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Is our healthcare system broken? - Harvard Health

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The Harvard Medical School published an article in which some contested issues as regards the health system in the U.S are discussed. Their system undoubtedly needs a major overhaul. This relates to last class's comments on the U.S health system.

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Here's a question that's been on my mind and perhaps yours: Is the US healthcare system expensive, complicated, dysfunctional, or broken? The simple answer is yes to all. Below are 10 of the most convincing arguments I've heard that our system needs a major overhaul. And that's just the tip of the iceberg. Remember, an entire industry has evolved in the US just to help people navigate the maddeningly complex task of choosing a health insurance plan.

The cost is enormous

High cost, not highest quality. Despite spending far more on healthcare than other high-income nations, the US scores poorly on many key health measures, including life expectancy, preventable hospital admissions, suicide, and maternal mortality. And for all that expense, satisfaction with the current healthcare system is relatively low in the US.

Financial burden. High costs combined with high numbers of underinsured or uninsured means many people risk bankruptcy if they develop a serious illness. Prices vary widely, and it's nearly impossible to compare the quality or cost of your healthcare options - or even to know how big a bill to expect. And even when you ask lots of questions ahead of time and stick with recommended doctors in your health insurance network, you may still wind up getting a surprise bill. My neighbor did after knee surgery: even though the hospital and his surgeon were in his insurance network, the anesthesiologist was not.

Access is uneven

Health insurance tied to employment. During World War II, healthcare was offered as a way to attract workers since employers had few other options. Few people had private insurance then, but now a layoff can jeopardize your access to healthcare.

Healthcare disparities. The current US healthcare system has a cruel tendency to delay or deny high-quality care to those who are most in need of it but can least afford its high cost. This contributes to avoidable healthcare disparities for people of color and other disadvantaged groups.

Health insurers may discourage care to hold down costs. Many health insurance companies restrict expensive medications, tests, and other services by declining coverage until forms are filled out to justify the service to the insurer. True, this can prevent unnecessary expense to the healthcare system - and to the insurance company. Yet it also discourages care deemed appropriate by your physician.

This can make for shortsighted decisions. For example, when medications are prescribed for rheumatoid arthritis, coverage may be denied unless a cheaper medication is prescribed, even if it has little chance of working. Asurvey (note: automatic download) found that 78% of physicians reported that this led people to abandon recommended treatments; 92% thought it contributed to care delays. And because the expensive medication may prevent future knee or hip replacements, delay may ultimately prove more costly to insurance plans and patients while contributing to more suffering.

Investments in healthcare seem misdirected

Emphasizing technology and specialty care. Our system focuses on disease, specialty care, and technology rather than preventive care. During my medical training, I received relatively little instruction in nutrition, exercise, mental health, and primary care, but plenty of time was devoted to inpatient care, intensive care units, and subspecialties such as cardiology and gastroenterology. Doctors practicing in specialties where technology abounds (think anesthesiology, cardiology, or surgery) typically have far higher incomes than those in primary care.

Overemphasizing procedures and drugs. Here's one example: A cortisone injection for tendinitis in the ankle is typically covered by health insurance. A shoe insert that might work just as well may not be.

Stifling innovation. Payment structures for private or government-based health insurance can stifle innovative healthcare delivery. Home-based treatments, such as some geriatric care and cancer care, may be cost-effective and preferred by patients. But, because current payment systems don't routinely cover this care, these innovative approaches may never become widespread. Telehealth, which could bring medical care to millions with poor access, was relatively rare before the pandemic, partly due to lack of insurance coverage. And yet, telehealth has flourished by necessity, demonstrating how effective it can be.

Fragmented care. One hallmark of US healthcare is that people tend to get care in a variety of settings that may have little or no connection to each other. That can lead to duplication of care, poor coordination of services, and higher costs. A doctor may prescribe a medicine that has dangerous interactions with other medicines the person is taking. Medicine prescribed years earlier by a doctor no longer caring for a person may be continued indefinitely because other doctors do not know why it was started. Often doctors repeat blood tests already performed elsewhere because results of the previous tests are not readily available.

Defensive medicine. Medical care offered primarily to minimize the chance of getting sued drives up costs, provides little or no benefit, and may even reduce the quality of care. Malpractice lawsuits are so common in the US that for doctors in certain specialties, it's not a matter of if but when they are sued. Though it's hard to measure just how big the impact of defensive medicine is, at least one study suggests it's not small.

No simple solution

Even insured Americans spend more out of pocket for their healthcare than people in most other wealthy nations. Some resort to purchasing medications from other countries where prices are far lower. The status quo may be acceptable to healthcare insurers, pharmaceutical companies, and some healthcare providers who are rewarded handsomely by it, but our current healthcare system is not sustainable (note: automatic download).

Other countries have approached healthcare quite differently, including single-payer, government-run systems, or a mix of private and public options. Perhaps some of the most successful can serve as a model for us. But, with so much on the line and competing interests' well-funded lobbying groups ready to do battle, it's far from clear whether reform of our healthcare system can happen anytime soon.

I haven't met many patients who think our current healthcare system is great. In fact, I don't know anyone who would design the system we currently have - well, other than those who are profiting from it.

The question going forward is whether there will be the trust, will, and vision necessary to build something better. It won't be easy, but the alternative - continuing to complain while waiting for the system to implode - is unacceptable.

Follow me on Twitter @RobShmerling

About the Author

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Is our healthcare system broken? - Harvard Health

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The US healthcare system is expensive, complicated, dysfunctional - and broken. The system needs a major overhaul, and the arguments for this fall into a few broad categories: high costs, uneven access, and undue emphasis on areas of spending that do not directly benefit patients

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Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England - Office for National Statistics

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Ethnicity and COVID-19 cases during the pandemic 

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Ethnicity and COVID-19 cases during the pandemic 

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This article presents some interesting information on what ethnic groups were most affected by the COVID-19 virus. It's a study-based article. In connection with last class, this article portrays the gaps in mortality among different ethnic groups and their backgrounds.

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During the first wave of the coronavirus (COVID-19) pandemic (24 January 2020 to 11 September 2020), people from all ethnic minority groups (except for women in the Chinese or "White Other" ethnic groups) had higher rates of death involving the coronavirus compared with the White British population.

The rate of death involving COVID-19 was highest for the Black African group (3.7 times greater than for the White British group for males, and 2.6 greater for females), followed by the Bangladeshi (3.0 for males, 1.9 for females), Black Caribbean (2.7 for males, 1.8 for females) and Pakistani (2.2 for males, 2.0 for females) ethnic groups.

In the second wave of the pandemic (from 12 September 2020 onwards), the differences in COVID-19 mortality compared with the White British population increased for people of Bangladeshi and Pakistani ethnic backgrounds; the Bangladeshi group had the highest rates, 5.0 and 4.1 times greater than for White British males and females respectively.

Whilst males and females of Black Caribbean and Black African background remained at elevated risk in the second wave, the relative risk compared with White British people was reduced compared with the first wave.

Adjusting for location, measures of disadvantage, occupation, living arrangements and pre-existing health conditions accounted for a large proportion of the excess COVID-19 mortality risk in most ethnic minority groups; however, most Black and South Asian groups remained at higher risk than White British people in the second wave even after adjustments.

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The Office for National Statistics (ONS) previously published analysis of deaths involving the coronavirus (COVID-19) by ethnic group for England and Wales between 2 March and 28 July 2020. In this article, we update the previous analysis to present provisional analyses of deaths involving COVID-19 by ethnic group for deaths occurring in England between 24 January 2020 ( the date when the first COVID-19 case was reported in the UK) and 31 March 2021, that were registered by 19 April 2021.

In our previous analyses, we adjusted for differences in location, measures of deprivation, occupation, living arrangements (retrieved from the 2011 Census) and comorbidities based on Hospital Episodes Statistics for 2017 to 2019. We extend this by linking the 2011 Census to the General Practice Extraction Service Data for Pandemic Planning and Research, which enables us to assess the extent to which the increased risk of COVID-19 mortality in some ethnic groups is explained by differences in the prevalence of certain pre-existing health conditions which are known to increase the risk of dying from COVID-19.

Analyses are presented separately for the first and second waves of the pandemic to explore whether differences in the relative risk of COVID-19 mortality between different ethnic groups have changed over the course of the pandemic. We classify deaths from 12 September 2020 onwards as having occurred in the second wave.

The study population comprised 29.3 million people (aged 30 to 100 years) enumerated at the 2011 Census and living in either private households or communal establishments in England at the start of the pandemic. See the Technical Appendix for additional details on the data used in this release.

Estimates for the second wave of the pandemic should be considered provisional because our period of analysis does not encompass all deaths occurring during the second wave, which goes beyond 31 March 2021.

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3. Difference between the risk of death involving COVID-19 by ethnic group in the first and second waves of the pandemic

To understand the drivers of differences in the rate of death involving COVID-19 between ethnic groups, we used Cox proportional hazards models to estimate how differences in the rates changed when adjusting for a range of factors affecting both the risk of infection and the risk of death if infected. For full details of the variables included in the models, see the Technical Appendix.

In our baseline model, we adjusted for age only. We then adjusted for:

1. residence type (private household, care home, other communal establishments)

2. geography (local authority district and population density)

3. socio-economic factors (deprivation, household composition and occupational exposure)

4. certain pre-existing health conditions

Figure 1 shows how the risk of death involving COVID-19 varied by ethnic background during the first wave, separately for males and females. We report hazard ratios (HRs) for each ethnic group relative to the White British group (the largest group). A HR greater than one indicates a higher rate of death involving COVID-19 than the reference group. HRs for the entire outcome period are reported in the datasets.

During the first wave of the pandemic (24 January 2020 to 11 September 2020), after adjusting for age (first bar in Figure 1), males from all ethnic minority groups were at elevated risk of COVID-19 mortality compared with males identifying as White British; females from all ethnic minority groups other than Chinese and White Other were also at greater risk. The increased risk relative to the White British population was highest for the Black African group (male HR: 3.7, female HR: 2.6), followed by the Bangladeshi (male HR: 3.0, female HR: 1.9), Black Caribbean (male HR: 2.7, female HR: 1.8) and Pakistani (male HR: 2.2 , female HR: 2.0) ethnic groups. Age-standardised mortality rates (ASMRs) can be found in the datasets.

Adjusting further for location, measures of disadvantage, occupation, living arrangements, and certain pre-existing conditions (second bar in Figure 1) substantially reduced excess COVID-19 mortality risk for most ethnic groups. Rates of COVID-19 mortality remained highest amongst the Black African group (male HR: 2.2, female HR: 1.5), but some groups (White Other, Mixed and Chinese for males; Bangladeshi, Black Caribbean, Mixed and Pakistani for females) were no longer at greater risk of death involving COVID-19 than the White British ethnic group.

Figure 1: In the first wave of the pandemic, differences in COVID-19 mortality compared with the White British population were highest for people of Black African background

Hazard ratios of death involving COVID-19 by ethnic group and sex, England: 24 January 2020 to 11 September 2020

Notes:

ONS figures based on death registrations up to 19 April 2021, for deaths involving COVID-19 that occurred between 24 January 2020 to 11 September 2020, of people aged 30 to 100 years that could be linked to the 2011 Census and General Practice Extraction Service Data for Pandemic and Planning Research; these figures are provisional.

Download the data

The first bar in Figure 2 shows age-adjusted HRs (relative to the White British group) for the second wave (12 September 2020 onwards). The excess risk of death involving COVID-19 for people from the Bangladeshi (male HR: 5.0, female HR: 4.1) and Pakistani (male HR: 3.4, female HR: 2.8) ethnic groups was higher in the second wave than in the first wave. Although people from Black African and Black Caribbean ethnic groups remained at higher risk of COVID-19 mortality than White British people during the second wave, the magnitude of excess risk was reduced compared with the first wave.

After adjusting further for other factors (second bar in Figure 2), people in the Bangladeshi (male HR: 2.5, female HR: 1.9), Pakistani (male HR: 2.0, female HR: 1.5), Indian (male HR: 1.7, female HR: 1.4), and Black African (male HR: 1.7, female HR: 1.2) ethnic groups and men from the Black Caribbean group (HR: 1.2) remained at higher risk of death involving COVID-19 than the White British group.

Figure 2: In the second wave of the pandemic, differences in COVID-19 mortality compared with the White British population increased for people of Bangladeshi and Pakistani ethnic backgrounds and decreased for people of Black African and Black Caribbean backgrounds

Hazard ratios of death involving COVID-19 by ethnic group and sex, England: 12 September 2020 to 31 March 2021

Notes:

ONS figures based on death registrations up to 19 April 2021, for deaths involving COVID-19 that occurred between 12 September 2020 to 31 March 2021, of people aged 30 to 100 years that could be linked to the 2011 Census and General Practice Extraction Service Data for Pandemic and Planning Research; these figures are provisional.
Download the data
Our findings demonstrate that people from most ethnic minority groups have experienced greater rates of death involving COVID-19 compared with people of White British background during the pandemic. The patterns of excess COVID-19 mortality risk by ethnic group have changed over the course of the pandemic; Bangladeshi and Pakistani groups were particularly at risk during the second wave (up to 31 March 2021), whereas the risk to the Black African and Black Caribbean groups relative to the White British population was lower during the second wave than the first. These results are consistent with our previous analysis and a recently published paper based on the OpenSAFELY platform.

Differences in location, measures of disadvantage, occupation, living arrangements, and certain pre-existing health conditions explain a large proportion (but not all) of the excess COVID-19 mortality risk observed in some ethnic groups. Residual unexplained risk may be attributable to factors that we have not been able to account for in the analysis. Further work is needed to increase our knowledge and understanding of the possible mechanisms underlying this unexplained risk.
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Age-standardised mortality rates

Age-standardised mortality rates (ASMRs) are used to allow comparisons between populations that may contain different proportions of different ages. The 2013 European Standard Population is used to standardise rates.

Cox proportional hazards regression model

The Cox proportional hazards regression model is a multiple regression procedure that measures the association between a time-to-event outcome and a characteristic of interest (such as ethnic group), while adjusting for other characteristics expected to also be associated with the outcome.

Hazard ratio

A hazard ratio is a measure of the relative differences in the instantaneous rate of mortality between groups. A hazard ratio greater than 1 indicates the rate of mortality is higher, and likewise, less than 1 lower in the population group under study compared with a reference group.

Deaths involving COVID-19

Deaths involving COVID-19 include those with an underlying cause, or any mention, of ICD-10 codes U07.1 (COVID-19, virus identified), U07.2 (COVID-19, virus not identified) or U09.9 (Post-COVID condition). A doctor can certify the involvement of COVID-19 based on symptoms and clinical findings - a positive test result is not required.
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6. Data sources and quality

These analyses are based on a unique linked dataset that encompasses 2011 Census records, death registrations, Hospital Episode Statistics (HES), and primary care records retrieved from the General Practice Extraction Service (GPES) Data for Pandemic Planning and Research (GDPPR) with England coverage only. For further details on the data used, including how they were constructed, please refer to the accompanying Technical Appendix.
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Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England - Office for National Statistics

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During the first wave of the coronavirus (COVID-19) pandemic (24 January 2020 to 11 September 2020), people from all ethnic minority groups (except for women in the Chinese or "White Other" ethnic groups) had higher rates of death involving the coronavirus compared with the White British population.

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This short article enlists some of the main issues found in the NHS after Brexit.

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The impact of Brexit on the NHS has been a source of debate and controversy since the figure of £350million appeared on the side of a bus during the EU referendum in 2016. As we get closer to 29th March 2019 - the official date the UK is due to leave the EU - what will the impact of Brexit really look like for the NHS, its staff and its patients?

There's a long list of concerns.

Firstly, there's the future recruitment and retention of NHS professionals from EU member states, and notably nurses. Since the referendum, there has been a huge drop in the number of nurses from EU countries on the nursing professional register.

Just yesterday, the Royal College of Nursing warned that Brexit could particularly affect nursing staff based near the border to the Republic of Ireland, and that this poses a big threat to patient care.Important challenges relate to the impact of Brexit on healthcare delivery in Northern Ireland; cross-border collaboration and co-operation currently facilitates the provision of care in a range of areas.

For example, children's cardiac surgery is no longer undertaken in Northern Ireland and children are instead transferred to a hospital in Dublin.

With this, as with many other questions, clarity on the position of the Irish border is vital.

If a withdrawal agreement with the EU is not finalised and the UK moves into a no-deal situation, UK patients will no longer be able to rely on their European Health Insurance Cards (EHIC) which currently give access to free or reduced cost for necessary medical care in EU member states.

The withdrawal agreement provides current UK citizens abroad, such as retirees in Spain, with rights to access healthcare under existing reciprocal EU rights - without it, they may be subject to considerable costs for treatment if they fall ill.

Those travelling at that time would be well-advised to ensure they have full travel insurance. Some patients with complex disorders, who are unable to obtain affordable travel insurance, may even decide they cannot take the risk of travelling.

Even if there is a withdrawal agreement and transition period until December 2020, there is as yet no agreement as to whether the EHIC insurance will continue in the future.

But what about the people in the UK? What impact will Brexit have on the supply of and access to medicines, for example?

Concerns have been expressed over possible new customs delays in a no-deal scenario.

The UK government has indicated that stockpiling of six weeks supply of medicines will take place. In the case of products that have a limited shelf life, such as medical isotopes used by radiographers, specific arrangements will be in place for these to be airlifted to the UK.

But such arrangements come at considerable additional costs to the NHS.

As things currently stand, without a specific deal made with the EU concerning medicines, post Brexit the UK will also no longer be part of the EU's regulatory regime.

So, what does this mean?

Currently some, though not all, medicines marketed in the UK are subject to approval by an EU body, the European Medicines Agency (EMA), and certain drugs such as paediatric medicines have to go through this centralised process.

If approved by the EMA, the authorisation is valid across the EU.

The government has stated there will be consultations in the autumn regarding changes needed to UK legislation in this area, including new regulation for medicines currently approved by the EMA.

While this would regularise the situation in the UK, manufacturers would need to get additional approval if they intended to market the drugs elsewhere.

The government has also indicated it wants to continue aligning itself with EU law regulating clinical trials on drugs; there's a new regulation due to come into force in 2019, but after the March cut-off point.

Without a special deal, the UK will then be excluded from other aspects of the approval process for these trials, such as a new centralised EU database.

Once no longer part of the EU pharmaceutical regulatory structure, the UK may no longer be seen by drug companies as a first priority launch market.

This would mean that new drugs may be launched later in the UK than other EU countries, and patients could suffer as a result.

There is still uncertainty as to whether the withdrawal agreement and transition period will be agreed in the autumn and the vital issue of the Irish border remains to be resolved.

The prospect of a no-deal, cliff-edge Brexit to an already cash-strapped NHS, desperately concerned with maximising resources and staff, is a very real concern - and the clock is ticking.
Professor Jean McHale was co-author to the report, Cost of No Deal Revisited from the The UK in a Changing Europe.

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The impact of Brexit on the NHS has been a source of debate and controversy since the figure of £350million appeared on the side of a bus during the EU referendum in 2016.

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Challenging the perception of belonging 

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Challenging the perception of belonging 

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This TED talk tackles the issue of feeling like a fish out of water.
How can we overcome cultural barriers?

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What happens when you're Russian, grow up in Israel and work for an international pharmaceutical company in Germany? You end up with a multinational background that may be difficult for your peers to understand or relate to on a personal level.

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I attach these pages from a course-book that I’m using with adult students. Here it can be observed how our gestures differ from one another’s depending on where you come from.