Saturday, November 05, 2005

The US Gets Less Bang for its Buck: The Health Affairs Six-Country Survey

A survey in Health Affairs of the experiences of sick patients in six countries (Australia, Canada, Germany, New Zealand, the UK, and the US) raises some important issues, especially here in the US. (The article is currently only available on the web here. Its citation is: Schoen C et al. Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Affairs 2005.)
The first issue is how the US performance compared with that of the five other countries on a variety of measures.
The US was best or next to the best of all the countries at: diabetes process of care, hypertension process of care, waiting times to see specialists, and waiting times for elective surgery.
The US was worst or next to worst at: medical errors, providing patients with regular doctors, waiting for appointments with regular doctors, providing care after hours, access problems due to cost, and out of pocket expenses.
As reported by the Washington Post , Dr. Carolyn Clancy, Director of the US Agency for Healthcare Quality and Research (AHRQ), commented, "The findings here reinforce how difficult it is coordinating care .... That's the next frontier."
What Dr. Clancy seems to have been implying, in her understated way, was that these results show that the US had difficulty providing continuous, comprehensive, and coordinated care, the sort of care which is generally provided by primary care and generalist physicians.
Thus this pattern corresponds to the US priority on specialized, high-technology, invasive care, while primary care/ generalist care has been taken for granted. Furthermore, as US costs have continued to rise, most of the pressure to cut costs has been applied to primary/ generalist care. As a consequence, primary care and generalist physicians must put up with reimbursement that barely keeps up with inflation, while the costs of running a practice rise much faster; with growing mounds of paperwork and bureaucratic intrusions, while, like Rodney Dangerfield, they get no respect. (See our previous posts on the worsening plight of primary care, for example, here, and our wooden-headed system of reimbursement, here.)
An even more striking issue is the contrast between how much the US spends and the performance of its health care system compared to that other countries. The US spends far more on the health care than the other countries, surveyed, 14.6% of gross domestic product versus 10.9% for Germany, the next biggest spender. Yet, as noted above the US was more often at the bottom than the top of the survey ratings. Thus, the US gets the least bang for the buck of any of the six countries. So, as the Washington Post reported, the first author of the Health Affairs study said, "What's striking is that we clearly are a world leader in how much we spend on health care. We should be expecting to be the best. Clearly, we should be doing better."
No hypothesis to explain this contrast appeared in the Health Affairs article, or in the comments of the experts quoted by the Wahington Post.
At best, the Post quoted Lucian Leape, of the Harvard School of Public Health, opined, "This provides confirming evidence for what more and more health policy thinkers have been saying. The American health care system is quietly imploding, and it's about time we did something about it." Why the system is imploding, and what should be done about it were apparently left unsaid.
I submit that the missing link here are some perennial topics on Health Care Renewal: the domination of health care by large, increasingly bureaucratic organizations, lead too often by the ill-informed, the conflicted, and at times the frankly corrupt.
What else explains how we can spend more than other countries, yet get less access, impose higher costs on patients, and provide by most measures, poorer quality care?
This really is something for those health policy thinkers to think about.

1 comment:

Dr. Bob Rauner said...

Why is the system imploding and why are we losing primary care physicians? I think we can take a lesson from what happened to the vaccine industry. The government via Medicare & Medicaid set the price for vaccinations. The price left little room for profit margins so companies left the vaccine industry or quit investing in new technology. Thus we are left with the antiquated industry that has failed to produce adequate amounts of flu vaccine in 3 of the past 5 years and has little or no ability to respond to a potential avian flu epidemic.

Likewise they have set the reimbursement for primary care services at a level that barely covers overhead. At the same time that they pass laws to increase our overhead (e.g., HIPAA rules), reimbursement is either lagging behinding the growth of our overhead or even decreasing each year.

Medical students and residents can see the writing on the wall. A recent article showed that only 19% of residents now in Internal Medicine plan on practicing General Internal Medicine. With this year's cut in Medicare reimbursement for physician visits, expect this to get even worse. This will leave Family Physicians as the only group left to provide primary care for Grandma & Grandpa. But this specialty is also in decline. 10 years ago approximately 2400 US grads went into Family Medicine. Now it is closer to 1300.

Will the CMS wake up to this problem before it drives primary care physicians to the point of extinction? They drive reimbursements for a large portion of E&M visits and they can reverse this by paying less for procedures and more for primary care visits. It seems as though noone in government cares or is paying attention, despite the recent studies showing decreased costs and mortality when there are more primary care physicians and fewer specialists. When will the government get a clue?!?!