• When a fantasy of higher health quality meets reality

    I’ve long thought, and often said, that to have good health is one’s most important asset. Do you agree with me? I bet most do.

    Yet health in America is not good. Across many measures and relative to our peer nations the quality of the US health system is, at best, mediocre. Sure, we’ve got a top notch system in certain, narrow ways. But broadly, we have a lot of work to do.

    Sometimes I fantasize about another world, one in which this is not the case. Imagine the US had the best health system, across a wide range of objective measures of quality and population health. Imagine we could support the statement that the US was number one in health. Imagine it was indisputable, common knowledge.

    But imagine also that our health spending was also as it is today, much higher than that of any other nation, even controlling for wealth. Finally, imagine we faced high and rising debt due to high and rising health spending, just as we do today. How would the debate about what to do be different in this imaginary world than the one we experience in our reality?

    In that imaginary world, I think the argument to keep spending more and more on health care would be more compelling.The argument for raising more tax revenue to keep pace with public health spending would be easier to make. All one would have to say to someone who wanted to cut back is that we owe our world-leading longevity, our record low infant mortality, and our supremely more healthy lives to our level of health spending. One could argue more credibly that as the nation becomes wealthier we should spend more of our wealth on health care because it works, it is money well spent. Note, I’m not saying that this argument need be a correct one. But one could at least make it if we had the best health outcomes in the world.

    We cannot make that argument now because we don’t have the world’s best health system. Far from it. Therefore, it is very easy for many to say we’re wasting a lot of money on health care. That’s very credible. I believe it. I also believe that simply cutting spending will not do a thing for increasing quality. It’s just not that simple.

    The debate over health care is disproportionately focused on spending, that it is too high and growing too rapidly. At the same time, reducing spending on health is very hard, due to political and economic factors. Increasing the quality of health care and improving population outcomes is no easy feat either. Still, it is worth asking, should we be exerting more effort trying to do so? If we did, and if we succeeded, the spending would be more easily justified, would it not?

    Increasing quality, or how to do so, is not without controversy either. Comparative effectiveness or, related, patient-centered outcomes research is not universally accepted as the way forward. Pay for performance demonstrations don’t have an undeniably and consistently stellar record. A lot of what drives poor health outcomes may have nothing to do with our health system directly and more to do with how we eat and live. Do you think Americans will easily accept messages to change their lifestyles? Even if they do, interested industries won’t. Finally, it might take even more money than we spend now to improve population health. It probably requires spending on things other than the health system, like education and investments that lead to greater and more widely shared income and wealth. It probably requires more income redistribution.

    So, don’t get me wrong, achieving high quality and better population health is a hard problem. But I wonder if it would be a more accepted goal than is reducing spending. In other words, what if we forget about health spending, for the moment, and just focus on health and well-being, and how to improve them broadly. I admit, it sounds foolishly idealistic to me. But so does gaining “control” over health spending.

    Given a choice, I’d rather have lower health spending and superb health. Today we have the worst of both worlds. It’s a great luxury to be so spendthrift. We have claimed that luxury as a legitimate exercise of freedom. If that is our right, do we deserve it? If you say that we do, what is the moral basis of your argument? If you agree with me that health is paramount why is it not a more protected right?

    • Overall your comments and reference to Aaron Carroll’s excellent survey of the Commonwealth Foundations international study are excellent.
      I am a practicing family doc with 40 years experience in patient care. I suggest there are only 2 health care reforms – only 2 are required and sufficient – which will accomplish everything you hope for….

      1. Promote primary care and increase by subsidy, financial reward and/or public esteem primary care practitioners. Must well function national health systems have a generalist to specialist ratio or 2 or 3 to 1. We have the reverse – 1:3. A primary doc naturally uses less intensive technology, naturally triages problems and refers to efficient more competent specialists, and coordinates care to improve efficiency and effectiveness. We have an absolute and growing shortage in this area.

      2. Kill all the insurance companies. They are the biggest expense in the medical system, consuming directly and through administrative inefficiencies about 30% of the premium dollar. It is documented from actual time and motion studies that each doc wastes approximately $70,000 per year coping with insurance companies.

      • Do you have a reference for that 30% estimate? I am not disputing it, but I want to sure I am on sound footing if I repeat it.

        • Looking at the “medical loss ratios,” i.e. funds collected in premiums by insurance companies and actually spent on medical care by 21 national health insurance companies from 2000 to 2008, the Congressional Research Service showed in “The Market Structure of the Health Insurance Industry,” Congressional Research Service, November 19, 2009 that insurance companies spent from 71.5 to 95.4 % of their premiums on medical care, with a mean of about 80%. It is easy to see how the multiple providers of care can spend another 10 to 20% of their income on administrative matters having to deal with insurance companies. (My own medical group has overhead costs of 14%,seen as an insurance company Medicare has administrative expenses of 3 to 5% – a great deal!) Two careful time and resource studies of actual medical groups have shown that $60,000 to $80,000 are spent per year per doctor to deal with commercial health insurance administrative matters.

    • How effectively we monitor quality of care becomes a crucial issue not just for building the case for or against the need for substantial changes to our healthcare system but also for implementing changes like competitive bidding for medicare. With an effective monitoring system, we could be confident that organizations that provide medicare for less aren’t compromising care.

      The key questions when it comes to quality of care are: What percentage of those at risk of a condition receive state of the art preventive care? What percentage are monitored in a way that gives them the best chance for an early diagnosis? and What percentage of people with a condition receive state of the art care?
      If we knew that, we’d know whether poor health outcomes were the result of poor care or other factors (lifestyle, environmental, racial, age of the population, deaths due to homicides or traffic accidents etc.)

      • There are some dramatic studies comparing outcomes of cancer diagnosis in Canada and the USA by Kevin Gorey, e.g. “Colon Cancer Care in Toronto, Ontario and San Francisco, California, 1996 to 2006: More Accessible Treatment and Better Survival Among Low-Income Canadians,”Kevin M. Gorey, et al, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, N9B 3P4, Canada
        Telephone: 519 253-3000, ext. 3085; FAX: 519 973-7036
        E-mail: gorey@uwindsor.ca
        His great studies show that even with larger number of poor and minorities in selected Canadian cities, breast and colon cancer survival is worse in the USA under the age of 65 when Medicare kicks in. A likely inference is that contributions to this phenomenon include culture, poor access to prevention and screening, delayed diagnosis, and poor access to competent medical care. The American cancer society has published similar data.
        Sir, the evidence is in: the greatest barriers to better health outcomes in the USA or not effective screening methods and good scientific treatment, but lack of access due to absence of universal health insurance.