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Family medicine lost a great friend on June 10th when Barbara Starfield died. A pediatrician by training, she entered into services research and spent her career describing the American Health Care system. She became convinced around 2004 that the system that she was describing was not only dysfunctional but directly led to the bad outcomes that she had been describing, detailed here in this interview.  She then spent the last 6 years of her life as a voice in the wilderness, trying to let people know how important family medicine was to the health of our fellow Americans.

She died at 78, much too young and with much left to do. In his June 24 newsletter (worth signing up for), Fitzhugh Mullins of Medical Education Futures has given us a sample of 5 of her most important articles. The one that made the biggest impression on me was published in 2005 in Health affairs and as abstracted in Medical Education Futures:

The effects of specialists supply on populations’ health: Assessing the evidence
Starfield B, Shi L, Grover A, Macinko J.
March 2005 – Health Affairs
“Analyses at the county level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States’ position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.”

Wow. I was sitting next to a colleague at a meeting this weekend, and upon hearing this study cited, he said to me “That can’t be true. Congress would have done something if it were to protect the American people.” As I told him, I am willing to vouch for the consistency and thoroughness of Dr. Starfield’s analysis. I also continue to be amazed by the way the entrenched medical industrial complex, first described by Arnold Relman in the 1980s,  has managed to protect the self-interest of the non-primary care infrastructure.

Requiem aeternam dona eis, Domine, et lux perpetua luceat eis.

Primum non nocere

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.