 Ask
Canadians which G8 country has the best healthcare, and
though we'd hope most will root for the home team, many
will probably have something flattering to say about Britain's
venerable National Health Service (NHS). Ask which has
the worst, and a phalanx of fingers will point straight
south. And the ultimate bogeyman of US-style healthcare
is the dreaded Health Maintenance Organization (HMO).
It might come as a surprise,
then, that Britain's Health Secretary John Reid recently
travelled to California to see what the NHS could learn
from the most famous of all HMOs, Kaiser Permanente.
A health minister's journey of discovery to Planet Capitalism
might raise a few eyebrows here in Canada, but it caused
collective apoplexy in Britain. One former health secretary
dryly suggested that maybe "John Reid should ask
Hillary Clinton what she thinks about their system."
DARING
TO COMPARE
The belief that Kaiser holds lessons for the NHS can
be traced to a hugely influential article that appeared
in the British Medical Journal (BMJ) in January
2002, by three Californian experts. Feachem et al's
conclusion was guaranteed to set the cat among the pigeons:
"The widely held beliefs that the NHS is efficient
and that poor performance in certain areas is largely
explained by underinvestment are not supported by this
analysis. Kaiser achieved better performance at roughly
the same cost as the NHS."
Such a statement, especially coming from Americans,
was guaranteed to set some pulses racing and sure enough
the BMJ duly received a record amount of letters.
The topic has been hotly debated in its pages ever since.
At the time, the authors' methodology was disputed by
many. In particular, defenders of the NHS objected to
their use of a "purchasing power parity" (PPP)
adjustment, which was intended to control for the fact
that drugs and doctors' salaries are cheaper in Britain.
After adjustment for average patient age, NHS annual
costs worked out at $1,161 US per capita and Kaiser's
at $1,951 US. But the arbitrary PPP adjustment made
these costs appear equal. "It's hugely illogical
to use a 1.52 multiplier to finesse Kaiser's inflated
funding when the excess is itself a reflection of the
failure of the private sector to control costs,"
commented Welsh radiologist Rhodri Davies at the time.
EMPIRE
STRIKES BACK
The enemies of the Kaiser model have returned to the
attack this month in the pages of the British Journal
of General Practice. As well as condemning the PPP,
they point out that Kaiser serves a fundamentally different
population: Kaiser takes on customers through their
employment and even though Kaiser cannot turn away less
healthy applicants, employers can and do. If Kaiser's
members lose their jobs, the HMO is obliged to offer
them a personal plan, but it can set prohibitive financial
terms to discourage sicker patients.
Unlike the NHS, Kaiser offers no longterm residential
care, funds no research grants and is not responsible
for training doctors. Even the one point that was universally
accepted from the initial paper, that Kaiser made better
use of acute beds, is challenged on the basis that Feachem
et al's BMJ paper used Organisation for Economic
Co-operation and Development (OECD) bed statistics,
not the NHS's own figures.
The British Journal of General Practice article
comes on the heels of a rebuttal from Britain's Department
of Health and the NHS itself, published in the BMJ
last November, which everyone agreed avoided these methodological
flaws and sensibly restricted its comparison to bed
use alone. And on this issue, there's no doubt that
Kaiser is a world leader.
NOT ALL BAD
Dr Robert Reid, a professor at the University of British
Columbia's Centre for Health Services & Policy Research
and advisor to the Group Health Cooperative in Seattle,
points out that Kaiser Permanente is rightly celebrated
for their seamless integration of inpatient and outpatient
services, and between primary care physician and specialist.
"There are rigid criteria for referral and for
hospital admission," he says.
Nobody occupies a Kaiser bed just because they're waiting
for an investigation. In fact, Kaiser's whole philosophy
is that hospitalization is an admission of failure.
"Its focus is much more towards primary care and
prevention. You could argue in that sense that it makes
more efficient use of resources," says Dr Reid.
Dr Reid feels that the adversarial stance being taken
by both sides is a bit counterproductive. "It's
true no straight comparison with the NHS is possible,
since Kaiser is not truly population-based," he
says. "But I believe the British Health Secretary
could learn valuable lessons from a visit to Kaiser.
Having said that, the whole US health system could learn
a lot from a publicly-funded system like the NHS."
Perhaps the most intriguing result of the latest research
has been to highlight not the differences between Kaiser
and the UK, but between Kaiser and the rest of the US.
Kaiser's patients often say it feels less materialistic
than other HMOs. It was founded by doctors who wanted
to work together and escape the worst excesses of the
US system. Whether or not it beats publicly-funded systems
for efficiency, it blows other US healthcare providers
clean out of the water.
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