The state of US health care

[snousle]

One of the most insidious propaganda campaigns going on right now - and a disturbingly effective one, too - is promoting the idea that single-payer systems in other countries have "failed" while the US is has the "best healthcare in the world". This is a plain, transparent lie, and because it's so easy to beat it into the ground, I am going to do so right now.

Measured by technical prowness, the US is almost certainly the best bet for those people that happen to have six-figure slush funds to put into their own health care through the private system. For that 99% of the country we have been hearing so much about lately, the ones that don't have that kind of spare change, the situation is a little different. There are so many sources to cite it's hard to list them all, but if you're a little on the nerdy/analytic side, a great place to start is the site gapminder.org, where you can configure your own charts, like this one, which tells pretty much the same story as any other source: the US has slightly worse health outcomes than most industrialized nations, but at about twice the price. Even as a percentage of GDP, the US spends about twice as much overall as comparable countries.

When it comes to subjective measures of patient satisfaction, the US also lags - see here and here, and for those of you who are worried about liberal media bias, here's something from Fox News saying the same thing.

What really shocked me was that the US already spends more in tax dollars alone than other countries:



That's from this article. Think about this for a bit. We already have a socialized medical system - one that is more socialized than other countries in the sense that it already consumes a slightly huger chunk of tax revenues than it does in, say, Canada or the UK. But to actually use it, we have to pay again. Either payment system alone should be enough to pay for decent medical care, but we have to pay twice.

That, I'm afraid, is "failure" on a grand scale. It is possibly the greatest waste of money in all history, and it is an outrage. And, as the article suggests, the right-wing take on this truly is denialism; there are no outcome- or satisfaction-based statistics I know of that contradict this picture, only heart-wrenching tales of grandma not getting her MRI when she wants it.

Let's be clear: running an effective health care system means saying "no" to a lot of people, and that is going to result in a whole lot of drama and dissatisfaction. The amount of money one could justify spending on health is literally unbounded, particularly as technology advances. If we can grow new hearts for a million dollars a pop, what elderly person wouldn't want one? Who wouldn't feel they have a right to one if it saves their life? It makes me clench my teeth whenever health care is framed as an entitlement; this path leads to ruin. Instead, it must be approached as a cost-benefit analysis, with the benefits measured in quality-adjusted life years (QALY).

There are a couple of ways to approach this. One is to say "no" in the easy cases, by shuffling them off to the side and hoping they die cheaply. Another is to say "no" in the hard cases, in dramatic situations that call for emotional demands for treatment, but where the treatments are unjustified because they don't provide the same QALY improvement as you'd get treating someone else. (In neither case do I oppose letting people pay out of pocket for procedures that the state doesn't cover.)

Unfortunately the US is caught in the reactionary, emotionally-driven mode, where preventative care is neglected and measurements of effectiveness are tossed out the window. The medical industry has capitalized on this and is quite good at the use of fear, self-dealing, and fantasy accounting to extract as much money as possible from patients. (I call it blackmail, and is a very good argument against letting private interests control medicine in the first place.) It is not clear if the political structure of the US even makes it possible to run a rational, evidence-based health care program. Obamacare might or might not be a step in the right direction.

BUT THE LIES HAVE TO STOP before there is any hope of progress.

This post is based on comments in a previous post.

Comments

[bitterlawngnome.livejournal.com]

the problem is not the availability of stats, it's that thing where people instinctively deny anything that contradicts their opinions

how does one circumvent that?

[snousle.livejournal.com]

One moves to a more favorable country? I don't know how to answer your question, I don't have solutions. Just observations.

agree!

[txkink.livejournal.com]

I agree with you on all of this and that graph is an eye-opener. The health care industry is so mucked up right now and many of the lies/half-truths continues to perpetuate.
Here’s a few of my observations working as a boots-on-the-ground doc in a public hospital:

- Health care has truly become a profit driven industry – not a “need” that is then met with a service, but a “create the need” mind set. Even in my public hospital there are administrators who talk of “we can bill for this so let’s provide the service”. One of the private hospitals built a small free-standing day surgery hospital near one of the major highways recently – was that because there was such a great need for day surgery centers in the city? No, it’s because surgical procedures are the easiest to bill for and day surgery means less overhead since no one stays in house. If there were patients needing day surgery and the dozens of surgery centers in town were not able to meet it then yes, build another, but the thought seems to be less of need and more of “can we bill”? Whenever we speak of needs at one of our hospital, the first question is always, Can you bill for it? and if so, how much?

- Which brings me to the second point; there are too many administrators and not enough health care providers. The bureaucracy is astounding and contributes nothing to patient care. Another factor is that most of these administrators are either newly minted college graduates who have never cared for a patient (and never will) or are nurses who haven’t touched a patient in 20 years. They write regs that sound good on paper but are never practical and carry such penalties for lack of compliance that it becomes more about following the letter of the regs and not about actual better care. For instance, one of the more recent “patient safety goals” put out annually is fall prevention. Sounds good on paper, but what it means is that so many hospitals fear the bad outcome of a patient who falls that they will not admit them to their units meaning that the patient must wait for hours in the ER while another hospital is found to take them.

- Final thought – the focus on the industry aspect of health care means you get people with no actual vocation to take care of people (some docs and nurses but especially technicians). I’ve seen this first hand – here we have TV commercials for these quickie schools that can get you trained to work “in the exciting health care industry.” While not the majority, I have been struck by the number of these graduates who have little sense of actually caring for patients and look on it as “just a job”. I think this leads to reduced overall care and the patients are able to tell as well.

I don’t know the answers but I know that the business side of all this has truly burdened the provision of care and where there’s money involved politicians are not far behind. The fear mongering is reprehensible as is the idea of using health care as a means to profit at the expense of good patient care.

Re: agree!

[snousle.livejournal.com]

Thanks for the observations!

Re: agree!

[h0gwash.livejournal.com]

I am currently finishing up a pharmacy technician certificate at a public school (which has recently lost its public funding thus doubling student costs) and I would have to say you are correct. While it is still a fascinating material to learn, I began the course with an understanding of the inefficiencies of our third party billing system but I simply saw it as a lot of gravy that maybe I could get a bit of. I continue to hope that the medical industry bubble won't burst until I've paid off my house in 6 years. (or at least until I get a job fetching drugs)

[danthered.livejournal.com]

Thundrous applause. Another effective lie that must stop is the hideously tortured American criticism of the Canadian health care system based on conflation of the Canadian administrative structure and the size and distribution of the Canadian market. Canada's a giant land mass with a small population, over 90% of whom live within 200km of the vastly more populous American market. That, I believe, is the primary reason why Canadians travel to the States for an MRI or whatever which other test that requires special equipment; outside of Toronto, Vancouver, Montreal and Calgary the sparse population makes amortising special equipment impossible compared to just getting in the car and going to the States for the test. I think this would be the case even if Canada's system were "No cash, no credit card, no health care" and the States had a Cuban- or British-style system.

[snousle.livejournal.com]

I was not aware of the geographic argument for cross-border MRIs. Another factor is that high tech imaging is emotionally charged, and people feel they "need" it in cases where it is demonstrably not effective. It can actually lead to worse health outcomes through overdiagnosis. You'd actually expect more MRI tourism from a well-managed system than from one that discarded evidence in favor of popular demand.

Of course, lots of Americans travel overseas for care as well, although numbers are hard to come by.

[bluebear2.livejournal.com]

An American friend of mine is going to Scandinavia for a procedure that the U.S. system isn't innovative enough to provide yet.

One moves to a more favorable country?

[ursine1.livejournal.com]

That's what I did, but healthcare wasn't my motivation for doing so.

In summary, I emigrated to Spain at the beginning of 2005. Spain has both public and private healthcare available. As a legal resident, I am entitled to use the public system, but I have private insurance. I pay about 200 € a month for both medical and dental and it even covers me when visiting the US. I do have co-pays, but no annual minimum. Doctor visits are 3 €, lab analysis (e.g. blood and urine) 4 €, a CT-scan 12 €.

Apparently drugs are subsidized as I pay 2.72 € for 50 tablets of 850 mg of metformin made by Merck (not generic). Pharmacies are less controlled (as my doctor explained to me) than in the US. When I go to my local private pharmacy 10 m from my home, I just hand them my old box of tablets and they bring out a new one. I don't have to show a prescription. If I want something that they don't have in stock, I go in the morning and they will have it for me that afternoon. When I bought my glucose measuring device (made by Bayer), the pharmacist took it out of the box and used it on me to show it works. I never have had that kind of service in the US.

Many doctors here work for both the public and private systems. Individual practices are rare, most share offices in a clinic setting. The medical center I go to has a number of doctors many of whom seem older and are bearded (but not "crusty" enough to appeal to Tony.) They also have a person who collects samples for analysis and likewise someone who does ultra-sound scans.

Another difference is that I, being the patient, always get the lab results and give them to the doctor.

My doctor and I have had several general discussion about the difference in approach of healthcare between the US and here. He thinks that in the US there is too much emphasis on tests and numbers and not enough on looking at the "whole person."

I would agree with txkink that "Health care has truly become a profit driven industry – not a “need” that is then met with a service, but a “create the need” mind set." And that "there are too many administrators and not enough health care providers." An example is that there is no "billing department" at the medical clinic I use. They do have a sign that says you have to pay 20 € if you don't bring your evidence of insurance with you. (They refund the amount when you come back and show the card.)

[equinas.livejournal.com]

I just can't understand why, as someone who treasures objective research, you are completely missing the statistics and studies for the real reason why our health care is so expensive.

I can't pull things up for you right now because of my limited connectivity, but give me two weeks and I will show you why the root of the problem is not the payer system, but the cost of malpractice insurance on health providers. While you're researching, you might compare the cost providers have to pay to protect themselves in the U.S. to those in the "higher rated" countries. The malpractice insurance industry has justified their exorbitant costs ($75,000/year for a GP, $250,000/year for an OB/Gyn) with stories of "jackpot lawsuits" that get a lot of press but in actuality are very rare. We need tort reform and malpractice insurance reform urgently, and legislation requiring providers to lower their costs to reflect this (because they tried it in Texas and the docs kept the savings). Then you'll see the cost of health care drop dramatically, and with it, the cost of health coverage for the average Joe.

[snousle.livejournal.com]

I am aware of the issue, and while it's not a small figure in total dollars, the largest estimate I have ever seen for the total cost of malpractice insurance and claims is 2% of medical spending. I find it hard to believe, even if this is a lowball figure, that it could be primarily responsible for the high cost of American medical care. I look forward to seeing your sources.

[snousle.livejournal.com]

The values you quote for malpractice premiums appear to be derived from the most expensive parts of the most expensive states - in the case of ob/gyn, that would be Dade County, FL, where the premiums are typically $200K. These are not reflective of overall costs, which are much lower in other states.

An interesting report, because it's from a group that generally promotes tort reform, concludes that "medical malpractice claims and premiums have almost no impact on the cost of health care. Medical malpractice premiums are less than one-half of one percent of overall health care costs, and medical malpractice claims are a mere one-fifth of one percent of health care costs." These people have an agenda of their own that might influence their take on it but given their goals I would expect their bias to go the other way; even allowing for great exaggeration it's still orders of magnitude away from explaining the 2x greater cost of medical care in the US.

Another report from NBER address the question of whether rising malpractice premiums affect the type of care delivered, possibly making it more expensive due to unnecessary tests. Cross-state comparisons say "not much".

Time had a fairly good article listing numerous reasons for high health care costs; malpractice is listed as a factor, which it is, but one of many.

[equinas.livejournal.com]

No, you're right, the direct premium cost has a lot less of an impact than what I thought. But the defensive medicine practiced in order to avoid malpractice lawsuits is getting a lot of the blame, even according to the study you cited, so I think the concept of malpractice and tort reform still has merit.

I really like that Time article, I think it sums it up nicely.

Don't get me wrong, btw. I could support a single-payer system if we could just do it right. Incorporating all the changes suggested in that article, and eliminating the incentives that hospitals (not so much physicians) have for keeping people as repeat customers.

Having said that, however, the danger lies in the budget incentives inherent in the public sector. For example, if a private company comes in under budget for a given year, they are rewarded with bonuses (typically). If a public agency comes doesn't use their entire budget, what happens? Their budget is reduced for the next year. So public agencies are incentivized to exceed their budgets so they get a bigger one next year. A reward for going over-budget. Until that kind of nonsense is stopped, I can't see a public health care system ever working in our country (even if we could get the people to agree to the necessary tax hike).

But good catch on the malpractice premium effect on health care costs...I stand corrected on that.

[bluebear2.livejournal.com]

Oh, I, and many others, just assume the the U.S. is going down sometime in the future. The path they're on is so messed up that it might not be possible to get it going in another direction before it just goes bankrupt.
In the meantime other countries where their people work together and aren't subjected to fear tactics are quietly doing well.

[barbarian-rat.livejournal.com]

What I found interesting in the graph was that all the countries listed from Canada through NZ the per capita spending was about 3K, but they all have different mixes of private/public/ individual spending, and assumedly different rules about what they cover and do not cover.