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The Official News & Technical Journal Of The International Society For Pharmacoeconomics And Outcomes Research

Commentary: Reflections on 'Sicko' by Michael Moore from a European Point of View

Wolfgang Greiner PhD, Health Economist, University of Bielefeld, Bielefeld, Germany, and Thomas Mittendorf PhD, Health Economist, University of Hanover, Hanover, Germany

The documentary film Sicko by Michael Moore gives us a very grim insight into the American health care system. A variety of individuals speak to the audience, all of them having major problems as necessary health care services (like bone marrow transplantation) were denied to them by their health care insurances in the past. The more urging problem in the United States, namely its over 45 million uninsured citizens is very strikingly represented by a man stitching an open wound on his leg by himself just like Sylvester Stallone already showed us some 25 years ago in the film “Rambo: First Blood”. Seeing all the sad and horrible cases some of the American viewers may very well lower their heads in shame, some may be outraged. For others it also may only be an anecdotal line up of short glimpses at countries around the world with a more or less 'socialized medicine'.

But one question remains: Do Europeans smile while watching this film?

Michael Moore has not been known in the past to present a completely balanced and unbiased picture of the given situation. He intelligently uses fast cuts and a satirical undertone while commenting the pictures we see on the big screen. In doing so he plays with the emotions of the audience aiming to reach his goal of gaining attention for a specific element going wrong in the ongoing development process of the American society. In this film especially Europeans are attracted to the content because Moore goes oversees to France and the UK to search for the Holy Grail in solving the problems of the US health care system. As much as we Europeans would like to sit back knowing that we possess this final recipe for the perfect health care system, we have to reflect for one moment if we actually are entitled to laugh and to point our finger over the Atlantic.

The image of the American health care system sketched in the film needs a second look at. It is true, that the health care market in the US compared to other industrialized countries is the one with the highest rate of un- or underinsured citizens, having in mind that over 15% of the American public is affected by this. Adding to that, in the European understanding of the phrase 'health insurance' this figure definitely will be much higher. Even public coverage schemes like Medicaid or Medicare bear a high financial risk to patients, as drug costs and co-payments may be substantial. On the other hand one has to keep in mind that the US health care system has high inherent innovative powers and a high rate and speed in the diffusion of treatment innovations. So it may be that the overall life expectancy, which often is cited in the film, isn't as high as in most European countries (but as in Cuba looking at WHO figures), on the other hand the survival rate after cancer treatment rather might be higher. Furthermore, the majority of developments in organizational or funding issues in health care finally are to some extent rooted in the US market. Topics from recent European history include disease management programs for chronic conditions, managed care or integrated health care concepts. Another example is diagnosis related group (DRG) systems for hospital services which were enacted in most European counties (like Germany) very recently. Europeans, especially German health politicians, tend to look exclusively to the US for new concepts having cost containment in the back of their head. The United States in the 80’s and 90’s undoubtedly was the laboratory for new health care concepts for the rest of the world.

The multilayered structure of the US health care market makes it a very competitive system, which is good, speaking as a health economist. But it also becomes very non-transparent to consumers and the general public. This problem is touched by Moore when he presents the tragic case of a mother loos-ing her young daughter after urgent treatment is denied by a hospital only because the health insurance insists on referral to another hospital the company has a contract with. This case cannot be typical and must not happen in the US simply because any hospital is obliged to offer life-saving services regardless of insurance coverage. Showing this as an example of profit maximizing insurance companies is unfair, since this simply seems to be a sound legal case the mother should fight in the name of her daughter. One thing this example does make crystal clear to a European, is that, in the US, not every hospital or physician is there to treat every single citizen. We are simply not used to the idea to be only entitled to go to those service providers our health insurance has a contract with. This non-transparency would present a major problem in our perception of the system as a whole.

One approach to tackle non-transparent treatment processes is to base decisions on treatment alternatives on scientific medical and health economic evidence and research. This trend has been and will be one of the most important political topics in Europe and definitely will be one of the topics in the US in the coming years. Some patients in the film do not receive specific treatments because supposedly no efficacy has been shown by scientific research up to that point. The assessment if there is scientific proof or not is very problematic in the hand of a single employee of an insurance, especially if this employee has an incentive to deny treatments simply because he can raise his salary by doing so. But looking at medical benefits as well as cost benefit ratios has been and must be an issue not only in Europe becoming more and more attractive in a world with budgetary constraints where everybody has the vision of 'value for money'. For some treatments some European countries (e.g. drugs for loosing weight in obese patients) reached different conclusion for their decision on re-imbursement. This urges the need for every health care system to evaluate innovations within its specific context and to define an optimal level of 'adequate' health care.

Looking over to Europe, Moore speaks with an English hospital physician who explains that he chooses a therapy only looking at the specific health care need of a patient and not at funding issues. The film is blanking out the long and painful time period the National Health Service (NHS) fought with substantial under-funding making no investments in the infrastructure. These days' problems with e.g. waiting lists for treatment are not so huge any more and salaries of physicians have gone up. To reach this goal Great Britain had to reach a broad societal consensus to spend a higher proportion of tax revenues on health care. This process was furthermore aided by the fact that Great Britain was lucky to find itself in an economically prosperous phase. If the stream of financial resources continues to flow in a recession still remains to be seen.

In wrapping things up, what implications does this film have to a European audience? We have the fear that a lot of Europeans only will experience a comforting but creepy sensation looking at this bizarre health care system which luckily seems to be very distant from ones own experience and beliefs. But we shouldn't make ourselves too comfortable in our cinema seat: An orientation of the European health care systems towards a more competitive approach seems inescapable with a much worse demographic change in Europe than in the United States as well as rising costs for health care due to the progress in medical technology. The vision at the end of the movie everybody should be nice and help one another and not only look at financial profits definitely cuts a long story too short. Individuals who use wrongly set incentives within the system for their own advantage exist everywhere regardless of the underlying system. The conflict of goals between general (and affordable) health care for all and a health care system that searches for efficiency via substantial competition between its participants is not solved as easily as Moore implies with his film.

With this in mind the scarecrow of 'socialized medicine' existing in all its different facets in Europe surely is not the Holy Grail for the US as their health care system isn't the one and only blueprint for health care systems in Europe

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