Dr Colin Mitchell, MRCP Specialist Registrar in Geriatrics/ General Internal Medicine North Western Deanery, Manchester, UK

Objectives Compare my experiences of two healthcare systems, in the UK and USA Analyze the differences in delivery, ideology, outcomes, and funding Elucidate why both systems are felt to be ‘failing’ Evaluate the options for improving healthcare Try not to make any glaring errors Try not to offend everybody

Compare my experiences of two healthcare systems, in the UK and USA

Analyze the differences in delivery, ideology, outcomes, and funding

Elucidate why both systems are felt to be ‘failing’

Evaluate the options for improving healthcare

Try not to make any glaring errors

Try not to offend everybody

Background and Bias

Full Disclosure & Potential Biases My biases What are yours? Our role Do we, as doctors, have a role in promoting health and healthcare within our sphere of control? Or are we just treating the patient in front of us?

My biases

What are yours?

Our role

Do we, as doctors, have a role in promoting health and healthcare within our sphere of control?

Or are we just treating the patient in front of us?

The NHS Created after WW2 as part of a series of welfare reforms High quality healthcare, “free at the point of need” Structure has changed, philosophy remains the same Entirely funded from taxation Every British national, visa-holder or refugee has a GP All care coordinated through GP, holds patients records and issues all repeat prescriptions. Only other charges are for prescriptions (around $14, often waived) and for long-term personal care / nursing homes.

Created after WW2 as part of a series of welfare reforms

High quality healthcare, “free at the point of need”

Structure has changed, philosophy remains the same

Entirely funded from taxation

Every British national, visa-holder or refugee has a GP

All care coordinated through GP, holds patients records and issues all repeat prescriptions.

Only other charges are for prescriptions (around $14, often waived) and for long-term personal care / nursing homes.

Being an NHS Doctor Undergraduate 5 to 6 year undergraduate degree (-$6k/yr) Junior Doctor 3 to 4 years as a junior trainee (avg $70k/yr, 50 hr wk) GP (Primary care) or Specialty track 1 year as a GP trainee or 5 years in a specialty ($90-100k/yr, 50hr wk) GPs/consultants earn $140-340k/yr Top rate of taxation is 40% (>$50k)

Undergraduate

5 to 6 year undergraduate degree (-$6k/yr)

Junior Doctor

3 to 4 years as a junior trainee (avg $70k/yr, 50 hr wk)

GP (Primary care) or Specialty track

1 year as a GP trainee

or 5 years in a specialty ($90-100k/yr, 50hr wk)

GPs/consultants earn $140-340k/yr

Top rate of taxation is 40% (>$50k)

My Experience at MUSC Familiarities Team working, camaraderie, humour Striving for high-quality care Frustration at the system Frustration at orthopaedic surgeons Differences Lower patient load, but intensive hours, high expectations No wards Rapid but effective training Useful medical students Sickle Cell Disease Choosing medicines based on the Walmart $4 list ICU Admissions

Familiarities

Team working, camaraderie, humour

Striving for high-quality care

Frustration at the system

Frustration at orthopaedic surgeons

Differences

Lower patient load, but intensive hours, high expectations

No wards

Rapid but effective training

Useful medical students

Sickle Cell Disease

Choosing medicines based on the Walmart $4 list

ICU Admissions

End of Life – Philosophy and Cost Major difference in ICU provision Edinburgh (pop 500,000) has: 38 ICU beds (level 2-3) 37 HDU beds (level 1-2), mostly surgical Generally, old with multiple comorbidities don’t get ventilated Policy is not guideline or evidence-based, and is variable Morning report – “America – where death is seen as optional” Few advance directives, many DNR decisions Anecdotally, much easier to discuss DNR in the UK Push towards ‘good’ death rather than life-extension

Major difference in ICU provision

Edinburgh (pop 500,000) has:

38 ICU beds (level 2-3)

37 HDU beds (level 1-2), mostly surgical

Generally, old with multiple comorbidities don’t get ventilated

Policy is not guideline or evidence-based, and is variable

Morning report – “America – where death is seen as optional”

Few advance directives, many DNR decisions

Anecdotally, much easier to discuss DNR in the UK

Push towards ‘good’ death rather than life-extension

Personal Biases Liberal, libertarian / socialist? Personal preference for Use of Clinical Skills Geriatric Medicine Generalists vs Specialists / partialists Healthcare as a right Strong possibility of working in the US Personal interest in remuneration for generalists My fiancee loves US healthcare

Liberal, libertarian / socialist?

Personal preference for

Use of Clinical Skills

Geriatric Medicine

Generalists vs Specialists / partialists

Healthcare as a right

Strong possibility of working in the US

Personal interest in remuneration for generalists

My fiancee loves US healthcare

Philosophy & Politics of Healthcare Equity vs opportunity (can’t we have both?) Healthcare as a right? Von Hayek “… in the case of sickness or accident… the case for the state helping to organise a comprehensive system of social insurance is very strong… there is no incompatibility in principle between the state providing greater security in this way and the preservation of individual freedom .” What is minimum provision? Is it cost effective? Who decides what is appropriate? Should the rich still be pay for whatever they want? “ Socialized” Medicine? A dirty word?

Equity vs opportunity (can’t we have both?)

Healthcare as a right?

Von Hayek

“… in the case of sickness or accident… the case for the state helping to organise a comprehensive system of social insurance is very strong… there is no incompatibility in principle between the state providing greater security in this way and the preservation of individual freedom .”

What is minimum provision?

Is it cost effective?

Who decides what is appropriate?

Should the rich still be pay for whatever they want?

“ Socialized” Medicine? A dirty word?

Philosophy & Politics of Healthcare Equity vs opportunity (can’t we have both?) Healthcare as a right? Von Hayek “… in the case of sickness or accident… the case for the state helping to organise a comprehensive system of social insurance is very strong… there is no incompatibility in principle between the state providing greater security in this way and the preservation of individual freedom.” What is minimum provision? Is it cost effective? Who decides what is appropriate? Should the rich still get whatever they want? “ Socialized” Medicine? A dirty word Nationalized Medicine - Almost patriotic

Equity vs opportunity (can’t we have both?)

Healthcare as a right?

Von Hayek

“… in the case of sickness or accident… the case for the state helping to organise a comprehensive system of social insurance is very strong… there is no incompatibility in principle between the state providing greater security in this way and the preservation of individual freedom.”

What is minimum provision?

Is it cost effective?

Who decides what is appropriate?

Should the rich still get whatever they want?

“ Socialized” Medicine? A dirty word

Nationalized Medicine - Almost patriotic

One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It's very easy to disguise a medical program as a humanitarian project…

One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It's very easy to disguise a medical program as a humanitarian project…

C O M M U N I S M Join the Party!

Ideological Investment Ideology is a poor driver, outcomes are more important UK: Free, fair, equitable access (mostly) National health US: Opportunity, freedom, make your own luck (mostly) Free market healthcare Do our healthcare systems really reflect this? UK: Not free, but relatively cheap, and fair(ish) US: Market - yes, free market – no.

Ideology is a poor driver, outcomes are more important

UK: Free, fair, equitable access (mostly)

National health

US: Opportunity, freedom, make your own luck (mostly)

Free market healthcare

Do our healthcare systems really reflect this?

UK: Not free, but relatively cheap, and fair(ish)

US: Market - yes, free market – no.

Covert / Overt Rationing Whether we like it or not, we work within a system Healthcare is expensive and getting more so Therefore care must be rationed somehow Overt or Covert rationing? Means or needs-based rationing? How can we reconcile this inevitability with a duty to do the best for our patient?

Whether we like it or not, we work within a system

Healthcare is expensive and getting more so

Therefore care must be rationed somehow

Overt or Covert rationing?

Means or needs-based rationing?

How can we reconcile this inevitability with a duty to do the best for our patient?

Treating individuals? Example - Statin therapy Undoubtedly a major step forward in prevention of cardiovascular events / mortality Widely felt to be cost-effective Quality indicators mandate prescription in many circumstances

Example - Statin therapy

Undoubtedly a major step forward in prevention of cardiovascular events / mortality

Widely felt to be cost-effective

Quality indicators mandate prescription in many circumstances

Statins – Primary Prevention Case scenario: 48y/o male, diabetic, non-smoker. No other PMH. BP 135/88 Cholesterol 230, HDL 30 Framingham 10-year CHD risk is 16% To prevent MI, Stroke & Death over 10 years: What is the NNT for this risk profile?

Case scenario:

48y/o male, diabetic, non-smoker.

No other PMH.

BP 135/88

Cholesterol 230, HDL 30

Framingham 10-year CHD risk is 16%

To prevent MI, Stroke & Death over 10 years:

What is the NNT for this risk profile?

Statins - NNT Recent statin data for type 2 DM weaker For this risk profile… According to 1999 JAMA meta-analaysis: OR 0.78 for ‘all bad things’ / 5 years NNT over 10yrs is 16 According to 2008 Lancet meta-analysis: OR 0.91 for ‘all bad things in DM’ / 5 years NNT over 10 years is 40 We’re already treating populations, not patients

Recent statin data for type 2 DM weaker

For this risk profile…

According to 1999 JAMA meta-analaysis:

OR 0.78 for ‘all bad things’ / 5 years

NNT over 10yrs is 16

According to 2008 Lancet meta-analysis:

OR 0.91 for ‘all bad things in DM’ / 5 years

NNT over 10 years is 40

We’re already treating populations, not patients

Free Market? Milton Friedman, interviewed in 2006 “ Instead of letting people hire their own physicians and pay them, no one pays his or her own medical bills. Instead, there’s a third party payment system. It is a communist system and it has a communist result… The end result is third party payment and, worst of all, third party treatment”

Milton Friedman, interviewed in 2006

“ Instead of letting people hire their own physicians and pay them, no one pays his or her own medical bills. Instead, there’s a third party payment system. It is a communist system and it has a communist result… The end result is third party payment and, worst of all, third party treatment”

“ I’m from the government. I’m here to help”

Cui expendo?

Summary – Part I Bias affects rational thinking. Be aware of yours We all work within a system, and can change it We are all treating groups / populations Socialized medicine ≠ communism US Healthcare ≠ free market US Healthcare is expensive. Is it better?

Bias affects rational thinking. Be aware of yours

We all work within a system, and can change it

We are all treating groups / populations

Socialized medicine ≠ communism

US Healthcare ≠ free market

US Healthcare is expensive. Is it better?

Comparing Healthcare

Methods of Comparison Comparing complex systems is difficult Observational data Multiple confounders Large-scale outcomes Life expectancy, infant mortality (WHO) Smaller, more direct national comparisons Cancer survival, transplant survival, suicide, asthma mortality, suicide rate, vaccination rate, cancer screening rates (OECD), HbA1C (health surveys) User surveys (Commonwealth Fund) NHS vs Kaiser Permanente (CA) study

Comparing complex systems is difficult

Observational data

Multiple confounders

Large-scale outcomes

Life expectancy, infant mortality (WHO)

Smaller, more direct national comparisons

Cancer survival, transplant survival, suicide, asthma mortality, suicide rate, vaccination rate, cancer screening rates (OECD), HbA1C (health surveys)

User surveys (Commonwealth Fund)

NHS vs Kaiser Permanente (CA) study

OECD (2005)

OECD Performance Indicators

NHS vs Kaiser Permanente Controversial economic study in 2002 Found Kaiser’s performance in every area to be equivalent or better, at similar cost Costs per capita: Kaiser $1951 NHS $1402, or with purchasing power parity: $1764 Analysis felt to be flawed due to Usual ‘complex systems’ problem Poor selection of comparison data PPP ‘fudge’ factor Kaiser patients mostly recruited through employment plans therefore substantially healthier

Controversial economic study in 2002

Found Kaiser’s performance in every area to be equivalent or better, at similar cost

Costs per capita:

Kaiser $1951

NHS $1402, or with purchasing power parity: $1764

Analysis felt to be flawed due to

Usual ‘complex systems’ problem

Poor selection of comparison data

PPP ‘fudge’ factor

Kaiser patients mostly recruited through employment plans therefore substantially healthier

Diabetes in the US and UK 2006 study compared diabetes management between adults in England (14000) and the US (5400) Notably lower incidence in England (2.7% vs 5.0%) Underdiagnosis? Adjustments made for age and socioeconomic factors HbA1C On ACE-I England 7.6 39% US (insured) 7.5 39% US (uninsured) 8.6 14%

2006 study compared diabetes management between adults in England (14000) and the US (5400)

Notably lower incidence in England (2.7% vs 5.0%)

Underdiagnosis?

Adjustments made for age and socioeconomic factors

WHOSIS

Commonwealth Fund (2007)

Cherry Picking?

Comparisons - Summary Comparing health systems is difficult Overall, minor differences between outcomes in the US and UK Insured population in the US maybe getting slightly better care Uninsured worse off Best in the world? Probably neither US nor UK

Comparing health systems is difficult

Overall, minor differences between outcomes in the US and UK

Insured population in the US maybe getting slightly better care

Uninsured worse off

Best in the world? Probably neither US nor UK

Failing Systems

Is the NHS Failing? Much beloved in the UK No fear of personal health catastrophe Free at point of need – what does it cost? Regional and urban/rural variation Political hot-potato Chronic underfunding, better recently Inefficiency death-spiral Move towards internal markets Private sector involvement

Much beloved in the UK

No fear of personal health catastrophe

Free at point of need – what does it cost?

Regional and urban/rural variation

Political hot-potato

Chronic underfunding, better recently

Inefficiency death-spiral

Move towards internal markets

Private sector involvement

NHS – Where are we going? Predictions of doom for 20+ years Recent problems with paying for: Cancer drugs (eg Avastin, Herceptin) Procedures (eg drug-eluting stents) Rationing becoming increasingly covert Introduction of the private sector Death knell for the NHS? Or creation of a two-tier system Despite this fear, proportion of private expenditure remains stable (15%)

Predictions of doom for 20+ years

Recent problems with paying for:

Cancer drugs (eg Avastin, Herceptin)

Procedures (eg drug-eluting stents)

Rationing becoming increasingly covert

Introduction of the private sector

Death knell for the NHS?

Or creation of a two-tier system

Despite this fear, proportion of private expenditure remains stable (15%)

Is US Healthcare ‘Failing’? US is only major developed country without some form of nationalized health care Debate re: fairness of free-market solution This isn’t a free-market solution Healthcare complex to ‘purchase’, sellers hold the cards Private health insurers / providers are profit maximizers, not cost-reducers. Drop chronic diseases / attract healthy preferentially Influence doctors’ spending, argue indications, deny claims Effectively underwritten by the government Less efficient Medicare’s admin costs around 5% Private healthcare plans around 9-17%

US is only major developed country without some form of nationalized health care

Debate re: fairness of free-market solution

This isn’t a free-market solution

Healthcare complex to ‘purchase’, sellers hold the cards

Private health insurers / providers are profit maximizers, not cost-reducers.

Drop chronic diseases / attract healthy preferentially

Influence doctors’ spending, argue indications, deny claims

Effectively underwritten by the government

Less efficient

Medicare’s admin costs around 5%

Private healthcare plans around 9-17%

Primary Care Patients prefer initial care from a PCP (94%) PCPs reduce unnecessary hospitalization and save money WHO World Health Report 2008 Theme is reinvigorating primary care US System rewards procedures Not time, quality, or correct diagnosis PCP wages around ½ of specialists Increased demands Chronic conditions, health screening, lifestyle advice Bureaucracy Medicare payments for primary care unattractive

Patients prefer initial care from a PCP (94%)

PCPs reduce unnecessary hospitalization and save money

WHO World Health Report 2008

Theme is reinvigorating primary care

US System rewards procedures

Not time, quality, or correct diagnosis

PCP wages around ½ of specialists

Increased demands

Chronic conditions, health screening, lifestyle advice

Bureaucracy

Medicare payments for primary care unattractive

Generalists – A dying breed

Why has The Market Failed? How do you choose a hospital to have your MI at? Is this really competition? Insurers / HMOs are much better at estimating risk than you are Even they can’t negotiate with providers HMO approved providers – free choice? Cartel? ‘ Personal responsibility’ Homo economicus doesn’t understand modern medicine, statistics, or risk

How do you choose a hospital to have your MI at? Is this really competition?

Insurers / HMOs are much better at estimating risk than you are

Even they can’t negotiate with providers

HMO approved providers – free choice? Cartel?

‘ Personal responsibility’

Homo economicus doesn’t understand modern medicine, statistics, or risk

Homo Economicus The informed consumer drives the market towards higher quality, competition drives down the cost Doctors work to be evidence-based Patients usually: Don’t have a medical degree Don’t understand NNT, relative vs absolute risk, regression to the mean etc Are scared Are strongly influenced by how they’re informed

The informed consumer drives the market towards higher quality, competition drives down the cost

Doctors work to be evidence-based

Patients usually:

Don’t have a medical degree

Don’t understand NNT, relative vs absolute risk, regression to the mean etc

Are scared

Are strongly influenced by how they’re informed

Making Health Decisions (1) A new disease is expected to kill 600 people. Two options to combat it: A: 200 people saved B: 1/3 rd chance that 600 saved, 2/3 rd chance that none are saved

A new disease is expected to kill 600 people. Two options to combat it:

A: 200 people saved

B: 1/3 rd chance that 600 saved, 2/3 rd chance that none are saved

Making Health Decisions (2) A new disease is expected to kill 600 people. Two options to combat it: A: 400 people die B: 1/3 rd chance that nobody will die, 2/3 rd chance that 600 will die

A new disease is expected to kill 600 people. Two options to combat it:

A: 400 people die

B: 1/3 rd chance that nobody will die, 2/3 rd chance that 600 will die

Making Health Decisions (1) A new disease is expected to kill 600 people. Two options to combat it: A: 200 people saved – 72% (risk averse) B: 1/3 rd chance that 600 saved, 2/3 rd chance that none are saved

A new disease is expected to kill 600 people. Two options to combat it:

A: 200 people saved – 72% (risk averse)

B: 1/3 rd chance that 600 saved, 2/3 rd chance that none are saved

Making Health Decisions (2) A new disease is expected to kill 600 people. Two options to combat it: A: 400 people die B: 1/3 rd chance that nobody will die, 2/3 rd chance that 600 will die - 78% (risk-taking)

A new disease is expected to kill 600 people. Two options to combat it:

A: 400 people die

B: 1/3 rd chance that nobody will die, 2/3 rd chance that 600 will die - 78% (risk-taking)

Making Health Decisions (2) A new disease is expected to kill 600 people. Two options to combat it: A: 400 people die B: 1/3 rd chance that nobody will die, 2/3 rd chance that 600 will die - 78% (risk-taking) Options are the same, but people choose different actions based on how the question is framed Private companies are extremely good at framing / manipulation It’s called advertising

A new disease is expected to kill 600 people. Two options to combat it:

A: 400 people die

B: 1/3 rd chance that nobody will die, 2/3 rd chance that 600 will die - 78% (risk-taking)

Options are the same, but people choose different actions based on how the question is framed

Private companies are extremely good at framing / manipulation

It’s called advertising

Barriers to Improvement People want change - FT Poll (2008) 12% said system works well 33% said system needs completely rebuilt Doctors want change? 2008 poll in Ann Health Res - 59% support single-payer AMA – 18% (1992), 42% (2004) Vested interest in current system Balanced constitutional system

People want change - FT Poll (2008)

12% said system works well

33% said system needs completely rebuilt

Doctors want change?

2008 poll in Ann Health Res - 59% support single-payer

AMA – 18% (1992), 42% (2004)

Vested interest in current system

Balanced constitutional system

McCain: Remove tax incentives for employers, provide tax credits for individuals to purchase insurance themselves No requirement for universal coverage Encourage cost savings by using nurse-practitioners, allow reimportation of drugs Provide consumers with more information on treatment options Require transparency regarding medical outcomes Pay a single bill for high-quality heart-care, rather than individual services Politics & Health

McCain:

Remove tax incentives for employers, provide tax credits for individuals to purchase insurance themselves

No requirement for universal coverage

Encourage cost savings by using nurse-practitioners, allow reimportation of drugs

Provide consumers with more information on treatment options

Require transparency regarding medical outcomes

Pay a single bill for high-quality heart-care, rather than individual services

Politics & Health Obama : Widen access to MedicAid and SCHIP Create a new public plan for small businesses and individuals, similar to the Federal employees plan Require all children to have health insurance No requirement for universal coverage for adults Prohibit insurers from denying coverage based on pre-existing conditions Tighter regulation, especially in non-competitive areas Promote generic drugs, allow drug reimportation Require hospitals and providers to publicly report measures of costs and quality

Obama :

Widen access to MedicAid and SCHIP

Create a new public plan for small businesses and individuals, similar to the Federal employees plan

Require all children to have health insurance

No requirement for universal coverage for adults

Prohibit insurers from denying coverage based on pre-existing conditions

Tighter regulation, especially in non-competitive areas

Promote generic drugs, allow drug reimportation

Require hospitals and providers to publicly report measures of costs and quality

Failing Systems - Summary The NHS is failing because of underfunding, politicization and poorly implemented market-force reforms Implementing a US-style solution on the cheap is a bad idea The US Healthcare system is failing because it is neither a free market nor a fair, transparently rationed system Generalists are necessary and effective, but poorly rewarded Private companies are very good at making money from healthcare Homo economicus doesn’t have an MD Only massive purchasers of healthcare have power to ensure value and quality Neither presidential nominee’s health plan addresses these issues, although Obama’s is more progressive

The NHS is failing because of underfunding, politicization and poorly implemented market-force reforms

Implementing a US-style solution on the cheap is a bad idea

The US Healthcare system is failing because it is neither a free market nor a fair, transparently rationed system

Generalists are necessary and effective, but poorly rewarded

Private companies are very good at making money from healthcare

Homo economicus doesn’t have an MD

Only massive purchasers of healthcare have power to ensure value and quality

Neither presidential nominee’s health plan addresses these issues, although Obama’s is more progressive

Fixing Healthcare

UK vs USA - Who won? Annoyingly, the WHO thinks it’s the French So I think it’s a draw… Overall, is US/UK healthcare largely good? Yes. Can you get better healthcare in the US? Yes. Is the overall standard better? No, possibly worse Costs are high Are there other benefits to universal healthcare? People are our greatest asset –shouldn’t we look after them?

Annoyingly, the WHO thinks it’s the French

So I think it’s a draw…

Overall, is US/UK healthcare largely good? Yes.

Can you get better healthcare in the US? Yes.

Is the overall standard better? No, possibly worse

Costs are high

Are there other benefits to universal healthcare?

People are our greatest asset –shouldn’t we look after them?

Another Way Singapore Model More free-market than the US, but full coverage safety-net Low taxes but mandatory health-savings Tightly regulated True free-market model. Scary? Otherwise, I think we should work towards: Single payer, transparent payment system High standard for all (cannot = best) Top-up insurance for niceties, less cost-effective treatments Informed consumers (not advertised-to) Generalists as co-ordinators / gatekeepers Incentives for correct diagnosis, appropriate care, time spent with patient, effective prevention

Singapore Model

More free-market than the US, but full coverage safety-net

Low taxes but mandatory health-savings

Tightly regulated

True free-market model. Scary?

Otherwise, I think we should work towards:

Single payer, transparent payment system

High standard for all (cannot = best)

Top-up insurance for niceties, less cost-effective treatments

Informed consumers (not advertised-to)

Generalists as co-ordinators / gatekeepers

Incentives for correct diagnosis, appropriate care, time spent with patient, effective prevention

Summary I’ve had amazing experiences in both US and UK healthcare There are significant problems with both systems You don’t want our system, and we don’t want yours… Holy-cow status, political ideology and vested interests prevent significant change Incremental change needs to be in the right direction Doctors are uniquely placed to influence this process The health and wealth of our nations is at stake

I’ve had amazing experiences in both US and UK healthcare

There are significant problems with both systems

You don’t want our system, and we don’t want yours…

Holy-cow status, political ideology and vested interests prevent significant change

Incremental change needs to be in the right direction

Doctors are uniquely placed to influence this process

The health and wealth of our nations is at stake

Thanks Laurel and Deborah Dr Clyburn Meredith Stafford All the physicians and students who’ve made we welcome at MUSC

Laurel and Deborah

Dr Clyburn

Meredith Stafford

All the physicians and students who’ve made we welcome at MUSC

Questions / Comments?

References WHOSIS data – www.who.int/whosis/en/ Milton Friedman image – www.freetochoosemedia.org Milton Friedman quote – Imprimis May 2006 – Hillsdale College http://www.hillsdale.edu Von Hayek, F – “The Road to Serfdom” NNT calculator - http://www.cebm.utoronto.ca/practise/ca/statscal/orToNnt.htm Statin data: CTT Collaborators “Efficacy of cholesterol lowering therapy in 18686 with diabetes” Lancet 2008; 371 Statin Data: Bandolier “Statins, NNT and Risk” http://www.medicine.ox.ac.uk/bandolier/booth/cardiac/statcalc.html Procedure rates: Goodman J, “Five Myths of Socialized Medicine” Cato’s Letter, Winter 2005 Vol3(1) Commonwealth fund data: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, The Commonwealth Fund, May 2007 Feachem et al, “Getting more for their dollar: a comparison of the NHS and California’s Kaiser Permanente”. BMJ (2002) Vol 324 Skidmore (1989) “Ronald Reagan and Operation Coffeecup: A Hidden Episode in American Political History”, Journal of American Culture Vol 12 (3) OECD Data – http://www.oecd.org Bodenheimer T (2006) “Primary Care – Will It Survive?” NEJM 355(9) FT/Harris Poll for the Financial Times – June 2008 Mainous et al (2006) “Diabetes management in the USA and England: comparative analysis of national surveys” J R Soc Med 2006(99) Admin costs: Merrill Matthews of CAHI “Medicare’s Hidden Administrative Costs” http://www.cahi.org Grumbach et al (1999) “Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists” JAMA 282(3) Bodenheimer and Fernandez (2005) “High and rising health care costs. Part 4: can costs be controlled while preserving quality?” Ann Intern Med 143(1)

WHOSIS data – www.who.int/whosis/en/

Milton Friedman image – www.freetochoosemedia.org

Milton Friedman quote – Imprimis May 2006 – Hillsdale College http://www.hillsdale.edu

Von Hayek, F – “The Road to Serfdom”

NNT calculator - http://www.cebm.utoronto.ca/practise/ca/statscal/orToNnt.htm

Statin data: CTT Collaborators “Efficacy of cholesterol lowering therapy in 18686 with diabetes” Lancet 2008; 371

Statin Data: Bandolier “Statins, NNT and Risk” http://www.medicine.ox.ac.uk/bandolier/booth/cardiac/statcalc.html

Procedure rates: Goodman J, “Five Myths of Socialized Medicine” Cato’s Letter, Winter 2005 Vol3(1)

Commonwealth fund data: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, The Commonwealth Fund, May 2007

Feachem et al, “Getting more for their dollar: a comparison of the NHS and California’s Kaiser Permanente”. BMJ (2002) Vol 324

Skidmore (1989) “Ronald Reagan and Operation Coffeecup: A Hidden Episode in American Political History”, Journal of American Culture Vol 12 (3)

OECD Data – http://www.oecd.org

Bodenheimer T (2006) “Primary Care – Will It Survive?” NEJM 355(9)

FT/Harris Poll for the Financial Times – June 2008

Mainous et al (2006) “Diabetes management in the USA and England: comparative analysis of national surveys” J R Soc Med 2006(99)

Admin costs: Merrill Matthews of CAHI “Medicare’s Hidden Administrative Costs” http://www.cahi.org

Grumbach et al (1999) “Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists” JAMA 282(3)

Bodenheimer and Fernandez (2005) “High and rising health care costs. Part 4: can costs be controlled while preserving quality?” Ann Intern Med 143(1)