yellowroom

Is this one of the big problems with the NHS at the moment? Genuine question, because I don't know. My GP always says "don't consult Dr Google, if you are worried about anything come and see me". Which is fine, if you can actually get an appointment - is that because his schedule is full of hypochondriacs or because he has too many patients and not enough time?

The difficulty with getting an appointment issue then leads to the rise in people seeking treatment at A&E for non-urgent problems. I think one of the issues is people don't realise how expensive it is to get treated in that setting. If co-pays were introduced there to discourage non-urgent users then I think I could (reluctantly) accept that, provided the money was invested in improving access to GP services & clinics.

If we could somehow wean people away from wanting to see their GP as their default port of call for all medical issues, and make better use of other medical staff such as nurses, midwives, pharmacists then perhaps we could spread the load. Eg I would like to see a rise in the availability of walk-in centres and/or nurse practitioner appointments. Sometimes all people need is re-assurance & monitoring and to talk through with someone "qualified".

fozzyb

Although having said that I've had private health insurance all my life, and never used it once. It is insurancein the UK, just like you have house insurance where you fully expect never to make a claim but have it just in case. In the US health insurance is more like a subscription plan.

My suspicion is that it would be too politically difficult to ever introduce a co-pay system into the NHS, but instead I suspect what we will see is a gradual push to make more of the "elective" procedures only effectively available on private.

Pulaski

If you mean "are people trying to use more medical services than the country can afford to pay for" (which is the eventual result of everything you said in your post), then most certainly "yes". Like it or not, there has to be some form or rationing (and there already is), and discouraging some of the use of the healthcare system at the front end needs to be part of the "rationing toolbox". It shouldn't be the only tool, but it needs to be added to the toolbox.

Pulaski

Not if it's a high deductible plan, which we have. We chose it voluntarily six years ago, and I frequently recommend it. The linked HSAs we have contain enough funds to pay for about five years, or more of maximum family deductibles. Many people in the US have been suckered into paying for massively more medical insurance than they objectively need.

fozzyb

I just knew you were going to say that.

Although when you have the option of a very heavily employer subsidised HMO plan it doesn't look so attractive - my out of pocket costs for when my oldest daughter was born in the US were less than when my second was born in the UK (Due to the exorbitant price of car parking at Addenbrookes).

But that just highlights one of the biggest problems with the US system - in that healthcare and employment are too intertwined.

Pulaski

I'm just spreadin' the word!

fozzyb

I just tried looking at my employer's benefits package - and there is no high deductible plan offered. If I had moved to the US it would basically a choice between a HMO or a PPO plan, or throw away the employer subsidy.

So they don't make sense for everyone.

kodokan

Agreed - you'd get people taking it a whole lot more seriously if they knew the actual cost of the premiums. One of the driving ideas of the HSA was to lose the flat co-pay model and make people more price-conscious because they'd have some skin in the game* - well, start with them knowing what their premiums cost in lost salary opportunity cost.

I'm as much of a fan of the HSA model as Pulaski, but it's still not cheap if you're paying it yourself. While unemployed earlier this year, we were paying $715 a month (family of 4) for a Bronze plan with deductibles of $6,500/ $13k. $8,580 a year, for what's essentially catastrophe insurance. Out of post-tax money. And that seemed a good deal compared to the COBRA offering of $1300 a month.

Now compare that to our current employer-subsidized HSA - $160 a month, so $2k a year out of pre-tax money, AND the employer bungs us $1k annually into the HSA; deductibles are... I don't even know, they're so low they didn't mentally register as financially relevant - couple of thou.

But although that's a screaming deal for us, it's masking the $10-15k increase in salary that'd otherwise be necessary. Give people that, and THEN you might see some market competition and price sensitivity. Or just make everyone's life easier and add that $10k into the tax system somewhere - individual or corporation - and have universal coverage though a single payer without all the ridiculous admin.

*it doesn't, of course - trying to get an upfront cost for a medical consult is a fun game I play, and lose, every time.

Pulaski

A high deductible plan may or may not "make sense", but your point, and a perfectly valid one, is that high deductible plans are not available to everyone (unless they opt out of employer-subsidized coverage).

scrubbedexpat091

How much is the deductible?


Trying to figure out if someone needs to see a doctor 5-7 times a year if it would be a viable alternative.

Other option is to just keep income under 30k a year, seems to be the magic number in California anyhow before the subsidies largely go bye bye.

Pulaski

About $3,000 each, $8,000 for the family, IIRC. "Traditional" insurance would cost about $6,000/yr more than we pay, so "HD insurance + HSA contribution" roughly = "traditional insurance", except that we have consistently kept about 80% of our HSA contributions each year.

For us it works out that we could incur costs well above the deductible on traditional insurance and still be better off with HD insurance because we save so much on the insurance premiums. I am not sure if that is equally true for everyone, or just a quirk of the terms of our insurance?

robin1234

In America, I've been going to the same doctors practice for maybe 18 years. It is one doctor, with a lineup of nurses and nurse practitioners and other folks. I haven't actually seen my doctor for years - he's a pleasant fellow, but just wants to discuss ice hockey and socialist politics. (He's Canadian.) I always go to see one of the nurse practitioners. They know what's what, give you a proper old fashioned physical exam and are ready to answer any serious question you have. As far as I know, I pay the same whether I'm seeing the doctor or the nurse practitioner...

petitefrancaise

Using nurses/midwives/health visitors as a first port of call works fine when the individual in question knows their professional limits - ie recognises when a patient needs to be seen by a real doctor. From what I've witnessed over the years this is the tricky part....and it's where people don't get the treatment they need quickly enough.

Far better to have a doctor (with all the years of training and experience) to decide that the patient would be ok with a nurse treating them than a nurse who thinks they know as much as the doctor failing to refer in time.

Biggest problem with the NHS is not abuse by patients it is that it is underfunded when compared with similar countries and yet everyone wants the same care and mortality rate as those other countries. We're not talking slightly underfunded, it's about 2% less of GDP.

The bureaucracy within the NHS is unbelievable.....a GP friend in Scotland has seen her admin load increased enormously. Funnily enough, whilst the bureaucrats will allow the patients to be treated by lower levels of staff, this extra admin MUST be done by the doctor. There is a shortage of doctors in the UK now, this friend is seriously thinking of going out to the Western Isles to live and practice, apparently they don't have a dr out there anymore.

scrubbedexpat091

Thanks.

Insurance down there has gotten so complicated. My first job with insurance in the late 90's was so simple, single employees no monthly premium. Co-pays $20 for all services except emergency which was I think around $75 and hospital stays where something like $30/day with a 300 max out of pocket.


I can't remember what families paid, but was still fairly cheap, back then the company absorbed most of the cost for the premium, then around 2002, they started to download more cost to employees while cutting our pay.....

My last job with benefits down there ,I think it was 75/check for the monthly premium (paid weekly) for a single person. The guy I worked with with a wife and 2 kids, paid something like 500/month which considering we only made 12/13 per hour is a boat load of money, but they needed the insurance.

scrubbedexpat091

Opposite in most of Canada, we haven't embraced the Nurse Practitioner like the US has. (Doctors could very well be against them for all I know.) but with the shortage of doctors in most of Canada, would surely help to have more Nurse Practitioners.

My doctors office is made up of about 15 doctors, a few medical office assistants, and 1 RN who mostly does nothing but calls you to the room to wait for the doctor, and vaccines and shots.

My GP books about 6 weeks in advance right now. Some doctors will leave space for same day appointments, but mine doesn't. I just go to the walk in clinic, and once to the ER since the walk in was closed due to not having a doctor available.