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!

We need more primary care to serve our people: Why do the medical schools lie? (reposted from April 5, 2021)

I recently re-read this blog post from 2-1/2 years ago, and decided that it was still important as well as relevant and accurate. So, in a "first" I am reposting it, since some folks may have missed it:

Every year the nation’s medical schools graduate thousands of people with MD and DO degrees. But this is just the start of becoming a practicing physician; they now need to complete residency programs in a specialty area, ranging from 3 to as many as 8 years, to become family physicians, surgeons, radiologists, dermatologists, orthopedists, etc. Indeed, for many physicians this “postgraduate” training (meaning post-medical school, since medical school itself is post-graduate, requiring a bachelor’s degree for entrance) can have two components as well. First there is the primary residency program, say an internal medicine residency of 3 years, and then there is subspecialty training, usually called “fellowship”, where that internist becomes a cardiologist, or endocrinologist, or pulmonary medicine physician. While the internist who completes 3-year residency may practice general internal medicine and thus become a primary care physician for adults, those subspecialists do not. A similar process exists for pediatrics. Family physicians completing their 3 year residencies can also do fellowships in a limited number of areas, and some limit their practices to sports medicine or geriatrics or adolescent medicine, but most add these skills to their primary care practice. And, of course, geriatrics and adolescent medicine are, like general internal medicine or general pediatrics, primary care for a particular population.

This is important. Primary care doctors provide care for their patients that is comprehensive and unrestricted, other than by age for pediatrics, internal medicine, and geriatrics. They meet the World Health Organization (WHO) criteria for primary care, providing continuous, comprehensive, community-and-family-centered care. Distilled down, this means that primary care physicians see their patients for everything, whatever concerns them, referring when needed. They are the doctors for their people, not for a particular disease or set of diseases. The lack of sufficient numbers of primary care doctors has significant negative impact on the health of our people. Of course, it falls hardest on those who are always most disadvantaged – the poor, members of minority groups, and rural residents. But it also has negative impact upon the health of privileged people who see lots of subspecialists, in two ways. One is that the specialist may be expert in their field, but miss appropriate treatments, and especially preventive measures, outside it. The other is that many specialties and subspecialties rely on and extensively use care that is very high-tech and expensive, which can lead to people getting tests and treatments that are not only costly but may not be of any benefit, and indeed may lead to harm.

 So, when a medical school claims that it is good at producing primary care physicians, this is serious, and should be accurate. But it usually is not, because schools want to look as good as possible so establish criteria that make them look good, counting a wide variety of specialties that their graduates might enter as “primary care”. The biggest “offender” in this regard is counting all graduates entering internal medicine residency programs as entering primary care. As described above, some of these end up doing fellowships to become subspecialists and do not practice primary care; indeed, “some” is an understatement as it is about 80%. In addition, about half the rest end up practicing as “hospitalists”, taking care of hospitalized patients only, rather than practicing primary care. So an approximation would be to assume about 10% of those entering internal medicine residencies will practice primary care. In pediatrics, continuing as a general pediatrician is much more common; the appropriate multiplier is probably 60%, and for family medicine as much as 95%. There are also residency programs in a combination of medicine and pediatrics (Med/Peds) which can produce primary care doctors, and whose graduates are less likely to pursue subspecialty training; however, they are very likely to choose only one of those areas (adult medicine or pediatrics) and also to become hospitalists.

In addition, some (or many) schools include in the primary care numbers specialties that are simply not primary care at all. Most commonly, they include emergency medicine and obstetrics/gynecology. Emergency medicine does indeed provide first-contact care, but it does not provide continuity. Obstetrics/gynecology can provide some aspects of primary care (and indeed OBGyns may be the only doctors some young women see) but it is limited in that it is not comprehensive; women are more than their reproductive tracts, and they can have a variety of conditions OBGYN does not care for (diabetes, hypertension, heart disease, depression, arthritis, asthma and other lung problems, substance abuse, etc., to name a few). Perhaps the most egregious abuse is counting all students who enter internal medicine “transitional” or “preliminary” years. Such one-year programs, which have replaced the old “rotating internships”, are required for many specialties such as neurology, anesthesiology, radiology, ophthalmology, dermatology, and others, whose practitioners do not do primary care at all.

If we want to know how well a school is doing in graduating students who actually practice primary care at the end of their residency and fellowship training, these inflated numbers do not inform us. Fortunately, one of the most popular sources of information on medical (and other) schools, US News, has worked with the Robert Graham Center, the policy center of the American Academy of Family Physicians (AAFP) to develop and publish a metric that does show which schools actually produce primary care physicians, available at https://www.usnews.com/best-graduate-schools/top-medical-schools/graduates-practicing-primary-care-rankings. The top of this list is dominated by schools of osteopathic medicine, which consistently graduate higher numbers of primary care physicians, and, among the allopathic schools, the mainly public schools who have been doing well in this area for a long time. The private, largely northeastern, schools that usually top rank lists are nowhere to be found.

It is important to look at this list, not the list of “Top Primary Care Schools”, to get accurate data on production of primary care physicians. The metric on percent of students going into primary care has also been fixed in the “Top Primary Care” rankings, so it is better, but it still only accounts for 40% of that ranking. “Peer Assessment” (subjective rankings) account for 30%, half from medical school deans and other leaders, and half from residency directors. The other 30% is half “faculty resources” (largely faculty ratio) which may be skewed to the advantage of research-intensive schools, because it includes faculty who are mostly in laboratories and not teaching, and half “student selectivity” (based on student grades and MCAT scores), which is actually negatively associated with entry into primary care. This doesn’t mean the students that enter primary care are not as smart; it means that the cachet of attending a research-intensive school makes the competition greater. Unsurprisingly, adding these other criteria does affect the rankings; Harvard, for example, is now #8 in “best primary care schools”, although it ranks #141 of 159 schools in percent of graduates practicing primary care. (In contrast, the University of Kansas, which ranks #9 in primary care, below Harvard, ranks #17 in graduates practicing primary care, at 37.8%). Reputation affects peer assessments in at least 3 ways. One is spillover effect -- well, it’s Harvard, and good in everything so it must be good in primary care. A second is the ignorance of non-primary care deans and residency directors about what kinds of doctors the school produces. Finally, the fact that “good in primary care” can mean things other than what specialties the graduates enter can have an effect; there are schools in which the family medicine and other primary care faculty are well-known for their research and leadership in national organizations, but which do not graduate very many students into primary care disciplines.

The fact remains, though, that the US very short of the primary care doctors it needs to provide quality health care to the American people. The way to begin to change that is to stop deceiving ourselves. Then we can start the process of producing a higher percentage, in every school.

We need more primary care to serve our people: Why do the medical schools lie?

Every year the nation’s medical schools graduate thousands of people with MD and DO degrees. But this is just the start of becoming a practicing physician; they now need to complete residency programs in a specialty area, ranging from 3 to as many as 8 years, to become family physicians, surgeons, radiologists, dermatologists, orthopedists, etc. Indeed, for many physicians this “postgraduate” training (meaning post-medical school, since medical school itself is post-graduate, requiring a bachelor’s degree for entrance) can have two components as well. First there is the primary residency program, say an internal medicine residency of 3 years, and then there is subspecialty training, usually called “fellowship”, where that internist becomes a cardiologist, or endocrinologist, or pulmonary medicine physician. While the internist who completes 3-year residency may practice general internal medicine and thus become a primary care physician for adults, those subspecialists do not. A similar process exists for pediatrics. Family physicians completing their 3 year residencies can also do fellowships in a limited number of areas, and some limit their practices to sports medicine or geriatrics or adolescent medicine, but most add these skills to their primary care practice. And, of course, geriatrics and adolescent medicine are, like general internal medicine or general pediatrics, primary care for a particular population.

This is important. Primary care doctors provide care for their patients that is comprehensive and unrestricted, other than by age for pediatrics, internal medicine, and geriatrics. They meet the World Health Organization (WHO) criteria for primary care, providing continuous, comprehensive, community-and-family-centered care. Distilled down, this means that primary care physicians see their patients for everything, whatever concerns them, referring when needed. They are the doctors for their people, not for a particular disease or set of diseases. The lack of sufficient numbers of primary care doctors has significant negative impact on the health of our people. Of course, it falls hardest on those who are always most disadvantaged – the poor, members of minority groups, and rural residents. But it also has negative impact upon the health of privileged people who see lots of subspecialists, in two ways. One is that the specialist may be expert in their field, but miss appropriate treatments, and especially preventive measures, outside it. The other is that many specialties and subspecialties rely on and extensively use care that is very high-tech and expensive, which can lead to people getting tests and treatments that are not only costly but may not be of any benefit, and indeed may lead to harm.

 

So, when a medical school claims that it is good at producing primary care physicians, this is serious, and should be accurate. But it usually is not, because schools want to look as good as possible so establish criteria that make them look good, counting a wide variety of specialties that their graduates might enter as “primary care”. The biggest “offender” in this regard is counting all graduates entering internal medicine residency programs as entering primary care. As described above, some of these end up doing fellowships to become subspecialists and do not practice primary care; indeed, “some” is an understatement as it is about 80%. In addition, about half the rest end up practicing as “hospitalists”, taking care of hospitalized patients only, rather than practicing primary care. So an approximation would be to assume about 10% of those entering internal medicine residencies will practice primary care. In pediatrics, continuing as a general pediatrician is much more common; the appropriate multiplier is probably 60%, and for family medicine as much as 95%. There are also residency programs in a combination of medicine and pediatrics (Med/Peds) which can produce primary care doctors, and whose graduates are less likely to pursue subspecialty training; however, they are very likely to choose only one of those areas (adult medicine or pediatrics) and also to become hospitalists.

In addition, some (or many) schools include in the primary care numbers specialties that are simply not primary care at all. Most commonly, they include emergency medicine and obstetrics/gynecology. Emergency medicine does indeed provide first-contact care, but it does not provide continuity. Obstetrics/gynecology can provide some aspects of primary care (and indeed OBGyns may be the only doctors some young women see) but it is limited in that it is not comprehensive; women are more than their reproductive tracts, and they can have a variety of conditions OBGYN does not care for (diabetes, hypertension, heart disease, depression, arthritis, asthma and other lung problems, substance abuse, etc., to name a few). Perhaps the most egregious abuse is counting all students who enter internal medicine “transitional” or “preliminary” years. Such one-year programs, which have replaced the old “rotating internships”, are required for many specialties such as neurology, anesthesiology, radiology, ophthalmology, dermatology, and others, whose practitioners do not do primary care at all.

If we want to know how well a school is doing in graduating students who actually practice primary care at the end of their residency and fellowship training, these inflated numbers do not inform us. Fortunately, one of the most popular sources of information on medical (and other) schools, US News, has worked with the Robert Graham Center, the policy center of the American Academy of Family Physicians (AAFP) to develop and publish a metric that does show which schools actually produce primary care physicians, available at https://www.usnews.com/best-graduate-schools/top-medical-schools/graduates-practicing-primary-care-rankings. The top of this list is dominated by schools of osteopathic medicine, which consistently graduate higher numbers of primary care physicians, and, among the allopathic schools, the mainly public schools who have been doing well in this area for a long time. The private, largely northeastern, schools that usually top rank lists are nowhere to be found.

It is important to look at this list, not the list of “Top Primary Care Schools”, to get accurate data on production of primary care physicians. The metric on percent of students going into primary care has also been fixed in the “Top Primary Care” rankings, so it is better, but it still only accounts for 40% of that ranking. “Peer Assessment” (subjective rankings) account for 30%, half from medical school deans and other leaders, and half from residency directors. The other 30% is half “faculty resources” (largely faculty ratio) which may be skewed to the advantage of research-intensive schools, because it includes faculty who are mostly in laboratories and not teaching, and half “student selectivity” (based on student grades and MCAT scores), which is actually negatively associated with entry into primary care. This doesn’t mean the students that enter primary care are not as smart; it means that the cachet of attending a research-intensive school makes the competition greater. Unsurprisingly, adding these other criteria does affect the rankings; Harvard, for example, is now #8 in “best primary care schools”, although it ranks #141 of 159 schools in percent of graduates practicing primary care. (In contrast, the University of Kansas, which ranks #9 in primary care, below Harvard, ranks #17 in graduates practicing primary care, at 37.8%). Reputation affects peer assessments in at least 3 ways. One is spillover effect -- well, it’s Harvard, and good in everything so it must be good in primary care. A second is the ignorance of non-primary care deans and residency directors about what kinds of doctors the school produces. Finally, the fact that “good in primary care” can mean things other than what specialties the graduates enter can have an effect; there are schools in which the family medicine and other primary care faculty are well-known for their research and leadership in national organizations, but which do not graduate very many students into primary care disciplines.

The fact remains, though, that the US very short of the primary care doctors it needs to provide quality health care to the American people. The way to begin to change that is to stop deceiving ourselves. Then we can start the process of producing a higher percentage, in every school.

US Health Rankings remain low and #Trumpcare will make them worse!

On many occasions this blog has made the point that, despite frequently-repeated claims that the US has “the best healthcare in the world”, we do not. This point is also made by dozens of other sources, recently including Kaiser Health News (KHN) editor-in-chief Elisabeth Rosenthal in her book “American Sickness”. In my book, “Health, Medicine and Justice: Designing a fair and equitable health care system”, and in many lectures I have given to physicians and students, I have cited the “37^th in the world”  ranking the US achieved in the comprehensive World Health Organization (WHO) report of 2000. The report’s Table 10, available as a pdf at that site, indeed lists the US as #37 in Overall Performance, just below Costa Rica and just above Slovenia. On an equally telling scale, Performance on Health Level (measured by Disability-Adjusted Life Expectancy, DALE) the US ranked #72, between Argentina and Bhutan. When many US news media led their stories with “Just ahead of Slovenia!”, the Slovenian ambassador took exception, noting that his country was working hard to improve their people's health status.

But, as I also pointed out in my lectures, this table is old, based on 1997 data, and I use it because it is the last time that WHO released such rankings. I supplement it with newer data, such as the Commonwealth Fund’s “Mirror, Mirror on the Wall” from 2014. This compares fewer countries, albeit appropriate, developed, wealthy, OECD countries. In this study, the US also ranks last overall and in many subscales; I have published this graphic before as well.  

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!

Given the recalcitrance of US health status to improvement, it is obviously important to look at the ”why” as well as the “what could be done?”. This is especially now, given that these ranking do not yet reflect any negative impact that may happen through the repeal of the Affordable Care Act (ACA) and its replacement by a a Republican plan (#Trumpcare). The contents of the bill that the Senate is currently working on, and which Majority Leader McConnell hopes to bring to a vote by July 4, remain secret not only to the public but also, apparently, to many or most senators. Therefore, the bill passed by the House of Representatives, the American Health Care Act (AHCA) remains our best guide to what the final plan may look like.

And it is not encouraging; the Congressional Budget Office (CBO) estimates that 23 million Americans willlose health insurance, about equally from loss of Medicaid expansion and from  cuts to support for the health insurance exchanges set up by ACA. This will unquestionably mean that the overall health status of Americans will go down, both in absolute terms and relative to other nations. Without health insurance, people will not access health care, especially for prevention and “minor” problems (or problems that are not really minor but so far not, or minimally, symptomatic). This means that by the time that their health is so bad that they seek care, they are less likely to survive or do well, and also that the cost of their care will be far higher. This is not a plan to most efficiently use healthcare dollars to maximize the health of the American people.

So what is going on? In a recent blog post (“Pre-existing conditions and profit-taking: the causes of our healthcare problems, May 29, 2017)  I wrote “The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.” That is true, but the question that still needs to be answered is “why”? Ultimately, it is a question of values: if the goal was to have the best possible health status for the American people, rich or poor, white or black, native born or immigrant, rural or urban, this would not be the system that we have and #Trumpcare would be designed to fix the problems with the ACA, not to exacerbate them. President Trump and the GOP have emphasized, in the campaign and since, that for many the ACA has not made insurance accessible because the premiums are too high. This is a good point, and a solution would be great; unfortunately, the AHCA would make them higher, and price out far more people. The values of the Republican leadership are clearly to maximize tax cuts and other financial benefits to the richest American people and corporations, and this AHCA will do. The perpetrators are not among those at the margins; even those congresspersons and pundits who are not truly wealthy have outstanding health insurance for life, and are certain that they will not be in the marginalized group, and that they will be able to access the “best health care in the world”.

Of course, even when you have great insurance and access to “everything”, it is not always better. Sometimes if you are too well-insured you get too much care, tests and procedures and drugs that can put you at risk of harm. And even in the “best” facilities things don’t always go well – medical errors are common, communication can be poor, and even when there are no screwups bad things can happen. Donald Berwick, head of the Institute for Healthcare Improvement (IHI), and former interim head of the Center for Medicare and Medicaid Services (CMS) talks about the US perhaps having the best “rescue care” in the world. But even that is not so good; many IHI initiatives are focused on changing that system to work better, including improvement capability, patient safety, and population health. Anyone who has been sick, or in the hospital, or had a close friend or relative in such a situation recently, can testify to the failings of our health care delivery system even for the well-insured.

So the situation in the US was not good up until now, and will almost certainly get worse with #Trumpcare. Many of the people who will suffer most are those who voted for the President and the GOP members of Congress. Maybe they think that the bad things will not happen to them and their families, but only to “others”.  But they will, and we need to move up in the rankings, to be closer to other OECD countries.

Maybe the solution for the US is not to mimic France, or Italy, or Canada. But whatever the solution is, it has to pass the empiric “does it make our people’s health better?” test. And clearly #Trumpcare will not.