MANAGED CARE April 2004. ©MediMedia USA
Experts, including many health plan medical directors, agree: We have a long way to go.
It's essential rhetoric for both political parties that America has the best health care in the world. Bill Clinton said so when he was president and George W. Bush says so today. Republican Senate Majority Leader Bill Frist says we do, and Louisiana Democrat Sen. John Breaux, ranking member of the Special Committee on Aging, agrees. But do we? Like most tenets and all rhetoric, truth relies on definition.
"It depends on what we mean by best," says W. Allen Schaffer, MD, senior vice president and chief medical officer of Cigna Healthcare. "If a person is fortunate enough to be part of an employer-sponsored health plan, he or she may have access to the best health care technology in the world. But the fact that we have so many uninsured in this country is a national disgrace."
Indeed so, says Robert Brook, MD, director of Rand Health. "I don't see how we can say we have the best health care in the world when we have nearly 44 million people uninsured," he says. "Those people are dying from lack of health care."
Managed care has made strides in helping control overall health care costs in the last decade, and an increasing number of health plans are implementing prevention and wellness and disease management programs that improve the quality of care, but "the burden of cost on our society created by the uninsured and underinsured continues to damage our ability to provide the best care possible," says Schaffer.
In addition to the uninsured, about 36 million more Americans who have insurance, often either Medicare or Medicaid, go unserved — that is, they can't get adequate care where they live when they need it, according a report titled "Nation's Health At Risk," issued March 23, 2004 by the National Association of Community Health Centers. "These people live in inner cities and in isolated rural communities," says Dan Hawkins, vice president for policy at NACHC. "No matter where they live, the story is the same. They can't get health care because there aren't enough doctors in their communities who are willing or able to care for them."
Georganne Chapin runs Hudson Health Plan, a 50,000-member Medicaid HMO in Tarrytown, N.Y. She sees our health care system from the perspective of someone serving a population of low-income patients, mostly children and women — the people who often need care the most and have the hardest time getting it.
"A major problem is a lack of continuity of care in our country," says Chapin. "It's a hellish system, and really no one understands it. It is nearly impossible to explain why it is so complex and mind-bogglingly obstructive."
So for many Americans, access to adequate health care is a big problem. But what about those Americans who do have access to care, the 80 million people enrolled in some form of employer-sponsored health plan? Surely they have the best care.
Maybe not, says Steven Udvarhelyi, MD, senior vice president and chief medical officer for Independence Blue Cross in Philadelphia. "Study after study shows that many Americans do not receive evidence-based care. And our care is very expensive. We are facing a crisis of quality care becoming simply unaffordable," he says.
We don't even have a nationally recognized basic set of criteria of what constitutes adequate coverage, say Schaffer and others — something addressed by the governments of all other industrialized nations. "That's a huge problem in itself," says Schaffer. "We have no nationally defined core basket of benefits determined to be appropriate for all our citizens."
"What does that even mean, the 'best in the world'?" asks Kenneth Kizer, MD, president of the National Quality Forum (which is developing a nationally acceptable set of quality measures) and former under secretary for health in the U.S. Department of Veterans Affairs. "Are we talking about the diffusion of state-of-the-art technology, biomedical research, medical training, access to care? In terms of research and technology available to those who can afford it, the answer is probably yes. In terms of coordination of care, access, and narrowing disparities of care, we are way down the list."
What do we mean by best? Are there measures we can agree on? Do we excel in making sure the sick are adequately treated? Are children adequately immunized and are the health needs of the elderly met? Do all, or even most, women receive adequate prenatal and perinatal care? Is our health care system safe?
Does spending more on health care than any country in the world — which we most certainly do, in the aggregate ($1.6 trillion in 2002, up from $1.4 trillion in 2001, according figures released by the Centers for Medicare & Medicaid Services in January) and per capita ($5,440 in 2002) — translate into the best care possible? In comparison, Canada spent $97.6 billion on health care in 2001 (that's $67.28 billion in 2001 U.S. dollars) and $2,163 per capita in 2001 (that's $1,358 in 2001 U.S. dollars).
In 2000, the last year worldwide aggregate figures were available, our spending was 44 percent higher than Switzerland's per capita spending and 134 percent higher than the median of $1,983 (in U.S. dollars) for the 30 industrialized countries in the Organization for Economic Cooperation and Development (OECD).
In interviews with nearly three dozen leaders of health plans and health care research organizations, purchasers, and physicians about the comparative status of American health care, one common thread emerges: No one actually providing care knows what the phrase "America has the best health care in the world" is supposed to mean.
And when we break the question into parts in an attempt to reach a coherent, cohesive answer — What about access? What is quality care? If I have a heart attack in America are my chances of survival better here than in other industrialized countries? — the response from experts and medical directors on the front line repeatedly is "no." Health care, no matter how you cut it, is not necessarily better here than there.
(The answer to the heart attack question, by the way, is no: The best place to have a heart attack is Japan if you are a man, France if you are a woman. We rank 22nd for men, 23rd for women among industrialized nations, according to the American Heart Association.)
The best that can be said about "best in the world" is that when politicians and federal officials use the expression, perhaps they are expressing aspiration rather than achievement. "It depends on your lens," says Kizer. "But it's really no more than a good five-second sound bite."
Take, for example, Carolyn Clancy, MD, director of the Agency for Healthcare Research & Quality and the highest ranking federal official whose prime responsibility is measuring and improving the quality of care. In a January 2004 written statement, she said that "Our nation's health system is the finest in the world, providing millions of Americans with life-saving care each and every day."
But in December 2003, her agency produced the first assessment of the overall quality of care in our country by the federal government, an assessment mandated by Congress. The report, titled The National Healthcare Quality Report, contained five key findings:
- High quality health care is not yet a universal reality.
- Opportunities for preventive care are frequently missed.
- Management of chronic diseases presents unique quality challenges.
- There is more to learn.
- Greater improvement is possible.
Hardly a ringing endorsement of a system that her boss calls the best. The AHRQ report went on to say that "the observation that quality of health care in America can be improved is not new. Lack of consistent provision of the best quality care means that not all Americans benefit from the nation's investments in biomedical science." In making that statement, the AHRQ report referenced an article in the Aug. 23, 2003 issue of the New England Journal of Medicine titled "Clinical Research to Clinical Practice — Lost in Translation?" by Claude Lenfant, MD, director of the National Heart, Lung, and Blood Institute of the National Institutes of Health:
One might question whether we have enjoyed the maximal return on the more than $250 billion that this country has invested in the National Institutes of Health since 1950. Consider that in 2000 the life expectancy at birth for men and women in the United States lagged behind that of 22 other countries, from Japan to Israel and including Canada and most of western Europe. If we view the longevity of citizens in our sister nations as an indication of what is possible in the modern world, then we must question why our reality is falling short. Some may believe that the difference between life expectancy in the United States and that in other economically developed countries is largely a manifestation of societal differences. I, however, believe the answer is this: we in the United States, both health providers and members of the public, are not applying what we know.
Another AHRQ report, issued at the same time and titled The National Healthcare Disparities Report, is more damming, or at least it was in its draft version in July 2003. Then the report said that disparities in health care are "national problems" that are "pervasive in our health care system" and have a large "personal and society price." The report issued in December concluded only that "some socioeconomic, racial, ethnic and geographic conditions exist." In January, several politicians from both parties sharply questioned that change and other revisions that appeared to water down the report, accusing HHS of playing politics with science. In February, HHS Secretary Tommy Thompson issued a statement saying that the changes were a mistake and AHRQ soon issued the July draft as its final report.
In speaking to health care leaders in Washington, D.C., at the World Health Care Congress in January 2004, Clancy quoted a 2003 study by the Rand Corp. In fact, almost every speaker addressing the status of the nation's health care at that conference quoted that study, the results of which were published in an article in the June 26, 2003 edition of The New England Journal of Medicine titled "The Quality of Health Care Delivered to Adults in the United States." Rand researchers concluded that "the deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted."
"We tend to take health care for granted," says the lead author, Elizabeth McGlynn, PhD, associate director of Rand Health. "This study shows we can't. There is a tremendous gap between what we know can work and what patients are actually getting. Virtually everyone in this country is at risk for poor care. And we are talking about the basics of good medical care, not the cutting edge."
The Rand study concluded that the quality of care varies widely according to medical condition, from 79 percent of recommended care for cataracts in old people to 11 percent of recommended care for people with alcohol dependence. Researchers found that 55 percent of heart attack patients did not get common medications that could reduce their risk of dying, that more than 75 percent of diabetics were not given semiannual blood tests by their doctors that could help prevent kidney failure and blindness, and that about 46 percent of patients who were put on antidepressants never got any follow-up from their doctor to see if the drugs were effective or had any side effects.
"Many of those people who do have adequate insurance are not receiving an appropriate level of care," says Brook. "Compared to other countries, we fall behind on too many basic measures to say we have the best care in the world."
Why? Because "our so-called health care system is designed to fail, not to work," says Donald Berwick, MD, a clinical professor of health care policy at Harvard Medical School and president of the not-for-profit Institute for Health Care Improvement. "We don't even have a real system of care. We have fragmentation to the point that the public remains without the basic information necessary to either demand what it needs or to get it."
We don't even all speak the same language, says Udvarhelyi. "It's difficult to even talk about quality, because its meaning varies so widely, and that's a serious problem," he says. "We are very good at many technical aspects of care, but Wennberg's work at Dartmouth shows that sometimes the problem with quality can even come from too much care."
He is referring to the work of John Wennberg, MD, director of Center for the Evaluative Clinical Sciences at Dartmouth Medical School and chief researcher for the Dartmouth Atlas of Health Care. His work demonstrates that the amount of care patients receive — including overuse of clinical services not supported by evidence of effectiveness — varies based on geography.
The results of a study by Wennberg and his colleagues published in the March 13, 2004, issue of British Medical Journal, titled Use of Hospitals, Physician Visits, and Hospice Care During the Last Six Months of Life Among Cohorts Loyal to Highly Respected Hospitals in the United States, are particularly telling. The researchers found that "striking variation exists in the utilization of end-of-life care among U.S. medical centers with strong national reputations for clinical care." End-of-life treatment patterns differed significantly at several academic medical centers studied, and "the likelihood of dying as a hospital inpatient, admissions to intensive care, and number of physician visits during last six months varies widely, even among medical centers in the same major U.S. cities."
The researchers weren't saying that one hospital demonstrated better care than others — in fact, they concluded that "using a variety of measures, two randomized trials of elderly patients from the U.S. Veterans Affairs health care system found that more frequent office visits and more intensive primary care were associated with increased use of the hospital but no improvement in health or function."
Looking at all this, the issue of comparative care seems to come down to three issues: access, the use of evidence-based medicine, and whether we are getting what we pay for. Where do we fall in comparison to other countries?
The most comprehensive study ever done comparing the world's health care systems was by the World Health Organization in the late 1990s. Its purpose was to look at the world's health care with respect to such fundamental issues as cost, access to health care, and how well the health system succeeds in producing good health outcomes in a population. Titled The World Health Report 2000 — Health Systems: Improving Performance, it compared performance data in 191 countries, defining performance as "the best that can be achieved given available resources," and using such criteria as infant mortality and overall mortality rates, access to and affordability of care, fertility rates, life expectancy, and other factors as criteria.
Collating that data, the WHO rated the United States 37th in overall performance, defined as "the best that could be achieved with [available] resources." We ranked first among surveyed nations in cost, both per capita and as a percentage of our gross national product.
|Basic indicators of health and percentage of GNP spent on health care|
|Probability of dying
(chance, per 1,000 people)
|Under Age 5||Between 15 and 59 years old||Life expectancy at birth (in years)
|Ranking among 191 WHO countries
|Country||Male||Female||Male||Female||Male||Female||% of GNP spent on health care (1997 data)||Level of health*||Overall health system performance**|
|*Defined by WHO as a health system's ability to make the health status of its participants as good as possible over a life cycle, including life expectancy.
**Defined by WHO as a health system's ability to achieve the highest level of health given its level of available financial resources.
SOURCE: THE WORLD HEALTH REPORT 2000 — HEALTH SYSTEMS: IMPROVING PERFORMANCE
The WHO outlined three primary goals for what a good health system should do:
- Good health, which it defined as "making the health status of the entire population as good as possible" across the whole life cycle,
- Responsiveness, which it defined as meeting people's expectations of respectful treatment and client orientation by health care providers, and
- Fairness in financing, which meant ensuring financial protection for everyone, with costs distributed according to one's ability to pay.
We did well in responsiveness, but not much else.
A more recent study was done by the Commonwealth Fund. Published in January 2004 and titled Mirror, Mirror on the Wall: Looking at the Quality of American Health Care Through the Patient's Lens, it compares our system with health care in four other English-speaking industrialized nations: Australia, Canada, New Zealand, and the United Kingdom. It used the quality criteria developed by the Institute of Medicine's 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
All four countries scored better than the U.S. in every category, and the U.S. ranked second-to-last on measures of "patient-centered" care. We did, however, have the shortest waits for hospitalization and elective surgery, and placed second (to New Zealand) on prompt access to primary care physicians and specialists.
|Patient ratings of physician care|
|Adults with health problems|
|Percent rating physician as excellent or very good:||Australia||Canada||New Zealand||United Kingdom||United States|
|How well he or she diagnosed your problem||67||62||68||57||58|
|Spending enough time with you||64||57||72||55||52|
|Being accessible by phone or in person||57||52||68||50||51|
|Listening carefully to your health concerns||72||66||76||65||62|
|SOURCE: 2002 COMMONWEALTH FUND INTERNATIONAL HEALTH POLICY SURVEY
COMMONWEALTH FUND/HARVARD/HARRIS INTERACTIVE
"We should begin to improve our status by building on our strengths," says Cigna's Schaffer. "We should address the issue of cost-shifting by facing our responsibility to the uninsured. We should encourage the use of evidence-based medicine, and endorse a standard set of core benefits. Right now 'best in the world' is a politically motivated statement, but there are many steps we can take to make it happen."