nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Monday, December 15, 2008


Sorry.  It’s been a while getting around to this second “One Issue” newsletter.  Recall the first Object Lesson on Ginkgo biloba (“untenable to recommend a drug or nutraceutical in the absence of efficacy evidence simply because it could possibly help and initially appears harmless.”)?  This is the second Object Lesson.


Also, a few folks have asked that I put them on the list to receive these … Columns? Newsletters? Commentaries? Rants?  I’m going to open it up for anyone who wants to receive it.  You can tell your friends to send me their email address (directly or through you) and I’ll add them to the distribution.  This will also help me get an idea how many are reading it. 


I guess I have to have a privacy policy, so please be assured that I will never distribute your address for any reason, and I will be sending the newsletter out with “blind” addresses, so none of you can see who else is getting it.


I publish this just to keep myself up-to-date.  Writing it down forces me to check my data and think things through.  And, hey…it’s free.

Doc D



Comparative Healthcare Systems


Frequently the American healthcare system is compared to those in other countries who have universal healthcare.  The comparison is intended to point the way to reforms for our current mess.  Arguments over which way to go, and uniformly glowing interpretations of foreign efforts, have been a staple of US health policy academia for decades.


Now there’s a very nicely done review and analysis of those universal systems, HEALTH CARE SYSTEMS AROUND THE WORLD by Alyssa Schabloski, of the Insure the Uninsured Project.  It covers 10 countries.  You can find the 38 page document here:  Very readable, but a lot of numbers.


Great data, some of which shows that the rosy interpretations may not be telling the whole story.  Some comments:

  1. The data doesn’t talk about Quality of medical care.
  2. The report includes subjective discussion about Access (but includes no data), which remains a problem in some of these countries.  Waiting times are a source of dissatisfaction, while overall there is widespread support for the idea of universal coverage.
  3. Where and how doctors practice medicine is controlled nationally in some cases, and in most countries decisions about what is a benefit and how much is covered is also controlled by the central or regional government.
  4. Several of the most successful countries are re-vamping their entire system because steadily rising Costs are making them unsustainable.  This is the same issue we have here; getting everybody covered is not going to solve the underlying problems, particularly those of cost.  Rising costs appears to be a global problem…and independent of whether you have universal coverage with cost controls.


I like this report because the organization that publishes it is an advocate for insuring the uninsured, but lets the data take you wherever it’s going, successes AND failures. How refreshing is that?


You have the reference to keep me honest, but here are some observations (my comments are in italics and emphasis in bold is also mine).  I’ve limited the review to only 5 of the countries to keep the verbiage down to a manageable level:


It should be recognized up front that all 10 countries deserve acclaim for succeeding at achieving (or attempting to achieve) primary care access for all.


“provinces and territories set much of their own health care policy and manage their own health services delivery”

“Six of the provinces…go so far as to outlaw insurance that attempts to provide alternative or faster access to health care already covered by Medicare.” (but the supreme court recently ruled that the law is unconstitutional if waiting times could compromise needed healthcare which could have been addressed by alternative insurance. Quebec has a year to comply)

“Canada(‘s) …essentially single-payor system has created a bottleneck for timely access to services.” (I read that over 50% of their physicians have referred patients to the US:  this may help to keep their system from collapsing, see next item)

Waiting lists are a point of dissatisfaction with care and erode public confidence in the system. The country as a whole also must address the rising costs of health care to ensure the sustainability of its programs”


Denmark (major reforms implemented in 2007, a system undergoing change)

“Financing for Denmark’s health care system has become more centralized through taxation only at the national level.”

“The distribution of general practitioners is regulated …to ensure an even distribution across the country. Entry is tightly restricted—…they can only enter practice by purchasing the goodwill of a retiring physician or obtaining permission from the regional authorities.”  (Imagine our physician workforce complying with this…whew!)

“About one-third of Danish residents purchase complementary insurance to cover (drug, dental, medical equipment) services.”

A small number of Danes—approximately 5% of the population—purchase supplementary insurance to move to the head of queues.

“reforms have yet to perfect some systemic issues

Denmark…must make sure that it can sustain universal coverage while satisfying increasing demand due to the aging population.”



“To cover the cost of “copayments”… 86% of the population purchased voluntary health insurance in 2000.”

“The number of general practitioners and specialists in France is almost evenly split—of the 194,000 physicians in France in 2000, 51% were specialists and 49% provided primary care

“private general practitioners in France still make home visits, which account for about 25% of their care activities.”  (I’m sure US doctors would do this…NOT)

“French residents may consume as much health care as they like; however, to increase their price sensitivity, they pay for their care upon receipt and do not receive full reimbursement.”  (This is pure genius:  how do you inhibit people from seeing a doctor unnecessarily, and driving up the government’s costs?  Make them pay cash upfront, then reimburse only a part of the total.  Wow.)

“The WHO has ranked France as the best health care system in the world.” (FINALLY, France is good at something.  Clearly they excluded French intellectuals from the decision-making process.)

France must address challenges relating to sustainable financing and meeting growing demand due to aging populations.”



Germany enacted another significant reform to its healthcare system in 2007.”

“The Ministry of Health introduces and executes health policy for the country.”

Germany offers residents coverage through the statutory system with the option to purchase supplemental private insurance.

“physicians receive payment based on an invoice of total services provided and calculated according to a relative value scale.”

“Individuals who have made more than US$60,000 per year for three consecutive years or the self-employed may opt-out of social insurance and purchase private insurance instead.”

“the Organization of Economic Cooperation and Development has criticized the plan for not doing enough to alleviate the rising costs of health care in Germany to the detriment of the population.”


United Kingdom

“The central government sets health priorities for NHS (National Health Service) as a whole and controls the overall pool of funds.”

“NHS is the largest publicly funded health system in the world.”

“Sustainability and improved quality are two of the major challenges facing the NHS.”

delays in receiving specialist care decrease consumer confidence in the system.”




Here are single blurbs on the last 5:

Israel:  biggest challenge is violence.

Japan:  fastest rising healthcare costs for the elderly in the world (one-third of all health costs).  30% co-pay to population.

The Netherlands:  inability to control costs in their former system led to reforms in 2006.

Sweden:  One of the best universal systems, but problems with shortage of primary care providers, quality, and patient safety.

Switzerland: extremely de-centralized system makes reform very difficult in the face of rising costs.



There’s a pattern here.  The most common challenge faced by these systems is Cost, followed by Access.  An affordable and accessible healthcare system requires attention to underlying forces in the delivery of medical care.  Universal coverage cannot be sustained without it.  (Object Lesson #2)



When the new administration rolls out their plan, look for how they deal with these issues.  Surely we can do better than France.


Doc D

Opinions are entirely my own.



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