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Healthcare Efficiency
Explore the delicate balance of efficiency and quality care.
Us vs. Them
Posted by:
Robert Burney on
October 18, 2009 at
5:00PM CST
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.
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