Brookings, Engelberg Center for Health Care Reform
November 9, 2011
Q&A
Mark McClellan, Director of the Engelberg Center: Another point (that you mentioned) was the availability of care at a low or at really no cost to patients, to consumers. That is a big difference from the United States, obviously, where not just the more conservative members of our legislatures, but others as well believe that patients should have some accountability, some responsibility for some of the costs, and, conversely, if they make decisions to stay healthier, if they make decisions to use care more effectively, that they should get some of the savings. You put a big emphasis on how these reforms are going to lead to more patient choice in terms of GPs, in terms of hospital care, in terms of specialist teams, and so on. As you said, money following the patient. Is that going to be enough? There are a lot of people here who believe that you really need even more consumer involvement, consumer stake in care to drive real reforms in care.
UK Health Minister Andrew Lansley: Well, I understand the view that says if people pay directly for something, they value it more. I actually think, in the British context, where health care is concerned, people understand the value of the health care that is provided to them. They don’t need to have it itemized in a bill sent to them and pay for it out of their own pocket to realize that the National Health Service provides them something that they should attach enormous value to. I think, generally speaking, it isn’t the case that people in Britain consume large amounts of health care, that they don’t need to, because it’s free. And in particular, I think through the intermediation process with general practitioners the relationship that is built up between the British public and their general practitioners is instrumental to the process of managing demand in a way that is responsible and effective. Now I think it’s not perfect, and I think that’s one of the central reasons why I think we need to give patients a greater say in decision making. I don’t think, in a free system, as a consequence of that we are going to see irresponsible or excessive demand. I think patients themselves, given good information and opportunities to make choices, on balance, will make decisions that are probably less costly, less invasive, less interventionist because they want to have care that supports them at home and very often they don’t want to be in the hospital. So issues like avoiding admissions to hospitals, I think patients are with us on this. They’re not conflicting with us. See, the one thing I would say is important in terms of access, that we don’t necessarily achieve, where we do need to act is to ensure that patients do have access to the latest and most effective treatments and medicines. And there, particularly, we acted, since the election, in the creation of the Cancer Drug Fund because we knew that, in Britain for example, there was a very low take-up of cancer medicines within five years of their being introduced. And I think that is absolutely an area where the public have an expectation and a right to expect that they should have access to whatever their clinicians regard as the most effective treatment available. Some of it’s cost effective but, you know, on that basis, with clinical judgement, they should be able to get access to it. I have to say, when you look at the cost, literally the transaction cost alone, of moving away from a taxpayer funded service as the NHS is, in the way in which we’re organized, at the moment we have something like five percent of NHS costs consumed in administration. I’m planning to bring that down to about three to three and a half percent over the course of the next four years. That alone will save us about one and one-half billion pounds a year. But that is very modest administration costs relative to the costs of administration of insurance systems in the United States. So on that basis alone I think there is, in a constrained financial bound, there’s no intrinsic merit in moving away from the structure of the system we have.
http://www.brookings.edu/events/2011/1109_uk_health_care.aspx
Comment:
By Don McCanne, MD
Health Minister Andrew Lansley of the United Kingdom is currently at the center of a storm of controversy over his efforts to further privatize their health care on the theory that expanding market competition for the National Health Service will improve quality and reduce costs. So it is instructive to ask if his views extend to include the U.S. concept of empowering consumers by requiring an even greater financial stake “to drive real reforms in care,” as former CMS Secretary Mark McClellan phrases it.
Although holding very conservative political views, Lansley almost scoffs at the suggestion that British citizens would consume large amounts of care merely because it is free. When you think about it, the suggestion that patients need price sensitivity to prevent over-consumption of health care is almost an insult. Patients want to consult with their physicians to obtain the most appropriate care for their medical circumstance, in an environment removed from financial considerations. They are not looking for bargain basement deals.
This is about health care, for Pete’s sake. It’s not like deciding whether you are going to purchase a garment at Walmart or at Nordstrom. The assumption in the United Kingdom and in all other wealthier nations, except the United States, is that public stewards will ensure that health care will always be there for you when you need it. It is not a commodity that wise shoppers will follow and then purchase only after it goes on sale.
The advocates of consumer-directed health care are going to have to do a better job of explaining how requiring patients to pay out of their pockets or savings accounts when they access care is an answer to a problem, when that problem doesn’t seem to even exist. As Minister Lansley states, “it isn’t the case that people in Britain consume large amounts of health care… because it’s free.” Further, “the relationship that is built up between the British public and their general practitioners is instrumental to the process of managing demand in a way that is responsible and effective.”
How about that! The traditional physician-patient relationship works!
The per capita health care spending in the United Kingdom is less than half that of the United States. The British did not have to use consumer empowerment through price sensitivity to control their health care spending.
It appears that the only significant impact of increasing the financial stake of the health care consumer has been to erect financial barriers to beneficial health care services. So this detrimental intervention is being offered as a solution to the problem of high health care costs that other nations effectively manage using a responsible relationship between patients and their physicians? Talk about a disconnect between a problem and a solution!
McClellan says, “There are a lot of people here who believe that you really need even more consumer involvement, consumer stake in care to drive real reforms in care.” We could scoff at those people, but they’re in charge now. That’s tragic!