The Treatment of SCI in Scotland and the US: What lessons can we learn?

Kathryn Pirie

West Virginia University

PUBA 671
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The healthcare system in the United States is complicated and expensive (Longest and

Darr, 2014). In this paper, I will compare and contrast a patient’s healthcare journey in the

United States and in Scotland to discover how the two systems are used and the likely outcomes

after a traumatic and life-changing medical event. I will then offer my suggestions of the steps

the United States needs to take in order to reach a more favorable outcome.

Hamish vs. Henry

Henry and Hamish are both 28 year old men living in small towns in the eastern part of

their respective countries. They both have a college degree and work in an accounting firm for

the past five years at a desk job. Neither are married nor have kids. Both like to play video games

and go camping with friends. They were both in a single-car motor vehicle accident in their

respective hometowns and sustained a C6 complete spinal cord injury (SCI), meaning limited use

of their shoulders and elbows and no sensory or muscle activation in their hands, trunks, or legs.

Neither have any significant past medical history and were generally active and healthy before

this incident. Henry lives in the United States and Hamish lives in Scotland. Both of them would

like to receive the best care and get back to life as normally and as quickly as possible.

Financing

Scotland

Hamish does not have private health insurance. He is entitled to access Scotland’s

National Health Service (NHS). According to their website, the NHS is a publically funded, free-

at-the-point-of-service system supported with general taxation. All the healthcare workers are

government employees, paid by salary or hourly rates, with no fees-for-service. No matter how

long or how many services Hamish receives through the NHS, his healthcare costs are covered
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by the population of Scotland. For the past five years, Hamish has paid about 25% of his income

into these taxes to support this system.

United States

Henry has private health insurance through his employer. He was not eligible for any

government insurance program because of his age, income and health status. Every month for the

past five years he has paid $100, while his company has paid $400 toward his healthcare

premium. He has a $5,000 deductible and his insurance company will cover 80% and he needs to

cover 20% of his costs. For 12 weeks after his initial injury, he is still eligible for his private

insurance but must pay the entire $500 premium himself; after that, he will no longer be

employed at his company. At that point, he may be eligible for Medicaid, but will have to apply

for it, a lengthy and complicated process and he seek legal counsel about his eligibility

requirements. His initial hospital bill will be paid by a combination of his private insurance and

his own funding, but continued care may be government and/or himself and/or charities and/or

write-off from the healthcare provider. It is not as straight forward as Hamish’s case.

Insurance

Scotland

As part of the NHS, Hamish’s access to care is determined by where he lives. He does

not get a choice about where he will go to receive his care, but rather has access to the nearest

hospital to him as well as the specialty hospital and outpatient clinics for his type of injury based

on his clinicians’ referrals. He also will be able to obtain some durable-medical equipment

(DME) and even some money for home modifications on the NHS.
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United States

Henry has a choice as to where he will go for his healthcare, but this choice is limited by

many factors. Firstly, when his accident initially happened, he was sent to the nearest hospital.

His insurance is a Managed Care Organization (MCO); fortunately, this hospital was a part of his

system, which should decrease his out of pocket expense. After his initial acute care stay, Henry

has a choice as to where to go for his rehabilitation. He needs to consult with his case manager

and his insurance company about his options for rehabilitation, inpatient rehabilitation facilities

(IRFs) vs skilled nursing units (SNU), inpatient vs. outpatient vs home health. He needs to learn

what care is in-network and what is out-of-network and what the benefits of his particular type of

insurance are; such as, how many days at certain types of facilities and what DME he can

receive. Liaisons from nearby SNUs and IRFs will come to meet him in his hospital to try to

market their facility. He will also have the option to decide to go to a further away, specialty

clinic for SCIs. He will need to balance the cost, geography and services offered as well as

medical advice when making his decision, while still in an acute care hospital, if he can get all

this information. His case manager should be able to provide some of this information, but it

takes time to get and process, as well as being a new language to him.

There is disparity in health knowledge for Henry and what knowledge he should have to

make his decision. He did not plan of getting an SCI and does not know enough about the health

system to even know how to ask the questions that he needs to get useful information. Henry will

only be at the acute care hospital for an average of 11 days (SCI Data Sheet, 2015) so will need

to make this decision quickly. Also, the information about what his expenses will be is not

straight-forward. He will not have a completely clear picture as to how much his rehabilitation

will cost him because it will depend on many factors including how many days he will be there
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and how many services he will receive. This makes a true comparison between facilities and

options impossible. Henry cannot make a fully informed decision. This is much more

complicated than Hamish’s case.

Delivery

Scotland

Within 24 hours of his accident, Hamish is sent to the Queen Elizabeth National Spinal

Injuries Unit (QENSIU) for Scotland. This unit is “responsible for the management of all

patients in Scotland who have a traumatic injury to the spinal cord” (Annual Report, 2017).

Unfortunately, because Hamish is from the other side of Scotland, the QENSIU is about a three

hour drive from home where his friends and family live. This makes travel difficult and he will

not have the same social support while his is inpatient then if he lived closer. Because Hamish

has a higher level of injury, based on the averages from the latest annual report available (2017),

Hamish will stay at the QENSIU for 114 days. While there, he will work with doctors, nurses,

occupational therapists, physiotherapists (physical therapists) and mental health councilors that

are the best specialists in his country for treating his type of injury. SCI is a specialized field. The

clinicians in each discipline will decide what is the most appropriate outcome measure to

objectively determine if he is making progress and by how much. They also will use their own

clinical reasoning to determine how much and what type of intervention is needed. The

equipment available on the unit is designed especially for people with SCI and the majority is

appropriate for Hamish.

While at QENSIU, Hamish will have the opportunity be involved with a weekly

therapeutic and fun outing, with his therapists and other patients, such as going to a nearby

shopping center, restaurants, ice skating, and movies. As he gets closer to discharge, there is a
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simulated apartment where Hamish can spend the night with his family members so they can see

what it will be like to have Hamish at home and be primary care givers.

Hamish’s wheelchair needs will be principally determined by his therapy team. He will

not have many options for adaptations and will be given a basic chair that will meet most of his

requirements. He will have this chair several weeks before discharge in order to learn how to use

it safely. Once Hamish has completed his rehabilitation, as determined solely by his clinical

team, he will discharge home. His family will have had over three months to make the necessary

modifications to his living environment with money from the government. If his home is not

ready at the time of discharge, he will go to a nearby hospital until it is. This only happens in

about 4% of cases (Annual report, 2017). He will receive follow-up care at a nearby satellite

outpatient facility to his home but continue to maintain a relationship to QENSIU, and may every

come back for care if determined by his outpatient clinical care team. However, the annual

reports states “most neurologically injured patients discharged from the Unit never require re-

admission” (2017). His follow-up care will be minimal due to good upfront medical care and

education. The clinical team has the team and the resources to fully prepare Hamish and his

family for re-integration into society upon discharge

United States

Henry decides to go to a local inpatient rehabilitation facility (IRF) because it is in-

network for his insurance, nearby his home and easier for friends and family to visit (Butin, et al.

2004) This facility has the disadvantage of not specializing specifically in SCI. The clinicians

have all encountered SCI before, but must manage multitude of other cases, not just neurological

cases. He will also receive medical care from doctors and nurses, therapy from occupational and
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physical therapists, and one session with a neuropsychologist. Some of the equipment in the IRF

is appropriate for him, some can be adapted to meet his needs, but most is not specific for SCI.

Even though Henry does not have Medicare, the facility follows Medicare guidelines due

to their high number of Medicare patients. This includes using the Functional Independent

Measure to objectively determine Henry’s functional status and progress. Unfortunately, this tool

may not be the best suited scale to analyze his improvement (Alexander, M. et al, 2009). Henry

will receive three hours of therapy a day, five days a week, split between occupational and

physical therapy per Medicare guidelines. The clinicians do not have the discretion to determine

what is individually appropriate for him. All of his therapy will be in the IRF because his

insurance company does not approve off-site outings.

Henry will stay at the IRF for 34 days (SCI Data Sheet, 2015) which gives his family a

total of 45 days between the acute care and rehabilitation hospitals to learn how to take care of

Henry and make necessary home modifications, which requires finding funding for those

modifications. They will be trained by the clinical staff on how to help Henry, but will have

limited opportunity to practice before discharge.

Henry will have a choice about what company he would like to supply his wheelchair,

but this is again limited but geography, his insurance, and his own medical knowledge. He will

meet with an assistive device professional along with his physical therapist to determine what

wheelchair will best meet his needs. Unfortunately, this wheelchair will take six to eight weeks

to build and ship, so will not be ready by the time of discharge and Henry will go home in a

loaner chair. The wheelchair he does get, however, will be tailored to him specifically. He will

continue his therapy on an outpatient basis and have a 30% chance of being readmitted into an

acute care hospital or IRF (SCI Data Sheet, 2015). At the time of discharge, Henry is not as
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prepared as Hamish and will continue to frequently use the healthcare system to manage his

condition.

Payment

Scotland

Hamish will have no out-of-pocket expenses for his hospital stay, adaptive equipment,

home modifications and outpatient visits. After a few weeks at home, Hamish will be

independent enough to return to work with reasonable accommodations in his office space for his

wheelchair and adaptive computer usage. His work has kept his job. Hamish will again be able to

pay into the system that paid for his healthcare as well as supporting himself.

United States

Henry will have significant out-of-pocket expenses. In addition to the several hundred he

has to pay in his premium, he will have a small co-pay each time he utilizes a healthcare service.

He will receive hospital bills and medical supply bills months after his initial injury. These will

total into the several thousands. He is also responsible for finding the funding for his own home

modifications. The US has some charities and program that can help him, and his case manager

may be able to help guide him toward them. In an effort for his insurance company to contain

costs, Henry will be discharged earlier from his inpatient rehabilitation facility, but his life-time

costs will be more with outpatient rehabilitation and likelihood of yearly readmissions.

Three months after his injury, Henry will not be ready to return to work, and he can no

longer access his employee sponsored health insurance for any continued healthcare utilization.

At this point, he will hope to receive Medicaid, but according to their website (2015) this process

can take about 45-90 days or longer, so he will have needed to start essentially as soon as he was

injured to not have a gap in coverage. He will have the option to privately-pay or try to find his
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own health insurance, but both of these options will be prohibitively expensive. Being out of

work already, Henry will have to rely on the hospital to write-off much of their expenses if he

cannot pay them. When Henry is ready to return to work, he may lose the benefits that he has

gained. It may make more financial sense for Henry to stay on Medicaid and collect disability

benefits then go back to work. He also cannot go back to his old job because they have re-hired

the position 12 weeks after Henry had his accident. This puts burden on the hospitals and other

healthcare facilities to cover their own expenses, on Henry and his family to find funding

sources, and on the American taxpayer to continue to pay for not only Henry’s medical needs but

to support him financially, perhaps for the rest of his life.

How do we get there?

The advantages of the Scottish system in treating SCI are it is less expensive, more

comprehensive, and has better access to specialists in the field with more discretion given to

those specialists. The advantages of the US system is care closer to home and better access to the

latest technology. The cost, however, is not just time and money. The American patient is given

the illusion of choice for his healthcare. He is mostly influenced by geography and what his

insurance company will do. Unlike other markets, he cannot compare prices because of the lack

of clear, transparent up-front pricing. Healthcare decisions are often time-sensitive, adding more

stress to an already traumatic situation. Furthermore, there is an inequality of knowledge of the

lay-person and health care providers. Providers can make their recommendations within reason

but must leave the final choice to the individual.

Any attempt to reform the healthcare system of the United States must address the issues

highlighted in this case study. The goal would be to create a system that is less expensive, gives

access to the right clinicians, allows those clinicians’ discretion within their scope of practice,
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while still providing the right equipment and technology, opportunities for healthcare closer to

home and giving people reasonable control over their own healthcare decisions. This system,

however, can not be designed from scratch because healthcare has to be an ever ongoing process

that cannot be stopped even for a moment (Gawande, A. 2009). Therefore, my recommendations

are based on the system that the US has currently with steps aiming towards meeting the ultimate

goal of better and affordable healthcare for everyone.

Assure and Ensure Insurance

Every person in America must have access to affordable healthcare, and because of the

system as we have currently, a third-party payer will need to provide this access. The most

practical way to ensure coverage for everyone to expand Medicare as an option for anyone,

regardless of age, disability or socioeconomic status. Medicare is already the biggest consumer

of healthcare and as a federally funded program would be in the position to cover all Americans,

equally, unlike Medicaid which is state-run. At this point, people would be automatically

enrolled in Medicare but can opt-out by proving they have insurance through other means, such

as employee based. The amount of money that people pay into the system will be on a sliding

scale of the amount of income. Tax corporations that do not offer employee-based health

insurance at a higher rate than those that do to help offset the costs of healthcare.

Simplify Billing

Once the majority of Americans are paying into and using Medicare, the next step would

be to simplify the process of insurance for Medicare. Get rid of deductibles and co-payments.

This will help simplify the billing process, which should in turn, theoretically, decrease costs due

to less resources used in a healthcare system for making and processing payments, and following

up on late bills. It will also guarantee healthcare facilities the reimbursement rates giving more
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stability within the system. No longer will healthcare facilities need to “write-off” costs because

every patient will be covered.

Decrease patient choice and increase provider protections

This is the most unpopular change and the biggest cultural shift. We have believed that

the choice in our healthcare is a good thing. However, not all healthcare choices should be made

by the patient. A patient should always have the right to refuse a service, but it is the clinicians

that should have the ultimate say in what services should be offered. Patients should not be able

to demand a service that is not medically necessary. Coupled with this providers need expanded

protection against malpractice lawsuits. Each profession needs to determine their best practice

guidelines which need to be the standard of care. This would not mean that a patient cannot

receive a service that they want, but that if they are to receive it, they would need to pay

privately. The professional bodies need determine minimum standards of care for quality control.

Deceasing patient choice would also decrease marketing costs, which should decrease the

overall cost of healthcare. While some marketing can be beneficial to the patient and establishing

connections between healthcare organizations will result in better care, marketing should be

between providers who have the health literacy and the empowerment and not to the patients.

Liaisons should not meet with patients. Patients should be sent to facilities that the clinical team

think is the best for each patient within reasonable geographical limitations.

Really protect the providers

To ultimately protect healthcare providers from unnecessary lawsuits, the healthcare

providers should become federal employees. This would give them protection under the Federal

Tort Claims Act and the might of the US government. This would also decrease reimbursement

rates. If the salary of a provider is already covered, the reimbursement rate for care should be
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less. It also eliminates uncertainty of payment schedules and allows easier budgeting for the

healthcare organization. This also eliminates fees-for-service which incentivize more services.

Salaries for clinicians could also decrease, leading to a less expensive healthcare system. To do

this, however, providers will need guaranteed student loan forgiveness or more subsidies to get

through higher education with contracts to work for the federal government once graduated.

Organizations at this point will have a choice to become federal facilities and treat the

majority of patients or become private and continue to deal with private insurances. They may

also become a more hybrid institution and have some beds that are standard and some beds that

you can privately pay/private insurance. At this point, people will no longer be able to “opt-out”

of Medicare, but rather every citizen will be guaranteed healthcare coverage paid for by general

taxation of income and corporations. This will decrease costs but eliminating the coding

department completely and the billing departments mostly. This would make a leaner and

cheaper healthcare system that needs less people to run it.

Conclusion

The process laid out above will take several years to implement and will not be easy or

popular. It will increase healthcare costs in the short-term, but will hopefully contain the costs

ultimately, which will lead to more support. There is already a movement growing amongst

Americans for “Medicare for all” or “Medicare for America” with the upcoming 2020 election.

The entire culture of America will need to shift so that people understand that affordable

healthcare should be given to every person. The free market fails to contain costs when costs are

not transparent and with a third party payer system. Our system needs to create more Hamishs

and less Henrys.

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References

Alexander MS, Anderson KD, Biering-Sorensen F, Blight AR, Brannon R, Bryce TN, et al.

(2009) Outcome measures in spinal cord injury: recent assessments and recommendations

for future directions. Spinal Cord. 47:582–91. doi: 10.1038/sc.2009.18

Applying for Medicaid (2015). Retrieved from: https://longtermcare.acl.gov/medicare-medicaid-

more/medicaid/applying-for-medicaid.html

Annual Report (2017). Queen Elizabeth National Spinal Injures Unit for Scotland.

https://www.spinalunit.scot.nhs.uk/wp-content/uploads/2018/07/Annual-Report-2017-18-

2.pdf

Butin, MB, Garten, AD, Paddock, S, Saliba, D., Totten, M., Escarce, J.J. (2004). How Much is

Post-Acute Care Use Affected by Its Availability? National Bureau of Economic

Research. doi: 10.3386/w10424

Gawande, A. (2009). Getting there from here. The New Yorker. January 26.

Longest, B.B. & Darr, K. (2014). Managing Health Services Organizations and Systems.

Baltimore: Health Profession Press, Inc.

NHS Scotland Website. Retrieved from: https://www.scot.nhs.uk/

SCI Data Sheet (2015). National Spinal Cord Injury Statistical Center, Facts and Figures at a

Glance. Birmingham, AL: University of Alabama at Birmingham. Retrieved from:

https://msktc.org/lib/docs/Data_Sheets_/MSKTC_SCIMS_Fact_Fig_2015.pdf