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!

Our health system: Not equitable, not effective, and not even efficient. Bad business!

Over a year ago, deep in the pandemic, a close friend felt she had a bladder infection. She went to the local Urgent Care (run by the large hospital system that also runs our University Medical Center) to be sure; they did a test on her urine, verified it was a bladder infection, and gave her a prescription for an antibiotic. It got better.

Not long ago she began getting dunning notices for the bill for this visit. She was surprised, as her primary insurer (Medicare) and her Medicare Supplement policy should have covered it all. Hours on the phone, with the health system and insurers, she determined it was because the system had not submitted the bill on time. Note that they have a year to submit a bill to Medicare. She talked it out, and thought that it was resolved. More recently, she received another dunning notice, followed by more phone calls. The billing department did not have her insurance information on file. She was surprised, she noted, as the Urgent Care clinic had taken photocopies. “Oh,” she was told, “that’s the clinic. We’re the billing department. We don’t have access to those.” Wait, you’re the billing department for the Urgent Care, but you don’t have access to the photocopies of the insurance cards that they took solely for the purpose of billing? What kind of an operation are you running here?

Sadly, and perhaps surprisingly, an operation of health care in the US, and perhaps business in the US altogether. Not efficient, not effective, poorly designed, and, of course, set up to make the victim – in this case the patient or the client – take the blame. Spoiler alert: It is their fault, not yours!

Every few years the Commonwealth Fund assesses the performance of health systems in 11 high income countries around the world. Since 2014 it has been called “Mirror, Mirror on the Wall”, and each time it comes out the US ranks last in overall performance, and also last or near last in most sub-areas (Healthy Lives, Quality,  Access,  Efficiency, Equity). It is worth looking over the whole report from 2021, but I am going to focus on Efficiency. When I first looked at the 2006 and 2008 reports (then called “Dimensions of a High-Performance Health System”) I was a bit surprised that the US’ worst score was on efficiency. Access, yes, I could understand. Equity, yes, of course not. Even Quality, depressed as it would be by the lack of access and equity. But efficiency? I thought of the waste that came from so many private systems which had (especially in those days before Electronic Health Records,  EHRs) so ability to share information. So you got a lab test or x-ray at one place, maybe an ER, but the next place couldn’t access it, so they did it again. Inefficient, and costly. And not good for you.

 

So did it get better with EHRs? Well, not per the 2014 report, in which the US ranks 11 out of 11 in Efficiency (as well as in Equity and Overall). Maybe it takes time, but the 2021 report shows that the US is – still dead last, now presented with 3-digit scores rather than simple ranking. Even though our health system’s corporations are, as I have often said, about making money for themselves rather than taking care of your health, their business systems are poorly designed, inefficient, and cause you no end of grief even if you are insured and not too sick. Of course, woe to you if you are uninsured and very ill! THEN you really suffer!

 

 

I once sat on the Billing Steering Committee of a large practice plan, and one of the issues that kept coming up was people not paying their bills. As a patient there, I suggested that it was hard when you got a bill for, say, your doctor visit, paid it, and then a few days later got the bill for the lab test or x-ray or something else. Since one of the purposes of creating the practice plan was to have a unified bill, I asked why they didn’t send out a monthly bill, so people could pay everything at one time. We do, they said, but only after we send out the individual ones. Gee, I noted, one monthly bill works for credit card companies. Can you imagine if you got individual bills all month for all your MasterCard or VISA charges that indicated that you had to pay them then, rather than one monthly bill? T What, I thought, if you got a bill today for a lunch you had 3 days ago, and tomorrow for the shirt you bought last week, and a few days later for the vacuum cleaner you’d ordered? And each indicated you were to pay it today? What would be the point of a credit card? What is the point of integrated practice billing? he concept of not sending out each individual bill was not only foreign to them, but incomprehensible.

They remained unconvinced, and it was dropped. The reason that they remained unconvinced is it wasn’t how they did things. And management of health systems (and, to a large extent, US business) is doing things how they do things. And congratulating themselves on how well they do. And rewarding  themselves handsomely for it. And blaming someone else (usually the client or patient) when it doesn’t work. They are wrong, they are fooling themselves, the data is in, but they persist. Because they have the power.

After World War II, a statistician named W. Edwards Deming developed systems for enhancing quality in business and manufacturing, a data-driven approach that became known as Continuous Quality Improvement, CQI (there are a number of good books by and about Deming and his methods, some very easy to read). It caught fire in a Japan trying to rebuild after the war, but was ignored in the US because, in the 1950s and early 1960s, US businesses were doing great. The reason, of course, was that the manufacturing capability of every other developed country had been decimated by the war, so US business had essentially no competition. It could have been run by monkeys and would have done well. But the monkey-impersonators who were actually running it convinced themselves that it was because they were so good! Then, of course, by the late 1960s Japan and Germany were outperforming the US in terms of quality, and profit. US industry was still not that concerned about quality, but they did want profit, and many CQI models were adopted (famously at Ford, but also at other large companies).

But progress, as those who study history or at least are old enough to have lived through a fair portion of it know, is not linear. Traditional bad practices are hard to erase, and without continuous reinforcement of better ones continue to recur. Especially difficult to control are those which can be (and are) interpreted by the management (who like to call themselves “leaders” though that is rarely what they are) as showing how good and smart (and deserving of high pay) they are. So, they do recur. These attitudes, that things are best when Wise Managers are in charge, has permeated not only for-profit business but even non-profits and membership organization, not always to the good. In “Good to Great for the Social Sector” business guru Jim Collins has observed that while non-profits are often urged to operate “like a business”, since most businesses are poorly run and operate poorly this is not always a good idea!

Very recently I learned of a health system which contracted for the services of a doctor from a government agency. Since the doctor was not their employee, the system couldn’t bill for the doctor’s services. So, they assigned a nurse practitioner who was their employee to accompany the doctor and bill under the NP and health system’s name. Except the doctor worried that this would be Medicare fraud, and consulted the attorneys for their actual employer, who agreed. This surprised the health system; they worked – as almost all of them do – under the assumption that the whole thing is a game, to maximize their income and profit. Heck, they upcode all the time to get more money from Medicare and other insurers!

So, what is the upshot? Health systems (and US businesses in general) have a total focus on making money, even when they are pretty inefficient at it. This sometimes clouds their attention to obeying the law. It certainly is more important than the quality of your care, or your financial health. As always, while it affects everyone, the most disadvantaged – the poorest, worst insured, least educated, and least empowered suffer the most. So what can we do?

For starters, we need a universal health insurance system, like improved an enhanced Medicare for All (HR 1976 this year). This will not by itself bring us up to par with the other nations, but it is a necessary start.