It’s a popular sport these days to look for a model for a new U.S. healthcare system.  Well, any “system” would be new, but that’s not the issue.  Some look to Canada, but European countries are popular targets.  Interesting that no one has proposed Mexico or Puerto Rico tho these are popular medical tourism destinations.  

It’s fairly easy to make the U.S. look bad by choosing your metrics and then tout your personal preference for a perfect system.  When evaluating such articles, it’s important to look carefully at the metric and ask first if this has anything to do with the healthcare system.  Infant mortality, for example, has more to do with whether the mother receives care in the first trimester, at all, and less to do with the type of care she receives.  Or just take life expectancy in general.  Largely determined by genes, personal habits, and environmental factors.  Cardiac care has some impact, but the rest of healthcare can be ignored.  One technique for evaluating these statements is to look at the company we’re in.  On life expectancy at age 60, for example, we rank near the bottom, with Portugal, Ireland, and Denmark.  Denmark? The Danes are frequently cited as having an ideal healthcare system.

Another question for the thoughtful reader is to ask if they have a national healthcare system.  That would explain why the comparison country (Sweden, Denmark, UK, Finland) has an electronic healthcare record system.  Some bureaucrat issued an edict, and presto!  In the U.S. electronic records have to make economic sense, and that case has yet to be made except in closed panel HMO systems.  

A2006 Health Affairs article states that “59% of children needing mental health care receive treatment.”  OK. Who says so?  Who defines “need,” and what bad things happened to the other 41%? Actually, I think all children over the age of 12 years need mental health care, so maybe that figure came from someone like me.

That same cynical skepticism can also be applied to any discussion of “quality” of care.  Quality is always a risky value judgement.  There are some tests or procedures that everyone recognizes as generally beneficial (mammograms, colonoscopy) and some that are disease specific (blood pressure in hypertension, FBS in diabetes).  Others are controversial (PSA for prostate CA),and it’s not always clear who’s job it is to talk to the patient about the need for this or that.  Is this family medicine or do we need a “medical home?”

Here’s a URL for you:  www.healthpowerhouse.com. This started as an effort to measure the quality of healthcare in different parts of Sweden and spread to include all of Europe.  The focus began with consumer interests, but the index now includes data on almost every aspect of every healthcare system in Europe.  Included are data on supply of physicians, cost per citizen, expenditures as % of GDP, life expectancy, etc.  The U.S. doesn’t contribute, but Canada does.  And for the record, Canada compares “reasonable well” with Europe on outcomes, average on generosity, and “at the absolute bottom” on waiting times, availability of pharmaceuticals, and a “bang-for-the-buck” index.  (Luxembourg is the champ in this latter category.)  Denmark is best overall and scores well in almost every category.  Their life expectancy is 76 (male)/81 (female)vs. comparable figures for the U.S. of 75/80.  DK spends 9.5% of GDP on healthcare vs. 15.3 for the U.S.  Since the U.S. doesn’t contribute, the figures for the U.S. are derived from other sources.

Cost per citizen range from $400 (Albania) to over $4,000 (Norway).  The comparable figure for the U.S. is just over $7,000.  Trivia question:  What country in the world has the highest per capita income?  (Hint, it isn’t the U.S.  Another hint:  it was named in the first sentence here.)

Two other interesting sources of comparative data:  The World Health Organization (www.who.int) and the Organization for Economic Cooperation and Development (www.oecd.org).  Some U.S. data are listed on these sites, especially for later years.  For example, we have 2.43 physicians per 1,000 population (2007).  This compares to 1.96 for Mexico, and 3.17 for Denmark. One factor that is not obvious in these data is the amount of healthcare by non-physician providers.  Sorting countries by number of physicians per 1,000 doesn’t produce a list of where you’d want to go for healthcare.  More physicians doesn’t equal better healthcare.  There’s probably a minimum, but more isn’t better.  And judging from the company we keep on this factor, our healthcare would not improve if we had more doctors.  But it would probably get more expensive.  One of the themes of the Dartmouth Atlas is that healthcare is supplier driven.  More providers means more healthcare, and consequently more money spent on healthcare.   

So where do we look for a model for healthcare reform?  Like so many things, it depends on where you want to go.  If you want to limit expenditure, Albania is your model.  Actually, any system where the government owns all the hospitals and all the providers are employees of the government is pretty good at limiting costs.  They also limit services, so a shift in that direction would be difficult politically in this country.  We do have examples of such systems here: the Veterans’ administration and the Indian Health Service.  Both have their virtues.  The VA, for example, is the poster child for patient safety in hospitals.  The IHS does well at providing comprehensive care in remote locations.  And neither involves any insurance companies.  We also have models where the means of production are entirely owned by a single entity--closed panel HMO’s, such as Kaiser and Mayo.  Mixed results, tho there are some virtues here.  Kaiser is an option in the Federal Employees Health Benefits plans, and not everyone chooses it.  That’s a message.  

None of the systems or countries mentioned employs any system to encourage efficiency in the provision of healthcare services.  The current situation in the U.S. is perhaps the most wasteful, tho there are some arguments to the contrary.  At least, most agree that we could do better.  But “better” at what?  Remember, we started talking about reform with two goals in mind:
healthcare for everyone
reduce the total amount spent, particularly for Medicare.

Congress hasn’t yet embraced either of these goals.

Are we there yet?

The answer depends on who you ask and how you define “there.”  A bill did pass the Senate yesterday.  And it does some of the things some people wanted done.  Before that becomes reality, however, it must be reconciled with the House version, and that’s where the interest groups are focusing.  

Even before the Senate vote, the insurance industry indicated their dislike for the current version by releasing a report that said insurance costs would go up if the bill passed.  That, of course, is a no-brainer and unrelated to any specific bill. Costs are going to go up, regardless of what the law looks like.  

For one thing, there is strong indication that the feds will tax insurance premiums by taking them out of after tax income.  That means you will pay tax on the money before you pay your insurance premiums.  Some may even be forced into a higher tax bracket by this added income, which they never see.  Oh well.  

For another, there is agreement among thinking folks that Medicare Advantage is a rip-off.  So the feds will stop subsidizing care for that part of the insurance industry.  If you’re currently in a Medicare Advantage program, expect to pay more.

True enough, there is nothing in the bill to address the costs of healthcare.  The Congressional Budget Office would not offer an opinion as to the financial implications of the bill, saying it is to complex to evaluate at present.  

Much was made of the lone Republican vote for the bill from Sen Olivia Snowe (R-ME).  However, the vote was 14 to 9, so they didn’t need her.  And Republicans were vehement in their condemnation of the bill.  So no hint of a bipartisan effort here.  the President’s assessment:  “. . . not perfect.”  And later, “We’re not there yet.”  Maybe it’s a good sign that this is a bill that no one likes.

There is, in fact, a competing bill that emerged from the Senate health committee, and the task for the Democrats now is to merge the two while maintaining enough support to pass the result.  

There is a mandate that everyone must have health insurance.  If not provided by your employer, you must purchase it. That’s where the insurance exchanges come in. Maybe.  There is, however, no mandate that employers must provide coverage--something for unions to hate.

The effort to cover everyone is behind a big expansion of Medicaid--something for states to hate.  

And what about tort reform?  Not much for anyone to like, except for the things that weren’t there.  Some thoughts of creating panels to review cases before they go to trial, but the plaintiff doesn’t have to accept the panel decision and can come back and sue anyway.  And, most important, nothing to fix the problem.  In our review of uh-oh’s, we consider three questions:

1. Was what happened OK?
2. If not, what should have happened?
3. What must we do to make this happen next time and every time?

The tort reform provisions in this bill do not answer any of these and do nothing to prevent the same undesirable outcome from happening again.  It’s still a matter of “how much must I pay you and your lawyer to shut up and go away?”

In the end, however, it’s mostly symbolic.  Malpractice--including “defensive medicine”--plays a miniscule role in healthcare finance.  Still, it would be nice to do the right thing.

“Are we there yet” isn’t really the right question.  We should be asking “Will we ever get there?”  And maybe, “Where is there, anyway?”