Once again, the US trails rich countries in health care -- except in cost! Why do we tolerate it?

Sometimes the news is good, sometimes it is bad (too much of the latter!!). Sometimes it is surprising, and sometimes it is not. Often it is more of the same, and sometimes this is surprising because we had thought or hoped that it had changed, preferably for the better, and sometimes it is not surprising because we knew it had not.

A good example of this is international health rankings, in which the US consistently and continually ranks at the bottom of the wealthy nations and has a health status that is in the middle of what are known as “middle income countries”. These are called middle-income because they are better off than the really poor countries, but compared to the US and similar countries, they are poor.  In 2000, the World Health Organization (WHO) published a ranking of health system performance in their member nations, based on 1997 data, in which the US ranked #37 in the world, between Costa Rica and Slovenia, on overall performance. When many were aghast that the US could be like Slovenia, the prime minister of that nation took offense and pointed out that his country had been making significant advances. In the area of Disability Adjusted Life Expectancy (DALE) the US in fact ranked #72! I had reproduced these tables in  US Health Rankings remain low and #Trumpcare will make them worse!, June 18, 2017, and do so again now.

Of course, 1997 is a long time ago. Maybe, since then, we, like Slovenia, have gotten better. Except we haven’t. This is the sadly non-surprising part of the news.

While the WHO has not redone that 2000 survey, in 2017 Bloomberg published its Global Health Index, and, as I said then,

Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!

For an ongoing comparison, the Commonwealth Fund publishes a report every few years called “Mirror, Mirror on the Wall” comparing US health outcomes and cost to other high-income countries. I have cited it, in its various editions, on many occasions (Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost, June 26, 2010, ACA: Where are we? And where should we go?, July 27, 2014, US Health Rankings remain low and #Trumpcare will make them worse!, June 18, 2017, Our health system: Not equitable, not effective, and not even efficient. Bad business!, March 24, 2022), and address it in detail in my 2015 book “Health, Medicine and Justice: Designing a fair and equitable health system” (Copernicus). The relative performance and ranking of the other countries varies a bit over the years, but the position of the US at the bottom of the heap, #1 only (and consistently) in cost, and worst in performance, is unchanging. The most recent report, “Mirror, Mirror 2024: A portrait of a failing US health system” has just come out, and the title provides the answer: not good. Not better. Failing. And, probably, failing worse. The study’s conclusion, in the Summary, is:

The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.

Here is the table of rankings:

And, if you prefer a visual portrayal about how much worse the US health system is performing:

But we do lead in spending:

And, logically, trail the pack by a lot in value for dollar spent:

This is the non-surprising non-news. But, while not surprising, it should be very concerning. It’s not getting better, and there is little reason to think that it will, if past performance is a predictor of future performance. And we’re talking more than two decades of consistent past performance. It is not a question of what the fact are, of what is true, no longer if it ever was. The US health system performs terribly as a health (or even medical care) system. Costs are enormously high, outcomes are consistently poor, and we dramatically underperform every other country that has in any way comparable resources (and many, many with far fewer resources). It is incredibly inequitable. See, for example, some of the countries grouped around the US in the 2017 Bloomberg rankings, such as Qatar, Brunei, and Bahrain – countries with money and inequitable distribution. So, the question is why are we not doing anything about it?

The answer simply requires a little re-framing of the data presented above. I, and likely you, see the incredible cost/performance ratio as a negative, something to be addressed and fixed. But all that money that is being spent is going somewhere, and certainly a large amount of it is not going to provide high-quality healthcare. It is going to profits for insurance companies and pharmaceutical companies and the Wall St. investors that own them, and for enormous salaries for the C-suite executives who run them, as well as those in the ostensibly non-profit sector (see Why many nonprofit (wink, wink) hospitals are rolling in money by Elisabeth Rosenthal (Washington Post, July 29, 2024). For them the current system is working very well, thank you, they are getting very rich. Your problem, and mine, is that we think that this system should be about providing high-quality and cost-effective care for the American people, at which it is obviously failing. But if we understand it as a cash-cow for these corporations, as a method for transferring money from the rest of the economy to them, it is working great. And, because it is working so well and they are making so much money and spending a great deal of it contributing to politicians, it is unlikely to change.

Unless YOU make it change.  There is, and has been for decades, a loud and effective rant from the corporations and individuals profiting from your health care dollars and their employees (or shall we say “beneficiaries of their largess”) in the legislative, think tank, and punditry arenas, that the Democratic party, and particularly its progressive wing, are radical socialists who are anti-American. This has been very successful. See above, we have kept to the unique American way of doing things. The one that takes money from you in premiums, co-pays, and deductibles and provides you with poor outcomes. That every other wealthy capitalist country has found a way of delivering higher quality for less money is the evidence that it is possible and will not destroy the country. But it will destroy the conveyor belt that takes your money and puts it into their pockets, and this is a terrifying thought, so that they will do anything to prevent it.

Their tactics include both painting mainstream Democrats who merely want to tinker around the edges of the system as flaming radicals, and funding organizations such as the Heritage Foundation to come up with truly radical proposals like Project 2025 (pdf of the health section here) that would institutionalize the worst, most anti-human practices going on today. The strategy is that if they can get half the country to support politicians who support those policies (whether those voters actually support those policies or not), it moves the center of the discussion to the “right” and means compromise will be much less threatening to them. But much more threatening to you.

People want good healthcare for themselves, for their families, and for their friends. They don’t want to pay ever-more for health insurance only to have the insurers deny their care, often as a matter of routine, when they need it. They deserve, as do the people of other countries, a health system that is intrinsically structured to provide the best possible health care for our people and not to make money for Wall St., big corporations, insurance companies and health systems. We know it can be done as it has been done everywhere else.

Make it the thing you vote for and let your representatives know it; you want health care, as the old saying goes, for people and not for profit!

Continuity of care? Hospitalists? Who calls the family?: Corporate control makes health care worse.

I was recently talking with a friend who was still (justifiably, IMO) furious at her local hospital. Last year her husband, 90, was admitted for an attack of diverticulitis. While hospitalized, he suffered a heart attack on a Sunday morning and was transferred to the Intensive Care Unit. The treatment was fine – indeed now, at 91, he is quite improved – but her complaint was that no one called to tell her! She found out when she went to visit him in the hospital that afternoon. I am sure that virtually any adult presented with this scenario would say “of course, as soon as possible, call the family!” Can you imagine that they didn’t?

Sadly, I can. It reflects a lot of issues in the medical care system. One that my friend identified was the hospitalist system, where the doctor who is responsible for the care of a person in the hospital is not their regular physician, but someone employed by the hospital (usually an internist or sometimes a family doctor). In itself this can be an issue, which I will discuss below, but the bigger problem she identified was the frequent change in who this responsible physician was, different on the weekends, and at night, and almost impossible for her to get to know. Indeed, she was not certain if the doctor she talked to later that day, the one who told her, not apologetically, that they were “trying to figure out what to do with him” (as if this was an excuse for not calling the wife of an 90-year-old patient to tell her that he had a heart attack) was the actual hospitalist or a resident working with them. If you don’t know the attending physician du jour, or even know who they are, it is hard to be sure. I might add that my friend is a highly educated and well-insured person. When they suffer such indignities, and they do, it is certainly far worse and more frequent for people who are not.

Why would doctors not want to call the family of a person in the hospital, especially but not only if they are old and frail and suffer a particular acute life-threatening event, as soon as possible? Is it imaginable that they do not? Why would they not want – insist upon – the family knowing who the responsible physician is? Do they just want to be anonymous, not to be bothered?

Maybe, sometimes, but I do not think that this is the primary reason. Think about it. You are the “hospitalist”, a hospital-based physician tasked with responsibility for the care of lots of people (“patients”) who you didn’t know before they were admitted. On top of that, you are not the weekday hospitalist, but the one covering for them on the weekend, a weekendist if you prefer (I sure don’t!). Maybe you are even the nocturnist, the night-time hospitalist. In any case, you have a list of patients to see, and to get to know, and maybe you come into the hospital in the morning to see them all (which, of course, has to be one at a time, someone first, someone last) when all of a sudden you hear from the nurses that one of them has had a heart attack. Maybe someone you have seen already, maybe not, maybe it is the afternoon, and you have already left the hospital. You tell them, the nurses and the residents working with you, to begin their well-practiced routine of treating an acute myocardial infarction (MI, heart attack) and give other instructions, including to call cardiology, and tell them to call you back. Do you specifically instruct them to call the family? Do you think that would be obvious to them? Does it even occur to you? Is it someone else’s job? Whose?

In the “old days”, when someone’s family doctor took care of them even when they entered the hospital, it was almost certain the family would be called. The doctor knew the person, often had been seeing them for years, and knew the family. They knew, of course, that the family would want to know, and felt it to be their responsibility to inform them. This changed with the creation of hospitalists as a separate specialty, and has accelerated with the corporate takeover of medical care and the dramatic increase in physicians as employees of corporations (most often hospitals, sometimes physician-owned groups, sometimes for-profit, often owned by private equity). Different physician roles have been identified, such as caring for people in the office (and very rarely at home), in the hospital, in nursing homes. While these roles had always existed, often the same doctor filled the different roles for their patients; now different doctors would. The delivery system, which had been patient-focused (“I’m your doctor and take care of you wherever you need care”) became provider-focused (“We, as the providers of care, will develop a system that works efficiently for us; unfortunately for you, that means you will not have the same doctor all the time”).

Actually, there were many good reasons for this change. It is not easy, was never easy, to be a “full-spectrum” family doctor, to see people in the office both with appointments and as walk-ins, to do home visits for those who were ill and found it difficult (from age or disease) to get to the office, to see people in nursing homes and in the emergency room, and make “rounds” on and care for your patients in the hospital. And, often, get up in the middle of the night to deliver a baby. It was tough on the doctor, and tough on their families, as many books and films have depicted. In addition, these family doctors had (and have) much lower incomes than most specialists, including those who do shift work where they know exactly which hours they will work. Plus, as more and more things could be cared for in an outpatient setting (we will leave, for now, whether this was always a good idea), the people admitted to the hospital were sicker and often required more specialized knowledge that a physician who focused only on hospital medicine could better stay up on.

But there were also bad reasons, many of them stemming from the movement of physicians from self-employed to employees, increasingly working for hospitals and even for corporations that had no health professionals in charge. This corporate model, based on the industrial concept called “scientific management” or “Taylorism”, focused on increasing efficiency as the most effective way to generate maximum profit. It is more efficient to have some doctors who stay in the hospital all the time and some doctors who care for people in the outpatient setting (“ambulists”, another term that fortunately hasn’t caught on), and others who care for people in nursing home or even in their own homes. This not only reduces travel time, but allows more people to be scheduled (“speed up”) and provides the basis for further increasing the number of patients seen and concomitantly decreasing the time spent with each (see "Direct primary care" not the answer for our health system. Beware "Project 2025"!, July 9, 2024),

The problem is that this is not always the best for the patient. Yes, it is good to have people who are expert and current on the care of people in the hospital (“inpatients”) to take care of you, just as, when you need one, it is good to have experts in an organ (cardiologists, nephrologists, pulmonologists, etc., and various types of surgeons if you need surgery). But it is also good if the person taking care of you knows something about who you are, or at least your medical history. If they have never seen you before you show up in the hospital, they have nothing to compare your current situation with: are you worse? A lot worse? Better? About the same? And, by the way, if someone actually knows you – your family would almost certainly get a call!

Is it possible to have most of the good with little of the bad? The continuity (sometimes called “primary care”) clinician – family doc, internist, pediatrician, family or adult or pediatric NP – can delegate the key medical decisions to hospital experts but stay as the leader of the team. The leader, not the pain-in-the-neck “local doctor”. The professional who can fill their role as the one who cares for the whole person, not as the subspecialist for only one disease or organ. The one who cared for the patient before admission and will continue to do so afterward, not as the hospitalist for whom the patient was essentially born the day of admission and will disappear the day of discharge. Someone who can provide context and understanding and, believe it or not, continuity!

Of course, we’d need more primary care clinicians, not fewer as is the current direction in which we have been and continue to be heading (Incredible (Terrible) Shrinking Physician Supply, Health Justice Monitor, Sept 7, 2024). This would decrease efficiency, perhaps, but increase effectiveness. And while it might cost more money (thus lower profits for the corporations) it might actually save money for the overall system by having historical memory of the person when they go from home to hospital to home, and not change almost daily each time a new doctor is in charge.

Worth thinking about!

Pro tip: If you have to be admitted to the hospital, or have a heart attack, try to do it on Monday, or at least Tuesday. Do not wait for the weekend!