Mirror, Mirror on the Wall
For every complex problem there is a simple answer – and it is wrong”.
H. L. Mencken
Earlier
this year Gene Ransom, MedChi Executive Director, gave me a copy of the
Commonwealth Fund’s report Mirror, Mirror on the Wall, a study on the U.S. health care system.
At about the same time I read Testing, Testing, an article in the New Yorker by Atul Gawande, M.D.
The
report and the article illuminate different facets of the issues of quality and
cost in health care. The
Commonwealth study details surveys of patients and primary care physicians in
seven industrialized countries. Dr.
Gawande’s article compares the evolution in our health care system with the
evolution in the food delivery system that took place at the start of the
twentieth century. Both start
with vivid depictions of the current problems and the challenges ahead, but both
end optimistically.
The
Commonwealth Fund surveyed patients and physicians in seven industrialized
countries (U.S., U.K., Netherlands, Germany, Canada, New Zealand, Australia) and
examined public health data with the goal of comparing outcomes and perceptions
of care in the domains of quality, access, efficiency, equity, and health
outcomes. Consistent with past Commonwealth studies, we ranked last or next to
last in all five domains and seventh overall, just behind Canada.
The Netherlands and the U.K. ranked first and second overall.
How can this be? This is how
the authors of the study, in their own words, summarized their key findings:
“Quality: The indications of quality were grouped into four categories:
effective care, safe care, coordinated care and patient-centered care.
Compared
to the other six countries, the U.S. fares best on provision and receipt of
preventive and patient-entered care. However,
its low scores on chronic care management and safe, coordinated care pull its
overall quality score down. Other
countries are further along than the U.S. in using information technology and
managing chronic conditions. Information
systems in countries like Australia, New Zealand, and the U.K. enhance the
ability of physicians to identify and monitor patients with chronic conditions.
“Access:
Not
surprisingly - given the absence of universal coverage - people in the U.S. go
without needed health care because of cost more often than people do in other
countries. American with health
problems were the most likely to say they had access issues related to cost, but
if insured, patients in the U.S. have rapid access to specialized health care
services. In other countries, like
the U.K. and Canada, patients have little or no financial burden, but experience wait times
for such specialized services. There
is a frequent misperception that such tradeoffs are inevitable; but patients in
the Netherlands and Germany have quick access to specialty services and face
little out-of-pocket cost.
Canada, Australia and the U.S. rank lowest on overall accessibility of
appointments with primary care physicians.
“Efficiency:
On indications of efficiency, the U.S. ranks last among the seven countries,
with the U.K. and Australia ranking first and second, respectively.
The
U.S. has poor performance on measures of national health expenditures and
administrative costs as well as on measures of the use of information
technology, rehospitalization, and duplicative medical testing.
Sicker survey respondents in Germany and the Netherlands are less likely
to visit the emergency room for a condition that could have been treated by a
regular doctor, had one been available.
“Equity:
the U.S. ranks a clear last on nearly all measures of equity.
Americans
with below-average incomes were much more likely than their counterparts in
other countries to report not visiting a physician when sick, not getting a recommended
test, treatment, or follow-up care, not filling a prescription, or not seeing
a dentist when needed because of costs.
On each of these indicators, nearly half of lower-income adults in the
U.S. said they went without needed care because of costs in the past year.
“Long,
healthy, and productive lives: The
U.S. ranks last overall with poor scores on all three indicators of long,
healthy, and productive lives. The
U.S. and U.K. had a much higher death rate in
2003 from conditions amenable to medical care than some of the other countries,
e.g., rates 25 percent to 50 percent higher than Canada and Australia.
Overall, Australia ranks highest on healthy lives, scoring in the top
three on all of the indicators.”
Those
are the conclusions. What are the
prospects for improvement? The
Report suggests that our prognosis is good, in part because of (1) the
anticipated impact of the Patient Protection and Affordable Care Act of 2010 on
access and equity as a result of the expansion of health insurance coverage and
(2) the expected effect of the American Recovery and Reinvestment Act (2009) on
the efficiency and coordination of care as a result of the more widespread
adoption of electronic health records.
In the end, the Commonwealth Fund holds that we have within our reach the
creation of a “high performance health system that can truly be called the
best in the world.”
But
of course this is likely to be very expensive, and that is at the heart of much
of the debate about health reform. How
can we afford it? Per capita health
expenditures in the US already exceed $7000 per year, at least twice that of
other industrialized nations. Sixteen
percent of our gross domestic product (GDP) goes to health care; in none of the
other six countries does this figure exceed 10 percent.
For businesses and individuals these costs translate to reduced
profitability and wages, higher taxes, higher health insurance premiums, greater
out-of-pocket expenditures, and even medical bankruptcies.
What is the answer?
The
point of Atul Gawande’s article is that no one really knows the answer yet,
and that’s okay. What we need to
be doing now, he proposes, is trying lots of things, “testing, testing,”
learning what works, and building on what we learn.
This seems to be the strategy built into the Patient Protection and
Affordable Care Act. Hundreds of
pages of the Act are devoted to describing pilot projects that might possibly
teach us how to provide care more efficiently and affordably.
Just about every creditable idea that has been proposed may be tested
over the next few years. The
strategy banks on the power of the empirical method to show us the way.
Is
there any reason to believe this can work? Gawande
says “yes” and, as an example, points to the transformation of American
agriculture in the 20th
century. In 1900, nearly half
of the American workforce was engaged in farming, and nearly half of a
family’s income was spent on food. America’s
growth as an industrial power and improvement in the standard of living required
finding ways to produce food more efficiently and less expensively.
In the end, the “market” didn’t find the solutions, and the
government didn’t prescribe them. What
the government did do was fund many small pilot projects, such as
“demonstration farms,” funded through the Department of Agriculture’s
extension programs, that demonstrated the dramatic benefits of
scientifically-informed farming methods. Innovation
followed innovation, most beginning as small-scale local efforts, and over time
the best solutions became apparent and were adopted by others.
It’s a complicated story of widespread, independent pilot efforts that
were facilitated - but not designed – by government.
But by the end of the century only two percent of the labor force was
engaged in farming, and only eight percent of a family’s income went for food.
Gawande
concludes that “ . . .the system won’t fix itself, and there’s no piece of
legislation that will have all the answers, either.
The task will require dedicated and talented people in government
agencies and in communities who recognize that the country’s future depends on
their sidestepping the ideological battles, encouraging local change, and
following the results. But if
we’re willing to accept an arduous, messy, and continuous process we can come
to grips with a problem even of this immensity.
We’ve done it before.”
I
waited until now to write about these pieces because the discussion on
healthcare reform has been so strident and emotional.
But it’s clear that we cannot wait to prepare for the future because
changes in the delivery system are barreling down on us at breakneck speed.
To be sure, this is partly the result of recent landmark legislation.
But it’s also because we recognize that our current system is both
unsatisfactory and unsustainable, and we know we can do better.
Robert P. Roca, M.D.
2010 President