The Untied States could model the United Kingdom and implement a health care system that covers everyone, regardless of ability to pay. A system should be adopted that still provides acceptable wait times. Having a system that covers everyone would allow America to get rid of uncompensated care costs and worries of rationing health care based on the ability to pay.
The healthcare in the US and the UK are different in many ways, but at the same time they have similar problems that both countries will face and will have to tackle some time. In the US we have the liberty to choose our own doctors with some restrictions such as, insurance coverage and preferences. In the UK you are also able to choose your own doctor with some exceptions like out of a predetermined boundary or the doctor has a good reason to refuse you care. Both countries have health care that needs work and they both can learn something’s from one another. The US could learn that by using a universal research criteria and a certain group the country can get information needed to improve care and not just financial gains for the private industry. The UK could learn from the US to give their citizens a bit more freedom with their health care choices could help improve overall health.
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