Health for life

Your doctor will see you now!

If only the U.S. health care system had the democracy of the French, the efficiency of the Germans, the primary care of the Brits and the common sense of the Swiss. Then wed be able to see our beret-wearing PCPs ad lib, receive care in 9 minute aliquots, mutter "bullocks!" when were told were too old for dialysis and then die old and quietly at home.

Victor Fuchs, writing in the Jan 2 edition of JAMA, has a slightly different perspective.  He notes that American history is dominated by waves of immigrants who came here to escape oppression. We are far more distrustful of government.  We are also less likely to support redistributive public policies. That may be partly due to a more heterogeneous population that is less sympathetic to the less fortunate when they fall outside the right social or demographic class. Last but not least, our system of government is quite inefficient compared, say, to a parliamentary system.

Thats why:

1. Government spending on health care is comparatively lower: 46% in the U.S. vs. 75% in Organization for Economic Co-operation and Development (OECD) countries.  As a result, a) administrative costs are fragmented, and b) there is less ability to negotiate prices with providers and suppliers

2. There is a different mix of services: in the U.S., less top-down control means more high tech, specialists and amenities with relatively less reliance on physicians and hospitals to render health care services.

What is the way forward?  Dr. Fuchs recommends that future health orm efforts not be modeled on Europe.  Instead, Americans should scale back their expectations and focus on what is necessary, not desireable.

If government is to assume a greater share of health care costs beyond the current 46% level, it should probably worry about funding basic care, not all care.  In addition, Americans are less likely to support total equality; they want to preserve the option of "buying up" when they can afford it.  Last but not least, future orm is going to have to find a middle ground between all the advocacy groups, stakeholders and special interests that dominate the mix of services.

Image from Wikipedia

Listen to the common wisdom about the state of health care in the U.S. and its easy to conclude that were on the verge of catastrophe.  Academics say we have a "non-system," politicians bemoan the "lack of coordination" and the policymakers condemn "unsustainable" costs. When our health care is compared to that of the Burgundy-sipping French, the olive-oil loving Italians and the bicyle-riding Dutch, our commentariat are ashamed that we Americans havent joined the rest of the civilized world in offering high value care to its citizens.

Is it really that bad?

To find out, the Disease Management Care Blog looked at these data from the Organisation for Economic Co-operation and Development. Take the test below and decide for yourself if the experts really have it right.  Answers are at the bottom.

1. Which country, as of 2009, had the highest percentage of persons who reported that their health is good?

A. Switzerland
B. Iceland
C. United States
D. New Zealand

2. Name the country that has the highest rate of obesity and the 2nd highest rate of diabetes?

A. Mexico
B. United States
C. Canada
E. New Zealand

3. An excess of physicians can drive increased health care costs.  Which country has the highest number of physicians per capita?

A. Netherlands
B. United States

4. Which country has the greatest number of MRI and CAT scanners per capita?

A. United States
B. Australia
C. Japan
D. Israel

5. Which country has the highest Cesarean section rates per 100 live births?

A. Italy
B. United States
C. Switzerland

6. Does the U.S or Canada have a higher percentage of women getting pap smears?

A. Canada
B. United States

7. Does the U.S or Belgium have a higher percentage of women age 50-69 getting  mammograms?

A. Belgium
B. United States

8. While the Slovak Republic leads the world in asthma admissions per 100K, which country is close behind in 2nd place?

A. Korea
B. United States
C. Poland

9. True or false: The United States rate of hospital admissions for uncontrolled diabetes is above the OECD average.

A. True
B. False.

10.  While the U.S. leads the OECD with a 20% rate of skipping a provider visit or going without a prescription, which country is in second place with a 17% rate?

A. Germany
B. Netherlands
C. France

11. While the U.S. spends more per capita for health care, health care costs are rising all the OECD countries:

True or False: from 2000 through 2009, the rate of increase in the U.S. health care costs was above the OECD average of 4.0%

12. While Americans make up the largest percentage of DMCB readers, which country in the last month came in second?

A. India
B. Canada
C. Great Britain

Answers:

1. C The U.S. So, while we spend more, it can be argued that we are getting our moneys worth

2. B The U.S. There may be lots wrong with the U.S. care system, but the U.S. also has a higher burden of disease. Toss in high trauma rates and other impacts from poverty and it can be argued that importing a new health system may not translate into greater health.

3. A The Netherlands.  In fact, both countries are below the OECD average.

4. C Japan, but the U.S. is second in the world in the per capita rate of scans.  We apparently use our scanners a lot more!

5. A Italy is higher. C-section rates are skyrocketing world wide.

6. B The U.S. is 78.7%, while Canada is 75.3%

7. B. The United States. In fact, Belgium is below the OECD average

8. B. This is one area where the U.S. should be doing better.

9. B. False.  Denmark and Sweden, by the way, are above average.

10. A Germany, which has universal insurance.

11. B. False  While absolute costs are a significant issue, the rate of cost increases also keep politicians and regulators awake at night. The U.S. rate was a relatively tame 3.3%, behind Belgium, the Netherlands and the United Kingdom, all of where were above average.

12. Everybody sing....."O Canada, our home and native land....."

The levers that control health care costs

Ask an average voter how health insurers reduce costs and, thanks to years of hostile anti-insurer rhetoric, he or she will tell you that they "deny."  Think of it as "deny^2" for both the person (who is no longer insured) as well as the procedure (which is "not covered"). 

Sophisticated Disease Management Care Blog readers know better. "Deny" stories are mostly anecdotal and that kind of misbehavior is largely prohibited. 

If insurers want to save money, there are far smarter ways to do it.  The same is true for government sponsored insurance.

After reading this Health Affairs article, the DMCB discovered that Canada, France Germany and England are using those smarter ways.

And so is the United States government.

Hows that you ask?

While health care costs in other developed countries are lower than the United States, the contrarian DMCB has pointed out that todays costs are not all that important. A far more ominous trend is the rate of growth, a.k.a. "trend."  Year-after-year increases in health costs that outstrip GDP are far more threatening to governments fiscal health, especially when budgets are being strained by other priorities, like combating terrorism, keeping tax-dodging French movie stars from moving to Belgium and helping Mr. Bieber retrieve his pet monkey from Germany.

So what are Canada, France, Germany and England doing to control health care costs?  According to the DMCBs read of Mark Stabile and colleagues article, they are using three strategies:

1. Budget shifting: This involves individual beneficiary cost-sharing, as well as cost-shifting to private insurers and/or local governments. Ottawa, Paris, Berlin and London are also eliminating coverage of "low-value" services, devices or drugs. Yet, since backing away from universal coverage is out of the question, the central governments are also providing funding that protects low income individuals from otherwise unaffordable out-of-pocket costs.  While theyre at it, coverage for "high value" services such as hospice, immunizations, dementia care (Germany) and hypertension care (France) is being expanded.

2. Budget setting: While England and France use national caps (that are flexible and subject to adjustments), all four countries have a growing reliance on regional or local price fixing as well as capitated payment arrangements. Pay-for-performance is being substituted for otherwise routine budget increases and consumers are being given their their own fixed personal spending accounts.  This helps limit the likelihood of future budget increases. 

3. Direct controls of health care supply: examples of this include cutting the number of hospital beds, eliminating coverage of certain drugs, increasing the number of primary care providers, using health technology assessment and relying on practice guidelines.

If this sounds familiar, it should.  As the DMCB noted here, the Feds are reducing Medicares risk exposure by asking individual beneficiaries, providers and State governments to take on a greater share of health care costs.  Theyre also imposing budget controls by capitating providers with bundled payment and risk contracting arrangements. Last, but not least, theyre controlling the supply of health care services by, for example, increasing payments to incent the adoption of electronic records and increase the pool of primary care providers.

It turns out rising health care costs are a global problem with the same set of policy options.