HOW GOOD IS THE US HEALTH CARE SYSTEM?
Our national debate has focussed attention on multiple aspects of health care. Much of the debate has involved manipulated and misinterpreted data. One of the “facts” repeatedly posted for us to ooh and aah over is how much shorter our life expectancy is than that of other industrialized nations. National life expectancy is posited as a measurement of health care quality. However, is that a correct assumption?
There is an interactive chart at http://www.worldlifeexpectancy.com/world-rankings-total-deaths#instructions that displays data on mortality rates and causes of death both worldwide and for many nations. One can choose the countries in which one has interest and display them next to each other for comparing causes of death. What is readily apparent is that cardiac disease, stroke, and lung diseases predominate as causes of death in most of the world. Some really striking data show Alzheimers/Dementia as the second leading cause of death in the US versus 22nd in world data. The chart is well worth spending some time interacting and analyzing scenarios. Compare reported data with what your preconception is. In this post, I will mostly be comparing the US and Japan.
If one extracts out just coronary, stroke and influenza (top three causes of death in the world) and compares these as a single rate with the US, Japan and the world, the rates of death are 2.1 per thousand in the US versus 2.8 in Japan and 2.6 in the world. Math is not my strongest point so, if someone finds an error in my analysis, let us know. These three conditions strike me as a better “proxy” for a nation’s health care system than overall mortality. I base this on the following:
- Overall mortality includes a number of causes of death not related to health care systems such as violence, accidents, suicide, poisoning and war. These causes of death tend to occur in younger persons so have a proportionately greater affect on life expectancy, and
- Any impact of the health care system on mortality from number 1, above, would be to lower mortality rate from those causes (i.e., excellent trauma care will prevent many deaths from violence, suicide, and accident), and
- Health management of cardiac disease, stroke, and influenza have direct impact on mortality. Granted, these are also impacted by nutrition and personal life style. Because these illnesses tend to occur in more elderly persons, extending life for their victims will have a lesser impact on population life expectancy. Persons dieing in their 70s will have less impact on overall life expectancy than those dieing in their 20s.
Looking at the aggregate of road accidents, other injuries, suicide, and violence, the rates are 5.37 per thousand in the world, 4.0 in the US and 4.5 in Japan. Note that these data are influenced more by national ethos than quality of health care. For example, Japan has almost as many suicide deaths as the US (31,571 versus 35,441) despite only 40 percent as much population. This is most likely due to the long time ethos related to suicide in Japanese culture.
One could play with these data for a long time and come up with all sorts of conclusions some of which might be useful and many of which would be silly. However, more value can be found by using data such as these in order to create national priorities for impacting death rates and national survival. For example, consider the following:
- Japan can get more value from developing national strategies that lower suicide deaths than they would from lowering motor vehicle deaths, and
- Coronary deaths are the major cause of death worldwide. Further research into prevention will yield greater value than treatment of this disease. Imagine the worldwide impact of delaying progression of coronary obstruction by several years, and
- National strategies directed toward healthier life styles would have major impact on cause of death. Type II diabetes mellitus, lung cancer, hypertension, and violence are among major causes of death that are related to specific life styles, and
- Influenza as a cause of death is very much affected by vaccinations. In the US, there were 57,722 influenza deaths from influenza versus 123,302 in Japan. This article, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)14870-2/fulltext discusses the low rate of vaccination for influenza in Japan and how it came to be so low. Rate of vaccination in the US was about 65 percent (of 65 and older) in 2001-02. Clearly, this cause of death can be impacted through a relatively low cost alternative and will be even more impacted with upcoming advances in vaccine technology (e.g., DNA vaccines), and
- Alzheimer/dementia in the US is the second leading cause of death. More than three times as many die of dementia as breast cancer in the US. Yet the NIH budget discussion mentions significant improvement in breast cancer survival that they attribute in part to NIH actions and investment in research but makes almost no mention of work on or impact on dementia.
- A major impact on life expectancy in the US relates to violence (murder, suicide, risk taking, etc). Lowering these causes of death is more a national ethos issue than a health care issue. I did not do the math but have seen more than one paper documenting that, if one abstracts out data of death due to violence, the US has one of the highest life expectancies.
Health care in the US consumes a major portion of our national productivity. I agree that we should expect better results than seem to be the case. I do not agree that our health care system is second rate compared with the rest of the world. Indeed, in a number of areas, our system excels based on data in this and other charts. Immunization rates in the US are a major success story and something of which to be proud. Our trauma survival rates are close to or superior to those seen in many countries that are more compact (i.e., closer to the trauma centers). Rather than using data to “make” political points, we should be using data to develop strategies for improving quality of life in this nation. Our strategies will not be the same as those of other nations that face different national ethos and different threats to health.
In summary, I have no idea whether health care is better, equal to, or not as good as other industrialized nations. The data found in the chart to which I referred and other sources seem to indicate that the system itself is equal to or more successful than other nations. I do know that our nation and its citizens invest huge sums into what they perceive as health care. Much is expended wastefully, much is on areas not impacting on health or longevity, and much provides major improvement to life and quality of life. There also is clear evidence that a significant portion of our population has poor access to health care. The Affordable Health Care Act was intended to address this as well as a number of other problems with access to care. Even early in its implementation, it has improved access through extended insurance coverage for young adults. Soon, further improved access will come through improved insurance alternatives for those in their late 50s to age 65. I doubt that it will have much impact on homeless and some of the other unserved members of our population. What is unclear is whether the improved access that it will create will impact on the quality of our health care system.
If I were the “health tsar” (a position to which I have absolutely no aspirations), I would direct assets into further improvements in vaccinations, research on prevention of dementias, better education of teens and young adults on risk taking (dangerous activities), better education on self care to prevent chronic disabling conditions, and getting tobacco use out of our national scene. I would work to implement a national primary care program that would provide high quality primary health care based on communities of persons (i.e., design the health program based on the community rather than expect the community to somehow meet the design of the health program). As my primary public health project, I would eliminate every sugar subsidy and maybe even forget my Objectivist aspirations and add sugar taxing in order to cut down the massive sugar load our citizens use.
As an aside, if we as a nation wish to move to the top of the chart of life expectancy, we can do so by cutting in half deaths from violence and other trauma, eliminating use of burned tobacco (smoking), and cutting motor vehicle deaths in half. Those achievements can be made with no changes to the health care system but would require draconian social interventions. Are we really willing to make those changes so that we can brag that we live longer than anyone else?
The impact of homicides and accidental deaths on the life expectancy rate is frequently ignored. Look at CNN and MSNBC. Neither mentions homicide or accidental death in their analysis of life expectancy/healthcare. An oversight grave enough to make me question their competency and/or honesty (let’s pretend they may have some).
Here’s a world homicide rate chart for comparisons. Here you can see traffic fatalities by country per 100,000 people.
United States of America 12.3
United Kingdom 3.59
Switzerland 4.7
Sweden 2.9
Spain 6.9
Netherlands 4.1
Italy 8.7
Ireland 4.06
Germany 4.5
France 6.9
And so it goes. The homicide and traffic death numbers alone have a huge impact on life expectany. But, it doesn’t serve the purpose of the socialists to be honest about this.
Even accounting for trauma and homicides, we still do not rate at the top. What is really awful is our ROI. We spend much more than everyone else, and do not have the improved outcomes to show for it.
Steve
Steve2,
I’m not sure you are correct on “Even accounting for trauma and homicides, we still do not rate at the top.” It is pretty difficult to abstract out the data but I have seen more than one report where this was done and our life expectancy was the same or better than most. Yes, we spend more on health care. A significant chunk of the cost is in pharmaceutical care (about 20 percent). Some of that is on drugs either not indicated or not beneficial. However, that is the case in many other nations also. I fail to understand why drugs cost more in the US, especially since many of the big pharm are not in the US anymore.
We spend a major chunk on cosmetic care the only benefit from which is to look nicer (I do not count reconstructive care in that).
We spend a serious percentage of our health care dollar in the final months of care. Whenever anyone suggests looking into that, the first charge is along the lines of “You want death squads.” and the issue is immediately dropped. A nurse was recently fired for suggesting a patient be seen by hospice care providers.
Fraud is an issue. However, I have a hard time accepting that it is more of an issue in the US than elsewhere.
Salaries (income) for pretty much all members of the health care team are higher in the US than other countries. Additionally, we seem to have far more members on the team.
Advocates for a single payer system believe it would lower costs. If it were to eliminate the profit portion of the total bill, it would lower costs about 8 to 10 percent maximum. Any further decrease would come from lower salaries, lower payment for drugs, technology, fewer people on the “team”, and increased productivity through which one could have fewer personnel. Much of that savings could very likely be “eaten up” by the coverage improvements for those not now receiving care. Bottom line, it seems unlikely to me that that would lower the total cost for the system.
I do not question that there are savings to be found in better efficiency. In the military system I was involved with, we instituted a primary care system designed for the needs of the specific communities we served (three pretty distinct groups) and, in the ensuing two years saw decreased total cost of care (direct plus CHAMPUS cost) of about 15 percent and this was accompanied by better satisfaction and even less ER use. This could be done in the private sector IF communities would agree to use such a system. We were able to do it because we ran the system and patients pretty much had to come to us. Initially, many were leery and did not expect to like the new system. After six months, they virtually all preferred the new system. My first strong indication of this was when the general commanding the second group that was to “come on line” called me wanting to know when his soldiers and families would be getting their clinic. But, the fact is that we really had to market the program initially even though it was the military.
ETH -
Can you tell us more about the “three distinct groups” and how the system worked?
If you are interested in why our system costs so much, let me recommend Aaron Carroll’s excellent series.
http://theincidentaleconomist.com/wordpress/what-makes-the-us-health-care-system-so-expensive-introduction/
Steve
Edward T. Haines, CHAMPUS (which uses the MEDICARE reimbursement rates for specific procedures) is the source of a significant portion of the “health care inflation” that the U.S. is experiencing, although I will grant it is not the only significant source—having employer-funded health care financing in the U.S. is also a significant contributor.
From my personal experience as a Navy retiree: When my 18 year old daughter was struck by an automobile while crossing the street, she was taken to the nearest Class I Trauma Center (Seattle’s Harborview Hospital). She was in the hospital from Tuesday evening until Saturday. The bill for the hospital (not including surgeon(s) anæsthesiologists, lab work, etc.) was $70,000. Tricare’s (what used to be called CHAMPUS) “allowed” was slightly more than $20,000. This was in 2007.
The Medicare reimbursement rates are set by formula in the original law. The percentage allowed, and thus the amount actually reimbursed by Tricare/Medicare, decreases uner that formula each year based on the assumed “efficiencies” which were embedded assumptions in the original legislation.
For the past decade and more, in order to prevent Tricare/Medicare patients from being unable to find a doctor, within reasonable distance of their abode, who accepts new patients, Congress has had to “suspend” those increases. The accumulated suspended increase in reimbursement rates now stands at about 27%, i.e., if Congress fails to “suspend” the changes this year the actual percentage that would be reimbursed by Tricare/Medicare, would fall from the ~29% it is now, to a notably lower figure. One specific fact I do not possess is whether the annual change is a change from the original percentage specified in its first year (IOW, 27% of 29%)—probably the case,—or from 29% to 27% (likely because otherwise reimbursment rates would have been programmed under the law to go to 0.0% in a foreseeable number of years, and I doubt that the law would have passed so quietly with that sort of absurd proposition.
The whole point of the above information is that now, after some 46 years of Medicare/Tricare, the providers have had to raise rates above the prior year to try to recapture the monies that were not reimbursed in the prior year, and this is a situation in which mathematical compounding applies with a vengeance!.
Most of those who populate our national government are, functionally, surrealists.
There was an article in the Journal of the AMA at about that time describing “Community Based Health Care.” The concept was to study a community of persons and then develop a primary care system for that community. A community with 80 percent women would have more GYNs. One with one or two factories would have a lot of occupational health care.
In our case, we had two brigades and a retired community. The three were pretty close in size. One of the brigades was a training organization and resembled a college more than anything else. A lot of geographical bachelors there for six to 52 weeks, a faculty, and family members. We approached the commander and convinced him that “donating” a few thousand feet of barracks space for us to develop a primary care system would be to his benefit. He bought into it. I then covinced my superiors that we should invest about $200,000 into remodelling that space into a clinic. We assigned several GP, a GYN, several PAs, and a nurse practitioner. This gave a ratio of about 1,200 persons per provider. Everyone (private through general) saw primary care at this site. We had open sick call for about two hours early in the AM to see acute issues that would affect troops ability to work. The rest of the day was all appointments. My instructions to the providers were that ALL issues were to be seen in one visit to the extent possible rather than the traditional one visit – one complaint. Over the next six months, our total visits dropped and the number of persons going to CHAMPUS (civilian care) plummeted. The plummeting was not only primary care but also specialty care as our people took care of patients.
After about six months, as we were getting the kinks worked out, the commander of the other brigade came to me to demand that he get “his” clinic also. That brigade was a combat support brigade that provided small numbers of supporting soldiers to units around the world. At any moment, the commander might have soldiers in up to 20 countries. Many of the deployments were abrupt with minimal preparation time. They were all assigned to the base so there were few geographic bachelors but lots of temporary partial families with all the stress that involves. In this clinic, we had more GYN care, PA, several GPs, and some first line emotional support. In addition, we placed great stress on 100 percent full time medical readiness for deployment. Even when there were only a few hours warning, we provided predeployment briefings covering self care, prevention, and health threats of the deployment site. The families were invited to the predeployment briefings.
The retirement community was seen at the hospital based clinics and those with chronic conditions were seen by internal medicine specialists. Retirees from the two brigades often asked to be seen in those communities and we welcomed that. Soldiers are always like family and love to be called by their rank long after retiring.
Long answer to your question. I am convinced that a similar system could work in many communities but am also convinced that many would refuse to do so. If a factory employing 2,000 people with 3,500 or so family members and a couple thousand retirees developed a primary care system addressing the health needs, stresses, and perceptions of its community, I believe they would see a 30 percent or more drop in total health care cost. Most of this would come from no longer paying for unneeded and inappropriate care that just sort of happens now. Having a full time occupational health physician at such a setting alone would be invaluable not only through timely treatment but through early identification of potential work hazards.
My good Edward,
You will find the blog of your fellow Author Janice a bottomless well of intelligent thinking on the superior virtues of community medicine:
http://whyisamericanhealthcaresoexpensive.blogspot.com/
H. M. Stuart
Alexandria
Yes, I have read several of her pieces.
Edward,
Thank you for your detailed answer.
Why do you think people would oppose this? Simply because it’s a new idea, or are there specific reasons?
I suppose this idea already exists naturally in some ways. Where I lived in the burbs in Minnesota there were lots of family practices and small clinics with daytime hours whereas where I worked downtown there were 24-hour urgent care centers. I can’t say if this adequately served everyone’s needs.
I think the biggest objection would be along the line of what our greatest early resistance was. The raised issues were “it is different and will it meet my needs?,” and “you mean that I (colonel’s wife) will be seen right along side a private?”, and “what if I don’t like what they say I need done?” In the military, one has the advantage of saying in reply “Suck it up soldier and see what happens.” Granted, we were a bit more diplomatic with the colonels’ wives (my wife fielded a lot of those comments with advice to “See how it goes.” By a few months into it, the colonels’ wives looked her up and admitted that they had been wrong.
Take the example of a factory. Will family members really be willing to go into the factory compound for their care? Will beneficiaries be willing to suspend the high level of paranoia about health care in this country to believe that this system is really for their benefit?
Personally, I believe that the greatest change was one the patients didn’t even know happened. It was the idea of taking care of everything in one visit. That visit might take an hour but would then eliminate several short visits with little benefit. One lady came to sick call. She had just married a soldier and had been seeing a free clinic for management of her high blood pressure. The doctor asked when her last Pap had been and it was about five years. He had the nurse set her up of a physical and pap (a real physical includes exam of ENT, neck, chest, breasts, heart, pulses, abdomen, pelvic, pap smear, and a medical history). In the course of examining her neck, he found her thyroid to be enlarged and diagnosed hyperthyroidism. That was the cause of her hypertension. She had a confirmatory test and was referred for curative treatment. Two visits to make a life changing diagnosis and treatment. This is what people really want but not what they and their politicians demand. What is demanded is massively fragmented care by a series of non interconnected care episodes leaving serious conditions unrecognized and untreated.
PS, When I retired from the Army and worked for a staff model HMO, I tried to convince them that we should stop counting total visits and provide full episode care. They told me to shut up and see six patients an hour. I quit after 1 1/2 years since I found the job unrewarding and frustrating.
What is demanded is massively fragmented care by a series of non interconnected care episodes leaving serious conditions unrecognized and untreated.
I hear that. I went for years with a steadily worsening undiagnosed thyroid condition (now thankfully and easily treated) while being sort of chewed regularly out about my high-cholesterol which I had even though I am physically active and was a vegetarian (which is related and basically disappeared after starting levothyroxin). Enough about me…
I understand the hesitation though (in the factory example). I wouldn’t have wanted to go to my husband’s last place of work for healthcare. Cuz I didn’t trust the f*ckers. Although, where I worked they had a day where doctors came in to give everyone flu shots for full and part-time employees, which I thought was great – it saves all those people separate trips to the doctor and saves the company the “cost” of the lost work. Of course they did it during the day so if you worked nights you had to come before your call. And both years they ran out of shots before most of the night people got there. Which is all sort of funny when you consider it’s a theatre so the actual product is being made by the people working at night and we all work in closer contact that the day people can ever imagine. So I guess it’s a toss up if the idea was good or not.
I’m babbling. This is because I do not want to pack my suitcase for traveling tomorrow.
Thanks for your answers. It’s given me much to think about.
And then, of course, there is this:
http://www.latimes.com/news/nation/nationnow/la-na-nn-medicare-fraud-20120228,0,6359381.story
When one has an industry sector like health care for which demand is not merely inelastic, but rather virtually fixed at in-finitude by virtue of the understandable craving of mortal creatures for more life; when one compounds this inescapable demand function by allowing the sector setting the pricing to play one non-consumer third party fundor (private health insurance) off against another non-consumer third party fundor (public health insurance) in order to maximize its revenues (how did that “doc fix” fare in this, its latest decade-plus year?); and then when on top of that you allow the system to regularly goose its already pathologically inflationary nature with additional greed ranging from the physician who wants that boat to the nurse who needs those extra meds to this clown above – remember, he is the one who has been found out and caught – then what we have is a system designed to produce nothing but positive price inflation feedback.
The most revealing opportunity we would ever have to find out exactly what our values and self-aggrandizing pathologies are with respect to health care can really only come if we had
Health Care Without Insurance.
Only in such a hypothetical case could we remotely approach establishing anything resembling a true market, that is, a situation where human health and the treatment of human illness have a chance to rise above the inherent path down which they are headed now, into perpetual animal husbandry, where the frailty of human flesh is deliberately and perpetually farmed for its implicit infinite return.
H. M. Stuart
Alexandria
Let me see if I can elaborate on this, and a bit differently.
Although the Hippocratic Oath, or at least lip service to it, theoretically binds all health care delivery under a common values perspective, the health care pricing gateway, through which those whose price has been paid are admitted for healing and those whose price has not been paid are rejected from healing, is not considered to be a factor covered under that oath.
The reason it is not is that health care understands itself and is understood by all as an extrusion of the Divine into the world of men, understood to operate in a numinous dimension separate from the quotidian world of human economics, and so it and all also uncritically accept that solving the problem of the pricing gateway – that is, that given which is also accepted without question by all that if you or someone else pays the prevailing price for health care you will be treated and allowed to live, and if you or someone else does not pay the prevailing price you will not be treated and you will be allowed to die – lies absolutely outside of medicine as a practice, notwithstanding that that numinous dimension of medical practice itself is in fact a vast and complexly interwoven global business complex and currently the fastest growing sector of any number of otherwise struggling economies.
Therefore, it is this status quo, or possibly more properly, this unearthly and atemporal perspective – that the pricing of medicine by its providers is not a part of medicine, but rather axiomatically lies outside of it in some sort of other, Klein bottle topology – which will necessarily lead every society which accepts it ultimately into an assymptotically medicalized economic sclerosis and bankruptcy.
H. M. Stuart
Alexandria
My good H.M.,
The Objectivist in me says that health care should be a free market system with care provided by those with a product (i.e., knowledge) of value to consumers able to pay value for this product. I really have confidence in free markets. However, health care, much like education defies the market model on a number of fronts. About ten percent of our population will never be able to produce the value needed to pay for their health care (disability, mental incapacity, emotional disease). A fully free market consignes these to either charity or no care. Another 30 to 40 percent would not be able to afford care beyond basics. A serious illness or injury would devastate the finances of these people. (I am fairly well off but had I had to self pay for the two surgeries and hospitalizations following my fall from a roof a couple years ago, I would no longer be “fairly well off.”
The problem for private insurance is simply one of responsible business management. A corporation has an ethical requirement to be profitable. The persons providing capital for that corporation depend upon its providing capital for part of their own income and wealth. The only way to ensure that the insurance corporation remains ethically profitable is to eliminate high risk people (dummies climbing around on roofs comes to mind), charge high rates, or ensure that lots of people including very low risks are covered. None of those three really works well in a free market since low risk people will either go uninsured or go to low cost alternatives. High risk people may not be offered coverage at rates that are affordable.
Ultimately, I believe we may have to revert to a model not unlike the public school system. Everybody pays premium for coverage. Those who wish can elect to pay additional for care by providers parallel to the system (not unlike what is the case in England). Since everyone pays, those preferring a private provider can always elect to reenter the public system if and when they desire to do so. I don’t expect to see this in my lifetime.
My good Edward,
I understand from your introduction of Objectivism and free markets and your tangential sojourn into the mechanics of insurance that you are making an alternate comment to mine rather than a reply to anything I myself introduced and wrote about, but just so that it is clear to the reader, I myself did not introduce or promote any Objectivist perspective of free market health economics in my own, separate, different comment which precedes yours.
Although our two different comments do share something in common, though: it is no longer possible to even think of health care pricing as variable. Generally health care pricing as a focus successfully evades our perspectives entirely, like the Predator’s optics-shifting invisibility suit, and when it does become even possible to think about, it can then only be thought of as a divinely fixed natural constant, like the speed of light, around which it is only possible for other variables to be manipulated one with respect to the other.
H. M. Stuart
Alexandria