Age-Based Rationing in Sweden?

Reader J.W. alerted me to this story in the Swedish news about apparent age-based considerations in drug subsidies.

Using Google translate, the article is entitled: "Age weighed in medicine bill" (March 10, 2013).

From the translated version:

Niklas Hedberg, head of the new drugs on the TLV, believes that there is an unfortunate wording, but that the work complies with legislation stipulating that they must weigh each consequence of a drug subsidy. 

-For us it is a very complex issue, the starting point is that society's resources for drugs is limited and we are commissioned to be those that prioritize the allocation between different patient groups. Since the legislation has made clear that we must weigh up different principles, and we will take account of drugs in a society holistically, says Niklas Hedberg. 

Would you expect that retirees actually costs if they survive? 

-What is unfortunate is that you can get the picture that it just is a matter of age, it only concerns pensioners. But I think your question is good and it is also very complex. Should we take into account that a patient can start working or not? It is then output effect comes into play.Consumption effect is always when you extend the life of a treat. 

Are pensioners lives worth less? 

-Everyone's health is valued as much, but the calculation model allows perched on top gives the socio-economic perspective, an added benefit of the treatments that allow the patient group can start working again.

In effect, those who are deemed more productive to society will be given higher priority in the national health system than those who are considered a net drain.

This is a nearly-inevitable outcome when medical care (and the system of payments) is considered a collective good that must be allocated accordingly.

The US isn't at this point yet.  But there are intellectuals and policy writers laying the groundwork for similar rationing here.

(One example is this article, "Principles for allocation of scarce medical interventions", co-authored by former Obama administration health policy advisor Zeke Emanuel, brother to former Obama chief of staff Rahm Emanuel.)

Private Health Care in Sweden

The Guardian reports on, "Private healthcare: the lessons from Sweden" (12/18/2012).

A couple of excerpts:

During an hour-long presentation to the Guardian, St Göran's chief executive, Britta Wallgren, says the 310-bed hospital, serving 430,000 people, outperforms state-owned rivals inside and outside the country.

She says emergency patients see a doctor within half an hour, compared with A&E waits of up to four hours in the NHS. "We took an A&E department that dealt with 35,000 patients a year and now treats 75,000," Wallgren says. "As admissions grow and we have an increasingly elderly population so must our performance improve."

Capio stresses that St Göran has low levels of hospital-acquired infections, and patient surveys record high levels of public satisfaction. It has also produced year-on-year productivity gains – something the state cannot match. Thomas Berglund, Capio's president, says the "profit motive works in healthcare" and companies run on "capitalism, not altruism".

One patient who opposed the private sector used it nonetheless:

"I am one of those Swedes who do not agree that private hospitals should exist," says Christina Rigert, 62, who used to work as an administrator in the hospital but resigned "on principle" when it was privatised a decade ago.

Now back as a patient after gastric band surgery, she says: "The experience was very good. I had no complaints. There's less waiting than other hospitals. I still do not think there should be private hospitals in Sweden but it's happening."

Note that she attacked it, even while benefiting from it.

The system is not perfect.  But it is an encouraging step in the right direction for Sweden.

Now there is an potential reverse argument some might make along the lines of, "Limited government advocates don't think government program X should exist, but they still take advantage of that service while opposing it.  So they're also being hypocritical!" (For instance, roads, schools, libraries, Post Office, Social Security, etc.)

But one key distinction is that these government programs typically use force "crowd out" (either directly or indirectly) the private options, thus leaving ordinary citizens with limited or no choice except to use the government option.

In contrast, introducing private health options into a socialist system adds choice rather than reducing it. And if over time the private choices "crowd out" the government option, I consider that a feature not a bug.

(Read the full text of "Private healthcare: the lessons from Sweden".  H/T: Dr. Matthew Bowdish.)

Quick Links: MA, AMA, Sweden

The 6/22/2011 Boston Business Journal reports that MA Attorney General Martha Coakley is demanding more price controls on health insurance. This is in addition to the proposed "global payments" (which are the 21st-century version of HMOs). For her, the solution to problems created by prior government controls is more controls. (Via Scott K.)

Dr. Mark Neerhof of Docs4PatientCare discusses why, "Obamacare Makes AMA Irrelevant to Doctors". His article gives many reasons why I'm not a member of the AMA.

Carl Svanberg debunks many of the American leftist myths about health care in his home country of Sweden at, "The Right To Wait".

How's That Swedish Universal Care Going?

John Stossel discusses the latest medical outrage in Sweden in his blog post, "Great Moments In Government-Run Health Care":

...What really astounds me is not that a Swedish man sewed up his own leg after waiting for a long time in a hospital. Heck, I wouldn't be surprised if things like that happened in all nations.

The really disturbing part of the story is that the hospital then reported the man to the police. A classic case of "blaming the victim." The bureaucrats in Sweden's government-run healthcare system obviously were not pleased that he called attention to their failure.

Here's the original news story.

Doctoring the Numbers for Socialized Medicine

My recent Washington Examiner OpEd on "health care czars" was the subject of a spirited discussion thread at LittleGreenFootballs.

My wife Diana brought this comment to my attention:

Funny. In Sweden, right now, the government has all the hospitals agree to this "guarantee of service" which means when you seek non-emergency care, you must be guaranteed to see a doctor within 7 days. And if the doctor sees it is needed, he will refer you to a specialist, and you must be seen within 90 days. Then if treatment is needed, you must be treated within 90 days.

Nice, but, the hospitals can't meet that arrangement, so hospitals are quietly asking their doctors not to issue referrals -- that way they get out of the 7-90-90 agreement, and the heavy fines imposed on the hospitals if they do not fill them.

This sort of "doctoring" of the numbers is not limited to Sweden.

Last year, a controversy erupted in the UK when it turned out that ambulance drivers were told to keep critically ill patients within the ambulance, even after the vehicle had pulled up to the hospital property just outside of the doors of the emergency rooms (called "A&E" for "Accident & Emergency" in Great Britain).

The patients were forced to wait within the ambulance so that their waiting time in the vehicle wouldn't count against the hospital's waiting time, thus allowing the hospitals to technically claim that their patients were treated within government-mandated standards of arrival within the hospital:

Scandal of patients left for hours outside A&E

Hospitals were last night accused of keeping thousands of seriously ill patients in ambulance 'holding patterns' outside accident and emergency units to meet a government pledge that all patients are treated within four hours of admission.

Those affected by 'patient stacking' include people with broken limbs or those suffering fits or breathing problems. An Observer investigation has also found that some wait for up to five hours in ambulances because A&E units have refused to admit them until they can guarantee to treat them within the time limit. Apart from the danger posed to patients, the detaining of ambulances means vehicles and trained crew are not available to answer new 999 calls because they are being kept on hospital sites.

If the US adopts government-run "universal health care", we will see American hospitals acting similarly and placing a higher priority on "doctoring their numbers" rather than their patients.

Nurses strike in Sweden

Currently, Swedish nurses are in the third week of a strike. This means at minimum delays and inconvenience for patients. Accident and emergency departments at the major hospitals in Stockholm close for a day each, meaning delays for patients without prior appointments. The first accident department to close in Stockholm was at St Goran's hospital, Sweden's fourth largest emergency hospital according to this article.

The first members of the Association of Health Professionals (Vårdförbundet) walked off the job April 21 after their demands for higher pay were not met. This Swedish newspaper article points out that Swedish newspaper editorials have devoted much time to analyzing this strike, and states that nurses' have had a better wage growth over the last 10 to 15 years than most other public sector employees at the county-level.

These strikes are not unusual in countries with government-run medical care. According to this article, Denmark is in the middle of a health care workers' strike, and Finland nurses threatened a similar action last year. In Denmark, around 65,000 nurses, midwives and laboratory assistants remain on strike, while retirement home workers and preschool workers have ended their strike. This strike over wages has led to some 40,000 canceled operations as of its second week, and is expected to be long-lasting.

Lines For Swedish Care Grow Longer

The February 4, 2008 edition of Investors Business Daily notes that rationing and waiting times continue to worsen in Sweden's system of socialized medicine. Here are some excerpts:

Waiting times for care, long a problem in Sweden and too often deadly wherever they're found, are now the longest on the Continent, says European think tank Health Consumer Powerhouse.

...Long waits are a hallmark of government health care anywhere it's employed. When the perception exists that treatment is free (it is not; Swedes pay more than half their gross income in taxes to support the welfare state), system overuse is inevitable. People can think of no reason to self-ration care. They show up in emergency rooms and doctor's offices with conditions for which they wouldn't seek treatment if they paid directly at the time of service.

Swedes are accustomed to cradle-to-grave care provided by the state. But rather than deal with long waits, they're opting for private care, which got a boost from limited reform in the 1990s. In private care, patients self-regulate and put less stress on the system.

Thanks to the profit motive, private health care providers have an incentive to cut waiting times, lest they lose customers to the competition. Government providers have no such motivation.

They do have incentive, however, to ration care when demand gets too high and costs soar. But to do so exposes "universal access" and "equal access" to be inaccurate descriptions. "Restricted access" would be more fitting.

Problems with Sweden's Single-Payer System

Sweden is often romanticized by Americans as a model for socialist ideas done correctly. So how does their government-run single-payer system work out in actual practice?

According to this new study by David Hogberg, Ph.D. of the National Center for Public Policy Research, not too well. Like any such system, they control costs by waiting lists and rationing. Here are some excerpts from his paper. (Items in bold are my emphasis):

"Sweden's Single-Payer Health System Provides a Warning to Other Nations", by David Hogberg, Ph.D.

Görann Persson had to wait eight months during 2003 and 2004 for a hip replacement operation. Persson was not considered to be a very pleasant person to begin with, and he became even grumpier due to the pain he endured while waiting for his operation. As a result, Persson walked with a limp, reportedly used strong pain medication and had to reduce his workload.

What made Persson unique was not his wait for hip surgery. Despite the government promise that no one should have to wait more than three months for surgery, 60 percent of hip replacement patients waited longer than three months in 2003 (see Figure 2). Rather, Persson stood out because he was Prime Minister of Sweden at the time. Persson could surely have used his position in the government to gain access to private care, essentially jumping the waiting list. Yet Persson stated that he planned on waiting for his surgery like everyone else.

Whether Prime Minister Persson did this out of benevolent motives is an open question. His party, the Social Democrats, have used the phrase "equal access to health care" to attack the center-right parties on the issue of health care for many years. Persson would have greatly undermined the effectiveness of that attack had he jumped the waiting list.

...While rationing may permit the government to save on costs and thereby restrain health care budgets, putting patients on waiting lists is not cost-free. One study that examined over 1,400 Swedes on a waiting list for cataract surgery found that 5.2 million kronas were spent on hospital stays and home health care for patients waiting for surgery. That was the equivalent of what it would have cost to give 800 patients cataract surgery.

A recent study that examined over 5,800 Swedish patients on a wait list for heart surgery found that the long wait has consequences far worse than pain, anxiety or monetary cost. In this study, the median wait time was found to be 55 days. While on the waiting list, 77 patients died. The authors' statistical analysis led them to conclude that the "risk of death increases significantly with waiting time." Another study found a mean wait time of 55 days for heart surgery in Sweden and a similar rate of mortality for those on the waiting list. Finally, a study in the Swedish medical journal Lakartidningen found that reducing waiting times reduced the heart surgery mortality rate from seven percent to just under three percent.

Sweden is one of several nations whose practices offer proof that single-payer health care systems lead to the proliferation of waiting lists. It also shows that waiting lists have adverse and sometimes tragic consequences for patients.

Conclusion

While Sweden is a first world country, its health care system - at least in regards to access - is closer to the third world. Because the health care system is heavily-funded and operated by the government, the system is plagued with waiting lists for surgery. Those waiting lists increase patients' anxiety, pain and risk of death.

Sweden's health care system offers two lessons for the policymakers of the United States. The first is that a single-payer system is not the answer to the problems faced as Americans. Sweden's system does not hold down costs and results in rationing of care. The second lesson is that market-oriented reforms must permit the market to work. Specifically, government should not protect health care providers that fail to provide patients with a quality service from going out of business.

When the United States chooses to reform its health care system, reform should lead to improvement. Reforming along the lines of Sweden would only make our system worse.