Thursday, October 20, 2011

American Exceptionalism and Health Care

Most Americans accept the concept of American exceptionalism, described as “the belief that the United States is an extraordinary nation with a special role to play in human history; a nation that is not only unique but also superior.”

Being exceptional, though, can have a less positive meaning, as in “The Boston Red Sox had an exceptionally bad September!”

So how exceptional is American health care? Exceptionally good in some respects, but exceptionally bad (and getting worse) in many others.

On Tuesday, the Commonwealth Fund released the results from its 2011 scorecard on the performance of the U.S. health care system, and for the most part it isn't good.

My colleague, Anna Stoto, was present when the report was released by the Commonwealth Fund, and this is her account:

“Unfortunately, the results of the latest scorecard were grim – though the US demonstrated some improvement in quality indicators, the health care system fell short of achievable goals overall. While the US continues to lead in per-capita spending, overall performance failed to improve between 2006 and 2011. The scorecard examined five dimensions of health system performance, measured across 42 indicators: Healthy Lives, Quality, Access, Efficiency and Equity. Scores are simple ratios of the US average to benchmarks, which are levels achieved by other countries or top US states, regions, health plans, or providers.

Several troubling findings emerged from the report:
· There were steep declines in access and affordability between 2006 and 2011, particularly as health care costs have risen higher in relation to incomes. The 2011 report demonstrated that the United States is losing states where premiums were relatively more affordable – employer premiums now represent 18% or more of median household income in half of the country.
· The system demonstrated a lack of equity overall – there is considerable variation in care across the US, and there are now 15 states where 1 in 4 adults do not have insurance.
· Many costs are going toward inefficient care, resulting in numerous preventable deaths and a constant churning of patients in and out of hospitals. Incentives must be aligned so that it makes good business sense to improve hospital readmissions.

Access proved to be the keystone of the report’s findings, as it is related to quality, costs, and efficiency. The Commission on a High Performance Health System, which produced the report, focused on better primary care and primary care coordination as the tools to improve and identified the need to work across teams that span the health care system. Reforms created by the Affordable Care Act are also expected to help improve access, reduce variations, emphasize primary care, and create greater accountability for health and cost outcomes. Notably, the 2011 report was based on 2009 data” (so it does not reflect changes made by the Affordable Care Act, which became law in March, 2010, and has only been partially implemented).

The Commonwealth Fund has prepared a sobering set of slides that show how the United States did on key indicators.

Some of the areas where the United States doesn’t do so well may reflect cultural and socioeconomic characteristics that may be at least partially outside the control of the health care system itself—like infant mortality, for instance—or that have been exacerbated by the prolonged economic downturn (like increases in the percentage of insured persons).

But these explanations don’t change the fact that the United States is “exceptional”—not in a good way—on many dimensions that are largely due to the health care system itself.

We spend far more than any other industrialized country, but we are second to last in visits to emergency rooms that could have been treated by a regular doctor, dead last on test results and medical records being available at the time of an appointment, worst on duplicate testing, worst on access problems relating to cost, third to last out of eight countries on getting access to care after hours, second to last on getting same day doctor appointments, worst on medical errors—and we spend the most on insurance administration!

The report card doesn’t just compare us to other countries, but presents benchmarks on variations in care within the United States compared to generally accepted measures of best outcomes—and for the most part we don’t measure up well here either.

I expect that some readers of this blog will respond by saying that they provide excellent care to their patients—and I have no doubt about that. They will point out that rich people in other countries sometimes come to the United States for care because we have the best to offer—and I have no doubt about that either.

But the evidence shows that although the United States provides the best of all possible care to some of the people, some of the time, for many of the people, much of the time, the care falls far short of what is needed. This isn’t the fault of American physicians, who struggle to provide their patients with the best care possible, but with a system that costs too much and yet too often fails to deliver.

It doesn’t do any good for us to sweep these problems under the rug. Saying that we have the best health care system in the world doesn’t make it true. And if you believe, as I do, in American Exceptionalism, wouldn’t you want our health care system to be exceptionally superior to everywhere else in the world, and to fight for reforms to make it so?

Today’s question: What is your reaction to the evidence that the American health care system is exceptional—but often not in a good way?


Steve Lucas said...

This report is not a surprise to many of us who follow the US medical system, even in a cursory manner. This is one of the more telling statements:

“Many costs are going toward inefficient care, resulting in numerous preventable deaths and a constant churning of patients in and out of hospitals. Incentives must be aligned so that it makes good business sense to improve hospital readmissions.”

We see this churn in the often heard statement: “we just want to be sure.” Test are repeated and office visit rescheduled just to generate income for the practice, not for any real medical need. “Good” doctors have openly stated they will ignore the latest guidelines regarding PSA testing because they know better, and like me, over the objections of patients.

My personal belief is the recent calls for a more market orientated medical system has less to do with markets and more to do with the frustration of the population watching ever larger amounts of household income going to an ever decreasing access and affordable medical system.

The drug and device companies have made a mockery of the FDA bringing out drug after drug with questionable benefits and very real negative side effects. The holy grail of psychiatry is a biomarker that will tell children they need medication for an event that may or may not happen at some future date.

Doctors have commented here on their frustration with drug companies dropping drugs in favor of the new and improved that only offer better margins for the drug company. A recent article highlighted how a drug company was adding a scoring mark to its drug and felt this should allow an extension of its patent.

My personal belief is that we need to get doctors out of the business of medicine and back into the practice of medicine. I see retainer and cash practices as one model. Access and cost are well known and a relationship with a doctor can develop over time. Five minutes of face time every 90 days does not a relationship make. Accommodations for those with low income will need to be made and contrary to some, I do not believe we can totally remove government from this part of our lives.

Insurance is needed for those events no one person can afford, cancer, accident, and long term care come to mind.

The drug and device companies need to be placed on a very short leash starting with an improved system of review of guidelines and compounds by those without financial conflicts. Today we have a system filled with drugs and guidelines whose only purpose is to make companies money, not improve patient health.

We have twice the money in our medical system as other developed countries, but the sick are pushed aside, the elderly warehoused, and the young are prostituted for their insurance.

Sadly, I have little hope this report will be acted upon in a timely manner, there is simply too much profit in our current medical system for the players to accept any changes that will cut their income, or place needed restraints on their business model.

Steve Lucas

ryanjo said...

When the health care system is out of the control of patients and their direct providers of care, what do you expect? Control by third parties is the disease that is killing US medicine. More top down "programs" like ACA will simply accelerate the rate of decline. We've been administering the wrong "treatment" for 30 years.

Steve Lucas said...

Ryanjo makes an important point. The one size fits all solutions coming from Washington do not always fit in our local communities. The political solutions I see favor hospitals and suburban medical practices. These come from good people reflecting their life experience in one of the most affluent parts of the country, DC.

Government can have a positive impact, as shown in Akron, Ohio. Here, a large cash based practice serving the poor and working poor was approached by the city to share its low cost lab. Simple things make a difference in availability of care. This practice was located on a major bus line, which helped with transportation problems for patients.

The doctors would write prescriptions for only the exact blood work needed for each patient, often the cost was 10% of the local hospital since the hospital did a whole blood panel, requested or not.

The result was people knew what the cost of a visit was going to be before seeing the doctor. Lower cost meant more visits and given the population this helped with the large number of diabetics and obese.

The city knew this practice could not serve all of those in need asked the practice to allow other doctors to access the lab and they in turn allowed a small number of patients to be part of a cash system. This was a win, win.

Bob Centor has posted for a number of years the need to look beyond the immediate medical needs of his VA patients and into their life style and living situations. Often chronic health issues are tied to poverty.

In both of these examples there is a need for a WalMart type store in order to provide, not necessarily the newest, but the most cost effective medications. Care is often the first step in curing problems and the goal for many patients is simply to feel better. Then they can move forward on improving their living situation or resolving a possible addiction.

Government as a facilitator can be a very positive force. Government as a dictator can have very negative unintended consequences.

Steve Lucas

DrJHO7 said...

What is your reaction to the evidence that the American health care system is exceptional—but often not in a good way?

Not an ah-hah moment, but an uh-duh moment, "do ya think...?"
Close to 50 million people (1/6 of our population) uninsured for even basic medical care.
Private insurers siphoning ____% off of the premium dollar for something that has various names in the expense column, none of which have very much to do with the provision of health care, while the premiums soar higher every year for individuals and employers.
Pharmaceutical companies charging three times for meds in the usa than they do abroad (where health care costs are 1/2 of ours, with similar or better health outcomes).
Diagnostic tests are sometimes ordered to improve one's bottom line, or to decrease the perceived likelihood of missing a diagnosis and being sued for malpractice, or out of ignorance of the fact that the test is unlikely to benefit the patient's health anyway, or despite the fact that the test was done recently anyway and the result didn't happen to be immediately available to the ordering physician.

Our medical education system is producing an excess of physicians who specialize in individual body systems or specific aspects of care, rather than whole-person oriented relationship-based medical care due to the high and rising cost of medical education and low salaries of the latter group.
Our political system is largely ignoring the above stated problems to varying degrees.

Could we fix the above problems? Sure! Will we? well.........
That depends on how much WE (our country) want to.
It will require courage and conviction. We some of this...during world war 2.

We have some irons in the fire...
delivery system and physician payment reform, if substantial enough, is a step in the right direction, patiented centered care initiatives, bolstering the primary care medical specialties, a focus on cost-effective accountable care, tort reform, insurance industry reform, regulating pharmaceutical costs to the system, health coverage and access to care for all citizens...

I know Santa, it's a long wish list, but there are 58 shopping days left!
Oh, and can we repeal the SGR, too!