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A new study by the Commonwealth Fund comes to an old conclusion.

The United States is still last in health system performance.

The 2010 version of Mirror Mirror updates comparative health system performance data from seven industrialized countries.  The sad conclusion is that the United States is last or next to the last in five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives.  And they are last overall.

This conclusion is no different than that reached in previous versions of the report issued in 2004,2006, and 2007.  This year’s update adds physician and patient survey data on care experiences and dimensions of care and also adds the Netherlands into the comparison.

The Netherlands – first;  The US – last

The Netherlands may not have made it to number 1 in soccer, but they leaped to the head of pack in health system performance.

Those who consistently tout the US health care system as the best in the world clearly are not paying attention to this and similar studies.  In fact, they are not listening to their neighbors, or at least to other Americans.

Although the U.S. spends more on health care than any other country and has the highest rate of specialist physicians per capita, survey findings indicate that from the patient’s perspective (emphasis added) , the quality of American health care is severely lacking. The nation’s substantial investment in health care is not yielding returns in terms of public satisfaction.

In addition:

Americans and higher-income Americans were more likely than their counterparts in other countries to report problems such as not getting recommended tests, treatments, or prescription drugs.18 This is undoubtedly a reflection of the lack of comprehensive health insurance coverage and the high out-of-pocket costs for care in the U.S., even among the insured and those with above-average incomes.

The study does not dwell on the cost of care, but instead focuses on its dimensions of a high performance health systems:  quality, access, efficiency, equity, and long, healthy and productive lives.

Quality

For some, this is supposed to be the one area that the US excels in.  Unfortunately, the only positive spin potential here is that this is the only dimension in the study that the US did not finish dead last in.  The US finished behind Canada on quality.  In fact, in one sub-dimension of quality we were number one – prevention.

Access

No surprise here.  The US finished last.  But one sub-dimension of access was timeliness of care.  Even here we finished next to the last in a survey that included questions like time needed for medical attention and emergency room waiting time.

Efficiency

This is the one dimension that examined cost and cost as a percentage of GDP.  But it also included re-admissions, duplicate tests and unnecessary trips to the ER.  The US finished last in this category.

Equity

The U.S. ranks low on all access to care measures and, as a result, does poorly on all measures of equity. … almost half of lower-income adults in the U.S. said they went without needed care because of costs in the past year.

Among the higher-income population, U.S. respondents often were more likely than their counterparts in other countries to report difficulty obtaining needed care because of costs.

Long Healthy and Productive Lives

This should be the ultimate outcome measure for a health care system.  This measure examines mortality that might be avoided with health care, infant mortality and healthy life expectancy.  The US finished last.

There is a lot in this report that deserves further discussion, but it is a stark reminder that the United States has a long way to go to rank as a high performing health care system.

Photo Credit:  The Commonwealth Fund

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You have heard the arguments.

In the first corner:  “We have the best health care system in the world.  People travel to this country from all over the world to get the best health care.  the parking lots in hospitals bordering Canada are full of cars with Canadian license plates.”

In the second corner: “There are 100,000 deaths per year from hospital infections and a similar number from prescription drug errors, and an equally horrific number of people who need to be re-admitted to the hospital for complications.  And what about “Never Events”, those medical errors that are described as adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.

And there is a voice in a third corner: “We have the most expensive health care system in the world yet the United States is not ranked among the top twenty nations in infant mortality, maternal mortality, longevity, or hospital admissions avoidable with access to health care.”

It’s a bit like arguing who won the Super Bowl (this is Super Bowl weekend, after all) by comparing rushing yardage, passing yardage, first downs, time of possession.  Unlike football, in health care there is no touchdown metric, no definitive “points on the board” that decides health care quality.

Which corner would you pick?

It might depend on what your immediate need is.  If you have a rare and complex disease, you might be sympathetic to the guy in corner one.  If you are scheduled for knee surgery, you might be paying attention to corner two.  You would certainly hope that the doctor doesn’t commit a “Never Event” by operating on the wrong knee.  If you are paying the health care bill, the logic of corner three should be compelling.

But the three points of view are only mutually exclusive in political debate.  In reality, quality includes all three perspectives, and to ignore any one of them is to ignore and important perspective.

However, it is corner three that gets short shrift, because it is the perspective that requires the broadest viewpoint.  The primary feature of our health care quagmire is its fragmentation forcing all stakeholders to see and focus only on that which they appear to have some control over.

A while back there was an article in Health Affairs that asked the question, does access to specialty care mean better quality health care.  This question touches on the perspectives of all three corners, but in particular corners one and three.

The authors used broad quality measures and to compare areas with poor access to specialty care to areas to good access to specialty care.  This generally meant comparing rural areas with urban areas.  They found that there was little difference in broad measures of healthcare quality.

Quality and specialty care

The interesting part of the study from my perspective is that they took another step.  They looked inside the areas with good access to specialty care and examined outcomes of people who were referred to specialists by primary care physicians and those who self-referred.  The concluded that self referrals generally had poorer outcomes.

The hypothesis that they offered as an explanation is that specialists are trained to interpret symptoms from the perspective of their own specialty.  Primary care physicians are better trained to make a judgment as to which specialist should treat the patient.

My conclusion is that our fragmented approach to health care blocks effort at achieving quality outcomes.  Efforts to achieve quality outcomes is focused in narrow manageable categories.  Quality managers ask the question – did this care have a good outcome?  They don’t dare ask the question – how did this person get to the point where he/she needs this care?  Could we have intervened earlier to avoid this care?

Patients without access to the health care delivery system don’t get appropriate interventions.  Most patient health care is not managed in any meaningful sense.  Managed care does not mean managing care but instead means confining patients inside a pricing network, whether or not it is to the betterment of broad quality outcomes.

Next week:

Why an improved patient delivery system is a necessary pre-condition for affordable and quality health care.

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How often have you heard the phrase, “The United States has the best health care system in the world.”?

What is wrong with that statement is the word “system”.

We could rephrase it – The United States can deliver some of the best health care services in the world (to those who can pay for it).

We could even argue  – The United States has some of the best health care systems in the world: the Mayo Clinic, the Veteran’s Administration, the Department of Defense.

But to assert that we have a system or that Americans (all Americans) receive the best care in the world is a stretch.  Why?

Over the last two weeks I wrote about our fragmented health care system and the closely related fragmented payment system.

I wrote about how patients are equally fragmented, migrating during their lives through several health plans, what I call patient delivery systems.

Why does this matter?

In most measures of health system performance the United States ranks embarrassingly near the bottom or at the bottom among industrialized countries.  From 2000 to 2009 male life expectancy fell six slots to 24^th in the world and female life expectancy fell from 28^th to 35^th.  Some would counter that life style, diet, or poverty had more influence on those drops than health care.

Isn’t that fragmented thinking?  If we had a health care “system” then it would take comprehensive approach to population health.

What are the incentives for doctors and hospitals?  Just as sunflowers follow the sun, health care providers, like the rest of us, follow the money.  And the money is paid for doing stuff, surgeries and tests, for example.  It is not paid for talking with or listening to patients, giving them lifestyle or treatment compliance assistance.

What are the incentives for patients?

Patients often lack the freedom to choose just any doctor.  Their incentive is to change doctors to conform with their current health plan rules.

It is not just patients who change health plans.  I have seen Participants change health plans during open enrollment, because a doctor they wanted was in the new health plan.  A couple of months later, they learn that their doctor is leaving that health plan over some real or imagined dispute.

Patients approach the delivery system through different health plans under different sets of rules regarding covered services, payments and bureaucratic processes. It’s not just that different patients are in different health plans.  The same patient migrates though different systems at different times.

Is it any wonder that doctors are confused and frustrated?

When doctors don’t know the rules

When doctors move in and out of health plan networks

When patients move through health plans – sometimes voluntarily, sometimes not.

When payment depends less on your own talents and more on who your patient is

When information systems are focused first on recovering payments not on coordinating care

When providers are rewarded for doing things, but not for advice, or just plain listening

Is it any wonder that care coordination should fall to the bottom of the priority list?  Not because its undesirable, but because its hard.

Is it any wonder that a long term perspective on patient care is totally lacking?

Disease management – an example

One of the burgeoning trends in the world of employer sponsored health plans are wellness programs and disease management programs. Wellness programs are  programs to promote healthy living.  Disease management programs are designed for people with chronic conditions such as asthma, hypertension, coronary artery disease or diabetes to help them better manage their disease.

Like many other ideas that originate in the United States, it has found strong adherents in other countries.  The Germans have incorporated individual and provider incentives for disease management in their recent reform efforts.  Curiously, the German word for disease management is Disease Management (Germans capitalize the initial letter of “their” nouns).

The logic  for such program is compelling.  That these are relatively new concepts may be puzzling.  But what is truly baffling is that they are not part of the package of services that is included with health care.  Our plan had the option of purchasing disease management services from our health plan, from our pharmacy benefit management firm, or from an independent specialty vendor.

Providers offer little resistance to disease management efforts. But why must they deal with a plethora of vendors?  Why aren’t they the organizing force behind disease and chronic condition management?

Geisinger Medical Center in my home state of Pennsylvania is often cited as model for delivering quality integrated health care to its community in north central Pennsylvania.  Ron Paulus, the Chief Technology Officer for Geisinger wrote in Health Affairs about its strategy for sustaining innovation.  In his conclusion he wrote:

Finally, for many organizations, the spread of value-enhancing collaboration and integration is restricted by regulations that preclude effective collaboration among payers in designing incentive systems and that impede collaboration between hospitals and physicians or among physician practices in a given region. Each payer has its own, largely fee-for-service, payment system—failing to align incentives to enhance value in the way that Geisinger has strived to do. New mechanisms that support collaboration and coordination of policies among private insurers and public programs are needed to achieve replication on a broader scale and sustainability over the longer term.

In other words even an integrated delivery system like Geisinger is thwarted in its efforts to enhance the value of health care by fragmented patient and payment delivery systems.

Does anyone think that health care reform will make the system simpler?