healthsignals new york

Rattling the Canadian system

We can't let the day pass without noting the court decision in the Canadian Province of Quebec overruling the state monopoly on health insurance. For now, the ruling apparently applies only to that Province, but it's caused an immense stir. There's lots of coverage:

• ABC: Canada Court Nixes Health Insurance Ban
• Boston Globe: Court ruling expected to change Canada's health care system
• The London Free Press: Provincial government in Alberta applauds the decision
• Another story regarding the reaction in Alberta from Canada.com
• Bloomberg: Canadian Court paves way for private health insurance

Will this make it harder for the single-payer advocates to point toward Canada? More later.

Web chatter on universal coverage

Several mainstream bloggers ("mainstream bloggers" - has it already come to that?) have been talking about universal health coverage, the lousy system in the US or some variation on the theme the past 10 days or so. Much of the subject matter may be wonky, but these are not health geeks so it's very interesting to see the debate unfold and it's interesting to note that it's going on now.

The summary version? In both cost and outcomes, the healthcare system in the US compares rather poorly to the systems in other Western countries. Some go the next step, describing the systems in particular countries and, in a couple of cases talking about what to do. We'll pick those up later.

This is a long post, especially if you follow the links - and even better to get the flavor - check some of the comments at those links. That's what happens when you're trying to connect the dots. This is but an introduction.

If nothing else there are some interesting personalities here. So enjoy them. My apologies to those who I left out. Here are some highlights for now.

And what do we get for our (high) spending?

Krugman's latest on healthcare, which by the way was yesterday's most e-mailed New York Times story. It's another on how poorly the US healthcare system stacks up to those in the rest of the developed world.

Comment on how the Swiss do it

What's wrong with this?

Trend changes and variations in reinstitutionalization

When we did our first studies of hospitalization of Medicaid clients in New York 15 years ago, admissions for psychiatric conditions were the most variable and by a lot. We suspected there were data problems, but also believed that most of the variation was real due to:

• Greater ambiguity in diagnosis (as compared to say, hip fracture)
• Lack of consensus on treatment (again as compared to say, hip fracture)
• Possibly real differences in care-seeking patterns

I was reminded of those observations by this article from the British Medical Journal, Reinstitutionalization and mental health care: comparison of data from six European countries (PDF). It explores whether reinstitutionalization is occurring in western countries and, if so, with what variations. The findings? Reinstitutionalization is occurring and there is variation:

Reinstitutionalization is occurring in European countries with different traditions of healthcare, although with significant variation between the six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to risk containment in a society, as indicated by the size of the prison population, may be more important than changing morbidity and new methods of mental healthcare delivery.

The authors also note that, "most of the data are consistent with the assumption that deinstitutionalization, the defining process of mental healthcare since the 1950s has come to an end." While the number of psychiatric hospital beds has generally continued to fall since 1990,  "this was partly or  more than compensated for by additional places or other forms of  institutionalized care." The authors refer to the latter process as "transinstitutionalization." If it's got its own word, it must be a significant phenomenon.

Social attitudes often overpower patterns of underlying illness, changes in other social supports for the ill (and not just those with mental illness), and available methods of care. Science advances. Methods and systems advance. But we also have to keep social attitudes in mind as we evaluate what's actually going on ... and not just for mental health care.