Saturday, June 26, 2010

Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost

On December 5, 2008, I commented on the data from the 2008 Commonwealth Fund report comparing health status in a number of countries (Not Getting What We Pay For). The US fared very poorly on that study. The Commonwealth Fund has just released its 2010 study “Mirror, Mirror on the Wall” (Commonwealth Fund executive summary, Commonwealth Fund full report) and the news is no better. In comparing 7 industrialized countries (Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States), the US is #1 in health expenditures per capita at $7,290, 87% higher than second-place Canada, over twice that of the average of the other 6 ($3354) and nearly 2.5 times as much as the UK. [“Expenditures shown in $US PPP (purchasing power parity)”.].

Distressingly, but unsurprisingly to those who pay any attention to the area, including having read this blog or having seen the 2006 or 2008 Commonwealth Fund reports, this expenditure does not lead to good performance on the study’s measures of Quality Care (comprised of Effective Care, Safe Care, Coordinated Care, and Patient-Centered Care), Access (comprised of Cost-related Problems and Timeliness of Care), Efficiency, and Equity, nor on the all-important health outcome “Long, Healthy, Productive Lives”. In fact, the US ranks last -- # 7 – on that outcome indicator. And while there is not one country that leads in all the categories – Australia, for example, ranks #3 overall, but is #1 in “Long, Healthy, Productive Lives”, and is tied with the US for last in “Access”; the UK, while #6 on “Long, Healthy, Productive Lives”, is #2 overall (behind the Netherlands) despite spending the 2nd lowest amount (to New Zealand’s lowest) per capita, and ranks #1 or #2 on 6 of 10 criteria, and #7 on only Patient-centered care.

The US ranks very poorly, as it did in 2008, on Efficiency, which is interesting. We can more easily understand low rankings in Access and Equity, given our completely inequitable system of funding and access, but poor Efficiency scores reflect our poor communication, with tests often being repeated because information is not carried forward, patients being readmitted, and a variety of other characteristics. There are 8 subcategories comprising Efficiency, and the US ranks #6 on 4 and #7 on 4 (and for the whole category).

Of course, this kind of report doesn’t seem to affect policy makers too much. We already knew this, and the health reform process was in part an attempt to address it, but the current bill, PPACA, certainly doesn’t do enough. Some of the additional funding that is targeted to public health will make a difference, but it is clear from the debate in Congress that there are many who simply do not support improving the health of the American people if doing so will require cuts to the profits of the big healthcare industries who contribute large sums to them.

Some critics of the Commonwealth Fund report, such as Dr. Richard Cooper of the University of Pennsylvania, have stated that the problem in the US is not that that we have a health system which is overbuilt on the high-tech, high-cost specialty end rather than on primary care, but rather that we have more poor people; he provides evidence that, on a large regional basis, areas of the country with more poor people (e.g., the Southeast) have worse health status than those with fewer poor people (e.g., the upper Midwest). There can be no doubt that poor health status is tied to low socioeconomic status, and that the large number of poor in the US is in significant part responsible for the poor health system performance identified by the Commonwealth report and others. However, as I and many others have pointed out in the past (Public Health and Changing People's Minds, May 15,2010; Poverty, Primary Care and the Cost of Medical Care, Feb 18, 2010; Health is more than Medical Care, Jan 27, 2010), health is not simply a result of the health care, or medical care, system. The other countries measured in the Commonwealth Fund report do not have a lower percentage of poor people by chance or luck; they are, to greater or lesser extents, social democracies with policies that ensure that their people have housing, food, and education. There are poor people in those countries, but their most basic needs are ensured and this goes a very long way to decreasing their health risk. Public health, medical professionals and others in those countries are well aware – expert in – the social and socioeconomic needs of the poor in their societies, but the situation of those people, is significantly improved, to a much greater degree than in the US by a much more extensive safety net.

Poverty is bad for your health, and programs that help ameliorate the impact of poverty improve the health of populations. In addition, the presence of adequate health care services, especially primary care services, further enhances outcomes. It is not an either/or choice. Shi and colleagues demonstrated that the increased infant mortality and low birthweight rates in poor communities are virtually eliminated by a higher primary care presence.[1]

The data provided by the Commonwealth Fund should be embarrassing to every policy maker, every person of influence, and every citizen of the US. It is incontrovertible data that demonstrates yet once again that the issue is not that we aren’t spending enough money, but is the way that the money is spent: We spend it in ways that make our health status poor and our health corporations wealthy. There should be no tension between increasing primary care, increasing public health and prevention, and providing the core needs of people for food, housing, education, and work. They are all components of a society that is not only basically decent, but which is concerned about its future, the health of its people, and its workforce. What we clearly do not need, however, is to continue to spend money in the way that we are on high-tech subspecialty care that benefits few patients and often not for very long. Indeed we need to spend much less, and use the money where it will have a positive impact.

Maybe by 2012 the Commonwealth Fund will show the US making some progress. I hope so, but it is going to take some serious structural changes.

[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380.

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