I’m screaming, because Austin can’t

Austin is out of town, I believe, so I’m taking it on myself to ARGH for him.

The NEJM has published a piece entitled, “What Business Are We In? The Emergence of Health as the Business of Health Care,” that’s getting a fair amount of press. It makes the argument that the health care industry should be more focused on the outcome people want – “health” – and less on the mechanism by which the industry currently tries to achieve that outcome.

However, this paragraph caught my eye (emphasis mine):

None of this evidence suggests that health care is not an important determinant of health or that it’s not among the most easily modifiable determinants. After all, we have established systems to support the writing of prescriptions and the performance of surgery or imaging but have found no easy way to cure poverty or relieve racial residential segregation. But the evidence does suggest that health care as conventionally delivered explains only a small amount — perhaps 10% — of premature deaths as compared with other factors, including social context, environmental influences, and personal behavior.4 If health care is only a small part of what determines health, perhaps organizations in the business of delivering health need to expand their offerings

NO! No, no no, no, no!

This factoid is commonly cited. But readers of the blog will know that Austin has thoroughly debunked it. He started here, when he followed up on the McGinnis study cited in the NEJM piece. It turned out that the “10%” number came from expert opinions. So Austin wrote:

Still, it seems to me there is no good reason to accept the 10% figure at the top of the left-hand side of the infographic. I’d like to know more how it got there. I’d like to hear the best argument as to why it’s correct.

Because Austin cares about, you know, facts, he followed up here. He found more citations that went nowhere, and “unpublished research”. He said:

It seems like folks want to say that 10% of our health is due to the health system (or access to it) without actually being able to point to anything substantial to back it up. Maybe my readers with super Google skills can track this down. I’m not saying there’s nothing to this 10% figure. I’m saying we shouldn’t have much confidence in it unless and until we can see the research that supports it. Where is it, and why didn’t the Bipartisan Policy Center track this down and cite a source that has some actual work behind it?

Excellent questions. Still, he wasn’t done, and wrote a piece at the AcademyHealth blog. You should go check it out. It was incredibly exhaustive, far more so than anything else I’ve seen. His conclusions:

There are other papers one could read on these topics, but this is all I had time for and/or could get in full text. From these, it looks like reasonable figures are 40% of reduction in cardiovascular mortality are due to medical care, while 66% or more of reductions in infant mortality are due to medical care. Therefore, I think Cutler’s ballpark of 50% of longevity due to medical care is reasonable.

When people want to discount the importance of access or minimize the problem of being uninsured, they say that it doesn’t matter anyway. They cite the 10% number to dismiss the actual value of getting health care. But it’s not true. Health care has much more value than that.

It’s not all that matters. Even at 50%, that means there’s lots of other stuff that affects mortality as well. But here at TIE we like to argue from evidence. The “fact” that only 10% of longevity gains are gue to health care is a zombie idea. It needs to die.


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