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US and them: an encounter with American primary care

27 March 2009

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Practice Manager
Burton Croft Surgery, Yorkshire

Dawn has worked in healthcare for more than 15 years. During that time, she gained an Open University business qualification, giving her the learning to underpin her knowledge and move into management. Before moving into primary care, Dawn worked for a private hospital group, managing many successful projects including new builds and IT implementations. Dawn is also a freelance writer and is currently writing an A–Z reference book for effective managers. She recently completed volunteer training with the Prince’s Trust to mentor young people embarking on new business ventures

It is often so easy to forget how lucky we are here in the UK and what benefits we, as a nation, enjoy through the NHS service available to us all.

Established around an ideal that good healthcare should be available to everyone, regardless of wealth, the NHS was launched on 5 July 1948. The government took over responsibility for all medical services with free diagnosis and treatment for all. Having celebrated its 60th birthday, the NHS – while under continual media scrutiny – continues to provide an excellent standard of care to our population, old or young.

When health secretary Aneurin Bevan, the son of a Welsh miner, opened the Park Hospital in Manchester, Britain embarked on a hugely ambitious plan to bring, for the first time, hospitals, doctors, nurses, pharmacists, opticians and dentists together as one organisation that would be free for all at the point of delivery. The plan was, and still is, that the service would be financed entirely from taxation.

The concept was created to meet the critical need for improved healthcare in postwar Britain. It has been faced with ever-increasing costs as a result of advances in medical knowledge, medicines and technology. At the same time it is faced with financial restrictions that are inevitable in a centrally funded service, with changing management perceptions and political beliefs. Had Mr Bevan, in 1948, been blessed with the power of foresight, would he have led Britain down the same health pathway, I wonder?

As a nation we all use the service, whether it is through primary or secondary care intervention, and I am sure we can all sight cases of good and bad service. A lot depends on our geographical location in the country and how well or badly the primary care trust is managed in that area. Generally speaking, however, we take it for granted that if we need to be seen by a doctor, we are seen at no cost.

Sunshine surgery
During a recent visit to Florida, my husband needed to visit a healthcare provider due to cellulites brought on by an insect bite. The backdrop to the walk-in centre was one of serene calm: palm trees swaying in the warm autumn breeze, adequate free parking and an air-conditioned waiting area. Arguably the surgery where I work as practice manager is situated in a leafy suburb of the city of Leeds and provides similarly tranquil surroundings for our patient population – although without the sunshine.

A large banner at the front of the walk-in centre, visible from Highway 27, boasted a 30-minute or less wait. Set within a complex of other healthcare providers, such as physical therapists, podiatrists, ophthalmologists, etc, the centre appeared purpose-built. The receptionist was hidden behind a sliding glass partition. Signs pointed us in the right direction and gave an indication of what was expected of each patient attending the facility: “Please complete all information fully to cut down on waiting times”; “We process insurance on behalf of patients”; and “insurance details and ID required at the desk”.

We put our name down on the list as instructed by another seasoned patient and when it was my husband’s turn he asked if it was possible to be seen. Yes it was possible, and no, an appointment wasn’t necessary. All patients were seen in the order they were placed on the list, no matter what the ailment. It was explained that we would be expected to pay for any treatment prior to departure, similar to any private facility in England. Taking the paperwork from the receptionist, we sat down to wait.

A health centre of two halves
We had obviously attended the centre on a busy day, as the hour-and-a-half wait proved to be much greater than the banner had indicated. It gave me plenty of time, however, to observe the processes being used within the facility.

The walk-in centre made up one half of the building, with an orthopedic clinic that was totally independent running in the other half. The signboard for the orthopedic centre bore the name of one consultant specialising in hip and knee reconstructive surgery. I imagine this was a way of cutting down on running costs, having two providers not working in competition with each other in one building.

When my husband’s name was eventually called, I followed him through into the consulting area of the building. The lady who greeted us, Mary Kay Ferrari, was bright, bubbly and extremely efficient.

Weight and height were checked automatically in the corridor prior to entering the consulting room. Temperature, heart rate and blood pressure were taken and noted. This would fit well with all our Quality and Outcomes Framework requirements over here. I was unsure whether this efficient and well-managed process was the same for every patient, or just first-time attendees.

In fact, I couldn’t help asking questions about how they ran things and it turned out that Mary Kay was actually the administrator (practice manager) of the facility; she came from a nursing background and was covering until their new incumbent started the following week. My questioning continued and she eventually stopped and asked: “Are you planning on setting up a facility in direct competition or something?”

I explained that I was a practice manager in the UK and wanted to get a comparison of how things were done in America. She relaxed a little and offered to speak to me later when the surgery had closed.

My husband was then seen by a nurse practitioner, who prescribed the required antibiotics and anti-inflammatory drugs. She informed me that she worked alongside a GP and clinical assistant (similar to a healthcare assistant).

Later when I spoke to Mary Kay, she informed me that the practice was privately owned by a four-doctor partnership. They did not work in the business, but employed a GP, two nurses and a medical assistant. Mary Kay ran the business just as we do in England. She was responsible for the financial side and ensuring that all state guidelines and protocols were met. They did not have a register of patients at the practice; however, she said that some local people used the centre regularly, ensuring continuity of care.

Continuity of care?
My main area of questioning was around the vulnerable people within society, ie, children, the elderly and those with chronic long-term conditions.

I asked about the elderly and housebound patients – people who could not get to the centre – and the management of long-term conditions within the locality. She explained that if patients could not get to the surgery the doctors didn’t provide home visits themselves.

Their process was to contact any one of a number of companies who specialise in care in the community and commission the service from them. Those companies employ health professionals who visit the patient, assess their requirements and manage their care independently. There was an affiliation with certain companies who would keep the doctors informed of the care provided to the patient.

As it was flu season in England, I asked about flu clinics in the Florida surgery. Again, these were not routinely taken care of; they would only be done in clinic if absolutely necessary.

I went on to ask about childhood immunisations for the infant population. The surgery did not immunise; they would only do updates if necessary during a general visit. All childhood immunisations were carried out by local paediatric centres. The school system did not get involved with childhood vaccinations either. I suppose if you are used to this system, it becomes a way of life and the expectation is different.

Just as in England, a practising doctor has to be registered with their governing body and the state sets guidelines for working practices within all hospitals and healthcare organisations. The doctors are expected to update their training continually and carry out accredited training courses to keep their registration current. They attend an appraisal update annually just as our doctors do in England.

All standards of service provided within any clinical establishment are governed by the US Department of Health and Human Services (HHS), a department of the US government. Representatives from this department can make unannounced visits to a provider to carry out inspections.

The high price of good health
Insurance providers can also carry out unannounced inspections. Insurance providers are a critical piece of the healthcare jigsaw in America as, generally speaking, most members of the public have insurance to cover them for any type of healthcare requirement.

The healthcare providers are faced with similar new initiatives, such as electronic paper records and electronic prescribing. Funding is often available to providers who take up the challenge of these initiatives. I would imagine it is more difficult in the States to establish “buy in” to these, as most facilities are independent and don’t rely on the government for funding. The IT infrastructure was obviously high on the agenda of the HHS as their website advertises that funding is available for IT and any changes made within a facility.

The HHS website contains a massive amount of information, and they assure their readers that good health is important to everyone. They advertise two health programmes on their website – Medicaid and Medicare – for individuals and families who can’t afford to pay for medical care. In fact, both programmes have their own independent government websites.

As the government website says:

“Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to the individual; it sends payments directly to their healthcare providers. It is a state administered program and each state sets its own guidelines regarding eligibility and services.”(1)

This answered many of my questions and concerns about deprived patients living in poverty. The state does look after its population, but there are stringent checks made to ensure eligibility to the scheme.

Unfortunately I didn’t have enough time with Mary Kay to establish answers to my questions about managing mental health, screening programmes, managing long-term chronic disease and many other issues. I may need a further visit to establish the answers to some of my outstanding queries!

I did, however, find out that the cost of healthcare in the US is high. My husband’s consultant with a nurse practitioner cost $158, his urinalysis was $25, and I knew when she gave us a coupon for $15 off his prescription that the bill was also going to be hefty. I wasn’t wrong. She prescribed strong antibiotics, five in total: the cost was around $50. And that was after the coupon!

I don’t know how any American can afford to be ill?

1. Centers for Medicare and Medicaid Services [homepage on the internet]. Available from: