Attributed to Hippocrates (more likely Thomas Sydenham)
During the health care debate, much was made about the ranking of the United States among nations regarding out system’s performance. In fact, we ended up Number 37 in World Health Organization rankings, a fact that was celebrated in song. While many feel that the poor performance of our health care system is the result of an inefficient system that rewards the wrong aspects of care, others argue vociferously that the system is the best in the world but that Americans are somehow sicker than other homo sapiens in ways that are difficult to measure.
An article was published in Health Affairs (subscription required but summarized here) that puts to bed the myth of “sicker” Americans. In this study the survival of folks ages 45-65 in United States was compared to survival in other countries with at least 7 million people and a GDP similar to America. This list included Australia, Austria, Belgium, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom. The study use 1975 as an index year and compared it to 2005. Although I’m not an expert in international comparisons, this one seemed pretty well put together.
The investigators found that between 1975 and 2005, American health care spending increased at a much greater pace than the other countries and Americans were more likely to die prematurely than the citizens of the other countries. This we already knew. What is news is the magnitude of the difference and the aspects of American society that do and do not contribute to the difference.
Population Diversity – As opposed to the deeply held believe that we have to spend so much on health care because of our sickly poor population, it turns out that our diversity does not contribute to our poor health standing.
Smoking Status – Americans actually smoke less than the residents of the comparison nations so it turns out that smoking status does not contribute to our poor health standing.
Obesity – Americans are more overweight than the residents of the other countries. America was proportionally as overweight when compared to the other countries in 1975 as it is today. If it is obesity that is the cause of our excessive health care spending, it should have increased proportionally (not logarithmically) over the past 20 years. Obesity is not the cause of our excessive health care cost.
Traffic Accidents and Homicides – Much was made of the perceived excessive costs of violence in American society during the recent health care debate, in particular among the underclass. The contribution of violence has in fact been stable over the past 20 years (and is relatively low) so these are not the cause of our excessive health care costs.
So what is the cause? The authors of this study speculate that the health care delivery mechanism in this country has become an expensive self-perpetuating system that directly contributes to poor outcomes. This is potentially a consequence of inefficiencies that occur with rising costs and relative underinsurance as well as absolute uninsurance. Excessive spending on individual health care consumption may have led to inadequate investment in public health and education initiatives. Unintended excessive care may lead to fragmentation and an increase in medical errors. Intended excessive care leading to life-shortening complications is a very real problem. In America the belief that the the “market” must dictate health care purchases may so distort consumption that people are unaware of just how poor the choices that they make actually are. Until they die, that is…
In a companion article summarized on the Commonwealth website, some of the specific reasons for the poor health of Americans as related to our healthcare system were listed:
- One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs, compared with as few as 5 percent of adults in the United Kingdom and 6 percent in the Netherlands.
- One-fifth (20%) of U.S. adults had major problems paying medical bills, compared with 9 percent or less in all other countries.
- Thirty-one percent of U.S. adults reported spending a lot of time dealing with insurance paperwork, disputes, having a claim denied by their insurer, or receiving less payment than expected. Only 13 percent of adults in Switzerland, 20 percent in the Netherlands, and 23 percent in Germany—all countries with competitive insurance markets that allow consumers a choice of health plan—reported these concerns.
- The study found persistent and wide disparities by income within the U.S.—even for those with insurance coverage. Nearly half (46%) of working-age U.S. adults with below-average incomes who were insured all year went without needed care, double the rate reported by above-average-income U.S. adults with insurance.
- The U.S. lags behind many countries in access to primary care when sick. Only 57 percent of adults in the U.S. saw their doctor the same or next day when they were sick, compared with 70 percent of U.K. adults, 72 percent of Dutch adults, 78 percent of New Zealand adults, and 93 percent of Swiss adults.
- U.S. , German, and Swiss adults reported the most rapid access to specialists. Eighty percent of U.S. adults, 83 percent of German adults, and 82 percent of Swiss adults waited less than four weeks for a specialist appointment. U.K. (72%) and Dutch (70%) adults also reported prompt specialist access.
In summary, it isn’t that America has more poor people and poor people are sicker. It’s that our system for the 20 years prior to the passage of the Affordable Care Act became efficient at transferring money into the Medical-Industrial complex at the expense of the health of our citizens. We can only hope that the change occurs rapidly.
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December 7, 2010 at 3:20 am
Robert C. Bowman, M.D.
It gets worse. From now until 2040, the US will be decreasing primary care by tens of thousands worth of primary care physicians. Instead of going from 280,000 to 400,000 in the next decades to recover primary care, the US is moving backwards to 250,000. This takes primary care equivalents per 100,000 from over 90 down to 74. The non-primary care physician concentration per 100,000 will increase 52% while primary care will decline 24%.
This is the impact of of the US designs that are increasing graduates, are increasing percentages of all sources in non-primary care, and are decreasing further below 30% primary care graduates remaining in primary care careers.
Do Americans realize that their primary care design is over 70% non-primary care in outcome for 28,000 annual graduates from 6 sources?
Every bit of the MD, DO, NP, and PA expansion will result in more hospital and specialty care and more care where there is already the most care, in 3400 zip codes clustered together in 4% of the land area.
The really bad news is that the 65% of the population residing in 30,000 zip codes outside of concentrations including all of the populations increasing the most in numbers and in primary care demand, will drop another 24% in primary care concentration and might increase in non-primary care – maybe. The maybe is that the US no longer produces the general types of specialists (gen surg, gen cardio, gen ob, gen ortho) that are most needed outside. This should not be a surprise in a nation that has not expanded the one reliable solution for all left behind, family medicine, from the 3000 annual graduates first reached 30 years ago – zero growth for 30 years despite great primary care demand in all the populations served by family physicians at multiple levels compared to other sources – is actually quite difficult to do without some planning and coordination to concentrate resources somewhere else.
And of course the big winner from 2010 to 2040 will be inside of concentrations where there will be a 60% increase in non-primary care concentration. And since locations inside of concentrations are set to take a 23% cut in primary care concentration, they are likely to use their concentrations of income, health care coverage, social organization, grant resources, and political contacts to outbid locations outside of concentrations to maintain their primary care.
This will result in even more resentment rising to higher levels for two-thirds of the population. They have not figured out why they are angry, but they are correct that the designs are not working out for them.
This will also result in more difficult choices for those outside attempting to find basic degree primary care nurses and primary care physicians and will not find them as they are being converted to hospital and subspecialty workforce for somewhere other than where needed.
In a few days yet another magical reinvention of primary care will be announced with great fanfare, media attention, and absolutely no hope of helping out in primary care recovery. This is also a consequence of the design. If you understand inside and outside of concentrations with excessive versus insufficient workforce, they you can understand why Continuity Homes, Accountable Care, Pay for Performance, expansions of internal medicine, hospitalists, convenience care, and other schemes promoted by those inside of concentrations – do not help those outside of concentrations. Those outside do not have the experienced, well trained, continuity primary care nursing, primary care staff, and primary care physicians to deliver the care – and when they attempt to develop them, the design results in them going somewhere else for better pay and support and less complex duties.
December 8, 2010 at 8:22 pm
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