Eyeworld

EW NEWS & OPINION 32 December 2017 Insights by J.C. Noreika, MD, MBA of outcomes, inadequacy of pre- ventive care, and, chiefly, its cost. Switzerland, the world's second most expensive system, lags far behind the U.S. in spending as a percentage of GDP. No one claims Switzerland to be at the forefront of technologic innovation. The U.S. is the world's undisputed medical dynamo. It absorbs prodigious costs while pro- viding untold benefit to its and the world's citizens and economies. The point? There is no social- istic Shangri-La, no free lunch. Attempts at improvement are admi- rable but all converge to cost versus equity. Government-run systems are sustained by taxation. Mick Mulvaney, director of the Office of Management and Budget, reported at a Georgetown University forum in October that "the top 20% of folks who file a tax return, the top 20%, pay 95% of the taxes." You make about $100,000 per year? You are in the top 20%. Here are "the questions that have to be asked." Is healthcare an innate right? If it is, am I willing to pay more for it? If I am not, who will? What freedoms am I willing to sacrifice for "free" healthcare? How long am I willing to wait for an "elective" procedure? How many curative breakthroughs am I willing to forgo to satisfy "fairness"? Will my lawmakers and regulators enroll in my insurance plan? The answers, Senator Sanders, can be a matter of life or death. EW Editors' note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years. Join the discussion on this article and others on the EyeWorld blog at blog.eyeworld.org. Contact information Noreika: JCNMD@aol.com France, the U.K., and Germany manifest very different approaches. Together they have only two-thirds of the population of the U.S. The size of a country affects logistics and distribution of medical resources. France is smaller than Texas. The U.S. is 40 times larger than the U.K. The European Union's juggernaut, Germany, had a GDP of $3.48 trillion in 2016; America's GDP was $18.7 trillion. Per-capita GDP in Germany was about $42,200 while the U.S. produced $57,608 per-capi- ta. It's been said that America spends more on healthcare because it can. Switzerland, Chile, and the Netherlands' strategies inspired Obamacare. For example, Switzer- land requires all its citizens to buy private insurance, i.e., an individual mandate. It is community-rated and issued regardless of pre-exist- ing conditions. Thirty percent of Swiss citizens receive subsidies; the amount of premium offset is based on income. It is a tiered program. The U.K.'s National Health Service is beloved by its citizenry. According to Britain's newspapers, its future is precarious. Per-capita spending is increasing and queues awaiting procedures are lengthen- ing. Britain's is a socialistic system; government owns the means of production that provides care for its citizenry. It must confront urgent realities: an aging population, cuts to safety nets supporting medicine, population growth outstripping the supply of practitioners, top-down bureaucracies and lifestyle pathol- ogies commanding more expen- sive treatments. Rationing of care is institutionalized; 3.78 million patients are awaiting treatment. The National Health Service recently proposed banning certain patients from surgery indefinitely until they lose weight or stop smoking. American healthcare is excori- ated for its lack of access, inequality of practices employ an electronic health record to document episode- pertinent information. No MIPS, PQRS, documented quality improve- ments or mandated web portals. Many practices enforce a one com- plaint per visit policy. Patients tol- erate deferral of elective services. It's not the doctor's fault that they have to wait for a knee replacement, cat- aract surgery, or an MRI. Everyone does. Everyone, that is, who doesn't cross the 49th parallel to Cleveland, Rochester, Minnesota, Seattle, or is wealthy enough to winter in Boca. Canadian physicians are said to be content—even happy—while their American counterparts burn out at an alarming rate. In last month's column, I sug- gested that a single-payer solution, Medicare-for-all, might not be as preposterous as once thought. Obamacare made clear that younger Americans show little enthusiasm to subsidize the well-being of wealthier, asset-blessed baby boomers. The conundrum of single-payer systems? If you have seen one, you have seen one. Each nation has its unique version of universal health- care. Even the U.S. boasts renditions of government-provided healthcare (the Veterans Administration and the Indian Health Service) and single-payer systems (Medicare and Medicaid). Declaring healthcare a human right, Sanders proselytizes a government-run system providing coverage to all financed through taxation. Looking around the rest of the world, no system is flawless. Geog- raphy, population size and homoge- neity, demography, culture, history, income disparity and economics guide nations to adopt arrangements accepted by their polity. A current darling, Singapore is a city-state of 5.6 million people. It relies on health savings accounts and spends only 4.9% of its GDP on universal care; America spends 17.2%. But Sin- gapore's workers are mandated to set aside 37% of their wages, a portion of which is contributed by em- ployers, toward benefits including healthcare. The government helps determine technologies adopted, medications purchased, the com- pensation of doctors and number of medical students. Economic dispar- ity defines level of care; outcome data is hard to come by. The world's politicians struggle with the challenge of providing cost-effective and timely healthcare for their citizens. Is there an ideal model? B ehavioral psychology advises avoidance of absolutes. They rarely add to an enlightened debate. Unlike behavioral econ- omists, these therapists maintain a low profile when discussing health- care. They enroll in the "if you can't change it, can you live with it?" camp. Yet health system absolutes are unavoidable: All governments, first to third world, have never solved the quandary of always providing quality healthcare at a reasonable cost leaving none excluded. On October 28, 2017, the Toron- to Star's headline trumpeted, "Bernie Sanders Awed by Canadian Health Care." A few days later, The New York Times' Margot Sanger-Katz followed with an article titled, "What Did Bernie Sanders Learn in His Week- end in Canada?" A Potemkin village- like spectacle, Sanders' road trip spotlighted a scheme maligned by conservatives and found wanting by progressives. The Commonwealth Fund found Canada outranking only the U.S. in key performance param- eters across 11 countries. Before dis- missing the media-generated hagiog- raphy of our country's most famous socialist, consider what he said: "We do not in the United States do a good job in looking around the rest of the world and asking the ques- tions that have to be asked." He may be onto something. To the clinician, Canada looks tantalizing. Primary care physicians earn 10% more than their American brethren. Specialists make a decent living. Office overhead averages an appealing 15–30% of revenues. There is no superfluity of insurance forms; pre-authorization require- ments and obstacles to specialty referrals are unknown. About 73% Distance learning: International healthcare J.C. Noreika, MD, MBA " There is no socialistic Shangri- La, no free lunch. Attempts at improvement are admirable but all converge to cost versus equity. "

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