• How do we rate the quality of the US health care system – Introduction

    After I finished the 10-part series on health care costs, many of you kept asking for a series on quality. I can’t blame you. After all, I kept saying that spending more would be OK if we were getting superior quality. I kept saying that we weren’t. At the time I asked you to trust me in my assertion that the quality of the US health care system wasn’t so hot.

    Now I’m going to walk you through why I believe that.

    Let me lay a few ground rules to start. First of all, you should know right away that there is no perfect metric for measuring quality. They are all flawed in some way or another. Some are dependent on more than the health care system. Some may be due to differences in countries’ measurements. Some may be simply irrelevant in your mind. I am therefore not going to give you one, or even a few, metrics to consider. I’m going to flood the zone.

    Additionally, when possible, I’m going to show you many years of data. Many years, from both right and left leaning administrations.  This should allow us to examine the rate of change, not just the levels. If you think levels are driven by country-specific factors that vary slowly in time, then the rate of change might help control for that.

    Finally, when appropriate, I am going to show you the US compared to a number of other countries. It’s just as ridiculous to cherry pick a country as it is to cherry pick a year or a statistic.  For most comparisons, I am going to show you countries from the G8 minus the Russian Federation (for which there are no data).  This includes Canada, France, Germany, Italy, Japan, the UK, and the US.  Yes, there are other countries I’m not including, but this is a good representation of other types of health care systems in countries with resources closest to ours.  These are countries that are almost as wealthy as the US, but that the US still outspends by a large margin.

    Most of the data I will use comes from one of two sources. The first is the Organization of Economic Cooperation and Development, or the OECD:

    For more than 40 years, OECD has been one of the world’s largest and most reliable sources of comparable statistics and economic and social data. As well as collecting data, OECD monitors trends, analyses and forecasts of economic developments and researches social changes or evolving patterns in trade, environment, agriculture, technology, taxation and more.

    The OECD is simply the largest and best place for comparative data for the US and other countries on health.  Some of you will claim that the data is somehow biased or skewed by the OECD (which is in France).  Remember, the United States provides its own data to the OECD. If various administrations thought they were being treated unfairly, they could have said something or changed their practice.  They didn’t.

    My other main source is The Commonwealth Fund:

    The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

    The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries.

    Over the last decade, they have performed a number of international surveys on health care systems that can teach us much about quality.  I will review them as well.

    You’re going to see a ton of data.  You won’t like a lot of it.  Some of you will not be happy with the inability to control for all the other factors that affect health beyond the health system itself. In response to this critique and in defense of my approach, I refer you to Austin’s post on descriptive evidence.  But I will ask you to remember the ground rules and not start screaming at me that a certain statistic is flawed or that I’ve cherry picked one or another.  Believe me, I’ve heard it before.

    Here’s the schedule:

    1. Introduction – October 18, 2010 (this post)
    2. Population Statistics – October 19, 2010
    3. Available Technology – October 20, 2010
    4. Disease Care – October 21, 2010
    5. Infrastructure – October 22, 2010
    6. Health Care Utilization – October 25, 2010
    7. Physician and Practice Reports – October 26 2010
    8. Patient Reports – October 27, 2010
    9. Executive Reports – October 28, 2010
    10. Conclusion – October 29, 2010

    As you can see from the schedule above, this is a two week series. Similar to the series on cost, there will likely be one or two follow-up posts to respond to comments. I’ll include those in the above list if/when they occur. So this post is where to find all the others.

    At the end of each post, I will present a scorecard for that topic area as well as a running overall scorecard.  I made them up myself.  They are not official rankings, and should not be used as such, but I hope they will show you where we seem to be doing well, and where there is room for improvement.

    Comments closed
    • I can’t wait to see this.

    • Look forward to this. I hope I have seen all of this before, but you do everyone a service by putting it into a coherent series. If so inclined, I hope you can address the controversy over the WHO data.


    • Thank you so much for writing this series of posts. You and Austin do a fantastic job on TIE, I hope you keep it going for the selfish benefit of readers like me if not for any other reason! :-)

      -ag [I incidentally live in Indiana, and work for IU]

    • As a health economist, I have been making similar arguments for over half a century. For that, I have gotten plenty of brickbats from health care providers, the insurance industry, and even the government. One of t most malicious enemies was former surgeon general C. Everett Koop, who effectively destroyed my career and employment by means of unlawful actions.

      To me, the most interesting aspect of the OECD and WHO data is their clear evidence of costs rising faster in the US than in countries with universal health coverage, and of deteriorating health status in the US relative to those countries. For example, the US raked about sixth in age-specific longevity, maternal survival and perinatal survival after World War II; but now we rank somewhere in the teens and 20s in all three. It’s not that health status among our insured citizens has gone down in the US so much as that it has improved in those countries faster than in the US..